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. 2000;2001(2):CD001078.
doi: 10.1002/14651858.CD001078.

Extubation from low-rate intermittent positive airways pressure versus extubation after a trial of endotracheal continuous positive airways pressure in intubated preterm infants

P G Davis  1 , D J Henderson-Smart
Affiliations

Extubation from low-rate intermittent positive airways pressure versus extubation after a trial of endotracheal continuous positive airways pressure in intubated preterm infants

P G Davis et al. Cochrane Database Syst Rev. 2000.

Update in

Abstract

Background: Failure of extubation and subsequent reintubation may result in additional stress and trauma to the premature infant. Testing infants about to be extubated with a period of endotracheal CPAP has been suggested as a method of demonstrating readiness for extubation. However, this process has been criticized as increasing the neonate's work of breathing and perhaps increasing the likelihood of extubation failure.

Objectives: In premature infants having their endotracheal tube removed, is direct extubation from low rate intermittent positive pressure ventilation (IPPV) more successful than that following a period of endotracheal continuous positive airway pressure (CPAP)?

Search strategy: The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE, previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching mainly in the English language.

Selection criteria: All trials using random or quasi-random allocation of premature infants to endotracheal CPAP or direct extubation following a period of IPPV were included.

Data collection and analysis: Data were extracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk.

Main results: Direct extubation from low rate ventilation is associated with a trend to increased chance of successful extubation when compared to extubation after a period of endotracheal CPAP, RR 0.45 (0.19,1.07), RD -0.103 (-0.200,-0.006), NNT 10 (5,167). When only truly randomized trials are considered, this result becomes both statistically significant and clinically important, RR 0.10 (0.01,0.78), RD -0.201 (-0.319,-0.083), NNT 5 (3, 12). Similar differences are seen for the secondary outcome, apnea.

Reviewer's conclusions: Preterm infants no longer requiring endotracheal intubation and IPPV should be directly extubated without a trial of ETT CPAP.

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Conflict of interest statement

None

Figures

1.1
1.1. Analysis
Comparison 1 Extubation from IPPV vs ETT CPAP, Outcome 1 Extubation failure.
1.2
1.2. Analysis
Comparison 1 Extubation from IPPV vs ETT CPAP, Outcome 2 Extubation failure (extubated to headbox).
1.3
1.3. Analysis
Comparison 1 Extubation from IPPV vs ETT CPAP, Outcome 3 Extubation failure (extubated to NCPAP).
1.4
1.4. Analysis
Comparison 1 Extubation from IPPV vs ETT CPAP, Outcome 4 Extubation failure (true RCTs only).
1.5
1.5. Analysis
Comparison 1 Extubation from IPPV vs ETT CPAP, Outcome 5 Apnea.
1.6
1.6. Analysis
Comparison 1 Extubation from IPPV vs ETT CPAP, Outcome 6 Apnea (true RCTs only).
See this image and copyright information in PMC

References

References to studies included in this review

Kim 1987 {published data only}
    1. Kim EH, Boutwell WC. Successful direct extubation of very low birth weight infants from low intermittent mandatory ventilation rate. Pediatrics 1987;80:409‐414. - PubMed
Kim 1989 {published data only}
    1. Kim EH. Successful extubation of newborn infants without preextubation trial of continuous positive airway pressure. J Perinatol 1989;9:72‐76. - PubMed
Tapia 1995 {published data only}
    1. Tapia J, Bancalari A, Gonzalez A, Mercado M. Does continuous positive airways pressure (CPAP) during weaning from intermittent mandatory ventilation in very low birthweight infants have risks or benefits? A controlled trial. Ped Pulmonol 1995;19:269‐279. - PubMed

Additional references

Davis 1997a
    1. Davis PG, Henderson‐Smart DJ. Prophylactic post‐extubation nasal CPAP in preterm infants. Cochrane Database of Systematic Reviews 1997, Issue 4.
Davis 1997b
    1. Davis PG, Henderson‐Smart DJ. Intravenous dexamethasone in neonates being extubated. Cochrane Database of Systematic Reviews 1997, Issue 4.
Gillespie 2003
    1. Gillespie LM, White SD, Sinha SK, Donn SM. Usefulness of the minute ventilation test in predicting successful extubation in newborn infants: A randomized controlled trial. Journal of Perinatology 2003;23:205‐207. - PubMed
Henderson‐Smart 1997
    1. Henderson‐Smart DJ, Davis PG. Prophylactic methylxanthine for extubation in preterm infants. Cochrane Database of Systematic Reviews 1997, Issue 4. - PubMed
Kamlin 2006
    1. Kamlin COF, Davis PG, Morley CJ. Predicting successful extubation of very low birthweight infants. Archives of Diseases in Childhood Fetal and Neonatal edition 2006;91:180‐183. [MEDLINE: ] - PMC - PubMed
LeSouef 1984
    1. LeSouef PN, England SJ, Bryan AC. Total resistance of the respiratory system in preterm infants with and without an endotracheal tube. J Pediatr 1984;104:108‐111. - PubMed
Lopes 1981
    1. Lopes JM, Muller NL, Bryan MH, Bryan AC. Synergistic behaviour of inspiratory muscles after diaphragmatic fatigue in the newborn. J Appl Physiol 1981;51:547‐551. - PubMed
Nugent 1988
    1. Nugent J, Matthews BJ, Goldsmith JP. Pulmonary care. In: Goldsmith, Karotkin editor(s). Assisted ventilation of the neonate. Philadelphia: WB Saunders, 1988:103‐4.

References to other published versions of this review

Davis 1998
    1. Davis PG, Henderson‐Smart DJ. Extubation from low‐rate intermittent positive airway pressure versus extubation after a trial of endotracheal continuous positive airway pressure in intubated preterm infants. Cochrane Database of Systematic Reviews 1998, Issue 3. - PubMed
Davis 2001
    1. Davis PG, Henderson‐Smart DJ. Extubation from low‐rate intermittent positive airways pressure versus extubation after a trial of endotracheal continuous positive airways pressure in intubated preterm infants. Cochrane Database of Systematic Reviews 2001, Issue 4. - PubMed

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