|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2022 | Volume
: 11
| Issue : 2 | Page : 97-101 |
|
Outcomes and factors associated with extubation failure in preterm infants
Abdulrahman Al-Matary1, Shahad AlOtaiby2, Saad F Alenizi3
1 Department of Neonatology, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
2 Research Center, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
3 Department of Respiratory Care, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| Date of Submission | 23-Aug-2021 |
| Date of Decision | 20-Sep-2021 |
| Date of Acceptance | 14-Dec-2021 |
| Date of Web Publication | 20-Apr-2022 |
Correspondence Address:
Abdulrahman Al-Matary
Department of Neonatology, King Fahad Medical City, 59046, Riyadh 11525
Kingdom of Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcn.jcn_106_21
Background: Preterm infants usually have multiple complications, mainly due to their low birth weight. Multiple factors may lead to the need for intubating preterm infants. However, some infants may suffer from difficult extubation and failure to extubate from ventilation. This failure can result in increased morbidity or mortality. Objective: This study aims to evaluate the factors contributing to the failure of extubation and their outcomes in preterm infants. Materials and Methods: This is a retrospective descriptive cohort study that included records from neonatal intensive care unit for patients who had failed extubation from January 2014 to December 2020. The data included information about patients' demographics, pregnancy and delivery, description of ventilation course, and outcomes. SPSS version 26 was used for statistical analysis. Results: Seventy-seven infants were included. Males represented 61%, birth weight 37.7% had a <1 kg, 45.5% of the patients had a gestational age <28 weeks. The mean duration for mechanical ventilation was 19.21 ± 3.2 days, while the duration of intubation was 26.53 ± 2.3 days, and the average length of hospital stay was 86.2 ± 6.7 days. Male gender (P = 0.023), birth weight less than one kilogram (P = 0.004), gestational age <28 weeks (P = 0.033), sedation (P = 0.043), caffeine administration (P = 0.048), and a previous history of extubation failure (P = 0.036), lower hemoglobin levels (P = 0.039), lower APGAR score at 5 min (P = 0.013), and a previous history of extubation failure (P = 0.036) were significant factors associated with failure of extubation. Patent ductus arteriosus presence is not associated with failure of extubation. Mortality was 24.7% and prolonged length of hospital stay was significantly higher in babies with failure of extubation. Conclusion: Failure of extubation is more with babies received sedation, male gender, birth weight <1 kg, lower gestation age, and lower Apgar at 5 min. Patients with failing extubation have high in-hospital mortality and prolonged hospital stay.
Keywords: Extubation, neonatal, preterm, tertiary hospital, ventilation
How to cite this article:
Al-Matary A, AlOtaiby S, Alenizi SF. Outcomes and factors associated with extubation failure in preterm infants. J Clin Neonatol 2022;11:97-101 |
How to cite this URL:
Al-Matary A, AlOtaiby S, Alenizi SF. Outcomes and factors associated with extubation failure in preterm infants. J Clin Neonatol [serial online] 2022 [cited 2023 Mar 21];11:97-101. Available from: https://www.jcnonweb.com/text.asp?2022/11/2/97/343413 |
| Introduction | |  |
Failure of extubation in the neonatal population is a common complication in up to a third of these patients.[1] Extubation is considered as a failure if re-intubation is required or if any respiratory supplementation is attempted within 2 days from extubation.[2] There are multiple reasons for reintubation; these include upper respiratory tract congestion, infection, prematurity, and atelectasis. However, the failure of extubation is considered multi-factorial.[3]
The most prevalent type of assisted ventilation is invasive mechanical ventilation. Preterm infants with low birth weight may need mechanical ventilation.[4] However, these patients may suffer from some complications such as pneumothorax, pneumonia and may reach up to death.[5] Accordingly, decreasing the duration on mechanical ventilation may enhance patients' outcomes and decrease the incidence of complications.[6]
Preterm infants have an undeveloped respiratory system, which results in unstable airways. This instability makes the extubating process more difficult.[7] Furthermore, re-intubation is correlated to a significant incidence of complications, such as prolonged hospital stays and a higher incidence of mortality.[8] Almost half of the patients who require a re-intubation suffer from hypercapnia and hypoxemia, as well as increased breathing efforts.[9]
Hence, identifying preterm infants with a higher risk of extubation failure is crucial to reduce their incidence of complications.[10] There are multiple factors contributing to the failure of extubation based on the body weight of the infant, gestational age, and type of ventilation support.[11] Some interventions can enhance the success rates of extubation comprising a continuous positive airways pressure as well as noninvasive ventilation.[12]
Nevertheless, risk factors for extubation failure among preterm infants in the gulf area are still unexplored. Hence, the present study will identify the risk factors contributing to the elevated incidence of extubation failure and their outcomes. Understanding these factors can result in improved success rates of extubation as well as improved patient outcomes.
