PC1084: Single-center Exploration of Respiratory Factors Associated with Extubation Failure in Infants in the NICU

Background: Mechanical ventilation (MV) is common in the NICU, with some studies estimating up to two-thirds of extremely low birthweight infants will be intubated at some point during their hospitalization. An estimated 20-40% of low birthweight infants will fail extubation and require reintubation, significantly more compared to children and adults. Reintubation can lead to destabilization, higher respiratory support requirements, increased overall duration of MV, and increased risk of MV associated complications. In an effort to minimize time on the ventilator while ensuring extubation success, previous studies have attempted to establish guidelines or markers for extubation readiness. This study further explores factors associated with extubation failure in neonates in an effort to predict extubation success.

Methods: A retrospective study of infants who underwent endotracheal intubation in the NICU at Memorial Hermann Children's Hospital from January 2017 to December 2021 was performed. Exclusion criteria included chromosomal abnormalities, cardiopulmonary and laryngopharyngeal congenital malformations, and intubations for surgical procedures. Extubation failure was defined as reintubation within a period of 7 days after initial extubation. Demographics including birthweight, gestational age, sex, and mode of delivery were compared, as well as pre- and postnatal factors/outcomes including administration of steroids, surfactant, caffeine, and racemic epinephrine; duration of initial intubation; tracheostomy; and mortality. Our primary outcome was extubation failure. Subgroup analyses for early (<=48hrs) versus late (>48hrs and <=7d) extubation failure, birthweight (VLBW, ELBW), and gestational age ( < 34wks, < 28wks) were also completed.

Results: Of 1115 infants in the original data collection, 307 met exclusion criteria and 808 infants included in the analysis. Of these, 640 were successfully extubated and 168 failed extubation. Successful extubation was associated with higher birthweight and gestational age, while extubation failure was more common in patients who received caffeine, postnatal steroids, and racemic epinephrine. Infants who failed extubation also had a longer duration of initial intubation and were more likely to require tracheostomy prior to discharge. Mortality was significantly different between successful and failed extubation groups only when analysis was limited to extremely preterm or ELBW infants. In the subgroup analysis of early versus late extubation failure, the two groups differed only in the number of surfactant doses received. However, intubation duration between failure groups became significantly different when analysis was limited to extremely preterm or ELBW infants.

Conclusion: There was a higher likelihood of mortality in ELBW and extremely preterm infants who failed extubation. Surfactant, caffeine, postnatal steroids, and racemic epinephrine did not increase the likelihood of successful extubation. Timing of extubation failure was not correlated with antenatal or postnatal steroids or racemic epinephrine, even when analysis was limited to only preterm, extremely preterm, or low birthweight infants.