Sudden versus gradual pressure wean from Nasal CPAP in preterm infants: a randomized controlled trial

Abstract

OBJECTIVE In preterm infants, nasal continuous positive airway pressure (NCPAP) is widely used for treatment of respiratory distress syndrome. However, the strategies for successfully weaning infants off NCPAP are still not well defined and there remains considerable variation between the methods. The objective of this study is to determine whether gradual weaning of NCPAP pressure is more successful than sudden weaning off NCPAP to room air. STUDY DESIGN A randomized controlled trial was conducted in a level 3 neonatal intensive care unit on 70 preterm neonates who were born between 26 and 32 weeks gestation and required NCPAP for at least 48 h. When infants were stable on NCPAP at 0.21 FiO2 and 5 cm H2O positive end expiratory pressure, neonates were randomized to the gradual wean group (reduction in pressure by 1 cm every 8 h until 3 cm H20 was reached) or to sudden wean group (one time NCPAP removal to room air). The primary outcome was a success at the first trial to wean to room air. Secondary outcomes were a number of trials, and weight and postmenstrual age (PMA) at the time of successful wean. Total number of days on NCPAP and length of stay (LOS) in the hospital were also compared between the groups. RESULTS Of the 70 infants included in the study, 35 were randomized to sudden group and 33 infants to gradual group (2 excluded for protocol deviation). In sudden and gradual groups, 14 and 22 infants, respectively, were weaned successfully in the first attempt (P = 0.03). The infants were successfully weaned at 32.7 ± 1.7 weeks versus 33.1 ± 2.4 weeks (P = 0.39) PMA and at a weight of 1651 ± 290 g versus 1589 ± 398 g (P = 0.46) in the sudden and gradual groups, respectively. The total number of days on NCPAP was 27 ± 19 days versus 32 ± 24 days (P = 0.38) and LOS was 63 ± 25 days versus 63 ± 22 days (P = 0.99) in the sudden and gradual groups, respectively. CONCLUSIONS Gradual weaning method was more successful as compared to sudden weaning method in the initial trial off NCPAP. There was no difference in the PMA, weight at the time of successful wean, total days on NCPAP and LOS between the two groups.

Sudden vs Pressure Wean From Nasal Continuous Positive Airway Pressure in Infants Born Before 32 Weeks of Gestation

“…The results of this study agree with findings of what to our knowledge is the only other RCT that compares sudden wean and pressure wean in very preterm infants. This study, by Amatya et al, 31 had a sample size of 68 infants born between 26 to 32 weeks of gestation and used successful wean during Abbreviations: IQR, interquartile range; nCPAP, nasal continuous positive airway pressure; NICU, neonatal intensive care unit; PMA, postmenstrual age. a Apgar score at 1 minute was unknown for 4 infants (2%) in the sudden wean group and 7 infants (4%) in the pressure wean group.…”

“…This differs from our results, in which the higher rate of successful weans during the first attempt only applied to infants who were born before 28 weeks of gestation. The study by Amatya et al 31 was not powered to perform a stratified analysis. A successful wean during the first attempt is an outcome that is highly dependent on the readiness and failure criteria used, in particular nCPAP pressure.…”

Helmet CPAP to Treat Acute Hypoxemic Respiratory Failure in Patients with COVID-19: A Management Strategy Proposal

“…We are aware that the latter approach is based on clinical observation and not on data from randomized clinical trials, but we believe that this procedure may reduce the number of patients that fail weaning from CPAP and expedite the course of hospitalization. Currently, to our knowledge, there are no shared recommendations on weaning from CPAP in adults with HRF and severe pneumonia [29], and so far, the majority of evidence on this topic comes from pediatric/neonatal studies [30]. We propose that, as the patient reaches clinical and respiratory stability, the weaning from the helmet should start from reducing the PEEP to the lower possible value (for the helmet, usually 5-6 cmH2O) maintaining a FiO2 not higher than 50%.…”

Weaning Humidified High Flow Oxygen Therapy among Paediatric Patients: An Integrative Review of Literature

“…Between the two general methods, sudden wean has been initially demonstrated to deliver shorter CPAP weaning duration and length of stay in the hospital (Todd et al, 2012). On the contrary, Amatya et al (2017) showed conflicting result in which gradual titration has been more successful in the initial trial but there was no significant difference in the over-all outcomes. However, this could be explained by the difference in the incremental CPAP time off between the two studies.…”