Diaphragmatic electromyography during a spontaneous breathing trial to predict extubation failure in preterm infants

Abstract

Background Premature attempts at extubation and prolonged episodes of ventilatory support in preterm infants have adverse outcomes. The aim of this study was to determine whether measuring the electrical activity of the diaphragm during a spontaneous breathing trial (SBT) could predict extubation failure in preterm infants. Methods When infants were ready for extubation, the electrical activity of the diaphragm was measured by transcutaneous electromyography (EMG) before and during a SBT when the infants were on endotracheal continuous positive airway pressure. Results Forty-eight infants were recruited (median (IQR) gestational age of 27.2 (25.6–30.4) weeks). Three infants did not pass the SBT and 13 failed extubation. The amplitude of the EMG increased during the SBT [2.3 (1.5–4.2) versus 3.5 (2.1–5.3) µV; p < 0.001]. In the whole cohort, postmenstrual age (PMA) was the strongest predictor for extubation failure (area under the curve (AUC) 0.77). In infants of gestational age <29 weeks, the percentage change of the EMG predicted extubation failure with an AUC of 0.74 while PMA was not associated with the outcome of extubation. Conclusions In all preterm infants, PMA was the strongest predictor of extubation failure; in those born <29 weeks of gestation, diaphragmatic electromyography during an SBT was the best predictor of extubation failure. Impact Composite assessments of readiness for extubation may be beneficial in the preterm population. Diaphragmatic electromyography measured by surface electrodes is a non-invasive technique to assess the electrical activity of the diaphragm. Postmenstrual age was the strongest predictor of extubation outcome in preterm infants. The change in diaphragmatic activity during a spontaneous breathing trial in extremely prematurely born infants can predict subsequent extubation failure with moderate sensitivity and specificity.

A Nomogram for Predicting Extubation Failure in Preterm Infants with Gestational Age Less than 29 Weeks

“…Consistent with most previous studies [12, 28–31], birth weight and PMA at extubation were important factors. Infants with lower birth weight and lower PMA at extubation usually have lower brain development, weaker breathing muscles, and lower lung maturity, resulting in spontaneous breathing failures.…”

Predictors of extubation failure in newborns: a systematic review and meta-analysis

“…Of these studies, 19 were prospective studies [ 17 , 19 , 23 – 39 ] and the remaining 15 studies were retrospective [ 10 , 16 , 40 – 52 ], of which seven were multicenter studies [ 16 , 17 , 19 , 23 , 37 , 39 , 49 ] and 27 were single-center studies [ 10 , 24 – 36 , 38 , 40 – 48 , 50 – 52 ].The sample size ranged from 34 to 926, with the two largest studies including 394 newborns [ 40 ] and 926 newborns [ 17 ], respectively. Three of these studies constructed clinical prediction models [ 16 , 42 , 49 ].…”

“…Therefore, the younger the gestational age of the fetus, the less likely it is that the fetus will be transferred to the NICU and receive mechanical ventilation. The development of the brain is critical for the control and regulation of breathing, and a study by Williams et al [ 38 ] showed that higher age at extubation was strongly associated with extubation success (ES) due to a more mature brain. This contradicts the findings of Dimitriou et al [ 27 ] and He et al [ 43 ], who suggested that prolonged ventilation before extubation causes disuse atrophy of the diaphragm, resulting in subsequent EF.…”

Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside

“…A recent study by Williams EE et al used transcutaneous electromyography of the diaphragm (dEMG) to study the electrical activity of the diaphragm (Edi) during an SBT to detect extubation readiness in preterm newborns [ 22 ]. They found that in babies born at a GA lower than 29 weeks, an increase in the Edi was the best predictor of extubation failure with moderate sensitivity and specificity [ 120 ]. Moreover, a study by Vento G et al described that the spontaneous minute ventilation during an Et-CPAP period before extubation was significantly lower in infants who failed extubation compared to the ones who were successfully extubated [ 121 ].…”