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

ABSTRACT: Background:The 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.

Objective:Perform a systematic review and meta-analysis to determine the most effective strategy for weaning preterm infants born before 37 weeks' gestation from NIVRS.

Method:EMBASE, 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.

Results:Fifteen 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.

Conclusion:A 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.

SUBMITTER: van Delft B

PROVIDER: S-EPMC7678397 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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

van Delft Brenda B Van Ginderdeuren Filip F Lefevere Julie J van Delft Christel C Cools Filip F

BMJ paediatrics open 20201119 1

<h4>Background</h4>The 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.<h4>Objective</h4>Perform a systematic review and meta-analysis to determine the most effective strategy for weaning preterm infants born before 37 weeks' gestation from NIVRS.<h4>Method</h4>EMBASE, MEDLINE, CINAHL, Google and Cochrane ...[more]

PMID: 33263087

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Project description:Respiratory support is crucial for the survival of preterm infants, and High-flow Nasal Cannula Oxygen Therapy (HFNC) and Continuous Positive Airway Pressure (CPAP) are commonly used for neonatal respiratory support. This meta-analysis aimed to compare the effects of HFNC and CPAP in primary respiratory support for preterm infants, to provide evidence-based support for clinical practice. PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CNKI, VIP, WANFANG and SinoMed were searched for eligible studies. The primary outcomes included the incidence of treatment failure and the application of mechanical ventilation. A total of 27 eligible studies with 3,351 participants were included. There was no significant difference in the incidence of respiratory support failure [RR = 1.17, 95%CI (0.88-1.56)] and the application of mechanical ventilation [RR = 1.00, 95%CI (0.84-1.19)] between HFNC group and CPAP group. HFNC resulted in lower rate of air leaks [RR = 0.65, 95%CI (0.46-0.92)], nasal trauma [RR = 0.36, 95%CI (0.29-0.45)] and abdominal distension [RR = 0.39, 95%CI (0.27-0.58)], and later time of mechanical ventilation initiating [SMD = 0.60, 95%CI (0.21-0.99)], less duration of oxygen therapy [SMD = -0.35, 95%CI (-0.68 to -0.02)] and earlier enteral feeding [SMD = -0.54, 95%CI (-0.95 to -0.13)]. Alternative non-invasive respiratory support after initial treatment failure resulted in no difference in the application of mechanical ventilation between the two groups [RR = 0.99, 95%CI (0.52-1.88)]. HFNC might be more effective and safer in primary respiratory support for preterm infants. Using CPAP as a remedy for the treatment failure of HFNC could not avoid intubation. For premature infants with the gestational age <28 weeks, HFNC as primary respiratory support still needs to be further elucidated. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022313479, identifier: CRD42022313479.

Project description:IntroductionRespiratory distress syndrome (RDS) or surfactant deficiency occurs primarily in premature infants resulting in composite outcomes of death or bronchopulmonary dysplasia. Initial management strategies for preterm infants with RDS includes early initiation of continuous positive airway pressure (CPAP) and titration of fractional inspired oxygen (FiO2), and may include the use of less invasive surfactant administration (LISA) to avoid the need for mechanical ventilation. In order to optimise success of non-invasive support, the use of early caffeine therapy may be critical to the success of LISA. The objective of our trial is to evaluate whether infants that receive early caffeine, CPAP and surfactant via the LISA method compared with infants that receive caffeine and CPAP alone, have a decreased need for invasive mechanical ventilation in the first 72 hours of life.Methods and analysisCaLI is an unblinded multicentre, randomised controlled, trial of 180 preterm infants (24+0-29+6 weeks corrected GA). Criteria for intubation/treatment failure will follow guidelines for the management of RDS, including: (1) CPAP level of 6-8 cmH20 and FiO2 >0.40 required to maintain saturations 90%-95% for 2?hours after randomisation; (2) a pH of 7.15 or less or a paCO2 >65?mm Hg on any (2) blood gases (arterial/capillary/or venous) at least 2?hours after randomisation and in the first 72 hours of life; (3) continued apnoea/bradycardia/desaturation events despite nasal intermittent minute ventilation mode of ventilation. Infants will be randomised by 1?hour of life and caffeine/LISA treatments administered by 2?hour of life. Caffeine will be administered prior to surfactant in the LISA arm and before 2?hours of life in the control arm.Ethics and disseminationChiesi Farmaceutici, S.p.A is the sponsor of CaLI. Ethical approval has been obtained. Results will be submitted for publication in peer reviewed journals.Trial registration numberwww.Clinicaltrials.gov: NCT04209946; Pre-results.

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Dataset Information

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

Publications

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

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