Pressure versus Sudden Wean from Nasal Continuous Positive Airway Pressure in Preterm Infants: A Systematic Review and Meta-Analysis

Abstract

<b><i>Background:</i></b> Nasal continuous positive airway pressure (NCPAP) is a well-studied treatment for respiratory problems in preterm infants. However, the best strategy for NCPAP weaning is unknown. <b><i>Objective:</i></b> We aimed to compare the success of progressive pressure wean versus sudden wean for discontinuation of NCPAP in preterm infants. <b><i>Methods:</i></b> We conducted a systematic review and meta-analysis of publications identified by searching MEDLINE, Embase, ­CINAHL, and CENTRAL. Randomized controlled trials comparing pressure wean to sudden wean for NCPAP in preterm infants were included. Primary outcomes were postmenstrual age (PMA) at successful weaning and weight gain. Secondary outcomes were total duration of ventilation, success of weaning strategy on first attempt, length of stay (LOS), and bronchopulmonary dysplasia (BPD). <b><i>Results:</i></b> Two trials (422 infants) were eligible for inclusion. Pressure wean was associated with a higher PMA at weaning (33.9 ± 2.1 vs. 32.1 ± 2.0 weeks, mean difference [MD] 0.88, 95% CI 0.40 to 1.35, low quality evidence). Daily weight gain was only reported in 1 trial. Total duration of ventilation was not reported. Pressure wean was associated with higher probability of successful weaning at first attempt (risk ratio [RR] 1.25, 95% CI 1.03–1.53). However, it was not associated with LOS (MD –2.5 days, 95% CI –7.3 to 2.4) or BPD (RR 0.92, 95% CI 0.52–1.63). <b><i>Conclusion:</i></b> Sudden wean of NCPAP was associated with a lower PMA at successful wean compared to pressure wean but also with a lower rate of successful wean at first attempt, most likely because of the developmental stage at which weaning is possible.

Predictors of successful trial off continuous positive airway pressure and high flow nasal cannula in preterm infants <30 weeks' gestation: A retrospective study

“…Further, two systematic reviews that aimed to address this issue have shown a higher mean PMA of 32-33 weeks and mean weight of 1600-1770 g at the time of successful trial off nCPAP. 37,38 weeks) and higher weight (1600-1900 g) at successful trial off of nCPAP. 10,12,13,22 In these studies, investigators reported time to come off nCPAP for the whole study population without stratifying according to GA.…”

“…Further, two systematic reviews that aimed to address this issue have shown a higher mean PMA of 32–33 weeks and mean weight of 1600–1770 g at the time of successful trial off nCPAP 37,38 . Similarly, several randomized control trials have shown higher mean PMA (32–35 weeks) and higher weight (1600–1900 g) at successful trial off of nCPAP 10,12,13,22 .…”

A randomised trial comparing weaning from CPAP alone with weaning using heated humidified high flow nasal cannula in very preterm infants: the CHiPS study

“…A systematic review of nCPAP weaning indicated that this method of abrupt cessation significantly reduced the PMA of successful weaning. [34][35][36] For a non-inferiority weaning study with the…”

“…We did not use lower pressures or cycling. A systematic review of nCPAP weaning indicated that this method of abrupt cessation significantly reduced the PMA of successful weaning 34–36. For a non-inferiority weaning study with the primary outcome being time of respiratory support, we chose a weaning method that resulted in the shortest time on support.…”

“…This has been noted in other studies35 and may reflect the more graded steps carried out with nHF weaning. Although a similar gradation could be achieved with nCPAP, such an approach has not been shown to reduce the PMA at which nCPAP is discontinued 36. On the other hand, before being ready to trial off, infants on nHF required more interventions (increases in flow) than those on nCPAP; therefore, there was no overall difference in PMA at successful wean when comparing the two groups.…”