Post-extubation Respiratory Support Research Articles

Protocol for the development of a guideline on post-extubation respiratory support for mechanically ventilated patients in the ICU

Prophylactic respiratory support for patients after extubation is effective in improving their outcomes and prognosis. However, the optimal post-extubation respiratory support for different populations and disease types of mechanically ventilated...

Guidelines for safe extubation and respiratory rehabilitation in the intensive care unit

Safe extubation and effective respiratory rehabilitation are pivotal in the recovery of critically ill patients in the intensive care unit (ICU). Extubation readiness is determined by assessing respiratory function, airway patency, neurological status, and hemodynamic stability. Tools such as spontaneous breathing trials (SBTs) and the cuff leak test provide valuable insights, while neurological and hemodynamic evaluations further guide decision-making. Ensuring the resolution of the primary illness is critical to minimize the risk of extubation failure and its associated complications. The process of extubation involves meticulous preparation and technique to ensure a smooth transition from mechanical ventilation. Pre-extubation interventions, including secretion management and corticosteroid administration for high-risk patients, are vital. Techniques like gradual cuff deflation and tube removal during peak inspiration, coupled with positioning strategies, reduce complications such as aspiration and airway obstruction. Post-extubation respiratory support, including high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV), plays a crucial role in stabilizing high-risk patients and preventing reintubation. Rehabilitation strategies focus on early mobilization, inspiratory muscle training, and pulmonary physiotherapy to enhance recovery and prevent long-term sequelae. Nutritional optimization is emphasized to counteract muscle weakness and promote tissue repair. Continuous monitoring for respiratory distress and addressing psychological impacts, such as post-intensive care syndrome (PICS), are integral to comprehensive care. Evidence-based protocols, individualized care plans, and multidisciplinary collaboration are essential to improving patient outcomes and reducing ICU-related morbidity and mortality.

Efficacy and safety of different noninvasive ventilation strategies for postextubation respiratory support in Neonatal Respiratory Distress Syndrome: a systematic review and network meta-analysis.

The study aimed to compare the efficacy and safety of different noninvasive ventilation (NIV) modalities as primary respiratory support following extubation in Neonatal Respiratory Distress Syndrome (NRDS). A search was conducted in PubMed, Embase, Cochrane, Web of Science, China National Knowledge Network (CNKI), Wanfang database, VIP, and Chinese Biomedical Literature databases with a search time limit of April 2024 for the year of construction, and included randomized controlled clinical trials of different modes of noninvasive respiratory support after extubation in NRDS. The primary outcome indicators were the need for re-tracheal intubation within 72 h of extubation on noninvasive ventilatory support and carbon dioxide retention (PCO2) 24 h after extubation. Secondary outcome indicators included the incidence of bronchopulmonary dysplasia (BPD), nasal injury, pneumothorax, intraventricular hemorrhage (IVH) or periventricular white matter softening (PVL), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), and mortality rate. A systematic review and network meta-analysis of the literature was performed by two investigators who screened, extracted, and evaluated the quality of the data. A systematic review and network meta-analysis were then performed using R software. A total of 23 studies involving 2,331 neonates were analyzed. These studies examined four noninvasive respiratory modalities: continuous positive airway pressure ventilation (NCPAP), noninvasive intermittent positive pressure ventilation (NIPPV), bi-level positive airway pressure ventilation (N-BiPAP), and noninvasive high-frequency oscillatory ventilation (NHFOV). Results indicated that NHFOV, NIPPV, and N-BiPAP were significantly more effective than NCPAP in reducing the risk of reintubation (all P < 0.05), with NHFOV being the most effective. For carbon dioxide clearance, NHFOV outperformed both NIPPV and NCPAP (P < 0.05). Regarding the reduction of bronchopulmonary dysplasia (BPD) incidence, NHFOV and NIPPV showed a significant advantage over NCPAP. This network meta-analysis (NMA) suggested that NHFOV is the most effective mode of noninvasive respiratory support post-extubation, while NCPAP is the least effective. However, these findings should be interpreted with caution due to the limited number and quality of the studies included. https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier (CRD42024544886).

How to prevent postextubation respiratory failure.

