Does continuous positive airway pressure (CPAP) during weaning from intermittent mandatory ventilation in very low birth weight infants have risks or benefits? A controlled trial. Randomised trial of methods of extubation in acute and chronic respiratory distress. Randomized, controlled trial of nasopharyngeal continuous positive airway pressure in the extubation of very low birth weight infants. Nasal continuous positive airway pressure facilitates extubation of very low birth weight neonates. Application of nasal continuous positive airway pressure to early extubation in very low birthweight infants. Randomized trial of continuous positive airways pressure to prevent reventilation in preterm infants. Postextubation nasal continuous positive airway pressure. A prospective controlled study. Elective use of nasal continuous positive airways pressure following extubation of preterm infants. Randomised, controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600 to 1250 g.
The purpose of this study was to evaluate three ventilator weaning strategies and to evaluate whether the use of continuous positive airway pressure (CPAP) via a nasopharyngeal or endotracheal tube would increase the likelihood of extubation failure in very low birth weight (VLBW) infants.
                We studied prospectively 87 preterm infants (mean +/- SD; birth weight: 1078 +/- 188 g; gestational age: 28.8 +/- 2.2 weeks) who were in the process of being weaned from intermittent mandatory ventilation (IMV). Infants were assigned by systematic sampling to one of the following three treatment groups: (1) direct extubation from IMV (D.EXT) (n = 30); (2) preextubation endotracheal CPAP (ET-CPAP) for 12-24 hr (n = 28); or (3) postextubation nasopharyngeal CPAP (NP-CPAP) for 12-24 hr (n = 29). Failure was defined as the need for resumption of mechanical ventilation within 72 hr of extubation due to frequent or severe apnea and/or respiratory failure (pH < 7.25, PaCO2 > 60 mm Hg, and/or requirement for oxygen FiO2 > 60%).
                There were no significant differences in failure rates among the three procedures. Failures were 2/30 (7%) in D.EXT; 4/28 (14%) in ET-CPAP; and 7/29 (24%) in the NP-CPAP. There were also no differences in FiO2, PaO2, and respiratory rates before and after discontinuation of IMV among the three groups. PaCO2 values were slightly higher in the NP-CPAP group 12-24 hr after weaning from IMV.
                We were unable to demonstrate a clear difference in extubation outcome by use of CPAP administered via an endotracheal or nasopharyngeal tube when compared to direct extubation from low-rate IMV in VLBW infants. Sixty infants (median gestational age 29 weeks) with acute and 60 infants (median gestational age 25 weeks) with chronic respiratory distress were randomised to be extubated either directly into a headbox or onto 3 cm H2O nasal continuous positive airway pressure (CPAP). Our aim was to test the hypothesis that extubation onto nasal CPAP rather than directly into a headbox was more likely to be associated with successful extubation in infants with acute rather than chronic respiratory distress. Overall the failure rate of extubation was approximately 33%, with no significant difference between the infants with acute and chronic respiratory distress. There was no significant difference in the failure rate of extubation among infants randomised to receive nasal CPAP or headbox oxygen in either the acute or chronic respiratory distress groups. We conducted a prospective, randomized controlled trial to determine whether extubation of very low birth weight infants was facilitated by the use of nasopharyngeal continuous positive airway pressure (CPAP). Eligible infants included patients weighing 600 to 1500 gm at birth who required tracheal intubation within 48 hours of birth and who met specific predetermined criteria for extubation by day 14 of life. We also sought to determine whether varying the duration of nasopharyngeal CPAP influenced the likelihood of successful extubation. Infants underwent random assignment to receive nasopharyngeal CPAP until resolution of lung disease (n = 40), 6 hours of nasopharyngeal CPAP (n = 42), or oxygen supplementation delivered by hood (n = 42). Extubation failure was predefined as a requirement for > or = 80% oxygen, pH < or = 7.20, severe apnea, or predefined clinical deterioration, and extubation success was predefined as the ability to remain free of a requirement for mechanical ventilation for 7 days and a 66% reduction in the need for supplemental oxygen. Each group was similar with regard to race, sex, and birth weight. Extubation was successful in 62%, 61%, and 60% of infants. After stratification by