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

Abstract

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.

Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures Were Equivalent?

“…34 A retrospective cohort study classified neonates extubated to CPAP into higher vs. equivalent, relative to the pre-extubation pressures and found a significantly lower reintubation risk using higher pressures. 35 Recently, Kidman et al published results from the ECLAT randomized controlled trial, demonstrating lower risk of extubation failure when using CPAP 10 cmH 2 O vs. CPAP 7 cmH 2 O post-extubation. 36 Based on these data, there is a signal that higher pressures may be superior to standard CPAP pressures as a post-extubation strategy, albeit more research is needed to identify optimal pressures for various clinical scenarios and patient pathophysiology.…”