Abstract
BackgroundThe use of mechanical ventilation is associated with lung injury in preterm infants and therefore the goal is to avoid or minimize its use. To date there is very little consensus on what is considered the "best non-invasive ventilation mode" to be used post-extubation. The objective of this study was to compare the effectiveness of biphasic nasal continuous positive airway pressure (BP-NCPAP) vs. NCPAP in facilitating sustained extubation in infants ≤ 1,250 grams.MethodsWe performed a randomized controlled trial of BP-NCPAP vs. NCPAP in infants ≤ 1,250 grams extubated for the first time following mechanical ventilation since birth. Infants were extubated using preset criteria or at the discretion of the attending neonatologist. The primary outcome was the incidence of sustained extubation for 7 days. Secondary outcomes included incidence of adverse events and short-term neonatal outcomes.ResultsSixty-seven infants received BP-NCPAP and 69 NCPAP. Baseline characteristics were similar between groups. The trial was stopped early due to increased use of non-invasive ventilation from birth, falling short of our calculated sample size of 141 infants per group. The incidence of sustained extubation was not statistically different between the BP-NCPAP vs. NCPAP group (67% vs. 58%, P = 0.27). The incidence of adverse events and short-term neonatal outcomes were similar between the two groups (P > 0.05) except for retinopathy of prematurity which was noted to be higher (P = 0.02) in the BP-NCPAP group.ConclusionsBiphasic NCPAP may be used to assist in weaning from mechanical ventilation. The effectiveness and safety of BP-NCPAP compared to NCPAP needs to be confirmed in a large multi-center trial as our study conclusions are limited by inadequate sample size.Clinical Trials Registration #NCT00308789Source of supportGrant # 06-06, Physicians Services Incorporated Foundation, Toronto, Canada. Summit technologies Inc. provided additional NCPAP systems and an unrestricted educational grant. presented at The Society for Pediatric Research Meeting, Baltimore, USA, May 2nd-5th, 2009 and Canadian Paediatric Society Meeting, June 23rd-29th, Ottawa, 2009.
Highlights
The use of mechanical ventilation is associated with lung injury in preterm infants and the goal is to avoid or minimize its use
It has been hypothesized that earlier extubation and use of nasal continuous positive airway pressure (NCPAP) may decrease lung inflammation and reduce the incidence of bronchopulmonary dysplasia (BPD) [7]
Baboon studies suggest that the early use of CPAP may mitigate the decreased brain growth and cerebral neuropathologies seen in preterm infants who require ventilation [8]
Summary
The use of mechanical ventilation is associated with lung injury in preterm infants and the goal is to avoid or minimize its use. With advances in neonatal care, > 85% of infants with birth weight < 1,500 grams survive [1,2] Parallel to this improved survival is the increase in the incidence of bronchopulmonary dysplasia (BPD). It has been hypothesized that earlier extubation and use of nasal continuous positive airway pressure (NCPAP) may decrease lung inflammation and reduce the incidence of BPD [7]. It may reduce ventilator-associated pneumonia and necrotizing tracheitis. Supporting evidence in human neonates comes from the results of the caffeine for apnea of prematurity trial where the investigators demonstrated that a reduction in the duration of positive pressure ventilation (of 1 week) [9] through an endotracheal tube was associated with an improved rate of survival without neuro-developmental disability (reduced rate of cerebral palsy and cognitive delay) [10]
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