348 - Extubation Failure rates and outcomes of neonates less than 28 weeks gestational age at a single level IV NICU that primarily uses non-invasive NAVA post-extubation

Studies have shown that extubation failure in extremely preterm infants may range from 20 - 40% with significantly increased morbidity and mortality for infants who fail extubation.

Objective: To evaluate extubation failure rates and clinical outcomes for infants < 28 weeks gestation.

Design/Methods:

Single center retrospective review at the University of Iowa level IV Neonatal Intensive Care Unit including infants born at less than 28 weeks gestation (Aug 2019 – Oct 2021) who were intubated for a minimum of 12 hours and did not have congenital abnormalities. Maternal data recorded included antenatal steroid administration and chorioamnionitis identified on pathology reports. For inborn patients, respiratory severity score was calculated using the highest MAP and FiO2 in the first 12 hours of age. Extubation failure was defined as reintubation within 14 days of extubation and reasons for reintubation were not exclusive. Respiratory failure prior to reintubation was defined as: 2 or more apnea events requiring PPV within 12 hours, FiO2 greater or equal to 0.7 for at least 4 consecutive hours, or pH less than 7.2 and pCO2 greater than 65 twice within 12 hours. P-values were calculated using chi-squared or t-test for categorical or continuous variables, respectively.

Results:

A total of 69 patients met inclusion criteria and 15 patients failed extubation (22%). The mean postmenstrual age at extubation was 30 weeks for those who were successfully extubated and 29 weeks for those who failed extubation (Table 1). The mean weight at extubation was 1315g and 1199g for extubation success and failure groups, respectively. Our patients were primarily extubated from high frequency jet ventilation (88%) and one patient from pressure-regulated volume control. Most of the patients were extubated to neurally adjusted ventilatory assist (NAVA) except for one patient who was extubated to CPAP. Only 27% of patients met the defined criteria for respiratory failure prior to reintubation. There were slightly increased morbidities for patients who failed extubation (Table 2) and patients who failed extubation had increased respiratory support at 36 weeks PMA (Table 3).

Conclusion(s): Despite our unit practice to extubate extremely premature infants to NAVA which requires a weight of  >900g, we still have a 22% extubation failure rate. In this small cohort study, we found no significant difference in ventilator settings prior to extubation between the extubation success or failure groups. Clinicians may benefit from machine learning-based extubation prediction models to help identify subtle patient differences.