Postextubation respiratory support treatment approaches, indications, and subgroups of patients with different responses to those therapies are rapidly changing. Planning optimal therapy in terms of choosing devices, timing of application and selecting settings with the goal of minimizing extubation failure is becoming a challenge. This review aims to analyze all the available evidence from a clinical point of view, trying to facilitate decision making at the bedside. There is evidence for high flow nasal cannula support in patients at low risk of extubation failure. Noninvasive ventilation based strategies should be prioritized in patients at very high risk, who are obese or are hypercapnic at the end of a spontaneous breathing trial. Patients not included in the previous groups merit a tailored decision based on more variables.Optimizing the timing of therapy can include facilitation of extubation by transitioning to noninvasive respiratory support or prolonging a planned preventive therapy according to clinical condition. Planning postextubatin respiratory support must consider the risk for failing and the presence of some clinical conditions favoring noninvasive ventilation.Extubation can be safely accelerated by modifying screening criteria and spontaneous breathing trial settings, but there is room to increase the role of postextubation noninvasive respiratory support for this indication, always keeping in mind the dangers of delaying a needed intubation.

A Comparative Study of Different Modes of Noninvasive Ventilation as Postextubation Respiratory Support and Their Effect on Hemodynamic Changes in Preterm infants

Abstract Background Noninvasive respiratory support has reduced the need for invasive mechanical ventilation (MV). This may reduce the incidence of bronchopulmonary dysplasia (BPD) in preterm infants. There are many different forms of noninvasive respiratory support which include nasal continuous positive airway pressure (NCPAP), Non-invasive high-frequency oscillatory ventilation (NHFOV) and High velocity nasal insufflation (HVNI). Little is known about the hemodynamic changes that occur during NIV, particularly during the weaning phase when lung compliance has improved. Aim of the Work To evaluate the outcome of NHFOV and Hi-VNI Vapotherm in comparison to nasal CPAP as a post extubation noninvasive respiratory support in preterm neonates. 2ry aim is to assess hemodynamic changes during periods of non-invasive respiratory support including echocardiographic, cerebral blood flow and mesenteric blood flow changes. Study Design This was a randomized control prospective study at Ain Shams Children Hospital, Cairo, Egypt. conducted on 61 mechanically ventilated preterm neonates 32-36 weeks gestational age with RDS, who were on invasive ventilatory support then extubated to non-invasive mode: Group A, 21 preterm neonates extubated on NCPAP. Group B, 20 preterm neonates extubated on NHFOV and Group C, 20 preterm extubated on Hi-VNI Vapotherm. The Three groups were studied for the need for re-intubation within the first 24 hours after extubation, length of hospital stay and duration of non- invasive ventilation (NIV), Retinopathy of prematurity (ROP), air leak syndromes, Intraventricular hemorrhage (IVH), Necrotizing enterocolitis (NEC), nasal trauma, Bronchopulmonary dysplasia (BPD) and mortality. Also assessing hemodynamic changes during and after weaning of non-invasive respiratory support including echocardiography, Anterior cerebral artery resistive index (ACA) RI, Middle cerebral arteries resistive index (MCA) RI, and superior mesenteric artery resistive index (SMA) RI. Results PaCO2 was unchanged from preextubation levels after weaning in the NCPAP and NHFOV but increased significantly after weaning from vapotherm. NCPAP had the shortest length of hospital stay median (IQR) 18 while the NHFOV has the longest duration of hospital stay median (IQR) 28. NHFOV had the least failure rate10% while post extubation to Vapotherm had the highest failure rate 40%, yet this did not reach statistical significance. Significant association found between failure on vapotherm and birth weight less than or equal to 1.75 kg with OR (95% CI) of 77.00 (4.114 – 1441.049) and with p-value = 0.004. A significant higher incidence of mortality was found in vapotherm failed group as compared to the succeed group (75% vs. 0%, p = 0.03). There was significantly higher nasal trauma among NHFOV group compared to the NCPAP and Vapotherm groups (P = 0.001). NHFOV had the least mortality rate 0% while post extubation to Vapotherm had the highest mortality rate 30%, yet this did not reach statistical significance. NCPAP had the least incidence of sepsis while the vapotherm had the highest incidence (P = 0.02). No significant difference between the 3 modes of noninvasive respiratory support in the occurrence of comorbidities as NEC, IVH, ROP and BPD. By Doppler echocardiography, NHFOV showed that both RVO, SVC flow significantly increased after weaning. ACA RI significantly increased after weaning from NHFOV. Also, it showed significant increase in RVO after weaning vapotherm with no significant effect on cerebral blood flow. NCPAP didn’t have significant effect on systemic &amp; pulmonary venous return by Doppler echocardiography. Although it showed that both ACA and MCA RI significantly increased after weaning. Conclusion Overall, these findings suggest that NHFOV may be a favorable option for respiratory support in preterm infants following extubation, as it was associated with better outcomes compared to NCPAP and Vapotherm. However, further research is needed to fully understand the potential benefits and risks of each mode of noninvasive respiratory support in this population. Infants in the Hi-VNI Technology group had significantly lower nasal trauma scores than those in the NCPAP and NHFOV groups with increased failure rate in preterm infants with a birth weight less than or equal to 1.75 kgs.