| Materials and Methods | | |
Study design
This is a retrospective study that involved data collection from infants' records. All data from neonates admitted to neonatal intensive care unit from January 2014 till December 2020 and those who suffered from failed extubation were eligible for inclusion. Infants with lethal malformations, neuromuscular disease, those with upper airway disease, or the need for surgery or procedures like magnetic resonance imaging were excluded.
Ethical considerations
Before collecting the data from patients' records, all ethical approvals were performed before data collections done.
Data collection
A preformulated excel sheet was used to collect data from infants' records. The collected data included information about infants' age, gender, birth weight, gestational age. Furthermore, pregnancy and delivery characters and complications were included (mode of delivery, use of surfactants), in addition to the description of ventilation course and the outcome of patients.
Statistical analysis
The data were analyzed such that means and standard deviations are used to describe numerical variables, while counts and percentages were used to describe categorical data. At a level of significance (P < 0.05), one-way analysis of variance is used to compare numerical variables, while Chi-square testing was used to compare categorical variables. Statistics package SPSs version 26 IBM, US was used for data analysis.
| Results | | |
Seventy-seven infants who had a failed extubation were eligible for inclusion in this study. Analysis and description of patients are shown below.
General characters of patients
Of the 77 infants, 61% were males. Birth weight was classified into five groups, starting from <1 kg and up to more than 2.5 kg; 37.7% of the patients had a birth weight <1 kg. In addition, 45.5% of the patients had a gestational age of fewer than 28 weeks. To identify the factors contributing to failed extubation, one sample Chi-square testing was used at the level of significance P < 0.05. Male gender (P = 0.023), birth weight less than one kilogram (P = 0.004), and gestational age <28 weeks (P = 0.033) all significantly contributed to failure of extubation, as illustrated in [Table 1].
Pregnancy and neonatal characters
As for the mode of delivery, 54.5% were born by Caesarean section. In addition, 7.8% had intrauterine growth restriction, 36.4% had patent ductus arteriosus, mothers of 49.4% had an antenatal steroid, and 57.1% had a surfactant. All pregnancy and delivery characters did not significantly contribute to the failure of extubation, as described in [Table 2].
Description of ventilation course
All the included patients had at least one course of intubation. Only one patient had an inotrope, while 66.2% required sedation, and 55.8% had caffeine. As for the mode of ventilation, majority on weaning mode 93.5% were put on synchronized intermittent mandatory ventilation with or without volume grantee and pressure support modes; in addition, 5.5% were extubated from assist control modes. Only one patient had bronchopulmonary dysplasia, and four patients had a previous history of extubation failure.
Factors significantly contributing to extubation failure regarding to ventilation using one sample Chi-square test were sedation (P = 0.043) and a previous history of extubation failure (P = 0.036), as described in [Table 3].
Scores, duration of ventilation, and hospital stay
The duration of intubation and mechanical ventilation was calculated. The mean duration for mechanical ventilation was 19.21 ± 3.2 days, and the average length of hospital stay was 86.2 ± 6.7 days. The average gestational age at extubation was 32.8 ± 5.5 weeks as described in [Table 4].
Hospitalization outcome was also evaluated; survival was estimated to be 75% among all the included patients, while 19 babies (24.7%) of the patients had in-hospital mortality, as described in [Figure 1].
