CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study

Area of Science:

• Neonatal respiratory support
• Mechanical ventilation strategies
• Postextubation care

Background:

• Nasal intermittent positive pressure ventilation (NIPPV) is generally considered superior to nasal continuous positive airway pressure (CPAP) for preterm neonates postextubation.
• Previous studies limited high CPAP pressures or rescue ventilation options, potentially skewing comparisons.
• This study investigated whether CPAP could be noninferior to NIPPV under conditions allowing higher pressures and rescue ventilation.

Purpose of the Study:

• To determine if nasal CPAP (nCPAP) is noninferior to NIPPV as a postextubation mode in preterm neonates (<29 weeks' gestation).
• To evaluate outcomes when higher CPAP pressures and rescue ventilation were permitted.
• To compare rates of initial mode failure and reintubation between nCPAP and NIPPV.

Main Methods:

• A pragmatic, comparative-effectiveness, noninferiority study using real-world data from 22 Canadian NICUs.
• Centers self-selected either nCPAP or NIPPV as their standard postextubation mode.
• Primary outcome: failure of the initial mode within 72 hours. Secondary outcomes: failure within 7 days, and reintubation within 72 hours and 7 days.

Main Results:

• Nasal CPAP was not noninferior (and was inferior) to NIPPV for initial mode failure within 72 hours (33.0% vs 26.3%) and within 7 days (40.7% vs 35.8%).
• However, nasal CPAP was noninferior (and equivalent) to NIPPV for reintubation within 72 hours (13.2% vs 16.1%).
• Nasal CPAP was also noninferior (and superior) to NIPPV for reintubation within 7 days (16.4% vs 22.8%).

Conclusions:

• Nasal CPAP was not noninferior to NIPPV for preventing initial mode failure postextubation in preterm neonates.
• Nasal CPAP demonstrated noninferiority for reintubation rates at both 72 hours and 7 days.
• Nasal CPAP may be a viable initial postextubation strategy when effective rescue ventilation options are available.