Post-extubation prophylactic nasal continuous positive airway pressure in preterm infants: Systematic review and meta-analysis

Objectives: To determine whether management with nasal continuous positive airway pressure (NCPAP) in preterm infants having their endotracheal tube removed following a period of intermittent positive pressure Ventilation (IPPV), leads to an increased proportion remaining free of additional ventilatory support, compared to extubation directly to headbox oxygen. Methodology: Search Strategy-Searches were made of the Oxford Database of Perinatal Trials, Medline, abstracts of conferences and symposia proceedings, expert informants, journal hand searching mainly in the English language and expert informant searches in the Japanese language. Selection criteria - All trials utilising random or quasi-random patient allocation, in which NCPAP (delivered by any method) was compared with headbox oxygen for postextubation care were included. Methodological quality was assessed independently by the two authors. Data collection and analysis - Data were extracted independently by the two authors. Meta-analysis using event rate ratios (ERRs) and event rate differences (ERDs) was performed using Revman 3.0 statistical software. Prespecified subgroup analysis to determine the impact of different levels of NCPAP and use of aminophylline were also performed using the same package. Similar analysis to investigate the effect of postnatal age on outcomes of interest was also undertaken. Results: Nasal CPAP, when applied to preterm infants being extubated following IPPV, reduces the incidence of adverse clinical events (apnoea, respiratory acidosis and increased oxygen requirements) indicating the need for additional ventilatory support. This result is both statistically significant and clinically important; ERR, 0.62 (0.49, 0.79) and ERD, -0.175 (-0.256, - 0.095). A trend towards reduction in the incidence of oxygen dependency at 28 days of age is also seen in the group extubated to NCPAP; ERR, 0.86 (0.67, 1.10) and ERD, -0.069 (-0.177, 0.039). Conclusions: Nasal CPAP is effective in preventing failure of extubation in preterm infants following a period of endotracheal intubation and IPPV. Further definition of the patient gestational age and weight groups to whom these results apply is required. Optimal levels of NCPAP as well as methods of administration remain to be determined.