Ultrasonographic predictors of extubation success in children: diaphragmatic, lung, and laryngeal assessment—a prospective pilot cohort study

Abstract

Extubation failure, occurring in 3-22% of pediatric intensive care unit (PICU) patients, contributes to increased morbidity, prolonged hospitalization, and healthcare costs. Point-of-care ultrasound (POCUS) provides a bedside, radiation-free method to assess extubation readiness. This pilot study evaluated the predictive value of lung, diaphragmatic, and laryngeal ultrasound for extubation success in mechanically ventilated children. In this prospective pilot study, 30 children (22 males, 8 females; aged 1 month-14 years) ventilated for > 24 h were enrolled. Patients with congenital diaphragmatic, pulmonary, or laryngeal abnormalities were excluded. Ultrasound examinations of the diaphragm, lungs, and larynx were performed within 24 h before and after extubation. Patients were classified as successful or failed extubation (reintubation within 48 h). Receiver operating characteristic (ROC) curve analysis was used to determine optimal cut-off values. Extubation succeeded in 18 (60%) and failed in 12 (40%) patients. Diaphragmatic excursion > 5.5 mm was the strongest predictor (sensitivity 100%, specificity 91.7%). Diaphragmatic thickening fraction > 29% (sensitivity 88.9%, specificity 66.7%); lung ultrasound score < 16.5 (sensitivity and specificity 80%); and body mass index > 14.8 (sensitivity 100%, specificity 63.6%) were also significant predictors. Reduced laryngeal air width difference moderately predicted failure (specificity 83.3%, p = 0.025). CONCLUSION: Diaphragmatic excursion and thickening fraction are the most accurate ultrasound predictors of extubation success, with lung and laryngeal assessments providing complementary insights. Combining these modalities may improve bedside evaluation of extubation readiness in critically ill children. WHAT IS KNOWN: • Extubation failure remains frequent in pediatric intensive care units, and currently used clinical predictors have limited reliability. • Bedside ultrasonography enables non-invasive assessment of diaphragmatic, pulmonary, and laryngeal function in critically ill children. WHAT IS NEW: • This pilot study integrates diaphragmatic, lung, and laryngeal ultrasonography into a single bedside extubation assessment strategy in children. • Diaphragmatic excursion and diaphragmatic thickening fraction emerged as the strongest ultrasound predictors of extubation success.