Association Between Diaphragm Ultrasound Measures and Extubation Outcomes in Neonates: A Systematic Review and Meta-Analysis.

OBJECTIVE

We conducted a systematic review and prognostic meta-analysis to evaluate the association between ultrasound-derived measures of diaphragm structure and contractile activity with the risk of extubation failure in mechanically ventilated neonates.

DATA SOURCES: MEDLINE, Embase, the Cochrane Library, CINAH, Scopus, and ClinicalTrials.gov were systematically searched from inception to January 12, 2026, without using language restrictions.

STUDY SELECTION: Observational studies including mechanically ventilated neonates (≤ 28 days old) undergoing planned extubation in whom diaphragmatic thickness, thickening fraction, or excursion were measured by ultrasound and extubation outcome were reported. Studies involving congenital diaphragmatic or neuromuscular disorders were excluded. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. Random-effects meta-analyses were conducted using mean differences (MD) with 95% confidence intervals (CI).

RESULTS

Of 1,522 records identified, 110 full-text articles were assessed, and seven prospective cohort studies (n = 255 neonates) met the inclusion criteria. Extubation failure occurred in 90 neonates (35%). Neonates who failed extubation had significantly lower diaphragm thickening fraction compared with those successfully extubated (MD = -9.51%; 95% CI: -14.73 to -4.29; p = 0.0004; I2 = 0%). Differences in diaphragm thickness and excursion were not statistically significant. Overall risk of bias was moderate to high, primarily due to inadequate adjustment for confounding and variability in outcome definitions.

CONCLUSIONS

Lower diaphragm thickening fraction is associated with extubation failure in mechanically ventilated neonates. Standardization of measurement protocols and prospective validation studies are needed before diaphragm ultrasound can be incorporated into routine extubation decision-making.

REGISTRATION: PROSPERO CRD420251045024.