Optimal Postextubation Support in Critically Ill Patients: One Size Does Not Fit All.

Extubation is a crucial step in the weaning process of critically ill mechanically ventilated patients. Some patients may develop postextubation respiratory failure that may lead to the need for re-intubation, which is associated with increased morbidity and mortality. This review comprehensively explores postextubation respiratory support strategies, focusing on the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and noninvasive ventilation (NIV) in reducing re-intubation rates among various patient populations. HFNC improves oxygenation and reduces the work of breathing. However, its effectiveness in preventing re-intubation varies according to the patient's characteristics and the predefined risk for re-intubation. NIV, alternatively, appears to provide substantial advantages in reducing the rates of re-intubation and respiratory failure, especially in patients with obesity and patients with hypercapnia. Therefore, the indiscriminate application of these support strategies without consideration of individual patient characteristics may not improve outcomes, highlighting the need for careful patient selection and tailored therapeutic strategies based on specific risk factors and clinical conditions. By aligning postextubation respiratory support strategies with patient-specific needs, we may improve the success rates of extubation, enhance overall recovery, and reduce the burden of reintubations in the intensive care setting.

Reducing Failed Extubations in Preterm Infants Via Standardization and Real-Time Decision Support.

Failed extubations are associated with pulmonary morbidity in hospitalized premature newborns. The objective of this study was to use quality improvement methodology to reduce failed extubations through practice standardization and integrating a real-time extubation success calculator into the electronic medical record (EMR). A specific, measurable, achievable, relevant, and time-bound aim was developed to reduce failed extubations (defined as reintubation <5 days from primary extubation) by 50% among infants <32 weeks' gestational age (GA) or <1500 g birth weight by December 31, 2022. Plan-do-study-act cycles were developed to standardize postextubation respiratory support and integrate the EMR-based calculator. Outcome measures included extubation failure rates. Balancing measures included days on mechanical ventilation and number of patients intubated <3 days. Process measures were followed for guideline compliance. Statistical process control charts were used to track time-ordered data and detect special cause variation. We observed a reduction in failed extubations from 10.3% to 2.3%, with special cause variation noted after both plan-do-study-act cycle #1 and #2. Special cause variation was detected in both GA subgroups: <28 weeks' GA (22.0%-8.6%) and ≥28 weeks' GA (4.6%-0.3%). Additionally, the average number of infants intubated <3 days increased (60.2%-73.6%), whereas average ventilator days decreased (10.8-7.0). Finally, the time from infants' extubation score reaching threshold (≥60%) to extubation decreased (14.1-6.4 days) after launching the EMR-integrated calculator. Practice standardization and implementation of an EMR-based real-time clinical decision support tool improved extubation success, promoted earlier extubation, and reduced ventilator days in premature newborns.

Noninvasive high-frequency oscillation ventilation as post- extubation respiratory support in neonates: Systematic review and meta-analysis.

