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Navigating Non-Invasive Respiratory Support for Preterm Neonates After Extubation

March 27, 2024

Editor’s Note: Dr. Alex Eaton (he/him) is a first-year resident physician in pediatrics at The Boston Combined Residency Program at Boston Children's Hospital and Boston Medical Center. He is interested in medical education and health disparities research, specifically pediatric pain management in the setting of historic practices of race-based medicine. Alex is planning to pursue a fellowship specializing in pediatric critical care. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics

In the world of caring for preterm neonates, choosing the right method of non-invasive respiratory support is crucial. Nasal continuous positive airway pressure (CPAP) and nasal intermittent positive airway pressure (NIPPV) stand out as the most commonly used methods. While CPAP offers a steady baseline pressure, NIPPV provides intermittent boosts above this baseline.

Previous studies comparing these techniques have shown NIPPV to be superior to CPAP, but these studies limited CPAP pressures to a maximum of 8 cm H2O, whereas in real-world clinical practice, higher pressures are often used.

Pediatrics is early releasing an article with accompanying video abstract entitled “CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study,” by Dr. Amit Mukerji from McMaster University and colleagues from 22 institutions in Canada (10.1542/peds.2023-064045). The authors analyze data from 1817 infants at 22 Canadian neonatal centers to compare the use of CPAP and NIPPV in preterm neonates born before 29 weeks’ gestation.

The authors found that CPAP did not exhibit non-inferiority to (meaning, it was not as good as) NIPPV when “extubation failure” was defined as use of another non-invasive method or escalation of settings, but was non-inferior to (meaning, was as good as) NIPPV when failure was defined as the need for re-intubation, at both the <72 hour and <7 day time points.

CPAP’s lack of inferiority in terms of re-intubation was largely because of rescue with other respiratory supports, including NIPPV itself.

There are several strengths to this study, including a large sample size, use of real-world data, and adherence to contemporary clinical practices. However, the study has limitations, notably the potential variability in clinician thresholds for defining failure, and the self-selection of CPAP versus NIPPV by centers. Additionally, while CPAP pressures were permitted to exceed traditional limits, equivalent pressures between CPAP and NIPPV were not consistently applied.

This study provides insights into the nuanced decision-making surrounding non-invasive respiratory support in preterm neonates. While CPAP may not be as good as NIPPV in all aspects, its flexibility and cost-effectiveness make it a compelling initial option, particularly in real-world clinical scenarios with resource constraints.

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