Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants

Bamat, Nicolas A.; Fierro, Julie L.; Mukerji, Amit; Wright, Clyde J.; Millar, David; Kirpalani, Haresh

doi:10.1002/14651858.cd012778.pub2

Cited by 24 publications

(25 citation statements)

References 56 publications

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“…The following were the secondary outcomes: (1) reintubation within 7 days; (2) escalation to an alternate form of noninvasive support within 7 days; (3) escalation of CPAP level to > þ3 cm H 2 O higher than preextubation mean Paw within 7 days; (4) cross-over to CPAP pressure levels of the alternate arm within 3 days; (5) cross-over to CPAP pressure levels of the alternate arm within 7 days; (6) total duration of all forms of positive pressure respiratory support; (7) total duration of the length of stay (at the tertiary-level NICU), (8) bronchopulmonary dysplasia (BPD) defined as requirement of positive pressure support and/or supplemental oxygen at 36 weeks' postmenstrual age (PMA; or sooner if transferred and 36 weeks' data unavailable); (9) air leak syndromes within 7 days; (10) intestinal perforation within 7 days; and (11) feeding intolerance (defined as withholding OR reducing by half of at least 1 feed) within 7 days. Note that the latter three outcomes were only counted if the patient was on the assigned pressure ranges during the occurrence of the event.…”

Section: Discussionmentioning

confidence: 99%

“…While the aforementioned studies focus on comparison against NIPPV, the optimal choice of CPAP pressures when used post-extubation remain uncertain based in limited data from randomized trials, as per a recent Cochrane review (6). In fact, this limitation in knowledge extends to all forms of NRS.…”

Section: Comparison To Previous Literaturementioning

confidence: 99%

“…There are limited published data guiding the selection of pressures and settings on non-invasive support post-extubation in preterm neonates. In particular, the optimal choice of distending pressures when using high CPAP to facilitate extubation from IMV remains unknown (6). It could be argued that the initial high CPAP pressure employed following extubation should be somewhat higher than the pre-extubation mean airway pressure (Paw), presuming some loss of pressure due to oropharyngeal leak.…”

mentioning

confidence: 99%

“…In particular, the optimal choice of distending pressures when using high continuous positive airway pressure (CPAP) to facilitate extubation from IMV remains unknown. 6 It could be argued that the initial high CPAP pressure employed following extubation should be somewhat higher than the preextubation mean airway pressure (Paw), presuming some loss of pressure due to oropharyngeal leak. However, unnecessarily higher CPAP pressures could prolong duration of respiratory support, while the potential for complications such as air leaks may remain a concern for clinicians.…”

mentioning

confidence: 99%

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Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

Khalid¹,

Albalushi²,

Manoj³

et al. 2022

Am J Perinatol

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Objective: To evaluate whether the initial pressure level on High CPAP (≥9 cmH2O), in relation to pre-extubation mean airway pressure (Paw), influences short-term clinical outcomes in preterm neonates. Design/Methods: In this retrospective-cohort study, preterm neonates <29 weeks’ gestational age (GA) extubated from mean Paw ≥9 cmH2O and to High CPAP (≥9 cmH2O) were classified into “Higher-level CPAP” (2-3 cmH2O higher than pre-extubation Paw) and “Equivalent CPAP” (-1 to +1 cmH2O in relation to pre-extubation Paw). Only the first eligible extubation per infant was analyzed. The primary outcome was failure within ≤7 days of extubation, defined as any one or more of: (a) need for re-intubation, (b) escalation to an alternate non-invasive respiratory support mode, or (c) use of CPAP >pre-extubation Paw +3 cmH2O. Secondary outcomes included individual components of the primary outcome, along with other clinical and safety outcomes. Results: Over a 10 year period (Jan 2011 to Dec 2020), 175 infants were extubated from mean Paw >9 cmH2O to High CPAP pressures. Twenty-seven subjects [median (IQR) GA 24.7 (24.0-26.4) weeks and chronological age 31 (21-40) days] were classified into the “Higher-level CPAP” group while 148 infants [median (IQR) GA 25.4 (24.6-26.6) weeks and chronological age 26 (10-39) days] comprised the “Equivalent CPAP” group. There was no difference in the primary outcome (44% vs. 51%; P=0.51), including post-adjustment for confounders (adjusted OR 0.47 [95% CI 0.17-1.29; P=0.14]). However, re-intubation risk within 7 days was lower with Higher-level CPAP (7% vs. 37%; P<0.01), including post-adjustment (aOR 0.07; 95% CI 0.02-0.35; P<0.01). Conclusions: In this cohort, use of initial distending CPAP pressures 2-3 cmH2O higher than pre-extubation Paw did not alter the primary outcome of failure, but did lower the risk of re-intubation. The latter is an interesting hypothesis-generating finding that requires further confirmation.

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Section: Discussionmentioning

confidence: 99%

Section: Comparison To Previous Literaturementioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

Khalid¹,

Albalushi²,

Manoj³

et al. 2022

Am J Perinatol

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“…Optimal CPAP pressure levels in preterm neonates remain uncertain 6–8. Higher pressures can improve oxygenation in underinflated lungs, but excessive pressure can worsen oxygenation through overdistension and risk air leaks 4.…”

mentioning

confidence: 99%

Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial

Bamat

Orians

Abbasi

et al. 2022

Arch Dis Child Fetal Neonatal Ed

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ObjectiveTo measure within-subject changes in ventilation/perfusion (V′/Q′) mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection.DesignSingle-arm, non-randomised, feasibility trial.SettingThree centres in the Children’s Hospital of Philadelphia neonatal care network.PatientsTwelve preterm infants of postmenstrual age 27–35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO2) >0.25 on CPAP of 4–7 cm H2O.InterventionsWe applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V′/Q′ mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V′/Q′ improved by more than 5%.Main outcome measuresWithin-subject change in V′/Q′ mismatch between baseline and best CPAP levels.ResultsThere was a median (IQR) within-subject reduction in V′/Q′ mismatch of 1.2 (0–3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5–8) cm H2O.ConclusionsNon-invasive measures of V′/Q′ mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed.Trial registration numberNCT02983825.

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Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants

Ho,

Kidman,

Chua

et al. 2024

Cochrane Database of Systematic Reviews

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Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants

Cited by 24 publications

References 56 publications

Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial

Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants

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