Higher versus lower nasal continuous positive airway pressure for extubation of extremely preterm infants in Australia (ÉCLAT): a multicentre, randomised, superiority trial

Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants

BACKGROUND

Preterm infants who are extubated following a period of invasive ventilation via an endotracheal tube are at risk of developing respiratory failure, leading to reintubation. This may be due to apnoea, respiratory acidosis, or hypoxia. Historically, preterm infants were extubated to head box oxygen or low-flow nasal cannulae. Support with non-invasive pressure might help improve rates of successful extubation in preterm infants by stabilising the upper airway, improving lung function, and reducing apnoea. This is an update of a review first published in 1997 and last updated in 2003.

OBJECTIVES

To determine whether nasal continuous positive airway pressure (NCPAP), applied immediately after extubation of preterm infants, reduces the incidence of extubation failure and the need for additional ventilatory support, without clinically important adverse events.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and trial registries on 22 September 2023 using a revised strategy. We searched conference abstracts and the reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

Eligible trials employed random or quasi-random allocation of preterm infants undergoing extubation. Eligible comparisons were NCPAP (delivered by any device and interface) versus head box oxygen, extubation to room air, or any other form of low-pressure supplemental oxygen. We grouped the comparators under the term no continuous positive airway pressure (no CPAP).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias and extracted data from the included studies. Where studies were sufficiently similar, we performed a meta-analysis, calculating risk ratios (RRs) with their 95% confidence intervals (CIs) for dichotomous data. For the primary outcomes that showed an effect, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to assess the certainty of the evidence for clinically important outcomes.

MAIN RESULTS

We included nine trials (with 726 infants) in the quantitative synthesis of this updated review. Eight studies were conducted in high-income countries between 1982 and 2005. One study was conducted in Chile, which was classified as upper-middle income at the time of the study. All studies used head box oxygen in the control arm. Risk of bias was generally low. However, due to the inherent nature of the intervention, no studies incorporated blinding. Consequently, the neonatal intensive care unit staff were aware of the assigned group for each infant, and we judged all studies at high risk of performance bias. However, we assessed blinding of the outcome assessor (detection bias) as low risk for seven studies because they used objective criteria to define both primary outcomes. NCPAP compared with no CPAP may reduce the risk of extubation failure (RR 0.62, 95% CI 0.51 to 0.76; risk difference (RD) -0.17, 95% -0.23 to -0.10; NNTB 6, 95% CI 4 to 10; I2 = 55%; 9 studies, 726 infants; low-certainty evidence) and endotracheal reintubation (RR 0.79, 95% 0.64 to 0.98; RD -0.07, 95% CI -0.14 to -0.01; NNTB 15, 95% CI 8 to 100; I2 = 65%; 9 studies; 726 infants; very low-certainty evidence), though the evidence for endotracheal reintubation is very uncertain. NCPAP compared with no CPAP may have little or no effect on bronchopulmonary dysplasia, but the evidence is very uncertain (RR 0.89, 95% CI 0.47 to 1.68; RD -0.03, 95% CI -0.22 to 0.15; 1 study, 92 infants; very low-certainty evidence). No study reported neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

NCPAP may be more effective than no CPAP in preventing extubation failure in preterm infants if applied immediately after extubation from invasive mechanical ventilation. We are uncertain whether it can reduce the risk of reintubation or bronchopulmonary dysplasia. We have no information on long-term neurodevelopmental outcomes. Although there is only low-certainty evidence for the effectiveness of NCPAP immediately after extubation in preterm infants, we consider there is no need for further research on this intervention, which has become standard practice.

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) reduces extubation failures in preterm neonates-A systematic review and meta-analysis

AIM

To analyse the evidence of non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm neonates compared to nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV).

METHODS

We performed a systematic review and meta-analysis of randomised controlled trials and included studies where NIV-NAVA was analysed in preterm (<37 gestational weeks) born neonates. Our main outcomes were the need for endotracheal intubation, the need for surfactant therapy, and reintubation rates. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

A total of five studies were included. The endotracheal intubation rate was 25% in the NIV-NAVA group and 26% in the nCPAP group (RR 0.91, CI: 0.56-1.48). The respective rates for surfactant therapy were 30% and 35% (RR 0.85, CI: 0.56-1.29). The reintubation rate in neonates previously invasively ventilated was 8% in the NIV-NAVA group and 29% in the nCPAP/NIPPV group (RR 0.29, 95%CI: 0.10-0.81). Evidence certainty was rated as low for all outcomes.

CONCLUSIONS

NIV-NAVA as the primary respiratory support did not reduce the need for endotracheal intubation or surfactant therapy. NIV-NAVA seemed to reduce the reintubation rate after extubation in pre-term neonates.

Non-Invasive Ventilatory Support in Preterm Neonates in the Delivery Room and the Neonatal Intensive Care Unit: A Short Narrative Review of What We Know in 2024

BACKGROUND

Guidelines recommend non-invasive ventilatory (NIV) support as first-line respiratory support mode in preterm infants as NIV is superior to intubation and mechanical ventilation in preventing death or bronchopulmonary dysplasia. However, with an ever-expanding variety of NIV modes available, there is much debate about which NIV modality should ideally be used, how, and when. The aims of this work were to summarise the evidence on different NIV modalities for both primary and secondary respiratory support: nCPAP, nasal high-flow therapy (nHFT), and nasal intermittent positive airway pressure ventilation (nIPPV), bi-level positive airway pressure (BiPAP), nasal high-frequency oscillatory ventilation (nHFOV), and nasally applied, non-invasive neurally adjusted ventilatory assist (NIV-NAVA) modes, with particular focus on their use in preterm infants.

