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