Comparison between surviving and deceased patients with extubation failure
To explore factors contributing to mortality in patients with extubation failure, a comparison has been made for different variables over surviving and deceased patients using Chi-square testing at a level of significance P < 0.05. Mortality was significantly higher among females (P = 0.041), patients with intrauterine growth restriction (P = 0.013), birth weight <1 kg (P = 0.036) as shown in [Table 5]. | Table 5: Comparison between surviving and deceased patients with extubation failure using Chi-square testing
Click here to view |
In addition, mortality was associated with a significantly shorter average length of hospital stay (P = 0.013), lower hemoglobin levels (P = 0.039), and lower APGAR score at 5 min (P = 0.013), as shown in [Table 6]. | Table 6: Comparison between surviving and deceased patients with extubation failure using one-way ANOVA testing
Click here to view |
| Discussion | | |
Preterm infants usually suffer from multiple complications and may require mechanical ventilation for different reasons.[13] The incidence of extubation failure in these patients is relatively high, with elevated in-hospital mortality.[14] Accordingly, understanding the factors contributing to extubation failure can reduce the rate of failure and improve patients' outcomes.[15]
The present study examined the factors contributing to extubation failure and outcomes in preterm infants in Saudi Arabia. The study illustrated increased in-hospital mortality among infants with failure of extubation, up to 25%. Infants eligible for inclusion were mainly of very low birth weight (37.7% had birth weight <1 kg) and had low gestational age (<28 weeks). In addition, males (P = 0.023), birth weight less than one kilogram (P = 0.004), gestational age <28 weeks (P = 0.033), sedation (P = 0.043), and a previous history of extubation failure (P = 0.036) all were identified factors for extubation failure.
Mortality rate among extubated babies were 24.7% which similar to reported by Chawla et al. 28%.[14] Factors contributing to mortality were also explored. Females (P = 0.041), infants with intrauterine growth restriction (P = 0.013), birth weight <1 kg (P = 0.036), lower hemoglobin levels (P = 0.039) and lower APGAR score at 5 min (P = 0.013) were associated with higher mortality.
Extubation failure has been examined in different settings. In India, Hiremath et al. examined the incidence and risk factors for extubation failure in neonates. He included 82 patients and followed them for 48 h following extubation. Results revealed that low hemoglobin levels (P = 0.004), sepsis (P = 0.034), and longer ventilation duration are contributors to extubation failure.[16]
Although the present study included a smaller number of patients, it has been demonstrated that lower hemoglobin levels (P = 0.039) were a predictor for mortality in extubation failure patients. It should be noted that none of the include patients in the present study had pneumonia or sepsis; this reflects the high levels of infection control standards at the site of the study. In addition, the present study examined more predictors, revealing more risk factors for extubation failure.
Furthermore, Hermeto et al. examined the main contributors to extubation failure. He reported an incidence of extubation failure of 23.1%. In addition, gestational age, low birth weight, APGAR score at 5 min were significant risk factors for extubation failure, and intracranial hemorrhage and patent ductus arteriosus were significantly higher in the same group.[17]
The factors identified are supported by the same predictors revealed by the present study for extubation failure; however, all the 77 patients had an extubation failure, with a quarter of them having in-hospital mortality. In addition, the incidence of patent ductus arteriosus was 36.4%; however, it did not contribute to extubation failure. Furthermore, none of the included patients in the present study had intracranial hemorrhage.
Furthermore, Costa et al. identified the factors linked to extubation failure in neonates through a prospective study that included 176 infants and followed them for 3 days. Similar to Hermeto et al.[17] and the present study, Costa et al. demonstrated that low birth weight and gestational age below 28 weeks along with low APGAR scores are all correlated to extubation failure. These findings confirm the results of the present study.[18]
Nevertheless, the present study is limited by its retrospective nature. This nature might affect the reliability of data due to incomplete or missing information. Furthermore, the small sample size might affect the representation of the patient population with failing extubation. These barriers and limitations should be overcome in future investigations.
