Assessment of Extubation Readiness Using Spontaneous Breathing Trials in Extremely Preterm Neonates

Abstract

IMPORTANCE Spontaneous breathing trials (SBTs) are used to determine extubation readiness in extremely preterm neonates (gestational age Յ28 weeks), but these trials rely on empirical combinations of clinical events during endotracheal continuous positive airway pressure (ET-CPAP).OBJECTIVES To describe clinical events during ET-CPAP and to assess accuracy of comprehensive clinical event combinations in predicting successful extubation compared with clinical judgment alone. DESIGN, SETTING, AND PARTICIPANTSThis multicenter diagnostic study used data from 259 neonates seen at 5 neonatal intensive care units from the prospective Automated Prediction of Extubation Readiness (APEX) study from September 1, 2013, through August 31, 2018. Neonates with birth weight less than 1250 g who required mechanical ventilation were eligible. Neonates deemed to be ready for extubation and who underwent ET-CPAP before extubation were included. INTERVENTIONSIn the APEX study, cardiorespiratory signals were recorded during 5-minute ET-CPAP, and signs of clinical instability were monitored.MAIN OUTCOMES AND MEASURES Four clinical events were documented during ET-CPAP: apnea requiring stimulation, presence and cumulative durations of bradycardia and desaturation, and increased supplemental oxygen. Clinical event occurrence was assessed and compared between extubation pass and fail (defined as reintubation within 7 days). An automated algorithm was developed to generate SBT definitions using all clinical event combinations and to compute diagnostic accuracies of an SBT in predicting extubation success. RESULTSOf 259 neonates (139 [54%] male) with a median gestational age of 26.1 weeks (interquartile range [IQR], 24.9-27.4 weeks) and median birth weight of 830 g (IQR, 690-1019 g), 147 (57%) had at least 1 clinical event during ET-CPAP. Apneas occurred in 10% (26 of 259) of neonates, bradycardias in 19% (48), desaturations in 53% (138), and increased oxygen needs in 41% (107). Neonates with successful extubation (71% [184 of 259]) had significantly fewer clinical events (51% [93 of 184] vs 72% [54 of 75], P = .002), shorter cumulative bradycardia duration (median, 0 seconds [IQR, 0 seconds] vs 0 seconds [IQR, 0-9 seconds], P < .001), shorter cumulative desaturation duration (median, 0 seconds [IQR, 0-59 seconds] vs 25 seconds [IQR, 0-90 seconds], P = .003), and less increase in oxygen (median, 0% [IQR, 0%-6%] vs 5% [0%-18%], P < .001) compared with neonates with failed extubation. In total, 41 602 SBT definitions were generated, demonstrating sensitivities of 51% to 100% (median, 96%) and specificities of 0% to 72% (median, 22%). Youden indices for all SBTs ranged from 0 to 0.32 (median, 0.17), suggesting low accuracy. The SBT with highest Youden index defined SBT pass as having no apnea (with desaturation requiring stimulation) or increase in oxygen requirements by 15% from baseline and predicted extubation success with a sensitivity of 93% and a specificity of 39%. CONCLUSIONS AND RELEVANCEThe findings suggest that extremely preterm neo...

Impact of Spontaneous Breathing Trials in Cardiorespiratory Stability of Preterm Infants

“…7,8 These findings are in keeping with a systematic review and meta-analysis that established the low specificity of the SBT. 9 Likewise, these results parallel those obtained in another study in which implementation of an SBT protocol did reduce the extubation failure rates among a cohort of very low birthweight infants. 13 Therefore, our results confirm that a 3-min SBT adds little benefit for the identification of extubation failures.…”

“…21 Finally, it is plausible that a different definition of SBT success or failure may have had a better ability to distinguish those infants with successful or failed extubation. However, in the recent diagnostic study by Shalish et al, 9 after evaluating > 40,000 different definitions of SBT success and failure, none were able to improve the accuracy of detection of extubation failures among extremely preterm infants.…”

“…[6][7][8] To deal with the inaccurate nature of clinical judgment, a number of units have adopted the practice of performing a spontaneous breathing trial (SBT) to determine an infant's readiness for extubation. 6,9 An SBT is a challenge in which the infant receives minimal to no ventilatory support for a short duration while spontaneously breathing via the endotracheal tube. The infant is then extubated if they remain hemodynamically stable in accordance with predefined criteria.…”

“…[12][13][14] In a recent large cohort study, the use of a 5-min SBT in extremely preterm infants had low accuracy for predicting extubation failures and exposed nearly 60% of infants to some form of cardiorespiratory instability. 9 Such information is not available for trials of a shorter duration in less immature preterm infants. Because our unit has adopted a weaning protocol incorporating an SBT to proceed with extubation, we performed this study to investigate the effects of a 3-min SBT on cardiorespiratory stability in preterm infants.…”

2019 Year in Review: Neonatal Respiratory Support

“…The Automated Prediction of Extubation Readiness (APEX) study prospectively enrolled subjects with birthweight < 1,250 g who were considered ready to extubate and underwent a 5-min spontaneous breathing trial (SBT) on endotracheal tube CPAP prior to extubation. 88 APEX utilized machine learning tools to characterize clinical variables and quantitative measures of cardiorespiratory events, including apnea requiring stimulation, bradycardia, desaturation, and requirement for increased F IO 2 . Of the 259 subjects who met inclusion criteria, 71% were successfully extubated (ie, defined as not requiring intubation within 7 d).…”