Postextubation Noninvasive Ventilation in Respiratory Distress Syndrome: A Randomized Controlled Trial

Abstract

Objective Successful extubation and prevention of reintubation remain primary goals in neonatal ventilation. Our aim was to compare three modalities of postextubation respiratory support—noninvasive positive pressure ventilation (NIPPV), nasal bilevel positive airway pressure (N-BiPAP), and nasal continuous positive airway pressure (NCPAP)—using the RAM cannula in preterm neonates with respiratory distress syndrome (RDS). Our secondary aim was to define the predictors of successful extubation.

Study Design A total of 120 preterm neonates (gestational age ≤35 weeks) with RDS who had undergone primary invasive ventilation were randomized to receive either NIPPV, N-BiPAP, or NCPAP. The incidence of respiratory failure in the first 48 hours postextubation, total days of invasive and noninvasive ventilation, duration of hospitalization, and mortality were measured and compared among the three different noninvasive support modalities.

Results There were no significant differences in the postextubation respiratory failure rates and the number of days of invasive as well as noninvasive ventilation among the three different support modalities (p > 0.05). The total number of days of mechanical ventilation and the duration of hospitalization were significantly higher in the N-BiPAP group than those in the NCPAP or NIPPV groups (p < 0.05). A gestational age of at least 29 weeks and a birth weight of at least 1.4 kg were predictive of successful extubation with a sensitivity of 98.2 and 85.3% and a specificity of 63.6 and 90.9%, respectively.

Conclusion Longer durations of mechanical ventilation and hospitalization were observed with N-BiPAP as a noninvasive mode of ventilation, but there was no significant difference in the extubation failure rates among the three modalities. Gestational age and birth weight were shown to be independent predictors of successful extubation of preterm neonates with RDS.

Key Points

• Successful extubation and reintubation prevention of preterms are primary goals in neonatal ventilation.

• NIPPV, N-BiPAP, and NCPAP could be used as postextubation noninvasive modes in preterm neonates.

• Gestational age and birth weight are independent predictors of successful extubation of preterms.

Keywords

noninvasive positive pressure ventilation - nasal bilevel positive airway pressure - nasal continuous positive airway pressure - RAM cannula

Authors' Contributions

All authors contributed to data interpretation and manuscript writing and have read and approved the final submission. R.A.E. and R.M.D. conceptualized and designed the study. E.A.A., E.A.E, M.A. T., and M.S.E. supervised data collection, reviewed manuscript, and approved the final manuscript as submitted. M.A.K., J.V.F., and R.S.A. contributed to data collection, and analyzed and interpreted the data. N.M.B. and M.A.E. drafted the initial manuscript and performed data analysis.

