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Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants
P G Davis1, D J Henderson-Smart
1Division of Paediatrics, Royal Women's Hospital, 132 Grattan St, Melbourne, Victoria, Australia, 3053. p.davis@obgyn-rwh.unimelb.edu.au
Insights
Nasal continuous positive airway pressure (NCPAP) effectively prevents extubation failure in preterm infants after intermittent positive pressure ventilation (IPPV). This reduces the need for additional respiratory support, improving outcomes for vulnerable newborns.
Area of Science:
- Neonatal Medicine
- Respiratory Physiology
- Clinical Pediatrics
Background:
- Preterm infants extubated after mechanical ventilation risk respiratory failure due to apnea, acidosis, and hypoxia.
- Nasal continuous positive airway pressure (NCPAP) stabilizes the upper airway and improves lung function, potentially aiding extubation.
Purpose of the Study:
- To evaluate if NCPAP management post-extubation increases the proportion of preterm infants free from additional ventilatory support compared to headbox oxygen.
Main Methods:
- Systematic review of randomized or quasi-random trials comparing NCPAP with headbox oxygen for post-extubation care in preterm infants.
- Data extraction and quality assessment by two independent authors.
- Analysis using relative risk (RR), risk difference (RD), and number needed to treat (NNT).
Main Results:
- NCPAP significantly reduces adverse clinical events (apnea, acidosis, increased oxygen needs) requiring additional ventilation (RR 0.62, NNT 6).
- A non-significant trend towards reduced chronic lung disease at 28 days was observed in the NCPAP group (RR 0.86).
Conclusions:
- NCPAP is effective in preventing extubation failure in preterm infants post-IPPV.
- Further research is needed to define optimal gestational age, weight groups, NCPAP levels, and administration methods.
Background:
Preterm infants being extubated following a period of intermittent positive pressure ventilation via an endotracheal tube are at risk of developing respiratory failure as a result of apnea, respiratory acidosis and hypoxia. Nasal continuous positive airway pressure appears to stabilise the upper airway, improve lung function and reduce apnea and may therefore have a role in facilitating extubation in this population.
Objectives:
In preterm infants having their endotracheal tube removed following a period of intermittent positive pressure ventilation (IPPV), does management with nasal continuous positive airways pressure (NCPAP) lead to an increased proportion remaining free of additional ventilatory support, compared to extubation directly to headbox oxygen?
Search Strategy:
Searches were made of the Oxford Database of Perinatal Trials, Medline, previous reviews including cross references, abstracts of conferences and symposia proceedings, expert informants, journal handsearching mainly in the English language and expert informant searches in the Japanese language by Prof. Ogawa.
Selection Criteria:
All trials utilising random or quasi-random patient allocation, in which NCPAP (delivered by any method) was compared with headbox oxygen for post-extubation care were included. Methodological quality was assessed independently by the two authors.
Data Collection And Analysis:
Data were extracted independently by the two authors. Prespecified subgroup analysis to determine the impact of different levels of NCPAP, differences in duration of IPPV and use of aminophylline were also performed using the same package. Data were analysed using relative risk (RR), risk difference (RD) and number needed to treat (NNT).
Main Results:
Nasal CPAP, when applied to preterm infants being extubated following IPPV, reduces the incidence of adverse clinical events (apnea, respiratory acidosis and increased oxygen requirements) indicating the need for additional ventilatory support [RR 0.62 (0.49, 0.79), RD -0.175 (-0. 256,-0.095), NNT 6 (4,11)]. A trend towards reduction in the incidence of chronic lung disease at 28 days of age is also seen in the group extubated to NCPAP. This does not reach statistical significance [RR 0.86 (0.67,1.10), RD -0.069 (-0.177,0.039)].
Implications For Practice:
nasal CPAP is effective in preventing failure of extubation in preterm infants following a period of endotracheal intubation and IPPV. Implication for research: further definition of the gestational age and weight groups in whom these results apply is required. Optimal levels of NCPAP as well as methods of administration remain to be determined.