Noninvasive High-Frequency Oscillatory Ventilation (NHFOV) is increasingly being adopted to reduce the need for invasive ventilation after extubation. To evaluate the benefits and harms of NHFOV as post-extubation respiratory support in newborns compared to other non-invasive respiratory support modes. We included randomized controlled trials comparing NHFOV with other non-invasive modes post-extubation in newborns. Data sources were MEDLINE (via Pubmed), Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WHO international clinical trials registry platform and Clinical Trial Registry, forward and backward citation search. Methodological quality of studies was assessed by Cochrane's Risk of Bias tool 1.0. This systematic review included 21 studies and 3294 participants, the majority of whom were preterm. NHFOV compared to nasal continuous positive airway pressure (NCPAP) reduced reintubation within seven days (RR 0.34, 95% CI 0.22 to 0.53) after extubation. It also reduced extubation failure (RR 0.39, 95% CI 0.30 to 0.51) and reintubation within 72 hrs (RR 0.40, 95% CI 0.31 to 0.53), bronchopulmonary dysplasia (RR 0.59, 95% CI 0.37 to 0.94) and pulmonary air leak (RR 0.46, 95% CI 0.27 to 0.79) compared to NCPAP. The rate of reintubation within seven days (RR 0.62, 95% CI 0.18 to 2.14) was similar whereas extubation failure (RR 0.65, 95% CI 0.50 to 0.83) and reintubation (RR 0.68, 95% CI 0.52 to 0.89) within 72 hrs were lower in NHFOV group compared to nasal intermittent positive pressure ventilation. There was no effect on other outcomes. Overall quality of the evidence was low to very low in both comparisons. NHFOV may reduce the rate of reintubation and extubation failure post-extubation without increasing complications. Majority of the trials were exclusively done in preterm neonates. Further research with high methodological quality is warranted.

Noninvasive High Frequency Ventilation as a Post-extubation Respiratory Support in Preterm Neonates

Abstract Background Noninvasive mechanical ventilation aims to provide respiratory support without the pulmonary and non-pulmonary complications associated with invasivemechanical ventilation including infection, subglottic stenosis, air leak syndrome and bronchopulmonary dysplasia (BPD). There is a notable increase in use of various types of noninvasive respiratory support post extubation to ensure the sucesss of extubation and avoid re-intubation. Noninvasive high frequency ventilation (NHFOV) is a new mode of noninvasive ventilation which is achieved through the use of noninvasive continuous flow with superimposed oscillations combining the benefits of high frequency oscillatory ventilaltion and noninvasive ventilation. Aim of Work The primary aim of the study is to compare re-ventilation rate between noninvasive positive pressure ventilation (NIPPV) and NHFOV when used as post extubation respiratory support. Secondary aim was to compare workof breathing, chest X-ray grade, incidence of pneumothorax and duration to reach full enteral intake between the 2 groups. Methodology Sixty preterm neonates with respiratory distress syndrome (RDS) who received invasive mechanical ventilation for more than 48 hours were included in this randomized controlled trial. Patients were randomly allocated post-extubation toNIPPV or NHFOV. The 2 groups were matched regarding weight, gestational age and comorbidities during invasive ventilation. Patients were compared regarding re-ventilation rate, work of breathing assessed by Downes score, chest X-ray grade, incidence of pneumothorax and duration to reach full enteral intake. Results Lower re-ventilation rate was found in NHFOV group (23.3%) compared to NIPPV group (30.0%). Median duration to reach full intake was shorter in NHFOV group (8 days) compared to NIPPV group (9.5 days) however, theseresults didn’t reach statistically significant difference (P value = 0.559 value and0.299 respectively). No difference was found between studied groups regarding work of breathing assessed by Downes’ score (P value = 0.634) nor regarding chest X-ray grades (p value= 0.902). Incidence of pneumothorax was equal in NHFOV group compared to NIPPV group with p value of 0.313. Conclusion NHFOV is a promising safe noninvasive mode for neonates post-extubation.

High-Risk Extubation Readiness Testing for Children With Cardiac Critical Illness.

A protocolized extubation readiness test (ERT), including a spontaneous breathing trial (SBT), is recommended for patients who are intubated. This quality-improvement project aimed to improve peri-extubation outcomes by using a high-risk ERT protocol in intubated cardiac patients in addition to a standard-risk protocol. After baseline data collection, we implemented a standard-risk ERT protocol (pressure support plus PEEP), followed by a high-risk ERT protocol (PEEP alone) in cardiac subjects who were intubated. The primary outcome, a composite of extubation failure and rescue noninvasive respiratory support, was compared between phases. Ventilator duration and use of postextubation respiratory support were balancing measures. A total of 213 cardiac subjects who were intubated were studied, with extubation failure and rescue noninvasive respiratory support occurring in 10 of 213 (4.7%) and 8 of 213 (3.8%), respectively. We observed a reduction in the composite outcome among the 3 consecutive phases (5/29 [17.2%], 10/110 [9.1%] vs 3/74 [4.1%]; P = .10), but this did not reach statistical significance. In the logistic regression model when adjusting for admission type, the high-risk ERT protocol was associated with a significant reduction of the composite outcome (adjusted odds ratio 0.20, 95% CI 0.04-0.091; P = .037), whereas the standard-risk ERT protocol was not (adjusted odds ratio 0.48, 95% CI 0.15-1.53; P = .21). This was not accompanied by a longer ventilator duration (2.0 [1.0, 3.0], 2.0 [1.0-4.0], vs adjusted odds ratio 2.0 [95% [1.0-6.0]; P = .99) or an increased use of planned noninvasive respiratory support (10/29 [35.5%], 35/110 [31.8%], vs 25/74 [33.8%]; P > .99). In this quality-improvement project, a high-risk ERT protocol was implemented with improvement in peri-extubation outcomes among cardiac subjects.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Respiratory Support After Extubation in Children With Pediatric ARDS.

