Prediction of extubation outcome in preterm infants by composite extubation indices

Dimitriou, Gabriel; Fouzas, Sotirios; Vervenioti, Aggeliki; Tzifas, Sotirios; Mantagos, Stefanos

doi:10.1097/pcc.0b013e3181fe3431

Cited by 31 publications

(22 citation statements)

References 37 publications

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“…On the other hand, inappropriately early discontinuation of MV (extubation) might precipitate a sudden deterioration with adverse consequences and necessitate re-institution of MV (reintubation) [2]. Various factors have been evaluated in order to predict extubation outcome, such as blood gases [3], minute ventilation [4,5], lung volume and compliance measurements [5,6,7], assessment of cardiorespiratory variability [8,9], and composite indices describing respiratory muscle efficiency [2,3,10]. Unfortunately, an accurate prediction of extubation outcome remains evasive as the evaluated indices have been shown to demonstrate high sensitivity, but only moderate specificity.…”

Section: Introductionmentioning

confidence: 99%

Relaxation Rate of the Respiratory Muscles and Prediction of Extubation Outcome in Prematurely Born Infants

2017

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Background: Accurate prediction of extubation outcome could result in a significant reduction of respiratory morbidity in premature neonates. Objectives: To assess whether the respiratory muscle time constant of relaxation (τ) predicted extubation outcome in mechanically ventilated, premature infants. Methods: Forty-six mechanically ventilated infants with a median gestational age of 26 (interquartile range [IQR] 25-29) weeks were prospectively studied. τ was calculated from the reciprocal of the slope of the decline in airway pressure as a function of time. Measurements of τ were done during 5-10 min of a spontaneous breathing test (SBT) prior to extubation. During the first and last minute of the SBT, τ₁ and τ₂, respectively, were assessed, and the difference between them was calculated (Δτ). Results: The median τ₂ was significantly higher in infants whose extubation failed (20.7 [IQR 12.9-34.7] s/cm H₂O) than in infants whose extubation succeeded (8.2 [IQR 6.2-17.8] s/cm H₂O, p = 0.002). The median Δτ was significantly higher in infants whose extubation failed (10.3 [IQR 4.4-23.9] s/cm H₂O) than in infants whose extubation succeeded (-1.63 [IQR -5.7 to 0.3] s/cm H₂O, p = 0.001). Extubation failure was associated with τ₂ (p = 0.011) and Δτ (p = 0.010) after correcting for postmenstrual age, patent ductus arteriosus, and intraventricular haemorrhage. Receiver operator characteristic curve analysis demonstrated that Δτ predicted extubation failure with an area under the curve of 0.937. A Δτ of +1.02 s/cm H₂O predicted extubation failure with 94% sensitivity and 83% specificity. Conclusions: The respiratory muscle time constant of relaxation during an SBT was significantly greater in infants whose extubation failed and could be used to predict extubation outcome in prematurely born infants.

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Section: Introductionmentioning

confidence: 99%

Relaxation Rate of the Respiratory Muscles and Prediction of Extubation Outcome in Prematurely Born Infants

2017

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“…These features should be validated by a clinician, but were taken from previous studies. Our model also contains a unique combination of variables, including PFratio, previously reported as an insignificant risk factor [4], and a novel variable, Monocyte cell count, not mentioned as a predictor or risk factor in any previously published reports. There is evidence that preterm neonates with RDS have altered levels of monocytes compared to healthy preterm neonates [10].…”

Section: Discussionmentioning

confidence: 99%

“…Validation of these metrics is ongoing. Other indices, such as diagrammatic pressure-time index and noninvasive respiratory muscle pressure-time index have been designed specifically for predicting extubation outcome in preterm neonates [4]. However, measurement of these parameters requires an intervention like taking the patient off the ventilator, thus making it impractical for automated prediction systems.…”

Section: Introductionmentioning

confidence: 99%

“…If improvement is noted within a few days or weeks, a clinical decision is made to extubate, and place the patient on a nasal continuous positive airway pressure (CPAP) trial. Across studies, 15%-40% of infants fail the trial, and must be re-intubated [2][3][4]. The failed trial exposes the infant to respiratory shock requiring re-intubation, increased ventilator support due to alveolar collapse (or atelectasis), and puts them at additional risks associated with the intubation procedure [5].…”

Section: Introductionmentioning

confidence: 99%

“…The risk factors are from a variety of sources such as demographics (e.g., gestational age, birth weight) [2], ventilator settings (e.g., breath rate, fraction of inspired oxygen, tidal volume), pulmonary mechanics measurements (e.g., work of breathing, minute volume, airway resistance) [3], [4], and blood gas measurements (e.g., base excess, partial pressure of arterial oxygen) [2], [4]. Validation of these metrics is ongoing.…”