SUMMARY

This is a narrative review with reference to published guidelines by European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. nCPAP is currently the most commonly used primary and secondary NIV modality for premature infants. However, there is increasing evidence on the superiority of nIPPV over nCPAP. No beneficial effect was found for BiPAP over nCPAP. For the use of nHFT, nHFOV, and NIV-NAVA, more studies are needed to establish their place in neonatal respiratory care.

KEY MESSAGES

The superiority of nIPPV over nCPAP needs to be confirmed by contemporaneous trials comparing nCPAP to nIPPV at comparable mean airway pressures. Future trials should study NIV modalities in preterm infants with comparable respiratory pathology and indications, at comparable pressure settings and with different modes of synchronisation. Importantly, future trials should not exclude infants of the smallest gestational ages.

Neonatal Exhaled Breath Sampling for Infrared Spectroscopy: Biomarker Analysis

Monitoring health conditions in neonates for early therapeutic intervention in case deviations from physiological conditions is crucial for their long-term development. Due to their immaturity preterm born neonates are dependent on particularly careful physical and neurological diagnostic methods. Ideally, these should be noninvasive, noncontact, and radiation free. Infrared spectroscopy was used to analyze exhaled breath from 71 neonates with a special emphasis on preterm infants, as a noninvasive, noncontact, and radiation-free diagnostic tool. Passive sample collection was performed by skilled clinicians. Depending on the mode of respiratory support of infants, four different sampling procedures were adapted to collect exhaled breath. With the aid of appropriate reference samples, infrared spectroscopy has successfully demonstrated its effectiveness in the analysis of breath samples of neonates. The discernible increase in concentrations of carbon dioxide, carbon monoxide, and methane in collected samples compared to reference samples served as compelling evidence of the presence of exhaled breath. With regard to technical hurdles and sample analysis, samples collected from neonates without respiratory support proved to be more advantageous compared to those obtained from intubated infants and those with CPAP (continuous positive airway pressure). The main obstacle lies in the significant dilution of exhaled breath in the case of neonates receiving respiratory support. Metabolic analysis of breath samples holds promise for the development of noninvasive biomarker-based diagnostics for both preterm and sick neonates provided an adequate amount of breath is collected.

Respiratory Severity Score and Oxygen Saturation Index during the First 2 Hours of Life as Predictors for Noninvasive Respiratory Support Failure in Respiratory Distress Syndrome

OBJECTIVE

 Noninvasive respiratory support (NRS) failure is common in preterm infants with respiratory distress syndrome (RDS). We evaluated the utility of respiratory severity score (RSS) and oxygen saturation index (OSI) during the first 2 hours of life (HOL) as predictors for NRS failure in moderate preterm infants.

STUDY DESIGN

 We conducted a retrospective cohort study of infants born between 280/7 and 336/7 weeks with RDS. Univariate and multivariable logistic regression analyses were used to assess whether the RSS and OSI summary measures were associated with NRS failure.

RESULTS

 A total of 282 infants were included in the study. Median gestational age and birth weights were 32 weeks and 1.7 kg, respectively. Fifty-eight infants (21%) developed NRS failure at the median age of 10.5 hours. RSS and OSI summary measures in the first 2 HOL were associated with NRS failure within 72 HOL.

CONCLUSION

 RSS and OSI during the first 2 HOL can predict NRS failure. Optimal RSS and OSI cutoffs for the prediction of NRS failure need to be determined in large cohort studies.

KEY POINTS

· Nearly one in five moderate preterm infants on NRS at 2 hours of life developed NRS failure.. · RSS and OSI during the first 2 HOL can predict NRS failure.. · Optimal RSS and OSI cutoffs for the prediction of NRS failure need to be determined..

High vs low CPAP strategy with aerosolized calfactant in preterm infants with respiratory distress syndrome

BACKGROUND

Optimal CPAP strategy to prevent CPAP failure defined as need for endotracheal intubation is unknown.

OBJECTIVE

To evaluate the risk of CPAP failure in infants treated with high vs low CPAP strategy while receiving aerosolized calfactant in the AERO-02 clinical trial and AERO-03 expanded access program.

METHODS

Infants born between 29 0/7 to 36 6/7 weeks were included. Comparisons were made between low and high CPAP groups (Low, 4-7 cm H2O; High, 8-10 cm H2O).

RESULTS

CPAP failure and pneumothorax were not different between the groups. Odds of CPAP failure were not different after adjustment for baseline characteristics (OR = 0.61; 95% CI: 0.29, 1.24).

CONCLUSION

We found no difference in CPAP failure among infants who received aerosolized calfactant that were treated with high vs low CPAP strategy. Efficacy of high CPAP strategy with aerosolized surfactant treatment needs to be evaluated in future studies.

Peri-extubation settings in preterm neonates: a systematic review and meta-analysis

OBJECTIVE

To systematically review: 1) peri-extubation settings; and 2) association between peri-extubation settings and outcomes in preterm neonates.

STUDY DESIGN

In this systematic review, studies were eligible if they reported patient-data on peri-extubation settings (objective 1) and/or evaluated peri-extubation levels in relation to clinical outcomes (objective 2). Data were meta-analyzed when appropriate using random-effects model.

RESULTS

Of 9681 titles, 376 full-texts were reviewed and 101 included. The pooled means of peri-extubation settings were summarized. For objective 2, three experimental studies were identified comparing post-extubation CPAP levels. Meta-analyses revealed lower odds for treatment failure [pooled OR 0.46 (95% CI 0.27-0.76); 3 studies, 255 participants] but not for re-intubation [pooled OR 0.66 (0.22-1.97); 3 studies, 255 participants] with higher vs. lower CPAP.

CONCLUSIONS

Summary of peri-extubation settings may guide clinicians in their own practices. Higher CPAP levels may reduce extubation failure, but more data on peri-extubation settings that optimize outcomes are needed.