Weaning strategies for the withdrawal of non-invasive respiratory support applying continuous positive airway pressure in preterm infants: a systematic review and meta-analysis

Abstract

Background: The optimal method to wean preterm infants from non-invasive respiratory support (NIVRS) with nasal continuous positive airway pressure (CPAP) or high-flow nasal cannula is still unclear, and methods used vary considerably between neonatal units.

Objective: Perform a systematic review and meta-analysis to determine the most effective strategy for weaning preterm infants born before 37 weeks' gestation from NIVRS.

Method: EMBASE, MEDLINE, CINAHL, Google and Cochrane Central Register of Controlled Trials were searched for randomised controlled trials comparing different weaning strategies of NIVRS in infants born before 37 weeks' gestation.

Results: Fifteen trials (1.547 infants) were included. With gradual pressure wean, the relative risk of successful weaning at the first attempt was 1.30 (95% CI 0.93 to 1.83), as compared with sudden discontinuation. Infants were weaned at a later postmenstrual age (PMA) (median difference (MD) 0.93 weeks (95% CI 0.19 to 1.67)). A stepdown strategy to nasal cannula resulted in an almost 3-week reduction in the PMA at successful weaning (MD -2.70 (95% CI -3.87 to -1.52)) but was associated with a significantly longer duration of oxygen supplementation (MD 7.80 days (95% CI 5.31 to 10.28)). A strategy using interval training had no clinical benefits. None of the strategies had any effect on the risk of chronic lung disease or the duration of hospital stay.

Conclusion: A strategy of gradual weaning of airway pressure might increase the chances of successful weaning. Stepdown strategy from CPAP to nasal cannula is a useful alternative resulting in an earlier weaning, but the focus should remain on continued weaning in order to avoid prolonged oxygen supplementation. Interval training should probably not be used.

Keywords: neonatology; therapeutics.

Figure 1

PRISMA flow diagram. Qualitative refers to qualitative assessment of the study methodology and quantitative is the number of studies included in the meta analysis. NIV, non-invasive ventilation; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RCT, randomised controlled trial; SR, systematic review.

Figure 2

Successful weaning at the first weaning trial (gradual weaning, stepdown strategy and interval training vs abrupt stopping).

Figure 3

Postmenstrual age in weeks at the first successful weaning trial (gradual weaning, stepdown strategy and interval training vs abrupt stopping).

Figure 4

Chronic lung disease at 36 weeks' gestation (gradual weaning, stepdown strategy and interval training vs abrupt stopping).