Postextubation respiratory support in pediatric ARDS may be used to support the recovering respiratory system and promote timely, successful liberation from mechanical ventilation. This study's aims were to (1) describe the use of postextubation respiratory support in pediatric ARDS from the time of extubation to hospital discharge, (2) identify potential risk factors for postextubation respiratory support, and (3) provide preliminary data for future larger studies. This pilot single-center prospective cohort study recruited subjects with pediatric ARDS. Subjects' respiratory status up to hospital discharge, the use of postextubation respiratory support, and how it changed over time were recorded. Analysis was performed comparing subjects who received postextubation respiratory support versus those who did not and compared its use among pediatric ARDS severity categories. Multivariable logistic regression was used to determine variables associated with the use of postextubation respiratory support and included oxygenation index (OI), ventilator duration, and weight. Seventy-three subjects with pediatric ARDS, with median age and OI of 4 (0.6-10.5) y and 7.3 (4.9-12.7), respectively, were analyzed. Postextubation respiratory support was provided to 54/73 (74%) subjects: 28/45 (62.2%), 19/21 (90.5%), and 7/7 (100%) for mild, moderate, and severe pediatric ARDS, respectively, (P = .01). OI and mechanical ventilation duration were higher in subjects who received postextubation respiratory support (8.7 [5.4-14] vs 4.6 [3.7-7], P < .001 and 10 [7-17] d vs 4 [2-7] d, P < .001) compared to those who did not. At hospital discharge, 12/67 (18.2%) survivors received home respiratory support (6 subjects died prior to hospital discharge). In the multivariable model, ventilator duration (adjusted odds ratio 1.3 [95% CI 1.0-1.7], P = .050) and weight (adjusted odds ratio 0.95 [95% CI 0.91-0.99], P = .02) were associated with the use of postextubation respiratory support. The majority of intubated subjects with pediatric ARDS received respiratory support postextubation, and a substantial proportion continued to require it up to hospital discharge.

Higher Cumulative Dose of Opioids and Other Sedatives are Associated with Extubation Failure in Norwood Patients.

The primary purpose of this study is to evaluate the relationship between sedation usage and extubation failure, and to control for the effects of hemodynamic, oximetric indices, clinical characteristics, ventilatory settings pre- and post-extubation, and echocardiographic (echo) findings in neonates with hypoplastic left heart syndrome (HLHS) post-Norwood procedure. Single-center, retrospective analysis of Norwood patients during their first extubation post-surgery from January 2015 to July 2021. Extubation failure was defined as reintubation within 48 h of extubation. Demographics, clinical characteristics, ventilatory settings, echo findings (right ventricular function, tricuspid regurgitation), and cumulative dose of sedation medications before extubation were compared between patients with successful or failed extubation. The analysis included 130 patients who underwent the Norwood procedure with 121 (93%) successful and 9 (7%) failed extubations. Univariate analyses showed that vocal cord anomaly (p = 0.05), lower end-tidal CO2 (p < 0.01), lower pulse-to-respiratory quotient (p = 0.02), and ketamine administration (p = 0.04) were associated with extubation failure. The use of opioids, benzodiazepines, dexmedetomidine, and ketamine are mutually correlated in this cohort. On multivariable analysis, the vocal cord anomaly (OR = 7.31, 95% CI 1.25-42.78, p = 0.027), pre-extubation end-tidal CO2 (OR = 0.80, 95% CI 0.65-0.97, p = 0.025), and higher cumulative dose of opioids (OR = 10.16, 95% CI 1.25-82.43, p = 0.030) were independently associated with extubation failure while also controlling for post-extubation respiratory support (CPAP/BiPAP/HFNC vs NC), intubation length, and echo results. Higher cumulative opioid doses were associated with a greater incidence of extubation failure in infants post-Norwood procedure. Therefore, patients with higher cumulative doses of opioids should be more closely evaluated for extubation readiness in this population. Low end-tidal CO2 and low pulse-to-respiratory quotient were also associated with failed extubation. Consideration of the pulse-to-respiratory quotient in the extubation readiness assessment can be beneficial in the Norwood population.

