The ideal strategy of weaning from nasal continuous positive airway pressure in preterm infants: are we there yet?

Abstract

Commentary on: Jensen CF, Sellmer A, Ebbesen F, et al. Sudden vs pressure wean from nasal continuous positive airway pressure in infants born before 32 weeks of gestation: a randomized clinical trial. JAMA Pediatr 2018 Jul 23. pii: 2687936. https://doi.org/10.1001/jamapediatrics.2018.2074. PMID: 30039171. The ideal strategy of weaning off nCPAP is not established. Premature discontinuation may lead to atelectasis, apnoea and bradycardia, respiratory distress, prolonged oxygen therapy and ultimately lung injury 1. On the other hand, undue prolonged therapy increases the risk of nasal trauma, gastric distension, pneumothorax and agitation 2. Previous studies showed conflicting results. Amatya et al. 3 found that more infants in the gradual wean group were successfully weaned off nCPAP as compared with the sudden wean group, with no difference in respiratory morbidity, weight gain, days on nCPAP and length of hospital stay. In contrast, Eze et al. 4 demonstrated that weaning CPAP in very preterm infants via sprinting (gradual increasing spontaneous breathing off nCPAP) versus weaning pressure down were comparable, regarding successful weaning and the occurrence of common neonatal morbidities. Jensen et al. have shown no difference in weight gain velocity from randomisation to 40 weeks PMA and in secondary outcomes between preterm infants born before 32 weeks of gestation, randomised to sudden weaning versus pressure weaning from nCPAP. The discrepancy in the findings of the Jensen et al.’ study and previous studies may be related to differences in gestational age and the severity of respiratory dysfunction, as infants enrolled in Jensen et al. and Amatya et al.’ studies had higher gestational age [median GA 30 (29–31), mean 28.7 ± 1.8 weeks, respectively], compared to Eze et al. [median 26.5 (23.6–30.6) weeks] and had less severe respiratory dysfunction as the need for surfactant was 36, 20%, respectively versus 63–73% in Eze et al. study. More infants <28 weeks of gestation at birth were successfully weaned from nCPAP during the first attempt in the pressure wean group compared with the sudden wean group. Similarly, Soe et al. 5 found that pressure weaning was more effective than cycling off nCPAP in infants born 24–27 weeks of gestation but not in infants over 28 weeks of gestation at birth. This may indicate that pressure weaning is more appropriate in these infants or that they should have different readiness to wean from nCPAP criteria such as lower FiO2 requirements, lower nCPAP pressure and older postnatal age. This is the largest RCT to date to compare sudden wean and pressure wean of very preterm infants from CPAP. However, the results of this study should be interpreted with caution, due to some limitations such as: Where do we go from here? In preterm infants <32 weeks of gestation, sudden discontinuation and gradual pressure weaning strategies seem to be equally effective approaches for weaning from nCPAP, and pressure wean may be preferred in infants who <28 weeks of gestation. However, future studies are warranted for refinement of readiness to wean from nCPAP criteria and to study the influence of different nCPAP weaning strategies on long-term pulmonary and neurodevelopmental outcomes. https://ebneo.org/2018/12/2018-12-weaning-from-nasal-cpap/ None. None.