A Prospective Randomized, Controlled Trial Comparing Synchronized
Nasal Intermittent Positive Pressure Ventilation Versus Nasal Continuous
Positive Airway Pressure as Modes of Extubation
M. Nabeel Khalaf, MD*; Nancy Brodsky, PhD*; John Hurley, RCP‡; and Vineet Bhandari, MD, DM*
ABSTRACT. Objective. To determine whether
syn-chronized nasal intermittent positive pressure ventila-tion (SNIPPV) would decrease extubaventila-tion failure com-pared with nasal continuous positive airway pressure (NCPAP) in preterm infants being ventilated for respira-tory distress syndrome (RDS).
Methods. Infants who were <34 weeks’ gestational
age and who were ventilated for RDS were randomized to either SNIPPV or NCPAP after extubation. The criteria for extubation were peak inspiratory pressure of<16 cm
H2O, positive end expiratory pressure of <5 cm H2O, intermittent mandatory ventilation rate of 15 to 25, and fraction of inspired oxygen <0.35. Pulmonary function
tests (PFT) were obtained before extubation. After extu-bation, blood gases were monitored for a minimum of 72 hours. Success was defined as remaining in the selected mode of treatment or demonstrating improvement (switching to oxyhood/nasal cannula/room air) by 72 hours.
Results. Thirty-two (94%) of 34 infants were extu-bated successfully with the use of SNIPPV versus 18 (60%) of 30 with the use of NCPAP (P<.01). There was no difference in apnea/bradycardia episodes in the 2 groups during the 72-hour study period. Among 55 in-fants who had PFT, 80% (8 of 10) with dynamic lung compliance of>0.5 mL/kg/cm H
2O and expiratory airway resistance of <70 cm H
2O/L/s were extubated success-fully. In infants with poor lung function (dynamic lung compliance: <0.5 mL/kg/cm H2O; expiratory airway re-sistance: >70 cm H2O/L/s), successful extubation was seen in 93% (27 of 29) in the SNIPPV group and 60% (15 of 25) in the NCPAP group. When weight was controlled for at the time of extubation, the odds of success in the SNIPPV group were 21.1 times higher (95% confidence interval: 3.4, 130.1) than that of the NCPAP group.
Conclusions. SNIPPV is more effective than NCPAP in weaning infants with RDS from the ventilator. PFT may be useful in predicting successful extubation.
Pediatrics 2001;108:13–17; respiratory distress syndrome, continuous positive airway pressure, nasal ventilation.
ABBREVIATIONS. CPAP, continuous positive airway pressure; NCPAP, nasal continuous positive airway pressure; NPCPAP, nasopharyngeal tube positive airway pressure; RDS, respiratory distress syndrome; NIPPV, nasal intermittent positive pressure ventilation; IMV, intermittent mandatory ventilation; SNIPPV,
synchronized nasal intermittent positive pressure ventilation; GA, gestational age; PFT, pulmonary function tests; NICU, neonatal intensive care unit; CLD, chronic lung disease; ROP, retinopathy of prematurity; PIP, peak inspiratory pressure; PEEP, positive end expiratory pressure; Fio2, fraction of inspired oxygen; CDYN,
dy-namic lung compliance; RAWE, expiratory airway resistance;
VLBW, very low birth weight.
C
ontinuous positive airway pressure (CPAP) frequently is used to wean infants from me-chanical ventilation. The common modalities of delivering CPAP are through nasal prongs (NCPAP),1–7 nasopharyngeal tube (NPCPAP),8 en-dotracheal tube,5,9or face mask.10These studies have yielded conflicting results in regard to their efficacy. Although some studies1,2,4,6showed that NCPAP fa-cilitates extubation as compared with oxyhood, oth-ers3,5,8 found no difference. Robertson and Hamil-ton7 did not find any difference between elective versus rescue NCPAP after extubation. However, a recent meta-analysis favors the use of prophylactic NCPAP postextubation.11 Endotracheal CPAP was found to be deleterious,5,9whereas face mask CPAP was shown to be beneficial.10We showed previously that NCPAP is as efficacious as NPCPAP in weaning infants with respiratory distress syndrome (RDS) from mechanical ventilation.12Nasal intermittent positive pressure ventilation (NIPPV) involves giving CPAP to the infant in the intermittent mandatory ventilation (IMV) mode. A number of studies have evaluated NIPPV.13–20 Gar-land et al13 found increased risk of gastrointestinal perforations in sick neonates who were on mechan-ical ventilation with either nasal prongs or face mask in a retrospective case-control study in the presur-factant era. Other investigators14 did not find any advantage of NIPPV over NCPAP in treating infants with apnea of prematurity. However, this crossover study evaluated the frequency of apnea/bradycardia for only 6 hours after extubation. They did not report any significant side effects. Two other studies15,17 were uncontrolled, whereas Lin et al16 found de-creased apnea in infants who were on NIPPV during a 4-hour observation period.
