Tidal Volumes and Outcome of Extubation in Mechanically Ventilated Premature Infants

Abstract

Objectives To compare the adjusted and unadjusted-for-weight tidal volume (V_T) in ventilated prematurely born infants who were successfully extubated compared with the ones who failed extubation and explore the ability of V_T to predict successful extubation.

Study Design This is a two-center, prospective, observational, cohort study of ventilated infants born <32 weeks of gestational age (GA) at King's College Hospital and St George's University Hospital, London, United Kingdom between February and September 2018. Expiratory V_T was recorded before extubation, and extubation was considered successful if the infants were not reintubated within 72 hours.

Results Fifty-six (29 male) infants with a median (interquartile range) GA of 26 (25–29) weeks were studied. The infants who successfully extubated (N = 36) had a higher GA (27 [25–30] weeks) and V_T (7.2 [4.8–9.5] mL) compared with the GA (25 [24–26] weeks) and V_T (4.3 [4.0–5.5] mL) of the infants who failed extubation (p = 0.002 and p = 0.001, respectively). V_T/kg was not different in infants who successfully extubated compared with the ones who failed extubation (p = 0.643). Following multivariate regression, V_T was associated with extubation success (adjusted p = 0.022) and GA was not (adjusted p = 0.167). A V_T > 4.5 mL predicted successful extubation with 82% sensitivity and 58% specificity (area under the curve = 0.786).

Conclusion Successful extubation was associated with higher unadjusted-for-weight V_Ts compared with failed extubation, and unadjusted V_T predicted extubation outcome with moderate sensitivity and specificity.

Keywords

extubation - tidal volume - prematurely born infants

• References

• 1 Peng W, Zhu H, Shi H, Liu E. Volume-targeted ventilation is more suitable than pressure-limited ventilation for preterm infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2014; 99 (02) F158-F165
• 2 Klingenberg C, Wheeler KI, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in neonates. Cochrane Database Syst Rev 2017; 10: CD003666
• 3 Keszler M. Volume-targeted ventilation: one size does not fit all. Evidence-based recommendations for successful use. Arch Dis Child Fetal Neonatal Ed 2019; 104 (01) F108-F112
• 4 Dawson C, Davies MW. Volume-targeted ventilation and arterial carbon dioxide in neonates. J Paediatr Child Health 2005; 41 (9-10): 518-521
• 5 Abman SH, Collaco JM, Shepherd EG. , et al; Bronchopulmonary Dysplasia Collaborative. Interdisciplinary care of children with severe bronchopulmonary dysplasia. J Pediatr 2017; 181: 12-28
• 6 Dassios T, Dixon P, Hickey A, Fouzas S, Greenough A. Physiological and anatomical dead space in mechanically ventilated newborn infants. Pediatr Pulmonol 2018; 53 (01) 57-63
• 7 Dassios T, Kaltsogianni O, Greenough A. Determinants of pulmonary dead space in ventilated newborn infants. Early Hum Dev 2017; 108: 29-32
• 8 Keszler M. Volume-targeted ventilation. Early Hum Dev 2006; 82 (12) 811-818
• 9 Klingenberg C, Wheeler KI, Davis PG, Morley CJ. A practical guide to neonatal volume guarantee ventilation. J Perinatol 2011; 31 (09) 575-585
• 10 Dreyfuss D, Saumon G. Ventilator-induced lung injury: lessons from experimental studies. Am J Respir Crit Care Med 1998; 157 (01) 294-323
• 11 Sant'Anna GM, Keszler M. Weaning infants from mechanical ventilation. Clin Perinatol 2012; 39 (03) 543-562
• 12 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 (01) F89-F97
• 13 Kamlin CO, Davis PG, Morley CJ. Predicting successful extubation of very low birthweight infants. Arch Dis Child Fetal Neonatal Ed 2006; 91 (03) F180-F183
• 14 Wright CM, Booth IW, Buckler JM. , et al. Growth reference charts for use in the United Kingdom. Arch Dis Child 2002; 86 (01) 11-14
• 15 Doyle LW, Cheong JL, Ehrenkranz RA, Halliday HL. Late (> 7 days) systemic postnatal corticosteroids for prevention of bronchopulmonary dysplasia in preterm infants. Cochrane Database Syst Rev 2017; 10: CD001145
• 16 Keszler M, Nassabeh-Montazami S, Abubakar K. Evolution of tidal volume requirement during the first 3 weeks of life in infants <800 g ventilated with Volume Guarantee. Arch Dis Child Fetal Neonatal Ed 2009; 94 (04) F279-F282
• 17 Nassabeh-Montazami S, Abubakar KM, Keszler M. The impact of instrumental dead-space in volume-targeted ventilation of the extremely low birth weight (ELBW) infant. Pediatr Pulmonol 2009; 44 (02) 128-133
• 18 Patel DS, Sharma A, Prendergast M, Rafferty GF, Greenough A. Work of breathing and different levels of volume-targeted ventilation. Pediatrics 2009; 123 (04) e679-e684
• 19 Dassios T, Kaltsogianni O, Greenough A. Relaxation rate of the respiratory muscles and prediction of extubation outcome in prematurely born infants. Neonatology 2017; 112 (03) 251-257
• 20 Dassios T, Kaltsogianni O, Dixon P, Greenough A. Effect of maturity and infection on the rate of relaxation of the respiratory muscles in ventilated, newborn infants. Acta Paediatr 2018; 107 (04) 587-592
• 21 Dassios T, Ali K, Makin E, Bhat R, Krokidis M, Greenough A. Prediction of mortality in newborn infants with severe congenital diaphragmatic hernia using the chest radiographic thoracic area. Pediatr Crit Care Med 2019; 20 (06) 534-539
• 22 Laudato N, Gupta P, Walters III HL, Delius RE, Mastropietro CW. Risk factors for extubation failure following neonatal cardiac surgery. Pediatr Crit Care Med 2015; 16 (09) 859-867
• 23 Sweet DG, Carnielli V, Greisen G. , et al. European Consensus Guidelines on the management of respiratory distress syndrome - 2016 update. Neonatology 2017; 111 (02) 107-125