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

Jensen, Christina Friis; Sellmer, Anna; Ebbesen, Finn; Cipliene, Rasa; Johansen, Anders; Hansen, Rikke Monrad; Nielsen, Jens Peter; Nikitina, Olga Hogreffe; Petersen, J.B.B.; Henriksen, Tine Brink

doi:10.1001/jamapediatrics.2018.2074

Cited by 27 publications

(47 citation statements)

References 45 publications

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“…All CPAP interfaces carry a risk of facial distortion and nasal trauma. When weaning smaller babies from CPAP, gradual reduction rather than sudden cessation of pressure results in greater likelihood of weaning on the first attempt [96]. …”

Section: Non-invasive Respiratory Supportmentioning

confidence: 99%

European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update

et al. 2019

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As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of “European Guidelines for the Management of RDS” by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

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Section: Non-invasive Respiratory Supportmentioning

confidence: 99%

European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update

et al. 2019

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“…Both the short-term success or failure of the different strategies (primary outcomes) as well as the more clinically relevant longer-term effects on CLD or ROP (secondary outcomes) were assessed. With gradual pressure wean, which was addressed by the largest included trial, 9 infants were possibly more successful in their first attempt to be weaned off CPAP as compared with sudden discontinuation, but they remained on CPAP for 1 week longer in terms of their PMA. This prolonged CPAP treatment did not affect the duration of hospitalisation.…”

Section: This Systematic Review and Meta-analysis Identified 13mentioning

confidence: 99%

Weaning strategies for the withdrawal of non-invasive respiratory support applying continuous positive airway pressure in preterm infants: a systematic review and meta-analysis

Delft

Ginderdeuren²,

Lefevere³

et al. 2020

bmjpo

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BackgroundThe optimal method to wean preterm infants from non-invasive respiratory support (NIVRS) with nasal continuous positive airway pressure (CPAP) or high-flow nasal cannula is still unclear, and methods used vary considerably between neonatal units.ObjectivePerform a systematic review and meta-analysis to determine the most effective strategy for weaning preterm infants born before 37 weeks’ gestation from NIVRS.MethodEMBASE, MEDLINE, CINAHL, Google and Cochrane Central Register of Controlled Trials were searched for randomised controlled trials comparing different weaning strategies of NIVRS in infants born before 37 weeks’ gestation.ResultsFifteen trials (1.547 infants) were included. With gradual pressure wean, the relative risk of successful weaning at the first attempt was 1.30 (95% CI 0.93 to 1.83), as compared with sudden discontinuation. Infants were weaned at a later postmenstrual age (PMA) (median difference (MD) 0.93 weeks (95% CI 0.19 to 1.67)). A stepdown strategy to nasal cannula resulted in an almost 3-week reduction in the PMA at successful weaning (MD −2.70 (95% CI −3.87 to −1.52)) but was associated with a significantly longer duration of oxygen supplementation (MD 7.80 days (95% CI 5.31 to 10.28)). A strategy using interval training had no clinical benefits. None of the strategies had any effect on the risk of chronic lung disease or the duration of hospital stay.ConclusionA strategy of gradual weaning of airway pressure might increase the chances of successful weaning. Stepdown strategy from CPAP to nasal cannula is a useful alternative resulting in an earlier weaning, but the focus should remain on continued weaning in order to avoid prolonged oxygen supplementation. Interval training should probably not be used.

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“…A second review conducted in 2015 came to similar conclusions, yet no studies directly comparing pressure to sudden wean had been published at that time [9, 10]. New randomized controlled trials (RCTs) comparing different methods of NCPAP weaning have since been published, and no systematic review or meta-analysis has been performed [11, 12].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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Background: 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. Objective: We aimed to compare the success of progressive pressure wean versus sudden wean for discontinuation of NCPAP in preterm infants. Methods: 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). Results: 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). Conclusion: 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.

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

Cited by 27 publications

References 45 publications

European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update

European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update

Weaning strategies for the withdrawal of non-invasive respiratory support applying continuous positive airway pressure in preterm infants: a systematic review and meta-analysis

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

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