birth weight, there were no significant differences in the rates of successful extubation among the treatment groups. We conclude that nasopharyngeal CPAP does not improve the likelihood of successful extubation of very low birth weight infants who are ready for extubation within the first 2 weeks of life. A prospective randomized trial was performed in 58 neonates comparing nasal continuous positive airway pressure (NCPAP) vs oxyhood following extubation of neonates weighing less than 1 kg. All neonates had been ventilated for the treatment of respiratory distress syndrome for at least 24 hours and weighed less than 1 kg at the time of extubation. Clinical criteria for elective extubation included improving pulmonary status, fraction of inspired oxygen (FIO2) less than or equal to 0.35, mean airway pressure less than or equal to 7 cm H2O, ventilator rate less than or equal to 20 breaths per minute, and weight at least 80% of birth weight. Informed consent was obtained and neonates were randomized to NCPAP or oxyhood following extubation. Success was defined as remaining free of additional ventilatory support for at least 5 days. Failure criteria included FIO2 greater than or equal to 0.60 to maintain pulse oximetry greater than or equal to 93%, PaCO2 greater than or equal to 60 mm Hg, pH less than or equal to 7.23, or moderate to severe apnea. Results demonstrate that 22 (76%) of 29 neonates were successfully extubated to NCPAP while only 6 (21%) of 29 were successfully extubated to oxyhood (P less than .0001). There were no differences in baseline characteristics between the two groups. Of the 23 neonates who failed oxyhood, 21 were then given a trial of NCPAP and 58% (12/21) remained extubated. Data indicate that using selected clinical criteria for elective extubation of neonates weighing less than 1 kg, NCPAP facilitates successful extubation. Using a preset protocol for early extubation, 50 babies were randomly selected to post-extubation headbox or post-extubation nasal continuous positive airway pressure (N-CPAP). All infants weighed less than 1500 g, had a gestational age of less than 34 weeks, and had been weaning from mechanical ventilation within seven days of life. The criteria for extubation included stable condition, fraction of inspired oxygen (FIO2) of < or = 35%, peak inspiratory pressure (PIP) of < or = 15 cm H2O (1.47 kPa), and ventilator rate of 6/minute. Before extubation, a loading dose of aminophylline was given followed by maintenance treatment. If reintubation was not required within 72 hours of the initial extubation the procedure was considered successful. The reintubation criteria included FIO2 > or = 70% to maintain arterial oxygen tension (PaO2) of > or = 50 mm Hg (6.67 kPa) or pulse oximetry between 90-96% and pH of < 7.25, and arterial carbon dioxide tension (PACO2) of > 60 mm Hg (8.00 kPa) and severe or recurring apnoea. The overall success rate of early extubation was 66% (33/50). The individual successful extubation rate of post-extubation in the N-CPAP group and the post-extubation headbox group were 84% (21/25) and 48% (12/25), respectively (p = 0.017; chi 2). There were no significant differences in clinical characteristics between the two groups. The most common cause of failure in early extubation was apnoea, and most occurred in the headbox group (9/12). These results suggest that application of N-CPAP to a preset protocol for extubation can achieve a better success rate of early extubation in very low birthweight (VLBW) infants. A prospective randomized controlled trial was performed comparing the use of a short period (24 hr) of postextubation nasal continuous positive airways pressure (CPAP) with direct extubation into headbox oxygen on the outcome of the need for reintubation within 7 days of initial extubation. Infants at less than 32 weeks of gestation who had received mechanical ventilation in the first 28 postnatal days and were being extubated for the first time were recruited. Ninety-seven babies were entered into the study (48 CPAP and 49 headbox oxygen). Twenty-four (49%) babies in the headbox group were reventilated within a week, compared to 16 (33%) in the CPAP group (P=0.17). By 14 days after initial extubation, 25 babies (51%) in the headbox group and 23 (48%) in the CPAP group required reventilation (P=0.9). There was a trend toward babies in the CPAP group requiring fewer reintubations (median, 2; range, 1-6) compared to those in the headbox group (median, 3; range, 1-7) (P=0.063). There was no significant difference between groups with respect to total number of days of ventilation (headbox median, 4; range, 1-24; CPAP median, 2; range, 1-20). In conclusion, this study showed that a short