So, although most studies support the notion that CPAP is beneficial compared with oxyhood1,2,4,6,10,11 and NCPAP is as efficacious as NPCPAP12in wean-ing infants from mechanical ventilation, there is scant information available in the postsurfactant era to suggest the benefit of nasal ventilation over NCPAP. In addition, most studies that evaluated
From the Departments of *Pediatrics and ‡Respiratory Care, Albert Einstein Medical Center, Philadelphia, Pennsylvania.
Received for publication May 31, 2000; accepted Oct 16, 2000.
Reprint requests to (V.B.) Division of Neonatology, 2601 Lifter, Department of Pediatrics, Albert Einstein Medical Center, 5501 Old York Rd, Philadel-phia, PA 19141. E-mail: [email protected]
NIPPV had a small number of infants,14 –16,18,20only looked at short-term effects,14 –20or did not evaluate lung function.14 –16,19 Thus, we hypothesized that synchronized NIPPV (SNIPPV) would decrease ex-tubation failure as compared with NCPAP in pre-term infants. Specifically, we conducted a prospec-tive, randomized, controlled study comparing the efficacy of SNIPPV versus NCPAP in the weaning of premature infants (ⱕ34 weeks’ gestational age [GA]) from mechanical ventilation with RDS. Furthermore, we determined whether pulmonary function tests (PFT) obtained on these infants before extubation would help us to identify infants with the best chance of success (ie, remaining extubated). In addi-tion, neonatal intensive care (NICU) outcome (up to patient discharge from hospital) was analyzed.
METHODS
The size of the prongs to be used for each infant was deter-mined by the infants’ weight as follows: large, for infants weigh-ing 1500 g; small, for infants 1000 to 1500 g; and X-small, for infants weighing 1000 g and under. The Argyle CPAP Nasal Cannula Kit (Sherwood Medical, St Louis, MO) was used.
The ventilators used were either the Bear Cub (Model BP 2001; Bear Medical Systems, Inc, Riverside, CA) or the Infant Star 500/ 950 (Infrasonics, Inc, San Diego CA), with synchronized IMV box (Star Sync; Infrasonics). The Infant Star was used in the infants who were assigned to the SNIPPV mode. PFT were obtained with the use of the Bicore CP-100 Neonatal Pulmonary Monitor (Bicore Monitoring Systems, Irvine, CA).
Patients
All neonates (ⱕ34 weeks’ GA) who were admitted to the NICU with the diagnosis of RDS and required mechanical ventilation formed the study group. Infants with major congenital malforma-tions were excluded. The study was approved by the Institutional Review Board of the Albert Einstein Healthcare Network, and signed consent was obtained from 1 or both parents. Data were collected as per the following definitions.
Definitions
Pregnancy-induced hypertension was defined as a maternal systolic blood pressure of⬎140 mm Hg and a diastolic pressure of
⬎90 mm Hg in the presence of proteinuria (⬎300 mg/24 hours) and nondependent edema. A positive culture from the amniotic fluid was defined as chorioamnionitis. In the absence of the above, chorioamnionitis was defined in the presence of organisms on Gram stain, sheets of leukocytes, or low glucose in the amniotic fluid in the presence of any 2 of the following clinical symptom-atology: maternal fever, leukocytosis, uterine tenderness, pus from the cervix, and fetal tachycardia. RDS was defined in the presence of clinical features and a positive chest x-ray. Air leaks were documented by positive evidence of pneumothorax, pneu-momediastinum, or pulmonary interstitial emphysema on the chest radiograph. PPV was inclusive of endotracheal tube venti-lation, SNIPPV, and NCPAP. Patent ductus arteriosus was docu-mented by echocardiography. Intraventricular hemorrhage was determined according to Papile’s classification of cranial ultra-sound findings of blood in the germinal matrix or ventricular system with or without ventricular dilation and parenchymal extension.21Periventricular leukomalacia was defined as cerebral
ultrasound findings of increased echogenicity and cystic lesions in the periventricular white matter.22 Chronic lung disease (CLD)
was defined as the need for oxygen supplementation at 36 weeks’ postconceptional age in association with characteristic radiograph changes.23 Sepsis was diagnosed by a positive blood culture.
