© Springer International Publishing Switzerland 2016
Antonio M. Esquinas (ed.)Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care10.1007/978-3-319-04259-6_4949. Noninvasive Ventilation Strategies to Prevent Post-extubation Failure: Neonatology Perspective
(1)
Department of Pediatrics, Division of Neonatology, The Children’s Hospital of Philadelphia, The University of Pennsylvania, 34th & Civic Center Boulevard, 2nd Floor Main Neonatology, Philadelphia, PA 19104, USA
(2)
Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
(3)
Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
(4)
Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
Keywords
Continuous positive airway pressureExtubation failureNoninvasive positive pressure ventilationHigh-flow nasal cannulaAbbreviations
BPD
Bronchopulmonary dysplasia
BW
Birth weight
CPAP
Continuous positive airway pressure
FRC
Functional residual capacity
HFNC
High-flow nasal cannula
MV
Mechanical ventilation
NAVA
Neurally adjusted ventilator assist
NICU
Neonatal intensive care unit
NIPPV
Noninvasive positive pressure ventilation
RCT
Randomized controlled trial
Funding Support
Georg M. Schmölzer is a recipient and a Heart and Stroke Foundation Canada Scholarship/University of Alberta Professorship of Neonatal Resuscitation.
49.1 Introduction
Respiratory failure is the most common problem encountered in the neonatal intensive care unit (NICU) [1]. Nearly two-thirds of infants born less than 29 weeks’ gestation require endotracheal intubation and mechanical ventilation (MV) while admitted to the NICU [1]. Although MV is often lifesaving, it is associated with multiple short- and long-term sequelae, including subglottic injury, infection, bronchopulmonary dysplasia (BPD), and neurocognitive impairment [2]. As a consequence, clinicians try to avoid or minimize the duration of MV and extubate infants as early as possible. Following extubation, application of a continuous distending pressure to the airways helps prevent alveolar collapse and maintain gas exchange [3]. Although noninvasive respiratory support has become routine for post-extubation management in preterm infants, optimal strategies to prevent extubation failure have not been clearly defined. This chapter aims to review the definitions of post-extubation failure and describe the available equipment and techniques for noninvasive post-extubation respiratory support in preterm infants.
49.2 Definitions of Post-extubation Failure
There are currently no uniform criteria to define “extubation failure” in preterm infants. As a consequence, there is considerable heterogeneity between studies for this outcome. Common definitions include post-extubation apnea, respiratory acidosis, increased supplemental oxygen requirement, or reintubation and MV [4, 5]. Among these criteria, the threshold used to define failure also varies [4]. Moreover, extubation failure rates depend on the window of observation following extubation. In a systematic review of the topic, Giaccone et al. [4] found that the average reintubation rate in studies primarily enrolling infants with birth weights (BWs) ≤1000 g increased without apparent plateau from 13 % at 24 h to 35 % a week after extubation.
49.3 Noninvasive Respiratory Therapies Following Extubation
49.3.1 Continuous Positive Airway Pressure
Noninvasive continuous positive airway pressure (CPAP) is typically generated in the NICU either by a ventilator or from a compressed gas source “bubbled” under a desired depth of water. It can be administered via short single or binasal prongs, longer nasopharyngeal prong(s), or by nasal mask. Compared with oxygen therapy alone, CPAP results in lower rates of extubation failure in preterm infants [5]. However, which CPAP pressure level, source, and interface are most effective to prevent extubation failure has not been established.
CPAP is typically initiated at 4–8 cm H2O, although pressures as high as 15 cm H2O have been used historically [3]. A minimum CPAP level of 5 cm H2O is likely necessary to provide adequate post-extubation support, although higher pressures may be more effective [5, 6]. Buzzella et al. [6] compared two CPAP ranges (4–6 vs 7–9 cm H2O) and reported lower extubation failure and reintubation rates within 96 h in extremely low birth weight infants (BW <1000 g) treated with the higher level. Gupta et al. [7] compared bubble CPAP to a variable flow CPAP device (both at 6 cm H2O) in 140 preterm infants. The overall incidence of extubation failure was similar between the groups, however, among infants mechanically ventilated for ≤14 days, fewer infants supported on bubble CPAP required reintubation (14 % vs 29 %, p = 0.046).
A 2008 Cochrane Review concluded that short binasal prongs are superior to single-prong interfaces for prevention of extubation failure [8]. More recently, Kieran et al. [9] reported lower reintubation rates within 72 h in preterm infants treated with a nasal mask compared with short binasal prongs (28 % vs 52 %, p = 0.007). However, a small paired crossover study found fewer apnea, bradycardia, and desaturation events with nasal prongs compared with mask [10]. Nasal trauma, the most common complication of nasal CPAP, occurs equally often with prongs and mask [11].
Although there are concerns for pneumothoraces with CPAP, the risk is likely overestimated [12]. With provider education, the risk of pneumothorax is decreased and, when present, need for urgent treatment of pneumothoraces is rare [12].
Related posts:
Predictive Models of Prolonged Mechanical Ventilation and Difficult Weaning
Postoperative Continuous Positive Airway Pressure (CPAP)
Noninvasive Mechanical Ventilation in Postoperative Spinal Surgery
BiPAP for Preoxygenation During Reintubation in Acute Postoperative Respiratory Failure
Discharge Planning of Neuromuscular Patients with Noninvasive Mechanical Ventilation After Difficult Weaning from Invasive Mechanical Ventilation: From ICU to Home Care
Organization of a Weaning Unit
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