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Clinical prediction of post-extubation radiological changes of the chest in newborn infants
1Department of Paediatrics, Prince of Wales Hospital, the Chinese University of Hong Kong, Shatin.
Insights
Routine chest radiographs after infant extubation may not be necessary. Clinical assessment, using specific criteria like retraction and oxygen needs, can predict most lung deterioration, improving neonatal care efficiency.
Area of Science:
- Neonatal Medicine
- Pediatric Pulmonology
- Critical Care
Background:
- The necessity of routine chest radiographs post-extubation in neonates is debated.
- Clinical assessment versus radiological findings for detecting lung deterioration after extubation remains controversial.
Purpose of the Study:
- To evaluate if clinical assessment can predict radiological deterioration after infant extubation.
- To determine the efficacy of clinical judgment in identifying post-extubation lung complications.
Main Methods:
- 100 post-extubation chest radiographs were analyzed in 85 neonates.
- Neonatologists assessed infants clinically, blinded to radiograph results.
- Continuous monitoring of respiratory and oxygenation status was performed.
Main Results:
- 23% of infants showed radiological deterioration; clinical assessment had low sensitivity (21.7%).
- Significant intercostal retraction and increased oxygen requirement (>7%) were key predictors (sensitivity 82.6%).
- Serial blood gas analysis showed limited predictive value.
Conclusions:
- Most post-extubation radiological lung deterioration is clinically predictable.
- Specific clinical criteria, not routine radiography, can guide management decisions.
Objective:
Whether a chest radiograph should be performed routinely in all infants after extubation, or selectively only in those with clinical deterioration, is a controversy in neonatal unit practice. This study tested the hypothesis that most cases of post-extubation radiological deterioration in the lungs could be detected by clinical assessment.
Methods:
A chest radiograph was performed at 8 h post-extubation in 100 episodes of extubation in 85 newborn infants ventilated for a variety of lung diseases. Each infant was assessed at the same time by a neonatologist blinded to the radiological findings, to determine whether a chest radiograph would have been requested based on clinical judgement. The infants were continuously monitored for their respiratory and oxygenation status before and after extubation.
Results:
Compared to the pre-extubation chest radiographs, 23 of the 100 post-extubation chest radiographs showed either deterioration of the pre-existing lung pathologies or appearance of significant new pathologies. The clinicians' assessment failed to detect most of the deterioration, with a sensitivity of only 21.7%. Systematic analysis of the infants' clinical parameters showed that the development of significant intercostal/subcostal retraction, and an increase in inspired oxygen concentration by > or = 7% after extubation, were the best predictors of post-extubation radiological deterioration (sensitivity 82.6%, specificity 62.3%, positive predictive value 39.6%, and negative predictive value 92.3%). Serial blood gas in contrast had little predictive value.
Conclusion:
We conclude that most cases of radiological deterioration of the lungs after extubation are clinically predictable, provided the correct clinical criteria are used.