Section: Introductionmentioning

confidence: 99%

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Prediction of extubation failure for neonates with respiratory distress syndrome using the MIMIC-II clinical database

Mikhno

Ennett

2012

2012 Annual International Conference of the IEEE Engineering in Medicine and Biology Society

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Abstract-Extubation failure (EF) is an ongoing problem in the neonatal intensive care unit (NICU). Nearly 25% of neonates fail their first extubation attempt, requiring reintubations that are associated with risk factors and financial costs. We identified 179 mechanically ventilated neonatal patients that were intubated within 24 hours of birth in the MIMIC-II intensive care database. We analyzed data from the patients 2 hours prior to their first extubation attempt, and developed a prediction algorithm to distinguish patients whose extubation attempt was successful from those that had EF. From an initial list of 57 candidate features, our machine learning approach narrowed down to six features useful for building an EF prediction model: monocyte cell count, rapid shallow breathing index, fraction of inspired oxygen (FiO 2 ), heart rate, PaO 2 /FiO 2 ratio where PaO 2 is the partial pressure of oxygen in arterial blood, and work of breathing index. Algorithm performance had an area under the receiver operating characteristic curve (AUC) of 0.871 and sensitivity of 70.1% at 90% specificity.

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Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants

et al. 2015

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IMPORTANCE Extubation failure is common in extremely preterm infants. The current paucity of data on the adverse long-term respiratory outcomes associated with reinitiation of mechanical ventilation prevents assessment of the risks and benefits of a trial of extubation in this population. OBJECTIVE To evaluate whether exposure to multiple courses of mechanical ventilation increases the risk of adverse respiratory outcomes before and after adjustment for the cumulative duration of mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective cohort study of extremely low-birth-weight (ELBW; birth weight <1000 g) infants born from January 1, 2006, through December 31, 2012, who were receiving mechanical ventilation. Analysis was conducted between November 2014 and February 2015. Data were obtained from the Alere Neonatal Database. EXPOSURES The primary study exposures were the cumulative duration of mechanical ventilation and the number of ventilation courses. MAIN OUTCOMES AND MEASURES The primary outcome was bronchopulmonary dysplasia (BPD) among survivors. Secondary outcomes were death, use of supplemental oxygen at discharge, and tracheostomy. RESULTS We identified 3343 ELBW infants, of whom 2867 (85.8%) survived to discharge. Among the survivors, 1695 (59.1%) were diagnosed as having BPD, 856 (29.9%) received supplemental oxygen at discharge, and 31 (1.1%) underwent tracheostomy. Exposure to a greater number of mechanical ventilation courses was associated with a progressive increase in the risk of BPD and use of supplemental oxygen at discharge. Compared with a single ventilation course, the adjusted odds ratios for BPD ranged from 1.88 (95% CI, 1.54–2.31) among infants with 2 ventilation courses to 3.81 (95% CI, 2.88–5.04) among those with 4 or more courses. After adjustment for the cumulative duration of mechanical ventilation, the odds of BPD were only increased among infants exposed to 4 or more ventilation courses (adjusted odds ratio, 1.44; 95% CI, 1.04–2.01). The number of ventilation courses was not associated with increased risk of supplemental oxygen use at discharge after adjustment for the length of ventilation. A greater number of ventilation courses did not increase the risk of tracheostomy. CONCLUSIONS AND RELEVANCE Among ELBW infants, a longer cumulative duration of mechanical ventilation largely accounts for the increased risk of chronic respiratory morbidity associated with reinitiation of mechanical ventilation. These results support attempts of extubation in ELBW infants receiving mechanical ventilation on low ventilator settings, even when success is not guaranteed.

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Prediction of extubation outcome in preterm infants by composite extubation indices

Abstract: Composite extubation indices such as the diaphragmatic pressure-time index and the noninvasive respiratory muscle pressure-time index can accurately predict extubation outcome in preterm neonates.

Cited by 31 publications

References 37 publications

Relaxation Rate of the Respiratory Muscles and Prediction of Extubation Outcome in Prematurely Born Infants

Relaxation Rate of the Respiratory Muscles and Prediction of Extubation Outcome in Prematurely Born Infants

Prediction of extubation failure for neonates with respiratory distress syndrome using the MIMIC-II clinical database

Effects of Multiple Ventilation Courses and Duration of Mechanical Ventilation on Respiratory Outcomes in Extremely Low-Birth-Weight Infants

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