Early weaning from CPAP to high flow nasal cannula in preterm infants is associated with prolonged oxygen requirement: A randomized controlled trial

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Abstract

Objective

To determine the better approach for weaning preterm infants from nasal continuous positive airway pressure (NCPAP) with or without transitioning to nasal cannula (NC).

Design/methods

This is a randomized, open label, controlled trial. Preterm infants born at ≥ 28 weeks gestation who were clinically stable on NCPAP of 5 cm H2O with FiO2 < 0.30 for at least 24 h were randomly assigned to one of 2 groups. The no-NC group were kept on NCPAP until they were on FiO2 = 0.21 for 24 h, and then were weaned off NCPAP completely without any exposure to NC. If they met failing criteria, NCPAP was re-instituted. The NC-group was weaned off NCPAP when FiO2 was ≤ 0.30 to NC (2 L/min) followed by gradual weaning from oxygen. Infants who failed NC were supported back with NCPAP for 24 h before making a second attempt of NC.

Results

Sixty neonates were enrolled; 30 in each group. The two groups were similar in birthweight, gestational age, sex, antenatal steroids, mode of delivery, use of surfactant and xanthines, and duration of mechanical ventilation. After randomization, the no-NC group had fewer days on oxygen [median (interquartile range): 5 (1–8) vs 14 (7.5–19.25) days, p < 0.001] and shorter duration of respiratory support [10.5 (4–21) vs 18 (11.5–29) days, p = 0.03]. There were no differences between groups regarding success of weaning from NCPAP.

Conclusions

Weaning preterm infants from NCPAP to NC is associated with increased exposure to oxygen and longer duration of respiratory support.

Introduction

Nasal continuous positive airway pressure (NCPAP) is frequently used in preterm infants [1], [2], [3]. Early NCPAP is associated with less surfactant use and less exposure to mechanical ventilation [4]. The benefits of NCPAP therapy originate from alveolar recruitment and reduction of airway collapse [5], [6]. Experimental evidence from animal models has demonstrated an improvement in lung growth after the prolonged use of CPAP [7]. However, NCPAP therapy is associated with complications as nasal trauma, gastric distension, obstruction by secretions requiring more labor by health care team, and overall perceived patient discomfort [2], [5], [8], [9], [10].

Currently there is an interest in using a nasal cannula (NC) in preterm infants as an intermediate step during weaning from CPAP. There is no data on the efficacy and safety of this approach. This method of administering oxygen to neonates is preferred by caregivers due to the ease of administration and the ability to feed and care for the infant while continuing oxygen administration. Infants cared for with NC can easily interact with parents, and environment; that could be developmentally advantageous [11]. The use of NC flow at 1–2 L/min is not a reliable source for positive pressure, although there are a few reports that demonstrated pressure produced in the airway of preterm infants when using NC [12], [13]. However, NC systems used in neonates routinely employ gas that is inadequately warmed and humidified, limiting the use of such flows due to increased risk of nasal mucosa injury, with subsequent nosocomial infections [14].

The purpose of this randomized controlled trial is to test the hypothesis that the use of NC, with premature discontinuation of CPAP, in preterm infants is associated with an increase in duration of oxygen therapy, duration of respiratory support, and length of hospitalization.

Section snippets

Study design and enrollment

We conducted a single-center, prospective randomized, open label, controlled trial in the neonatal intensive care unit at Mansoura University Children's Hospital (MUCH) in Egypt between January 2009 and January 2010. Inclusion criteria for infants enrolled in this study were as follows: a) born prematurely at or after 28 weeks of gestation, b) receiving NCPAP at a pressure of 5 cm H2O with FiO2 requirement ≤ 0.30 to maintain oxygen saturation ≥ 87%, c) clinically stable on these CPAP parameters for

Results

Sixty preterm neonates were enrolled; 30 in the no-NC group and 30 in the NC-group. The groups were similar in demographic and clinical characteristics at baseline (Table 1). There was no difference between the two groups in the frequency of xanthine use (73% vs 80%). None of the recruited subjects received post-nanatal steroids. During the weaning process, none of the infants had any major apnea or bradycardia requiring resuscitation, intubation or mechanical ventilation. Six (6/30) infants in

Discussion

This study emphasizes the drawbacks of weaning preterm infants from NCPAP to NC. We observed an average of a nine day increase in the duration of oxygen therapy and a 7.5 day increase in the duration of respiratory support in infants weaned to NC in this single institutional experience.

In addition to surfactant deficiency, premature lungs do not have adequate alveoli to independently perform gas exchange. The use of CPAP keeps the alveoli open, improves the functional residual capacity, stents

Acknowledgement

We thank Ahmed H. Abdel-Hady for the figure preparation in this manuscript.

The trial is registered at www.Clinicaltrial.gov # NCT01093495.

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