Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

Sanjay Chawla, Girija Natarajan, Seetha Shankaran, Benjamin Carper, Luc P Brion, Martin Keszler, Waldemar A Carlo, Namasivayam Ambalavanan, Marie G Gantz, Abhik Das, Neil Finer, Ronald N Goldberg, C Michael Cotten, Rosemary D Higgins, Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, Alan H Jobe, Michael S Caplan, Richard A Polin, Abbot R Laptook, William Oh, Angelita M Hensman, Dan Gingras, Susan Barnett, Sarah Lillie, Kim Francis, Dawn Andrews, Kristen Angela, Michele C Walsh, Avroy A Fanaroff, Nancy S Newman, Bonnie S Siner, Kurt Schibler, Edward F Donovan, Vivek Narendran, Kate Bridges, Barbara Alexander, Cathy Grisby, Marcia Worley Mersmann, Holly L Mincey, Jody Hessling, Ronald N Goldberg, Kathy J Auten, Kimberly A Fisher, Katherine A Foy, Gloria Siaw, Barbara J Stoll, Susie Buchter, Anthony Piazza, David P Carlton, Ellen C Hale, Stephanie Wilson Archer, Brenda B Poindexter, James A Lemons, Faithe Hamer, Dianne E Herron, Lucy C Miller, Leslie D Wilson, Mary Anne Berberich, Carol J Blaisdell, Dorothy B Gail, James P Kiley, W Kenneth Poole, Margaret Cunningham, Betty K Hastings, Amanda R Irene, Jeanette O'Donnell Auman, Carolyn Petrie Huitema, James W Pickett 2nd, Dennis Wallace, Kristin M Zaterka-Baxter, Krisa P Van Meurs, David K Stevenson, M Bethany Ball, Melinda S Proud, Ivan D Frantz 3rd, John M Fiascone, Anne Furey, Brenda L MacKinnon, Ellen Nylen, Monica V Collins, Shirley S Cosby, Vivien A Phillips, Maynard R Rasmussen, Paul R Wozniak, Wade Rich, Kathy Arnell, Renee Bridge, Clarence Demetrio, Edward F Bell, John A Widness, Jonathan M Klein, Karen J Johnson, Shahnaz Duara, Ruth Everett-Thomas, Kristi L Watterberg, Robin K Ohls, Julie Rohr, Conra Backstrom Lacy, Dale L Phelps, Nirupama Laroia, Linda J Reubens, Erica Burnell, Pablo J Sánchez, Charles R Rosenfeld, Walid A Salhab, James Allen, Alicia Guzman, Gaynelle Hensley, Melissa H Lepps, Melissa Martin, Nancy A Miller, Araceli Solis, Diana M Vasil, Kerry Wilder, Kathleen A Kennedy, Jon E Tyson, Brenda H Morris, Beverly Foley Harris, Anna E Lis, Sarah Martin, Georgia E McDavid, Patti L Tate, Sharon L Wright, Bradley A Yoder, Roger G Faix, Jill Burnett, Jennifer J Jensen, Karen A Osborne, Cynthia Spencer, Kimberlee Weaver-Lewis, T Michael O'Shea, Nancy J Peters, Beena G Sood, Rebecca Bara, Elizabeth Billian, Mary Johnson, Richard A Ehrenkranz, Harris C Jacobs, Vineet Bhandari, Pat Cervone, Patricia Gettner, Monica Konstantino, JoAnn Poulsen, Janet Taft, Sanjay Chawla, Girija Natarajan, Seetha Shankaran, Benjamin Carper, Luc P Brion, Martin Keszler, Waldemar A Carlo, Namasivayam Ambalavanan, Marie G Gantz, Abhik Das, Neil Finer, Ronald N Goldberg, C Michael Cotten, Rosemary D Higgins, Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network, Alan H Jobe, Michael S Caplan, Richard A Polin, Abbot R Laptook, William Oh, Angelita M Hensman, Dan Gingras, Susan Barnett, Sarah Lillie, Kim Francis, Dawn Andrews, Kristen Angela, Michele C Walsh, Avroy A Fanaroff, Nancy S Newman, Bonnie S Siner, Kurt Schibler, Edward F Donovan, Vivek Narendran, Kate Bridges, Barbara Alexander, Cathy Grisby, Marcia Worley Mersmann, Holly L Mincey, Jody Hessling, Ronald N Goldberg, Kathy J Auten, Kimberly A Fisher, Katherine A Foy, Gloria Siaw, Barbara J Stoll, Susie Buchter, Anthony Piazza, David P Carlton, Ellen C Hale, Stephanie Wilson Archer, Brenda B Poindexter, James A Lemons, Faithe Hamer, Dianne E Herron, Lucy C Miller, Leslie D Wilson, Mary Anne Berberich, Carol J Blaisdell, Dorothy B Gail, James P Kiley, W Kenneth Poole, Margaret Cunningham, Betty K Hastings, Amanda R Irene, Jeanette O'Donnell Auman, Carolyn Petrie Huitema, James W Pickett 2nd, Dennis Wallace, Kristin M Zaterka-Baxter, Krisa P Van Meurs, David K Stevenson, M Bethany Ball, Melinda S Proud, Ivan D Frantz 3rd, John M Fiascone, Anne Furey, Brenda L MacKinnon, Ellen Nylen, Monica V Collins, Shirley S Cosby, Vivien A Phillips, Maynard R Rasmussen, Paul R Wozniak, Wade Rich, Kathy Arnell, Renee Bridge, Clarence Demetrio, Edward F Bell, John A Widness, Jonathan M Klein, Karen J Johnson, Shahnaz Duara, Ruth Everett-Thomas, Kristi L Watterberg, Robin K Ohls, Julie Rohr, Conra Backstrom Lacy, Dale L Phelps, Nirupama Laroia, Linda J Reubens, Erica Burnell, Pablo J Sánchez, Charles R Rosenfeld, Walid A Salhab, James Allen, Alicia Guzman, Gaynelle Hensley, Melissa H Lepps, Melissa Martin, Nancy A Miller, Araceli Solis, Diana M Vasil, Kerry Wilder, Kathleen A Kennedy, Jon E Tyson, Brenda H Morris, Beverly Foley Harris, Anna E Lis, Sarah Martin, Georgia E McDavid, Patti L Tate, Sharon L Wright, Bradley A Yoder, Roger G Faix, Jill Burnett, Jennifer J Jensen, Karen A Osborne, Cynthia Spencer, Kimberlee Weaver-Lewis, T Michael O'Shea, Nancy J Peters, Beena G Sood, Rebecca Bara, Elizabeth Billian, Mary Johnson, Richard A Ehrenkranz, Harris C Jacobs, Vineet Bhandari, Pat Cervone, Patricia Gettner, Monica Konstantino, JoAnn Poulsen, Janet Taft

Abstract

Objectives: To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates.

Study design: This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation.

Results: Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27).

Conclusions: Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities.

Trial registration: ClinicalTrials.gov: NCT00233324.

Keywords: bronchopulmonary dysplasia; extremely preterm; extubation; neonatal morbidity.