Necrotizing enterocolitis was defined asⱖstage 2 as per modified Bells criteria.24Gastroesophageal reflux was diagnosed by a
pos-itive pH probe test. Retinopathy of prematurity (ROP) was de-fined as per the international classification.25
Management of RDS
Infants were treated as per nursery standards for RDS. Initial ventilator settings of infants with RDS included peak inspiratory pressure (PIP) at 16 to 20 cm H2O, positive end expiratory
pres-sure (PEEP) at 4 to 6 cm H2O, an inspiratory time of 0.35 to 0.45
seconds, a rate of 40 to 60/min, and fraction of inspired oxygen (Fio2) adjusted to keep saturations at 90% to 96%. Exogenous
surfactant (Survanta; Ross Laboratories, Columbus, OH) was used only as rescue therapy. The infant was weaned as clinically toler-ated and monitored by serial blood gas analyses. The criteria for extubation were PIPⱕ16 cm H2O, PEEPⱕ5 cm H2O, IMV rate of
15 to 25, Fio2 ofⱕ.35, aminophylline level of ⱖ8 mg/L, and
hematocrit ofⱖ40%.
Once the infants fulfilled the criteria for extubation, PFT were conducted by the neonatal respiratory therapist. PFT included dynamic lung compliance (CDYN) and expiratory airway
resis-tance (RAWE) measurements. PFT were considered reliable for
analyses only if air leak was ⬍20% and reproducible optimal flow-volume and pressure-volume loops were obtained.
Infants were assigned randomly either to SNIPPV or to NCPAP with the use of sealed envelopes and 3 birth weight blocks as follows: 500 to 749 g, 750 to 999 g, and⬎1000 g. Infants who were randomized to NCPAP were put on CPAP of 4 to 6 cm H2O.
Infants who were randomized to SNIPPV received synchronized IMV at the same rate as they were receiving before extubation, PIP was increased by 2 to 4 cm H2O, and the PEEP was kept atⱕ5 cm
H2O; Fio2was adjusted in all infants to maintain oxygen
satura-tions at 90% to 96% on pulse oximetry. The flow rate was kept at 8 to 10 L/min in both modes of respiratory support. A blood gas was obtained 1 to 3 hours after extubation as is routine in our NICU. Blood gas analyses were conducted from samples that were obtained from indwelling arterial lines (in 35 [55%] of 64 infants) or arterialized capillary blood that was obtained from a warmed heel. Thereafter, blood gases were conducted as clinically indi-cated, but at least once every 8 hours in the first 24 hours postex-tubation, then every 12 hours for 48 hours as long as the infant was on the NCPAP/SNIPPV mode. Ventilator rates could be increased to 25/min in the SNIPPV mode, if needed, to maintain normal blood gases (vide infra).
After careful evaluation of the infant’s respiratory status, the infant was weaned from SNIPPV/NCPAP to nasal cannula, oxy-hood, or room air. This was done by the attending neonatologist with the use of the following guidelines: in the SNIPPV group, once the infants had ventilator settings of PIP/PEEP 14/4 cm H2O,
rate ofⱕ20/min, and Fio2ⱕ0.3 with normal blood gases; in the
NCPAP group, once CPAP reached 4 cm H2O and Fio2ⱕ0.3 with
normal blood gases. Success was defined as remaining in the selected mode of treatment or demonstrating improvement (switching to nasal cannula/oxyhood/room air) by 72 hours.
Extubation failure was defined as the need for reintubation and mechanical ventilation. Reintubation was performed in the pres-ence of any of the following (within 72 hours of extubation): a pH
⬍7.25, PaCO2⬎60 mm Hg, a single episode of apnea needing bag
and mask resuscitation, frequent (⬎2–3/hour) apnea/bradycardia spells (cessation of respiration for⬎20 s associated with a heart rate of⬍100/min) not responding to theophylline therapy, fre-quent desaturations (⬍85%)ⱖ3 episodes/hour not responding to increased ventilatory settings or an increase in Fio2to 1.0, or a
Pao2⬍50 mm Hg despite an Fio2of 1.0.
Infants were monitored as per standard nursing protocols in our NICU. Cranial ultrasound was done on all infants at days 1 to 3 and 7 to 10, at discharge, and as indicated. X-rays, cardiac echocardiography, blood cultures, and pH probe tests were con-ducted when clinically indicated. Eye examinations were per-formed on the infants by pediatric ophthalmologists at 4 to 6 weeks of age and repeated every 1 to 2 weeks as indicated. Specialist physicians who performed the cranial ultrasound, echo-cardiographic, and eye examinations were not aware of the child’s grouping status. The rest of the medical treatment of these infants was as per the attending neonatologist.
Statistical Analysis
SNIPPV and NCPAP groups were compared with the use of student’sttest,2, or Mann-WhitneyUanalyses, as appropriate.
Mantel-Haenszel2was used for the subgroup analyses. Logistic
regression was used to examine factors that influenced successful extubation.P⬍.05 was considered statistically significant.
