Failed Extubation in the Neonatal Intensive Care Unit

The Group A infants were intubated for an average of 88.7 days, compared with 43.2 days for the Group B children. There were 2.69 average failed extubation attempts in the Group A babies, compared with 1.33 in the Group B infants. The average number of DLBs was 1.82 for Group A and 1.17 for Group B. In addition, DLB findings indicated abnormal airways in 92.7% of Group A and 90.9% of Group B. Subglottic stenosis or edema was seen in 44% of Group A and 23.1% of Group B.

Overall, we found that Group A had double the number of days of ventilated, failed extubations and incidence of subglottic compromise when compared to Group B, Dr. Smith said. The majority of our neonates overall who underwent direct endoscopy for failed extubation eventually had tracheostomy, specifically 80.1 percent.

Based on their findings, the researchers recommended that after the second failure of extubation, physicians do a detailed head and neck examination and flexible endoscopy. They said a third extubation trial should be preceded by optimizing pulmonary function, vigorously treating for gastroesophageal reflux, decongesting the nose, removing all nasal and oral tubes prior to extubation, and providing intravenous dexamethasone 48 hours before extubation and 24 hours after.

After a third failure at extubation, they recommended endoscopy in the OR and surgical intervention, depending on the findings.

Risk Factors

The researchers concluded that neonates with chronic lung disease, gestational age of 30 weeks or less, and very low birth weight are twice as likely to have subglottic edema and fail extubation when compared to older and larger infants with similar comorbidities.

Multiple attempts at extubation are unlikely to yield positive results in this group and could make a case for earlier airway intervention, Dr. Smith said.

On the other hand, older infants with higher birth weights could benefit from additional attempts at extubation unless the severity of laryngotracheal obstruction dictates otherwise, according to the research team.

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