Efficay of high-flow nasal cannula in the paediatric population: A systematic evidence map

ProblemHigh-flow nasal cannula (HFNC) has been widely used in paediatric medicine as a non-invasive ventilation mode for respiratory support. However, the differences in its efficacy across different diseases and intervention types remain poorly understood. Eligibility criteriaAn extensive literature search was performed across multiple academic databases to investigate the systematic reviews and meta-analyses of HFNC. SampleThis study included 35 systematic reviews and meta-analyses, which collectively examined 355 randomised controlled trials and assessed 51 outcome indicators. ResultsThe findings suggest that the existing clinical research evidence predominantly supports the therapeutic efficacy of HFNC. Notably, there is a significant focus on treating acute lower respiratory infection, hypoxaemia, bronchiolitis, and respiratory distress syndrome following extubation. However, concerning the respiratory status, the existing clinical research evidence mainly demonstrates the therapeutic benefits in post-extubation respiratory support and primary respiratory support. ConclusionsThe research on HFNC has witnessed significant expansion, primarily focusing on respiratory disorders, post-extubation respiratory support, conscious sedation, and related fields. The evidence mapping provides a systematic and comprehensive overview of the available evidence on HFNC therapy in paediatric patients. ImplicationsThis study systematically and comprehensively assessed the clinical subjects and populations involved in HFNC therapy. Notably, this study analyzed the trends, current status, and evidence gaps of research, and furnished decision-makers and relevant researchers with a more comprehensive reference basis.

Noninvasive high frequency oscillatory ventilation versus noninvasive positive pressure ventilation in preterm neonates after extubation: A randomized controlled trial.

Weaning from mechanical ventilation is a challenging phase of neonatal respiratory support [1]. Choosing efficient and safe noninvasive modality to prevent re-intubation and choosing the optimal time for weaning are key points for weaning success. The aim of the study is to compare the efficiency and safety of noninvasive high frequency oscillatory ventilation (NHFOV) versus noninvasive positive pressure ventilation (NIPPV) as respiratory support after extubation in preterms with respiratory distress syndrome (RDS). Also, the study compared the lung ultrasound findings between these 2 modalities and assessed the use of lung ultrasound score (LUS) as predictor for extubation outcome. This study is a randomized controlled trial conducted on 60 preterm neonates with RDS. Patients were allocated into one of 2 groups: NIPPV or NHFOV as post-extubation noninvasive respiratory support. The 2 groups were compared regarding the incidence of extubation failure within 72 hours from extubation, oxygen needs, duration of application of the noninvasive modality, duration of admission, safety and mortality rate. LUS was assessed pre-extubation and 2 hours post-extubation. The study did not show a difference in re-ventilation rate in NHFOV group (23.3%) compared to NIPPV group (30.0%), p = 0.56t. Oxygen needs were significantly lower in NHFOV group compared to NIPPV groups (0.38±0.11 vs 0.32±0.06, p = 0.007). The duration of the used noninvasive modality, CO2 concentration, LUS, and mortality rate showed statistically insignificant difference between 2 groups. There was a significant correlation between LUS and extubation outcome. NHFOV is a feasible noninvasive modality for respiratory support post-extubation in premature infants. LUS is a good predictor of extubation outcome in neonates.

Pressure support versus continuous positive airway pressure for predicting successful liberation from invasive ventilation in children: an open label, randomized non-inferiority trial.

