This systematic review and prognostic meta-analysis evaluated whether diaphragm ultrasound measures — thickening fraction, end-expiratory thickness, and excursion — taken before planned extubation could predict extubation failure in mechanically ventilated neonates (≤28 days old), pooling 7 prospective cohort studies (n=255) published 2021–2026.
Extubation failure occurred in 90/255 neonates (35%). Neonates who failed had significantly lower diaphragm thickening fraction (pooled MD = −9.51%; 95% CI: −14.73 to −4.29; p=0.0004; I²=0%). Diaphragm thickness (MD = −0.09 mm; p=0.171; I²=83.2%) and excursion (MD = −0.56 mm; p=0.073; I²=70.4%) were not significantly different between groups. GRADE certainty was moderate for thickening fraction and very low for thickness and excursion.
- Moderate-to-high risk of bias across all studies, driven mainly by inadequate adjustment for confounders (gestational age, illness severity, ventilatory settings). - Substantial variability in extubation failure definitions (72 h to 7 days), timing of ultrasound, and ventilatory support conditions during image acquisition limits between-study comparability. - Only 7 small studies (total n=255); formal publication bias assessment was not feasible, and findings cannot be generalized to neonates with congenital or neuromuscular conditions.
A lower diaphragm thickening fraction before extubation is associated with extubation failure in neonates, but do not yet use it as a standalone decision-making tool — measurement protocols need standardization and prospective validation before routine clinical use.
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