Interventions to Improve Rates of Successful Extubation in Preterm Infants

Abstract

Clinicians aim to extubate preterm infants as early as possible, to minimize the risks of mechanical ventilation. Extubation is often unsuccessful owing to lung disease or inadequate respiratory drive.OBJECTIVE To conduct a systematic review and meta-analysis of interventions to improve rates of successful extubation in preterm infants.DATA SOURCES Searches were undertaken in PubMed and The Cochrane Library. STUDY SELECTIONThe review was conducted using the methods of the Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they were randomized clinical trials published in English, enrolled intubated preterm infants (born <37 weeks' gestation), and reported 1 or both of the primary outcomes. DATA EXTRACTION AND SYNTHESISOne thousand three hundred seventy-nine titles were screened independently by 2 investigators to assess need for full-text review. Disagreements were resolved via consensus of all authors. Where no Cochrane Review existed for an intervention, or not all identified studies were included, a new pooled analysis was performed.MAIN OUTCOMES AND MEASURES Primary outcomes were treatment failure or reintubation within 7 days of extubation.RESULTS Fifty studies were eligible for inclusion. Continuous positive airway pressure reduced extubation failure in comparison with head-box oxygen (risk ratio [RR], 0.59; 95% CI, 0.48-0.72; number needed to treat [NNT], 6; 95% CI, 3-9). Nasal intermittent positive pressure ventilation was superior to continuous positive airway pressure in preventing extubation failure (RR, 0.70; 95% CI, 0.60-0.81; NNT, 8; 95% CI, 5-13). High-flow nasal cannula therapy and continuous positive airway pressure had similar efficacy (RR, 1.11; 95% CI, 0.84-1.47). Methylxanthines reduced extubation failure (RR, 0.48; 95% CI, 0.32-0.71; NNT, 4; 95% CI, 2-7) compared with placebo or no treatment. Corticosteroids (RR, 0.18; 95% CI, 0.04-0.97; NNT, 12; 95% CI, 6-100) and chest physiotherapy (RR, 0.32; 95% CI, 0.13-0.82; NNT, 15; 95% CI, 7-50) both reduced extubation failure rates but were associated with significant adverse effects. Doxapram did not aid successful extubation (RR, 0.80; 95% CI, 0.22-2.97).CONCLUSIONS AND RELEVANCE Preterm infants should be extubated to noninvasive respiratory support. Caffeine should be used routinely, while corticosteroids should be used judiciously, weighing up the competing risks of bronchopulmonary dysplasia and neurodevelopmental harm.

Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation

“…Use of NIPPV has been associated with higher rates of successful extubation in randomized controlled trials. 24 As the current study did not control the use of respiratory support postextubation, we think that the higher use of NIPPV among the failed extubation group was related to the level of immaturity and sickness of the patients. Whether the association between extubation failure and morbidities such as severe ICH were related to the extubation procedure itself could not be determined from these data.…”

“…A recent systematic review noted that prophylactic methylxanthines reduce the rate of extubation failure in premature infants. 24 We noted higher use of noninvasive positive pressure ventilation (NIPPV) in the group that failed extubation (23.5%) compared with the successful extubation group (13.8%). Use of NIPPV has been associated with higher rates of successful extubation in randomized controlled trials.…”

European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update

“…There is no evidence favouring any particular weaning protocol [117]. Hypocarbia and severe hypercarbia are associated with worse outcomes and should be avoided by regular or continuous assessment of CO 2 .…”

The effects of nasal continuous positive airway pressure and high flow nasal cannula on heart rate variability in extremely preterm infants after extubation: A randomized crossover trial

“…In extremely preterm infants, the use of non‐invasive respiratory support after extubation is evidence‐based practice . While infants are most commonly extubated to either nasal continuous positive airway pressure (NCPAP) or non‐synchronized nasal intermittent positive pressure ventilation (ns‐NIPPV), high flow nasal cannula (HFNC) has emerged as an attractive alternative .…”