Noninvasive High-Frequency Oscillatory Ventilation vs Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation as Postextubation Support for Preterm Neonates in China

Abstract

for the Nasal Oscillation Post-Extubation (NASONE) Study Group IMPORTANCE Several respiratory support techniques are available to minimize the use of invasive mechanical ventilation (IMV) in preterm neonates. It is unknown whether noninvasive high-frequency oscillatory ventilation (NHFOV) is more efficacious than nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) in preterm neonates after their first extubation.OBJECTIVE To test the hypothesis that NHFOV is more efficacious than NCPAP or NIPPV in reducing IMV after extubation and until neonatal intensive care unit discharge among preterm neonates. DESIGN, SETTING, AND PARTICIPANTSThis multicenter, pathophysiology-based, assessor-blinded, 3-group, randomized clinical trial was conducted in 69 tertiary referral neonatal intensive care units in China, recruiting participants from December 1, 2017, to May 31, 2021. Preterm neonates who were between the gestational age of 25 weeks plus 0 days and 32 weeks plus 6 days and were ready to be extubated were randomized to receive NCPAP, NIPPV or NHFOV. Data were analyzed on an intention-to-treat basis. INTERVENTIONSThe NCPAP, NIPPV, or NHFOV treatment was initiated after the first extubation and lasted until discharge.MAIN OUTCOMES AND MEASURES Primary outcomes were total duration of IMV, need for reintubation, and ventilator-free days. These outcomes were chosen to describe the effect of noninvasive ventilation strategy on the general need for IMV.RESULTS A total of 1440 neonates (mean [SD] age at birth, 29.4 [1.8] weeks; 860 boys [59.7%]) were included in the trial. Duration of IMV was longer in NIPPV (mean difference, 1.2; 95% CI, 0.01-2.3 days; P = .04) and NCPAP (mean difference, 1.5 days; 95% CI, 0.3-2.7 days; P = .01) compared with NHFOV. Neonates who were treated with NCPAP needed reintubations more often than those who were treated with NIPPV (risk difference: 8.1%; 95% CI, 2.9%-13.3%; P = .003) and NHFOV (risk difference, 12.5%; 95% CI, 7.5%-17.4%; P < .001). There were fewer ventilator-free days in neonates treated with NCPAP than in those treated with NIPPV (median [25th-75th percentile] difference, −3 [−6 to −1] days; P = .01). There were no differences between secondary efficacy or safety outcomes, except for the use of postnatal corticosteroids (lower in NHFOV than in NCPAP group; risk difference, 7.3%; 95% CI, 2.6%-12%; P = .002), weekly weight gain (higher in NHFOV than in NCPAP group; mean difference, −0.9 g/d; 95% CI, −1.8 to 0 g/d; P = .04), and duration of study intervention (shorter in NHFOV than in NIPPV group; median [25th-75th percentile] difference, −1 [−3 to 0] days; P = .01).CONCLUSIONS AND RELEVANCE Results of this trial indicated that NHFOV, if used after extubation and until discharge, slightly reduced the duration of IMV in preterm neonates, and both NHFOV and NIPPV resulted in a lower risk of reintubation than NCPAP. All 3 respiratory support techniques were equally safe for this patient population.

Lung volume changes during apnoeas in preterm infants

“…We speculate that the direction of results would be similarly favourable for nHFOV in less stable infants. In fact, a recent large multicentre trial demonstrated that nHFOV used as post-extubation respiratory support reduced duration of mechanical ventilation compared with nCPAP or non-invasive intermittent positive pressure ventilation 31. Second, EIT data only show relative changes rather than absolute lung volumes.…”

Non-Invasive High Frequency Oscillatory Ventilation Versus Nasal Continuous Positive Airway Pressure in Transient Tachypnea of the Newborn: A Randomized Controlled Trial

“…17 Zhu et al included in their study 1440 very preterm infants to test the success of various modalities to prevent from re-intubation and found that re-intubation was lower in infants receiving nHFOV when compared to nCPAP. 9 In a metaanalysis investigating the use of nHFOV and nCPAP as primary respiratory support in RDS, it was found that nHFOV reduced the intubation rate. 18 In the present study, we also focused on secondary complications that may be related to non-invasive positive pressure ventilation.…”

“…8,19,20 Consistent with recent studies, we found that air leak syndrome was similar between the nHFOV and nCPAP groups. 9,[14][15][16][17] Compared to nCPAP, studies have shown that nHFOV does not further increase the risk of bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity, and pulmonary hemorrhage. 9,[13][14][15][16] Similar to our results, other studies have found no difference in mortality between nH-FOV and nCPAP groups in the preterm population.…”

“…9,[14][15][16][17] Compared to nCPAP, studies have shown that nHFOV does not further increase the risk of bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity, and pulmonary hemorrhage. 9,[13][14][15][16] Similar to our results, other studies have found no difference in mortality between nH-FOV and nCPAP groups in the preterm population. 9,[15][16][17] These results show us that nHFOV is a safe and tolerable ventilation mode that can be used in the neonatal period both in preterm and term infants.…”

“…8 One of the most important advantages is that nHFOV does not need the synchronization and providing a high mean airway pressure, effective carbon dioxide removal and reduction of gas trapping are other advantages nHFOV use has been shown to offer. 9,10 Although nHFOV is being increasingly studied in the NICU on very preterm infants with respiratory distress syndrome (RDS), to the best of our knowledge, there is no study on the use of nHFOV in late preterm and term infants with TTN. We hypothesized that, based on the unique physiologic advantages nHFOV offers, it might result in a decrease in the duration of non-invasive positive pressure ventilation and oxygen therapy.…”