Pressure support (PS) as a spontaneous breathing trial (SBT) was considered inferior to continuous positive airway pressure (CPAP) and T-piece because PS underestimated post-extubation work of breathing in physiologic studies. We aimed to compare PS and CPAP as SBT methods for assessing clinical outcomes in children. This was an open label randomized non-inferiority trial conducted between December 2019 and August 2021 among children aged 1 month to 12 years deemed ready for weaning after at least 48h of invasive ventilation in PICU. Children were randomized to undergo a 2-h SBT with PS of 8cmH2O in addition to PEEP 5-6cm H2O or CPAP (5-6cm H2O). The primary outcome was successful liberation from invasive ventilation for 72h after first SBT. Secondary outcomes included first SBT pass rate, need for post-extubation respiratory support (high flow oxygen and/or non-invasive ventilation), and length of PICU stay. Of the 247 enrolled children, 244 completed the trial (121 in PS and 123 in CPAP group). Median (IQR) age was 24 (9, 84) months. Median (IQR) duration of invasive ventilation before randomization was 4.5 (3, 6.5) days. Successful liberation from invasive ventilation after first SBT occurred in 97 (80.2%) children in PS and 93 (75.6%) children in CPAP group [difference 4.6; 95% CI (-5.8, 15); p=0.39]. First SBT pass rate between PS and CPAP [111 (91.7%) versus 105 (85.4%); difference 6.3; 95% CI (-1.6, 14.3); p=0.12] was similar. Need for post-extubation respiratory support [52 (43%) versus 49 (40%)], rate of reintubation within 72h [14 (11.6%) versus 12 (9.8%)] and median (IQR) length of PICU stay [9 (6, 15) versus 8 (5.5, 13) days] were comparable. Four (1.6%) children, all in CPAP group had unfavourable outcome (1 died, 3 discontinued care). In invasively ventilated children, 2-h SBT with pressure support was non-inferior to CPAP in predicting successful liberation from invasive ventilation. None.

Association Between Dead Space to Tidal Volume Ratio and Duration of Respiratory Support After Extubation in Critically Ill Children.

The dead-space-to-tidal-volume ratio (VD/VT) has been used to successfully predict extubation failure in children who are critically ill. However, a singular reliable measure to predict the level and duration of respiratory support after liberation from invasive mechanical ventilation has remained elusive. The objective of this study was to evaluate the association between VD/VT and the duration of postextubation respiratory support. This was a retrospective cohort study of subjects who were mechanically ventilated and admitted to a single-center pediatric ICU between March 2019 and July 2021, and who had been extubated with a recorded VD/VT. A cutoff of 0.30 was chosen a priori, with subjects divided into 2 groups, VD/VT < 0.30 and VD/VT ≥ 0.30, and postextubation respiratory support was recorded at specified time intervals (24 h, 48 h, 72 h, 7 d, and 14 d). We studied 54 subjects. Those with VD/VT ≥ 0.30 had a significantly longer median (interquartile range) duration of respiratory support after extubation (6 [3-14] d vs 2 [0-4] d; P = .001) and longer median (interquartile range) ICU stay (14 [12-19] d vs 8 [5-22] d; P = .046) versus the subjects with VD/VT < 0.30. The distribution of respiratory support did not differ significantly between VD/VT at the time of extubation (P = .13) or at 14 d after extubation (P = .21) but was significantly different during the intervening time points after extubation (24 h [P = .01], 48 h [P < .001], 72 h [P < .001], and 7 d [P = .02]). VD/VT was associated with the duration and level of respiratory support needed after extubation. Prospective studies are needed to establish if VD/VT can successfully predict the level of respiratory support after extubation.

Efficacy of noninvasive high-frequency oscillatory ventilation versus nasal intermittent positive pressure ventilation as post-extubation respiratory support in preterm infants: a Meta analysis