period of nasal CPAP is not associated with a reduction in reventilation. Nasal continuous positive airway pressure (N-CPAP), applied immediately after extubation, was prospectively evaluated in 18 neonates recovering from respiratory distress syndrome. Patients were randomly assigned to N-CPAP (group 1, N=9) or a control group given oxygen by hood (group 2, N=9). Groups were comparable in birth weight and duration of intubation. In the 24-hour period following extubation, group 1 showed a significantly lower mean respiratory rate (46 +/- 2 vs 74 +/- 4), alveolar-arterial oxygen gradient (94 +/- 9 vs 134 +/- 12 mm Hg), PCO2 (45 +/- 1 vs 50 +/- 1 mm Hg), higher pH (7.33 +/- 0.01 vs 7.30 +/- 0.01), and less atelectasis by roentgenographic scores. This was associated with considerably better clinical courses in group 1 when compared with group 2, in which six patients required a late trial of N-CPAP because of respiratory deterioration and two patients needed reintubation. Postextubation N-CPAP has a striking beneficial effect on respiratory function and prevention of atelectasis. The aim of this study was to determine whether elective use of nasal continuous positive airways pressure (CPAP) following extubation of preterm infants was well tolerated and improved short- and long-term outcomes. A randomized comparison of nasal CPAP to headbox oxygen was undertaken and a meta-analysis performed including similar randomized trials involving premature infants less than 28 days of age. A total of 150 infants (median gestational age 30 weeks, range 24-34 weeks) were randomized in two centres. Fifteen nasal CPAP infants and 25 headbox infants required increased respiratory support post-extubation and 15 nasal CPAP infants and nine headbox infants required reintubation (non significant). Eight infants became intolerant of CPAP and were changed to headbox oxygen within 48 h of extubation; 19 headbox infants developed apnoeas and respiratory acidosis requiring rescue nasal CPAP, 3 ultimately were re-intubated. Seven other trials were identified, giving a total number of 569 infants. Overall, nasal CPAP significantly reduced the need for increased respiratory support (relative risk, 0.57, 95% CI 0.43-0.73), but not for re-intubation (relative risk 0.89, 95% CI 0.68-1.17). Nasal CPAP neither influenced significantly the intraventricular haemorrhage rate reported in four studies (relative risk 1.0, 95% CI 0.55, 1.82) nor that of oxygen dependency at 28 days reported in six studies (relative risk 1.0, 95% CI 0.8, 1.25). In two studies nasal CPAP had to be discontinued in 10% of infants either because of intolerance or hyperoxia.
                Elective use of nasal continuous positive airways pressure post-extubation is not universally tolerated, but does reduce the need for additional support. To determine whether extubation to nasal continuous airway pressure (NCPAP) results in a greater proportion of infants remaining free of additional ventilatory support for one week after extubation compared with those extubated directly to headbox oxygen.
                A randomised, controlled, clinical trial was conducted at the neonatal intensive care unit of the Royal Women's Hospital, Melbourne, of infants with birthweights between 600 and 1250 g, ventilated via an endotracheal tube for more than 12 hours, requiring less than 50% oxygen, a ventilator rate < or = 20/minute, considered by the clinical management team to be ready for extubation. Infants were randomly allocated either to NCPAP or to oxygen administered via a headbox. Success was defined by no requirement for additional ventilatory support over the week following extubation. Failure criteria were (i) apnoea; (ii) absolute increase in oxygen requirement greater than 15% above than required before extubation; or (iii) respiratory acidosis (pH < 7.25 with pCO2 > 6.67 kPa).
                Thirty one of 47 (66%) infants were successfully extubated to NCPAP compared with 18 of 45 (40%) for headbox oxygen. The increase in failure rate in the headbox group was due primarily to increased oxygen requirements in this group. Of the 27 who failed headbox oxygen, 26 were given a trial of NCPAP and 13 did not require endotracheal reintubation. There was no significant difference between the groups in the total number of days of assisted ventilation or the duration of inpatient stay.
                NCPAP applied prophylactically after endotracheal extubation reduces the incidence of adverse clinical events that lead to failure of extubation in the seven days after extubation. This reduction is clinically important. The benefits of NCPAP do not seem to be associated with an increased incidence of unwanted side effects.