Summary: A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants.
Topic: De-escalation Support
Collins CL, Holberton JR, Barfield C, Davis PG. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J Pediatr. 2013 May;162(5):949-54.e1.
Collins and colleagues compared the efficacy of high velocity nasal insufflation (HVNI) to nasal continuous positive airway pressure (NCPAP) therapy post-extubation in 132 infants less than 32 weeks gestation. If extubated to NCPAP, infants were started at 7-8 cmH2O, if extubated to HVNI, flow rate was started at 8 L/min.
In the study, the clinicians used the FiO2 and level of respiratory distress to wean therapy in both groups. All infants stayed on their assigned mode of respiratory support until they were able to manage without respiratory support or changed to unhumidified low flow subnasal oxygen <0.2 L/min. The primary outcome of extubation failure in the 7 days after extubation was defined a priori. Individual failure criteria were not mutually exclusive and were defined as follows: apnea (respiratory pause >20 seconds), more than 6 episodes in 6 hours or 1 requiring intermittent positive pressure ventilation; acidosis, pH <7.25 and PCO2 >66 mmHg and >15% sustained increase in FiO2 from extubation. Extubation failure was deemed to have occurred if any single criterion was met in any one of the 7 days after extubation. The decision to reintubate an infant remained with the treating physician.
Based on the defined failure criteria, there were no statistical differences in the rate of extubation failure or bronchopulmonary dysplasia(BPD) between groups or in any gestational age stratification; although BPD rates were not different, there was a trend for shorter duration of supplemental oxygen use in the HVNI infants although not statistically significant (p < 0.06). The absolute percentage of infants meeting the criteria for failed extubation was less for HVNI (22%) than for NCPAP (34%). Additionally, infants assigned to HVNI had significantly less nasal trauma (p < 0.001), and 13 (20%) of the infants assigned to NCPAP were rescued with HVNI because of nasal trauma.
This prospective randomized controlled trial concluded that HVNI and NCPAP produced similar rates of extubation failure in the first 7 days after extubation. The authors note that further adequately powered randomized controlled trials are required to ascertain the safety and efficacy of HVNI in the preterm population, particularly in infants born at less than 28 weeks’ gestation.
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