Alarcon-Martinez Tugba, Latremouille Samantha, Kovacs Lajos, Kearney Robert E, Sant'Anna Guilherme M, Shalish Wissam
Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.
Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia.
Arch Dis Child Fetal Neonatal Ed. 2023 Nov;108(6):643-648. doi: 10.1136/archdischild-2022-325245. Epub 2023 May 16.
To describe the thresholds of instability used by clinicians at reintubation and evaluate the accuracy of different combinations of criteria in predicting reintubation decisions.
Secondary analysis using data obtained from the prospective observational Automated Prediction of Extubation Readiness study (NCT01909947) between 2013 and 2018.
Multicentre (three neonatal intensive care units).
Infants with birth weight ≤1250 g, mechanically ventilated and undergoing their first planned extubation were included.
After extubation, hourly O requirements, blood gas values and occurrence of cardiorespiratory events requiring intervention were recorded for 14 days or until reintubation, whichever came first.
Thresholds at reintubation were described and grouped into four categories: increased O, respiratory acidosis, frequent cardiorespiratory events and severe cardiorespiratory events (requiring positive pressure ventilation). An automated algorithm was used to generate multiple combinations of criteria from the four categories and compute their accuracies in capturing reintubated infants (sensitivity) without including non-reintubated infants (specificity).
55 infants were reintubated (median gestational age 25.2 weeks (IQR 24.5-26.1 weeks), birth weight 750 g (IQR 640-880 g)), with highly variable thresholds at reintubation. After extubation, reintubated infants had significantly greater O needs, lower pH, higher pCO and more frequent and severe cardiorespiratory events compared with non-reintubated infants. After evaluating 123 374 combinations of reintubation criteria, Youden indices ranged from 0 to 0.46, suggesting low accuracy. This was primarily attributable to the poor agreement between clinicians on the number of cardiorespiratory events at which to reintubate.
Criteria used for reintubation in clinical practice are highly variable, with no combination accurately predicting the decision to reintubate.
描述临床医生在再次插管时使用的不稳定阈值,并评估不同标准组合在预测再次插管决策方面的准确性。
对2013年至2018年间从前瞻性观察性拔管准备自动预测研究(NCT01909947)中获得的数据进行二次分析。
多中心(三个新生儿重症监护病房)。
纳入出生体重≤1250g、接受机械通气并正在进行首次计划拔管的婴儿。
拔管后,记录14天内或直至再次插管(以先到者为准)的每小时氧气需求量、血气值以及需要干预的心肺事件的发生情况。
描述再次插管时的阈值,并将其分为四类:氧气需求增加、呼吸性酸中毒、频繁的心肺事件和严重的心肺事件(需要正压通气)。使用自动算法从这四类中生成多个标准组合,并计算它们在捕获再次插管婴儿(敏感性)而不包括未再次插管婴儿(特异性)方面的准确性。
55名婴儿再次插管(中位胎龄25.2周(四分位间距24.5 - 26.1周),出生体重750g(四分位间距640 - 880g)),再次插管时的阈值差异很大。与未再次插管的婴儿相比,拔管后再次插管的婴儿氧气需求量明显更大、pH值更低、pCO更高,心肺事件更频繁且更严重。在评估了123374种再次插管标准组合后,约登指数范围为0至0.46,表明准确性较低。这主要归因于临床医生在再次插管时的心肺事件数量上缺乏一致性。
临床实践中用于再次插管的标准差异很大,没有一种组合能够准确预测再次插管的决策。