| Conclusion | | |
Preterm infants are at high risk of failure of extubation, with a high incidence of complications as well as in-hospital mortality. Multiple factors (some of them are avoidable) can contribute to extubation failure; these factors are either related to infants' gender, gestational age, and birth weight or to ventilation modes and parameters. Understanding these factors can help in reducing the incidence of extubation failure. Future studies with robust design and prospective nature carried in a multicenter setting are needed to confirm the findings of this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Shalish W, Latremouille S, Papenburg J, Sant'Anna GM. Predictors of extubation readiness in preterm infants: A systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2019;104:F89-97.  |
| 2. | Shalish W, Kanbar LJ, Rao S, Robles-Rubio CA, Kovacs L, Chawla S, et al. Prediction of extubation readiness in extremely preterm infants by the automated analysis of cardiorespiratory behavior: Study protocol. BMC Pediatr 2017;17:167. |
| 3. | Manley BJ, Davis PG. Solving the extubation equation: Successfully weaning infants born extremely preterm from mechanical ventilation. J Pediatr 2017;189:17-8. |
| 4. | Wang SH, Liou JY, Chen CY, Chou HC, Hsieh WS, Tsao PN. Risk factors for extubation failure in extremely low birth weight infants. Pediatr Neonatol 2017;58:145-50. |
| 5. | Giaccone A, Jensen E, Davis P, Schmidt B. Definitions of extubation success in very premature infants: A systematic review. Arch Dis Child Fetal Neonatal Ed 2014;99:F124-7. |
| 6. | Seo YM, Sung IK, Yum SK. Risk factors associated with prolonged mechanical ventilation after surgical patent ductus arteriosus ligation in preterm infants. J Matern Fetal Neonatal Med 2020:1-8. Online ahead of print. |
| 7. | Saikia B, Kumar N, Sreenivas V. Prediction of extubation failure in newborns, infants and children: Brief report of a prospective (blinded) cohort study at a tertiary care paediatric centre in India. Springerplus 2015;4:827. |
| 8. | Manley BJ, Doyle LW, Owen LS, Davis PG. Extubating extremely preterm infants: Predictors of success and outcomes following failure. J Pediatr 2016;173:45-9. |
| 9. | Gupta D, Greenberg RG, Sharma A, Natarajan G, Cotten M, Thomas R, et al. A predictive model for extubation readiness in extremely preterm infants. J Perinatol 2019;39:1663-9. |
| 10. | Gupta D, Greenberg RG, Sharma A, Natarajan G, Cotten M, Thomas R, et al. A predictive model for extubation readiness in extremely preterm infants. J Perinatol 2019;39:1663-9. |
| 11. | Shalish W, Kanbar L, Keszler M, Chawla S, Kovacs L, Rao S, et al. Patterns of reintubation in extremely preterm infants: A longitudinal cohort study. Pediatr Res 2018;83:969-75. |
| 12. | Shalish W, Kanbar L, Kovacs L, Chawla S, Keszler M, Rao S, et al. Assessment of extubation readiness using spontaneous breathing trials in extremely preterm neonates. JAMA Pediatr 2020;174:178-85. |
| 13. | Ferguson KN, Roberts CT, Manley BJ, Davis PG. Interventions to improve rates of successful extubation in preterm infants: A systematic review and meta-analysis. JAMA Pediatr 2017;171:165-74. |
| 14. | Chawla S, Natarajan G, Shankaran S, Carper B, Brion LP, Keszler M, et al. Markers of successful extubation in extremely preterm infants, and morbidity after failed extubation. J Pediatr 2017;189:113-9.e2. |
| 15. | De Bisschop B, Derriks F, Cools F. Early predictors for INtubation-SURfactant-extubation failure in preterm infants with neonatal respiratory distress syndrome: A systematic review. Neonatology 2020;117:33-45. |
| 16. | Hiremath GM, Mukhopadhyay K, Narang A. Clinical risk factors associated with extubation failure in ventilated neonates. Indian Pediatr 2009;46:887-90. |
| 17. | Hermeto F, Martins BM, Ramos JR, Bhering CA, Sant'Anna GM. Incidence and main risk factors associated with extubation failure in newborns with birth weight <1,250 grams. J Pediatr (Rio J) 2009;85:397-402. |
| 18. | Costa AC, Schettino Rde C, Ferreira SC. Predictors of extubation failure and reintubation in newborn infants subjected to mechanical ventilation. Rev Bras Ter Intensiva 2014;26:51-6. |
[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
|
Search Pubmed for