Randomised controlled trial of weaning strategies for preterm infants on nasal continuous positive airway pressure

Abstract

BackgroundThe optimal strategy for weaning very preterm infants from nasal continuous positive airway pressure (NCPAP) is unclear. Reported strategies include weaning NCPAP to a predefined pressure then trialling stopping completely (abrupt wean); alternate periods of increased time off NCPAP whilst reducing time on until the infant is completely weaned (gradual wean); and using high flow nasal cannula (HFNC) to assist the weaning process. The aim of this study was to determine the optimal weaning from NCPAP strategy for very preterm infants.MethodsA pilot single centre, factorial design, 4-arm randomised controlled trial. Sixty infants born <30 weeks gestation meeting stability criteria on NCPAP were randomly allocated to one of four groups. Group 1: abrupt wean with HFNC; Group 2: abrupt wean without HFNC; Group 3: gradual wean with HFNC; Group 4: gradual wean without HFNC. The primary outcomes were duration of respiratory support, chronic lung disease, length of hospital stay and time to full suck feeds.ResultsThe primary outcome measures were not significantly different between groups. Group 1 had a significant reduction in duration of NCPAP (group 1: median 1 day; group 2: 24 days; group 3: 15 days; group 4: 24 days; p = 0.002) and earlier corrected gestational age off NCPAP. There was a significant difference in rate of parental withdrawal from the study, with group 2 having the highest rate. Group 3 had a significantly increased duration on HFNC compared to group 1.ConclusionsUse of high flow nasal cannula may be effective at weaning infants from NCPAP but did not reduce duration of respiratory support or time to full suck feeds. Abrupt wean without the use of HFNC was associated with an increased rate of withdrawal by parent request.Trial registrationThis study is registered at the Australian New Zealand Clinical Trials Registry (www.anzctr.org.au/). (Registration Number = ACTRN12610001003066).

Weaning Premature Infants from Nasal Continuous Positive Airway Pressure – Current Practice and Scientific Evidence

“…To date, eleven respective randomized controlled trials can be found in the literature [2,3,13,27,29]. All these trials comprise a rather small number of participants.…”

“…Application of the CICADA method not only shortened the duration of nCPAP, but was also associated with less chronic lung disease, less time on supplemental oxygen and a shorter duration of overall hospital stay [5,30]. The trials of Singh et al [21], Soe et al [22] and Tang et al [29] also reported a shorter duration of nCPAP when weaning was abruptly stopped. Nair et al [17] found no differences, when comparing these strategies.…”

“…It must be noted, that all before-mentioned studies have methodological weaknesses, mainly a reduced sample size. Three studies are pilot studies comprising a very limited number of patients [17,23,29] and two studies are only published as abstracts [21,22]. Despite the limited available evidence, it may at least be concluded that cycling nCPAP on/off is not superior to an abrupt weaning strategy.…”

Nasal high flow therapy for neonates: Current evidence and future directions

“…Four RCTs have examined nHF as a strategy for weaning from CPAP, with conflicting effects seen on the duration of supplemental oxygen and respiratory support . Two studies found no difference in outcome when weaning directly from CPAP was compared with changing to nHF.…”

“…Four RCTs have examined nHF as a strategy for weaning from CPAP, with conflicting effects seen on the duration of supplemental oxygen and respiratory support . Two studies found no difference in outcome when weaning directly from CPAP was compared with changing to nHF. The third study found that using nHF to wean from CPAP resulted in more days of supplemental oxygen and respiratory support, and a fourth study found the reverse to be true .…”