Publikationsverlauf

Eingereicht: 13. Juli 2020

Angenommen: 09. Januar 2021

Artikel online veröffentlicht:
23. Februar 2021

• References

• 1 Berger J, Mehta P, Bucholz E, Dziura J, Bhandari V. Impact of early extubation and reintubation on the incidence of bronchopulmonary dysplasia in neonates. Am J Perinatol 2014; 31 (12) 1063-1072
• 2 Chawla S, Natarajan G, Gelmini M, Kazzi SNJ. Role of spontaneous breathing trial in predicting successful extubation in premature infants. Pediatr Pulmonol 2013; 48 (05) 443-448
• 3 Shalish W, Sant' Anna GM, Natarajan G, Chawla S. When and how to extubate premature infants from mechanical ventilation. Curr Pediatr Rep 2014; 2 (01) 18-25
• 4 Zaoutis LB, Chiang VW. Comprehensive Pediatric Hospital Medicine. Elsevier Inc.; 2007. DOI: 10.1016/B978-0-323-03004-5.X5001-7
• 5 Higgins RD, Richter SE, Davis JM. Nasal continuous positive airway pressure facilitates extubation of very low birth weight neonates. Pediatrics 1991; 88 (05) 999-1003
• 6 Owen LS, Morley CJ, Davis PG. Neonatal nasal intermittent positive pressure ventilation: what do we know in 2007?. Arch Dis Child Fetal Neonatal Ed 2007; 92 (05) F414-F418
• 7 Narasimhan R, Krishnamurthy S. A review of non-invasive ventilation support in neonates. Paediatr Child Heal (United Kingdom) 2014; 24 (01) 7-11
• 8 Ramanathan R. Nasal respiratory support through the nares: its time has come. J Perinatol 2010; 30: 67-72
• 9 Nzegwu NI, Mack T, DellaVentura R. et al. Systematic use of the RAM nasal cannula in the Yale-New Haven Children's Hospital Neonatal Intensive Care Unit: a quality improvement project. J Matern Fetal Neonatal Med 2015; 28 (06) 718-721
• 10 Salvo V, Lista G, Lupo E. et al. Comparison of three non-invasive ventilation strategies (NSIPPV/BiPAP/NCPAP) for RDS in VLBW infants. J Matern Fetal Neonatal Med 2018; 31 (21) 2832-2838
• 11 Cutland CL, Lackritz EM, Mallett-Moore T. et al; Brighton Collaboration Low Birth Weight Working Group. Low birth weight: case definition & guidelines for data collection, analysis, and presentation of maternal immunization safety data. Vaccine 2017; 35 (48 Pt A): 6492-6500
• 12 Schulz KF, Altman DG, Moher D. CONSORT Group. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010; 340 (7748): c332
• 13 Greenough A, Kavvadia V, Johnson AH, Calvert S, Peacock J, Karani J. A simple chest radiograph score to predict chronic lung disease in prematurely born infants. Br J Radiol 1999; 72 (858) 530-533
• 14 Sweet DG, Carnielli V, Greisen G. et al. European Consensus guidelines on the management of respiratory distress syndrome - 2016 update. Neonatology 2017; 111 (02) 107-125
• 15 Lista G, Castoldi F, Fontana P. et al. Nasal continuous positive airway pressure (CPAP) versus bi-level nasal CPAP in preterm babies with respiratory distress syndrome: a randomised control trial. Arch Dis Child Fetal Neonatal Ed 2010; 95 (02) F85-F89
• 16 Gizzi C, Papoff P, Giordano I. et al. Flow-synchronized nasal intermittent positive pressure ventilation for infants <32 weeks' gestation with respiratory distress syndrome. Crit Care Res Pract 2012; 2012: 301818
• 17 Ramanathan R, Sekar KC, Rasmussen M, Bhatia J, Soll RF. Nasal intermittent positive pressure ventilation after surfactant treatment for respiratory distress syndrome in preterm infants <30 weeks' gestation: a randomized, controlled trial. J Perinatol 2012; 32 (05) 336-343
• 18 Khalaf MN, Brodsky N, Hurley J, Bhandari V. A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics 2001; 108 (01) 13-17
• 19 Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92 (04) 529-534
• 20 Kliegman RM, Walsh MC. Neonatal necrotizing enterocolitis: pathogenesis, classification, and spectrum of illness. Curr Probl Pediatr 1987; 17 (04) 213-288
• 21 Victor S, Roberts SA, Mitchell S, Aziz H, Lavender T. Extubate Trial Group. Biphasic positive airway pressure or continuous positive airway pressure: a randomized trial. Pediatrics 2016; 138 (02) e20154095
• 22 Friedlich P, Lecart C, Posen R, Ramicone E, Chan L, Ramanathan R. A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol 1999; 19 (6, pt.): 413-418
• 23 Lee M, Choi EK, Hee Park K, Shin J, Choi BM. Effectiveness of nCPAP for moderate preterm infants compared to BiPAP: a randomized, controlled non‐inferiority trial. Pediatr Int 2020; 62 (01) 59-64
• 24 Jasani B, Nanavati R, Kabra N, Rajdeo S, Bhandari V. Comparison of non-synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as post-extubation respiratory support in preterm infants with respiratory distress syndrome: a randomized controlled trial. J Matern Fetal Neonatal Med 2016; 29 (10) 1546-1551
• 25 Barrington KJ, Bull D, Finer NN. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics 2001; 107: 638-641
• 26 O'Brien K, Campbell C, Brown L, Wenger L, Shah V. Infant flow biphasic nasal continuous positive airway pressure (BP- NCPAP) vs. infant flow NCPAP for the facilitation of extubation in infants' ≤ 1,250 grams: a randomized controlled trial. BMC Pediatr 2012; 12: 43
• 27 Jónsson B, Katz-Salamon M, Faxelius G, Broberger U, Lagercrantz H. Neonatal care of very-low-birthweight infants in special-care units and neonatal intensive-care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilation: gains and losses. Acta Paediatr Suppl 1997; 419 (419) 4-10
• 28 Ammari A, Suri M, Milisavljevic V. et al. Variables associated with the early failure of nasal CPAP in very low birth weight infants. J Pediatr 2005; 147 (03) 341-347
• 29 Zhou B, Zhai JF, Jiang HX. et al. Usefulness of DuoPAP in the treatment of very low birth weight preterm infants with neonatal respiratory distress syndrome. Eur Rev Med Pharmacol Sci 2015; 19 (04) 573-577
• 30 Bhandari V, Finer NN, Ehrenkranz RA. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Synchronized nasal intermittent positive-pressure ventilation and neonatal outcomes. Pediatrics 2009; 124 (02) 517-526
• 31 Rong ZH, Li WB, Liu W. et al. Nasal bi-level positive airway pressure (BiPAP) versus nasal continuous positive airway pressure (CPAP) in preterm infants ≤32 weeks: a retrospective cohort study. J Paediatr Child Health 2016; 52 (05) 493-498
• 32 Aguiar T, Macedo I, Voutsen O. et al. Nasal bilevel versus continuous positive airway pressure in preterm infants: a randomized controlled trial. J Clin Trials 2015; 5 (03) 221
• 33 Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2017; 2 (02) CD003212
• 34 Kirpalani H, Millar D, Lemyre B, Yoder BA, Chiu A, Roberts RS. NIPPV Study Group. A trial comparing noninvasive ventilation strategies in preterm infants. N Engl J Med 2013; 369 (07) 611-620
• 35 Iyer NP, Chatburn R. Evaluation of a nasal cannula in noninvasive ventilation using a lung simulator. Respir Care 2015; 60 (04) 508-512
• 36 Drescher GS, Hughes CW. Comparison of interfaces for the delivery of noninvasive respiratory support to low birthweight infants. Respir Care 2018; 63 (10) 1197-1206