Toward Optimal High Continuous Positive Airway Pressure as Postextubation Support in Preterm Neonates: A Retrospective Cohort Study

Objective This study aimed to evaluate whether the initial pressure level on high continuous positive airway pressure (CPAP; >= 9 cm H (2) O), in relation to preextubation mean airway pressure (Paw), influences short-term clinical outcomes in preterm neonates. Study Design In this retrospective cohort study, preterm neonates <29 weeks' gestational age (GA) extubated from mean Paw >= 9 cm H (2) O and to high CPAP (>= 9 cm H (2) O) were classified into higher level CPAP (2-3 cm H (2) O higher than preextubation Paw) and equivalent CPAP (-1 to +1 cm H (2) O in relation to preextubation Paw). Only the first eligible extubation per infant was analyzed. The primary outcome was failure within <= 7 days of extubation, defined as any one or more of (1) need for reintubation, (2) escalation to an alternate noninvasive respiratory support mode, or (3) use of CPAP >preextubation Paw + 3 cm H (2) O. Secondary outcomes included individual components of the primary outcome, along with other clinical and safety outcomes. Results Over a 10-year period (Jan 2011-Dec 2020), 175 infants were extubated from mean Paw >9 cm H (2) O to high CPAP pressures. Twenty-seven patients (median GA = 24.7, [interquartile range (IQR)]: (24.0-26.4) weeks and chronological age = 31, IQR: [21-40] days) were classified into the higher level CPAP group while 148 infants (median GA = 25.4, IQR: [24.6-26.6] weeks and chronological age = 26, IQR: [10-39] days) comprised the equivalent CPAP group. There was no difference in the primary outcome (44 vs. 51%; p = 0.51), including postadjustment for confounders (adjusted OR [aOR] = 0.47 [95% confidence interval (CI): 0.17-1.29; p = 0.14]). However, reintubation risk within 7 days was lower with higher level CPAP (7 vs. 37%; p < 0.01), including postadjustment (aOR = 0.07; 95% CI: 0.02-0.35; p < 0.01). Conclusion In this cohort, use of initial distending CPAP pressures 2 to 3 cm H (2) O higher than preextubation Paw did not alter the primary outcome of failure but did lower the risk of reintubation. The latter is an interesting hypothesis-generating finding that requires further confirmation.

Automated summary

This study aimed to evaluate whether the initial pressure level on high continuous positive airway pressure (CPAP) affects short-term clinical outcomes in preterm neonates. The results showed that using initial distending CPAP pressures 2 to 3 cm H (2) O higher than preextubation Paw did not alter the primary outcome of failure but did lower the risk of reintubation.