Noninvasive respiratory support lowers extubation failure odds in children

Key takeaways:

• CPAP, high-flow nasal cannula and bilevel positive airway pressure each reduced the odds for extubation failure vs. oxygen therapy.
• CPAP was the “most effective” in combating extubation and treatment failure.

Use of CPAP, high-flow nasal cannula or bilevel positive airway pressure lowered odds for extubation failure within 2 to 3 days among critically ill children compared with conventional oxygen therapy, according to data in JAMA Pediatrics.

CPAP appeared to have the lowest likelihood of extubation failure, although both it and bilevel positive airway pressure (BiPAP) showed small increases in abdominal distension and nasal injury.

In a systematic review of three databases up until May 2022, Narayan Prabhu Iyer, MBBS, MD, assistant professor of clinical pediatrics in the department of pediatrics at Keck School of Medicine at the University of Southern California, and colleagues analyzed results from nine randomized controlled trials (n = 1,421) that assessed how effective various noninvasive respiratory support methods are following extubation among children aged 18 years or younger who required invasive mechanical ventilation for more than 24 hours.

Researchers compared conventional oxygen therapy with three different forms of noninvasive respiratory support — high-flow nasal cannula (HFNC), CPAP and BiPAP — in random-effects models to evaluate rates of extubation failure, defined as reintubation 48 to 72 hours after extubation. Additional outcomes included treatment failure (reintubation plus higher noninvasive respiratory support or switch to another form of support), pediatric ICU mortality, ICU and hospitalization duration, abdominal distension and nasal injury.

Primary outcomes

Effect estimates showed children who received CPAP had lower odds for extubation failure (OR = 0.43; 95% credible interval [CrI], 0.17-1.02) and treatment failure (OR = 0.26; 95% CrI, 0.1-0.56) vs. children who received conventional oxygen therapy.

Similar to CPAP, researchers found that HFNC use resulted in a decreased likelihood for extubation failure (OR = 0.49; 95% CrI, 0.24-1.01) and treatment failure (OR = 0.33; 95% CrI, 0.15-0.65) compared with conventional oxygen therapy use.

BiPAP tended to reduce extubation (OR = 0.63; 95% CrI, 0.24-1.64) and treatment (OR = 0.45; 95% CrI, 0.17-1.16) failure compared with conventional oxygen therapy; however, these findings were not statistically significant, according to researchers.

Using surface under the cumulative rank curve (SUCRA) values to rank the three forms of respiratory support, researchers observed that CPAP had the highest efficacy in terms of preventing extubation failure (SUCRA, 0.83) and treatment failure (SUCRA, 0.91), followed by HFNC (SUCRA, 0.67; 0.64) and then BiPAP (SUCRA, 0.43 for both).

In subgroup analysis adjusted by age, researchers found that infants aged 6 months or younger had lower odds for treatment failure with each of the noninvasive respiratory support modes than infants aged older than 6 months, with no difference seen for extubation failure.

Secondary outcomes

Although pediatric ICU duration among children using HFNC or CPAP did not differ from that of children using conventional oxygen therapy, those using HFNC spent 8.7 fewer days (95% CrI, –19 to 1.1) in the hospital vs. those using conventional oxygen therapy, and CPAP users spent 9 fewer days (95% CrI, –20 to 2.4).

Researchers found comparable ICU mortality rates among CPAP, HFNC and conventional oxygen therapy users.

Notably, 3.8% of children using CPAP and 8.7% of children using BiPAP experienced a nasal injury, which represented increases compared with conventional oxygen therapy.

Abdominal distention was also more prevalent in BiPAP (3.2%), CPAP (2.8%) and HFNC (2.4%) compared with conventional oxygen therapy.

“CPAP was likely to be the best intervention to prevent [extubation failure] and [treatment failure],” Iyer and colleagues wrote. “Future studies are needed in children older than 2 years and in specific populations at higher risk of [extubation failure].