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

Abstract

Objective This study aimed to evaluate whether the initial pressure level on high continuous positive airway pressure (CPAP; ≥9 cm H₂O), in relation to preextubation mean airway pressure (Paw), influences short-term clinical outcomes in preterm neonates.

Study Design In this retrospective cohort study, preterm neonates <29 weeks' gestational age (GA) extubated from mean Paw ≥9 cm H₂O and to high CPAP (≥9 cm H₂O) were classified into “higher level CPAP” (2–3 cm H₂O higher than preextubation Paw) and “equivalent CPAP” (−1 to +1 cm H₂O in relation to preextubation 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 (1) need for reintubation, (2) escalation to an alternate noninvasive respiratory support mode, or (3) use of CPAP >preextubation Paw + 3 cm H₂O. Secondary outcomes included individual components of the primary outcome, along with other clinical and safety outcomes.

Results Over a 10-year period (Jan 2011–Dec 2020), 175 infants were extubated from mean Paw >9 cm H₂O to high CPAP pressures. Twenty-seven patients (median GA = 24.7, [interquartile range (IQR)]: (24.0–26.4) weeks and chronological age = 31, IQR: [21–40] days) were classified into the “higher level CPAP” group while 148 infants (median GA = 25.4, IQR: [24.6–26.6] weeks and chronological age = 26, IQR: [10–39] days) comprised the “equivalent CPAP” group. There was no difference in the primary outcome (44 vs. 51%; p = 0.51), including postadjustment for confounders (adjusted OR [aOR] = 0.47 [95% confidence interval (CI): 0.17–1.29; p = 0.14]). However, reintubation risk within 7 days was lower with higher level CPAP (7 vs. 37%; p < 0.01), including postadjustment (aOR = 0.07; 95% CI: 0.02–0.35; p < 0.01).

Conclusion In this cohort, use of initial distending CPAP pressures 2 to 3 cm H₂O higher than preextubation Paw did not alter the primary outcome of failure but did lower the risk of reintubation. The latter is an interesting hypothesis-generating finding that requires further confirmation.

Key Points

• Use of high CPAP pressures (≥9 cm H₂O) is gradually increasing in the care of preterm neonates.

• This study compares higher level versus equivalent CPAP in relation to preextubation Paw.

• The findings demonstrate no difference in failure as defined with use of higher level CPAP pressures.

Keywords

noninvasive respiratory support - continuous positive airway pressure - reintubation - CPAP failure - invasive mechanical ventilation

Ethics Approval

The study protocol was approved by the Hamilton Integrated Research Ethics Board (REB no.: 5461). Consent was waived by the ethics board in light of the retrospective nature of the study design.

Authors' Contributions

L.K., S.A., N.M., S.R., and H.J. performed the primary data collection for all patients. L.S. and S.D. provided methodological input in study design and analysis. A.M. devised the study concept, performed statistical analyses and revised the manuscript into its final form. All authors approved the final version of the manuscript.

Publikationsverlauf

Eingereicht: 21. Juni 2022

Angenommen: 17. August 2022

Accepted Manuscript online:
17. August 2022

Artikel online veröffentlicht:
01. Oktober 2022

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