BackgroundInvasive mechanical ventilation in critically ill neonates aims to restore gas exchange and reduce work of breathing, which is mainly delivered by the diaphragm. As the lung condition improves, mechanical ventilation is weaned and ultimately the neonate is extubated, often towards non-invasive support. It is assumed that extubation will increase the neonateu2019s breathing effort. Aim of this study is to investigate the changes in breathing effort before and after extubation, assessed by transcutaneous electromyography of the diaphragm (dEMG).MethodsA multicenter, prospective, observational study was conducted in neonates (>26 weeks of gestation) who were mechanically ventilated for more than 24 hours and deemed ready for extubation from conventional mechanical ventilation (CMV) or high-frequency ventilation (HFV). Spontaneous breathing was recorded with dEMG from fifteen minutes before (baseline) until three hours after extubation. Stable data segments of 60 seconds were analyzed and the percentage change (median (IQR)) in dEMG amplitude and peak activity at different time points after extubation were compared to baseline.Results Thirty neonates (mean gestational age 31.4 u00b1 6.5 weeks, mean birth weight 1917 u00b1 1382 grams) were included. Seven neonates were on CMV and 23 on HFV. One infant failed extubation within 72 hours. Ten minutes post-extubation, the amplitude of the dEMG signal increased significantly compared to baseline (median +17,6% (+1,2 to +48,0%), p=0,01), due to an increase in peak activity (median +14,0% (-7,7 to +43,8%), p=0.08). The dEMG amplitude returned to baseline values thereafter.ConclusionDiaphragmatic activity increases directly after extubation and returns to baseline values in successfully extubated neonates.