705 - Implementation of a standardized peri-extubation strategy with higher post-extubation pressures in a tertiary NICU: Impact on re-intubation within 7 days

Publication Number: 4689.705

Amit Mukerji, McMaster University, Hamilton, ON, Canada; Jamie McLellan, Hamilton Health Sciences Centre, Barrie, ON, Canada; Nandita Manoj, McMaster University Michael G. DeGroote School of Medicine, Hamilton, ON, Canada; Lucy H. Chen, McMaster University Michael G. DeGroote School of Medicine, Toronto, ON, Canada; Heather Johnson, McMaster University Michael G. DeGroote School of Medicine, Hamilton, ON, Canada; Melanie Amyotte, Hamilton Health Science, Hamilton, ON, Canada

Background: Optimal peri-extubation strategies in preterm neonates, including post-extubation non-invasive settings, remain unknown. Emerging evidence suggests that higher pressures on non-invasive support modes may reduce extubation failure.

Objective: To assess the impact of implementing a standardized peri-extubation guideline (Figure 1) in the NICU at McMaster Children's Hospital. We hypothesized that this practice would reduce the risk of re-intubation within 7 days.

Design/Methods: We conducted a single-center, pre-post cohort study from July 2020 to December 2024. Neonates < 29 weeks' GA undergoing their first eligible extubation at ≥72 hours' age from a mean airway pressure (Paw) ≤13 cmH2O- with an endotracheal tube leak < 50% were included. The guideline standardized use of CPAP with initial post-extubation pressures 2 cmH2O higher than the pre-extubation mean airway pressure (Paw). Data for the post-implementation period (July 2023-December 2024) were collected prospectively and compared to retrospectively collected data from the pre-implementation period (July 2020-June 2023). The primary outcome was re-intubation within 7 days; secondary outcomes included bronchopulmonary dysplasia (BPD) and safety parameters (mortality, pneumothorax, gastrointestinal perforation). Univariate and multivariable logistic regression analyses were conducted.

Results: The study included 187 eligible neonates (127 pre-implementation, 60 post-implementation). Demographic and baseline characteristics were similar between groups, except a higher post-extubation CPAP level in the post-implementation period (Table 1). Re-intubation within 7 days (Table 2) was significantly reduced from 40% in the pre-implementation to 22% in the post-implementation period (p=0.013), including after adjustment for confounders (aOR 0.40, 95% CI 0.20, 0.96, p=0.038). Incidences of BPD and safety parameters were not significantly different (Table 2).

Conclusion(s): The implementation of a standardized peri-extubation guideline with use of higher post-extubation pressures on CPAP, relative to pre-extubation Paw, was associated with a significant reduction in re-intubation within 7 days.

Figure 1: Standardized peri-extubation guideline


Table 1: Demographics and baseline characteristics
Denominators are the number of infants with available data.
Abbreviations: BPD bronchopulmonary dysplasia; CPAP continuous positive airway pressure; FiO2 Fraction of inspired oxygen; GA gestational age; HFV High frequency ventilation; Paw mean airway pressure; SD standard deviation; SNAP score for neonatal acute physiology

Table 2: Primary and secondary outcomes
Denominators are the number of infants with available data.
Abbreviations: CNN Canadian neonatal network; GI gastrointestinal
*Logistic regression was adjusted for gestational age, complete course of antenatal steroids, caesarean section, outborn, systemic steroids at time of extubation (for BPD), SGA ( <10%), and HFV as pre-extubation mode.