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Clinical usefulness of reintubation criteria in extremely preterm infants: a cohort study
  1. Tugba Alarcon-Martinez1,2,
  2. Samantha Latremouille1,
  3. Lajos Kovacs3,
  4. Robert E Kearney4,
  5. Guilherme M Sant’Anna1,
  6. Wissam Shalish1
  1. 1 Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada
  2. 2 Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia
  3. 3 Department of Neonatology, Jewish General Hospital, Montreal, Quebec, Canada
  4. 4 Biomedical Engineering, McGill University, Montreal, Quebec, Canada
  1. Correspondence to Dr Wissam Shalish, McGill University Health Centre, Montreal, QC H4A 3J1, Canada; wissam.shalish{at}


Objective To describe the thresholds of instability used by clinicians at reintubation and evaluate the accuracy of different combinations of criteria in predicting reintubation decisions.

Design Secondary analysis using data obtained from the prospective observational Automated Prediction of Extubation Readiness study (NCT01909947) between 2013 and 2018.

Setting Multicentre (three neonatal intensive care units).

Patients Infants with birth weight ≤1250 g, mechanically ventilated and undergoing their first planned extubation were included.

Interventions After extubation, hourly O2 requirements, blood gas values and occurrence of cardiorespiratory events requiring intervention were recorded for 14 days or until reintubation, whichever came first.

Main outcome measures Thresholds at reintubation were described and grouped into four categories: increased O2, 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).

Results 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 O2 needs, lower pH, higher pCO2 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.

Conclusions Criteria used for reintubation in clinical practice are highly variable, with no combination accurately predicting the decision to reintubate.

  • Intensive Care Units, Neonatal
  • Neonatology

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors The research question for this study was conceived by WS and developed by WS, TAM and GMS'A. TAM undertook the data extraction. WS and TAM undertook the data analysis. WS and TAM drafted the first draft of the manuscript. All authors were involved in interpretation, review and revision of the draft manuscript and approval of the final version. WS had full access to all the data in the study and take full responsibility for the integrity of the data and accuracy of the data analysis. WS is the guarantor of the study.

  • Funding This project received funding via an operational grant from the Canadian Institutes of Health Research.

  • Disclaimer The funding body did not have a role in the design and collection, analysis or interpretation of the data.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.