PC1083: Validation of Extubation Readiness Tool in Extremely Premature Neonates at a Regional Perinatal Center

Background: In neonates born extremely premature, prolonged invasive mechanical ventilation with an endotracheal tube and failure to extubate are factors associated with increased mortality and morbidities such as bronchopulmonary dysplasia, retinopathy of prematurity requiring prolonged hospitalization leading to poor outcomes. In the absence of accurate tools to assess extubation readiness, many infants fail their extubation attempt which also increases complications. Gupta et al. have developed a valuable online calculator that could be helpful to assess the chances of extubation success in extremely preterm neonates. Our objective was to a) validate the extubation readiness calculator in our cohort at a regional perinatal center to predict successful extubation and b) understand if the same factors used in the extubation calculator are applicable to our patient population.

Methods: Neonates < 29 weeks, who were admitted to our newly built state-of-the-art tertiary NICU over a 2-year period who were on invasive mechanical ventilation, and had an elective extubation attempt within 60 days of age were included. The primary outcome was to validate the extubation success using the calculator, defined as surviving for at least 5 days after extubation, without a need for reintubation. The secondary outcome was to model factors associated with predicting extubation readiness in the calculator. Infants who died or had unplanned extubation were excluded.

Results: There were 118 infants between 2018 and 2019 who were included. Of the eligible infants, 66% were successfully extubated while 34% of them failed (Fig 1a). The receiver operating characteristic curve (ROC) analysis for the extubation readiness calculator in our cohort was statistically significant with various validity models shown in Figure 1b. 79% had the best sensitivity, specificity, PPV & NPV along with the highest accuracy shown in Figure 1c. At the time of extubation, these infants were larger, born at older gestation, and had higher pre-extubation pH and lower oxygen (O2) requirements than those who failed extubation (Fig 2). Only the mode of delivery and weight at extubation were statistically significant in our model to predict extubation readiness i.e vaginal delivery and higher birth weight favoring extubation success. This could also be secondary to the fact that our median time of extubation is 9 -10 days after birth as opposed to 3-4 days in the study by Gupta et al.

Conclusion: In our cohort that included data for 2 years, with our current practice, the calculator was validated in infants who were extubated with variable chances of success rate. This tool could provide quantitative evidence in helping predict significant improvements in extubation outcomes in the extreme preterm population. With evolving change in ventilation practices in our neonatal intensive care unit, we intend to evaluate other factors that could influence early extubation and its effect on BPD and mortality.