A Prediction Model of Extubation Failure Risk in Preterm Infants

Abstract

Objectives: This study aimed to identify variables and develop a prediction model that could estimate extubation failure (EF) in preterm infants. Study Design: We enrolled 128 neonates as a training cohort and 58 neonates as a validation cohort. They were born between 2015 and 2020, had a gestational age between 25^0/7 and 29^6/7 weeks, and had been treated with mechanical ventilation through endotracheal intubation (MVEI) because of acute respiratory distress syndrome. In the training cohort, we performed univariate logistic regression analysis along with stepwise discriminant analysis to identify EF predictors. A monogram based on five predictors was built. The concordance index and calibration plot were used to assess the efficiency of the nomogram in the training and validation cohorts. Results: The results of this study identified a 5-min Apgar score, early-onset sepsis, hemoglobin before extubation, pH before extubation, and caffeine administration as independent risk factors that could be combined for accurate prediction of EF. The EF nomogram was created using these five predictors. The area under the receiver operator characteristic curve was 0.824 (95% confidence interval 0.748-0.900). The concordance index in the training and validation cohorts was 0.824 and 0.797, respectively. The calibration plots showed high coherence between the predicted probability of EF and actual observation. Conclusions: This EF nomogram was a useful model for the precise prediction of EF risk in preterm infants who were between 25^0/7 and 29^6/7 weeks' gestational age and treated with MVEI because of acute respiratory distress syndrome.

Keywords: early-onset sepsis; extubation; hemoglobin; mechanical ventilation; preterm infant.

Figure 1

(A) Kaplan–Meier curve showing proportion of infants remaining extubated during hospitalization: Among those who failed extubation during hospitalization, 63.6% underwent reintubation within 5 days; (B) Kaplan–Meier curve showing proportion of infants remaining extubated within 5 days: Among those who failed extubation within 5 days, 80.0% underwent reintubation within 3 days.

Figure 2

Extubation failure risk nomogram. The extubation failure risk nomogram was developed in the cohort, with 5-min Apgar score, the dignosis of EOS, pH before extubation, HB before extubation, and the caffeine treatment. To estimate the probability of extubation failure, mark infant values at each axis, draw a straight line perpendicular to the point axis, and sum the points for all variables. Next, mark the sum on the total point axis and draw a straight line perpendicular to the probability axis. EOS, early-onset sepsis; HB, hemoglobin concentration; EF, extubation failure.

Figure 3

Receiver operating characteristic curve for the prediction model: Area under the curve was 0.824 (95% confidence interval 0.748–0.900).

Figure 4

(A) Calibration curves of the nomogram to predict extubation failure in training cohort; (B) Calibration curves of the nomogram to predict extubation failure in validation cohort. The horizontal axis shows the predicted probability of extubation failure, and the vertical axis shows the observed probability of extubation failure. Perfect prediction would correspond to the 45° broken line. The dotted and solid lines indicate the observed (apparent) nomogram performance before and after bootstrapping. EF, extubation failure.