Knowing when to extubate an ELBW is never an easy task. Much has been written about extubation checklists including such measures as mean airway pressure minimums and oxygen thresholds as well as trials of pressure support at low rates. The fact remains that no matter how hard we try there are those that fail even when all conditions seem to be met for success. The main culprit has been thought to be weakening of the diaphragm as the infant stays on the ventilator for longer periods of time. Specifically, myofibrillar contractile dysfunction
and myofilament protein loss are what is occurring leading to a weakened diaphragm which may be incapable of supporting the infant when extubated even to CPAP. More recently in Neonatology the use of point of care ultrasound (POCUS) has gained in popularity and specifically use of lung ultrasound has helped to better classify various disease conditions not only in determining which disease is active but also following its course. Using POCUS to measure thickness and excursion of the diaphragm has been employed in the adult world so using it in neonates to determine extubation readiness seems like a logical next step.
An Observational Cohort Study
Bahgat E et al published Sonographic evaluation of diaphragmatic thickness and excursion as a predictor for successful extubation in mechanically ventilated preterm infants in the European Journal of Pediatrics. This small study sought to look at preterm infants born under 32 weeks and assessed a number of measurements of their diaphragm bilaterally including thickness of both during the respiratory cycle and the excursion (measured as most caudad and cephalad position during respiration). All patients underwent a similar process prior to extubation using PSV with a support of +4 over peep with measurements taken 1 hour prior to planned extubation. All infants met unit criteria for a trial of extubation based on blood gases, FiO2 and MAP being less than 8 cm H2O. All infants received a PSV trial for 2 hours before being extubated to CPAP +5. The sonographic assessment technique is laid out in the paper and the study end point was no reintubation in the 72 hours after extubation. The decision to reintubate was standardized as follows: more than six episodes of apnea requiring stimulation within 6 h, or more than one significant episode of apnea requiring bag and mask ventilation, respiratory acidosis (PaCO2 > 65 mmHg and pH < 7.25) or FiO2 > 60% to maintain saturation in the target range (90–95%).
Differences between the groups at baseline included a longer median day of extubation by 3 days, total duration of mechanical ventilation, higher mean airway pressure and FiO2 all in in the failure group.
Results of the study find a key difference in measurements
Looking at table 2 below the main finding of the study was that the biggest difference between those infants who succeeded and those that failed was the excursion of the diaphragm rather than the thickness. The greater the excursion the better the chance at successful extubation. In experienced hands the measurement does not take that long to do either.
As the authors point out in the paper:
“A right hemidiaphragmatic excursion of 2.75 mm was associated with 94% sensitivity and 89% specificity in predicting successful extubation. A left hemidiaphragmatic excursion of 2.45mmwas associated with 94% sensitivity and 89% specificity in predicting successful extubation”
Is this the holy grail?
There is no question that this technique adds another piece to the puzzle in helping us determine when it is safe to extubate. If I can pick one fault with the study it is the use of a pressure of +5 to support the extubated infants. If you look at the mean level of MAP the infants were on prior to extubation in the two groups it was 6.3 in the successful group and 6.6 in those who failed. By choosing to extubate the group that was already on a mean of about 24% to an even lower pressure level I can’t help but wonder what the results would have looked like if extubation occurred at a non-invasive level above that when they were intubated. Our unit would typically choose a level of +7 to extubate such infants to and avoid pulmonary volume loss so what would the results show if higher pressures were used (someone feel free to take this on).
One thing though that is borne out of all this however is that if diaphragmatic weakening happens in the neonate with prolonged ventilation as well it would be supported by the long length of ventilation in the failure group that also has less diaphragmatic thickness and excursion. What this study in my mind really says is that extubation should occur as early as possible. Every time you hear someone say “why don’t we wait one more day” you can now imagine that diaphragm getting just a little weaker.
As I said on a “tweet” recently “No one should brag about having a 100% extubation success rate”. If that is your number you are waiting too long to extubate. Based on the information here it should be a reminder that the plan for extubation needs to start as soon as the tube is inserted in the first place.