Prediction of extubation success using the diaphragmatic electromyograph results in ventilated neonates

Hunt, Katie; Hunt, Ian; Ali, Kamal; Dassios, Theodore; Greenough, Anne

doi:10.1515/jpm-2020-0129

Cited by 8 publications

(8 citation statements)

References 22 publications

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“…Indeed, our finding that a higher PMA is associated with successful extubation has been demonstrated in other previous studies and may also be linked to such infants having greater brain maturity, the development of which is crucial in controlling and regulating breathing. 4 , 6 , 26 , 46 …”

Section: Discussionmentioning

confidence: 99%

“…This software has been used previously by our research group for several studies in the neonatal population, in both term and preterm infants. 26 , 33 , 34 The Polybench software has also be utilised to measure diaphragmatic activity in preterm infants in response to caffeine therapy. 35 …”

Section: Methodsmentioning

confidence: 99%

“…A previous study of EMG in ventilated infants, however, did not show a significant difference in the results between those infants who were successfully extubated or failed extubation. 26 In that study, however, the EMG was measured during invasive ventilatory support, which could have suppressed the respiratory drive and hence any difference in diaphragmatic function would not have been observed. The use of a spontaneous breathing trial (SBT) has been reported to be 97% sensitive but of low (40%) specificity in predicting readiness for extubation, 27 making use of an SBT alone not routinely recommended in preterm infants given the inaccuracy in predicting extubation failures 28 , 29 along with reports of clinical instability.…”

Section: Introductionmentioning

confidence: 91%

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

et al. 2022

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 91%

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

et al. 2022

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“…Previous studies measuring the electrical activity of the diaphragm with electromyography (dEMG) in critically ill patients extubated from IMV have shown conflicting results. Some reported a difference in diaphragm activity between successful and failed extubation attempts, whereas others did not (19)(20)(21). Furthermore, some of these studies were hampered by their small sample size (19,20) or the lack of recording diaphragmatic activity "after" extubation (20,21).…”

mentioning

confidence: 99%

“…Some reported a difference in diaphragm activity between successful and failed extubation attempts, whereas others did not (19)(20)(21). Furthermore, some of these studies were hampered by their small sample size (19,20) or the lack of recording diaphragmatic activity "after" extubation (20,21). Postextubation activity might also contain predictive value which could limit delay in reintubation and clinical deterioration.…”

mentioning

confidence: 99%

Diaphragm Activity Pre and Post Extubation in Ventilated Critically Ill Infants and Children Measured With Transcutaneous Electromyography*

Leuteren

Waal

Jongh

et al. 2021

Pediatric Critical Care Medicine

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Swift extubation is important to prevent detrimental effects of invasive mechanical ventilation but carries the risk of extubation failure. Accurate tools to assess extubation readiness are lacking. This study aimed to describe the effect of extubation on diaphragm activity in ventilated infants and children. Our secondary aim was to compare diaphragm activity between failed and successfully extubated patients. DESIGN:Prospective, observational study. SETTING:Single-center tertiary neonatal ICU and PICU. PATIENTS:Infants and children receiving invasive mechanical ventilation longer than 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS:Diaphragm activity was measured with transcutaneous electromyography, from 15 minutes before extubation till 180 minutes thereafter. Peak and tonic activity, inspiratory amplitude, inspiratory area under the curve, and respiratory rate were calculated from the diaphragm activity waveform. One hundred forty-seven infants and children were included (median postnatal age, 1.9; interquartile range, 0.9-6.7 wk). Twenty patients (13.6%) failed extubation within 72 hours. Diaphragm activity increased rapidly after extubation and remained higher throughout the measurement period. Pre extubation, peak (end-inspiratory) diaphragm activity and tonic (end-inspiratory) diaphragm activity were significantly higher in failure, compared with success cases (5.6 vs 7.0 μV; p = 0.04 and 2.8 vs 4.1 μV; p = 0.04, respectively). Receiver operator curve analysis showed the highest area under the curve for tonic (end-inspiratory) diaphragm activity (0.65), with a tonic (end-inspiratory) diaphragm activity greater than 3.4 μV having a combined sensitivity and specificity of 55% and 77%, respectively, to predict extubation outcome. After extubation, diaphragm activity remained higher in patients failing extubation. CONCLUSIONS:Diaphragm activity rapidly increased after extubation. Patients failing extubation had a higher level of diaphragm activity, both pre and post extubation. The predictive value of the diaphragm activity variables alone was limited. Future studies are warranted to assess the additional value of electromyography of the diaphragm in combined extubation readiness assessment.

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Validation of a non-invasive pressure–time index of the inspiratory muscles in spontaneously breathing newborn infants

Dassios

Vervenioti

Tzifas

et al. 2022

J Clin Monit Comput

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To validate the pressure–time index of the inspiratory muscles as a non-invasive index of inspiratory muscle function in spontaneously breathing infants by comparing it against the gold-standard pressure–time index of the diaphragm. Prospective observational cohort study of consecutive infants breathing unsupported in room air in a tertiary neonatal intensive care unit, studied prior to discharge from neonatal care. The invasive pressure–time index of the diaphragm was calculated using a transdiaphragmatic dual-pressure catheter that measured transdiaphragmatic pressure by subtraction of the oesophageal from the gastric pressure. The non-invasive pressure–time index of the inspiratory muscles was calculated using pressure measurements at the level of the mouth via a differential pressure transducer connected to a face mask. Both indices were calculated as the product of the ratio of the mean inspiratory pressure divided by the maximum inspiratory pressure and the ratio of the inspiratory time divided by the total time of a respiratory cycle. One hundred and thirty infants (79 male) were included with a mean (SD) gestational age of 35.2 (3.2) weeks, studied at a median (IQR) postnatal age of 9 (6–20) days. The mean (SD) pressure–time index of the diaphragm was 0.063 (0.019) and the mean (SD) pressure–time index of the inspiratory muscles was 0.065 (0.023). The correlation coefficient for the two indices was 0.509 (p < 0.001). The mean (SD) absolute difference between the pressure–time index of the inspiratory muscles and pressure–time index of the diaphragm was 0.002 (0.021). In convalescent infants, the non-invasive pressure–time index of the inspiratory muscles had a moderate degree of correlation with the invasively derived pressure time index of the diaphragm measured with a transdiaphragmatic catheter.

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Prediction of extubation success using the diaphragmatic electromyograph results in ventilated neonates

Abstract: AbstractObjectivesExtubation failure is common in infants and associated with complications.MethodsA prospective study was undertaken of preterm and term born infants. Diaphragm electromyogram (EMG) was measured transcutaneously for 15–60 min prior to extubation. The EM… Show more

Cited by 8 publications

References 22 publications

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

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

Diaphragm Activity Pre and Post Extubation in Ventilated Critically Ill Infants and Children Measured With Transcutaneous Electromyography*

Validation of a non-invasive pressure–time index of the inspiratory muscles in spontaneously breathing newborn infants

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