To systematically evaluate the efficacy and safety of noninvasive high-frequency oscillatory ventilation (NHFOV) versus nasal intermittent positive pressure ventilation (NIPPV) as post-extubation respiratory support in preterm infants. China National Knowledge Infrastructure, Wanfang Data, Chinese Journal Full-text Database, China Biology Medicine disc, PubMed, Web of Science, and the Cochrane Library were searched for articles on NHFOV and NIPPV as post-extubation respiratory support in preterm infants published up to August 31, 2022. RevMan 5.4 software and Stata 17.0 software were used for a Meta analysis to compare related indices between the NHFOV and NIPPV groups, including reintubation rate within 72 hours after extubation, partial pressure of carbon dioxide (PCO2) at 6-24 hours after switch to noninvasive assisted ventilation, and the incidence rates of bronchopulmonary dysplasia (BPD), air leak, nasal damage, periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP). A total of 9 randomized controlled trials were included. The Meta analysis showed that compared with the NIPPV group, the NHFOV group had significantly lower reintubation rate within 72 hours after extubation (RR=0.67, 95%CI: 0.52-0.88, P=0.003) and PCO2 at 6-24 hours after switch to noninvasive assisted ventilation (MD=-4.12, 95%CI: -6.12 to -2.13, P<0.001). There was no significant difference between the two groups in the incidence rates of complications such as BPD, air leak, nasal damage, PVL, IVH, and ROP (P>0.05). Compared with NIPPV, NHFOV can effectively remove CO2 and reduce the risk of reintubation, without increasing the incidence of complications such as BPD, air leak, nasal damage, PVL, and IVH, and therefore, it can be used as a sequential respiratory support mode for preterm infants after extubation.

Noninvasive ventilation in preterm neonates - Nasal continuous positive airway pressure vS Nasal intermittent positive pressure ventilation – A randomised controlled trial

Background: Noninvasive ventilation (NIV) has been used in preterm neonates in the past few decades, with the main objective of reducing the exposure to invasive ventilation. It proves to be safe and effective but the best option is yet to be determined. Objective: To determine, if nasal intermittent positive pressure ventilation (NIPPV) decreases the need for mechanical ventilation in the first 48 h when given as a respiratory support post-extubation in preterm neonates compared to nasal continuous positive airway pressure (NCPAP). It is a randomised controlled trial. Method: Preterm neonates (gestational age 28-36 weeks) with respiratory distress requiring invasive ventilation were randomly assigned to receive NIPPV or NCPAP as postextubation respiratory support. The primary outcome was the need for mechanical ventilation within the first 48 hours of life. Results: A total of 32 neonates in postextubation NIV group after stratification to gestational age of 28-32 weeks and 33-36 weeks. The need for invasive mechanical ventilation in the first 48 h was not different in both NIPPV (11.1%) and NCPAP (7.1%). The complications associated with these modes were also compared and analysed. There was no difference noted. Conclusions: NIPPV did not decrease the need for mechanical ventilation compared to NCPAP, overall, in the first 48 hours of support. It could be considered as safe and beneficial compared to NCPAP. However, further studies have to assess the potential benefits and complications associated with NIPPV in preterm neonates.

Comparison Between Continuous Positive Airway Pressure and High-Flow Nasal Cannula as Postextubation Respiratory Support in Neonates: A Systematic Review and Meta-Analysis.

The interest in noninvasive respiratory support has been increasing, including continuous positive airway pressure and recent respiratory methods, namely high-flow nasal cannula. It is discussed if high-flow nasal cannula can reduce continuous positive airway pressure or invasive ventilation use. This systematic review and meta-analysis aimed to compare continuous positive airway pressure and high-flow nasal cannula as postextubation respiratory support in neonates. A literature search, based on Preferred Reporting of Items of Systematic Reviews and Meta-Analyses guidelines, was conducted across MEDLINE (through PubMed), Scopus, and Web of Science in 15 years (2006-2021) assessing randomized controlled trials that compared continuous positive airway pressure with high-flow nasal cannula as postextubation interventions in neonates. The primary outcome was extubation failure at 72 hours and/or at 7 days and the secondary outcomes included air leak syndrome, pneumothorax, bronchopulmonary dysplasia, nasal trauma, abdominal distension, and mortality. Seven studies were included, comprising 1044 neonates. No statistically significant differences were found between high-flow nasal cannula and continuous positive airway pressure in extubation failure (at 72 hours and 7 days), air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality. High-flow nasal cannula was associated with a lower incidence of nasal trauma (odds ratio = 0.21; 95% CI 0.08-0.52; P = .0008). Studies assessing extreme premature infants (<28 weeks) raised some efficacy and safety concerns. High-flow nasal cannula may be as effective and safe as continuous positive airway pressure, with similar extubation failure and risk of air leak syndrome, pneumothorax, bronchopulmonary dysplasia, abdominal distension, and mortality with the advantage of less nasal trauma. High-flow nasal cannula should be considered as an alternative to continuous positive airway pressure in postextubation settings in neonates. Further studies are needed to establish efficacy and safety in lower gestational ages.