RESULTS
Between September 1998 and September 1999, 119 infants who wereⱕ34 weeks’ GA were admitted to the NICU. Sixty-eight percent (81 of 119) had RDS and hence were eligible for enrollment in this study. Consent was obtained for 64 patients. Infants (N ⫽
17) who were not randomized had demographic characteristics similar to the study patients (data not shown). Thirty-four infants were randomized to SNIPPV, and 30 infants were randomized to NCPAP. The mean birth weight was 1088 versus 1032 g, re-spectively; the GA was 28 weeks for both SNIPPV and NCPAP groups. Study infants also were similar in other characteristics as shown in Table 1.
The median age and weight at study were similar in both groups (Table 2). Before extubation, the mean airway pressure, Fio2, RAWE, and CDYNwere similar in both groups (Table 2). Postextubation blood gases also were similar in the 2 groups for 72 hours (data in Table 2 indicates the pH, Pco2of the first gas).
However, 32 (94%) of 34 infants who were ran-domized to receive SNIPPV were extubated success-fully as compared with 18 (60%)of 30 on NCPAP (P⬍.01; Table 2). Two infants failed SNIPPV, both of them on day 2 of the study. One was reintubated because of frequent apnea, the other because of an increase in Paco2. Twelve infants who were random-ized to NCPAP failed extubation because of multiple desaturations/frequent or significant apnea; 8 in-fants failed on day 1, and 4 inin-fants failed on day 2. Ten infants were reintubated. Although crossover was not part of the study design, the remaining 2 infants were placed on SNIPPV (at the discretion of the attending neonatologist) and remained extubated successfully. Even when these 2 infants were ex-cluded from analyses, the success rate of SNIPPV over NCPAP (32 [94%] of 34 vs 16 [57%] of 28) remained significant (P⫽.001).
We also looked at “late failures” (ie, infants who required reintubation after 72 hours of the study period). There were 4 infants in the SNIPPV com-pared with 1 infant in the NCPAP who were reintu-bated after the designated study period; this was not
significantly different (P ⫽ .4). Even after the late failures were taken into account, more infants on SNIPPV remained successfully extubated as com-pared with infants on NCPAP (28 [82%] of 34 vs 17 [57%] of 30;P⫽.03).
We analyzed the data regarding PFT (55 [86%] of 64). Cutoff points for RAWE and for CDYN were chosen by the use of normative data (as per the study manual of the Bicore CP-100 pulmonary monitor) in predicting successful extubation. The normal value for CDYNwas 0.5 to 1.0 mL/kg/cm H2O, whereas it was 35 to 70 cm H2O/L/s for RAWE. Among all infants (SNIPPV and NCPAP) with RAWEofⱕ70, 10 (83%) of 12 were extubated successfully. With the use of a cutoff value ofⱖ0.5 for CDYN, 33 (77%) of 43 of the infants were extubated successfully. In infants (SNIPPV and NCPAP together) with good lung func-tion (by combining the above 2 cutoff values), 8 (80%) of 10 were extubated successfully. Thus, the sensitivity, specificity, positive predictive value, and negative predictive value were 86%, 16%, 80%, and 22%, respectively. In infants with poor lung function (RAWE ⬎70 cm H2O/L/s and CDYN ⬍0.5 mL/ kg/cm H2O), successful extubation was seen in 27 (93%) of 29 infants on SNIPPV versus 15 (40%) of 25 on NCPAP (P⬍.01).
There were no differences between infants who were or were not extubated successfully except that success was associated with a higher weight at the time of extubation (1.24⫾0.04 vs 4.95⫾0.08 kg;P⫽
.001). However, by logistic regression analysis, both mode of extubation (P⫽.001) and weight (P⫽.006) predicted successful extubation. When weight was controlled for, the odds of successful extubation in the SNIPPV group were 21.1 times higher (95% con-fidence interval: 3.4, 130.1) than that of the NCPAP group.
There were no deaths in either group. Days on PPV, oxygen days, neonatal sepsis, air leaks, patent ductus arteriosus, use of postnatal steroids, intraven-tricular hemorrhage, perivenintraven-tricular leukomalacia, necrotizing enterocolitis, ROP, CLD, and length of stay were not significantly different in the 2 groups (Table 3).
We also did a subgroup analysis of the successful
TABLE 1. Demographic Data Parameter SNIPPV
(n⫽34)
NCPAP (n⫽30)
P
Value BW (g)* 1088⫾64 1032⫾76 .57 GA (wk)* 27.7⫾0.4 27.6⫾0.6 .87 Male gender [n(%)] 17 (50) 17 (57) .63 African American
mother [n(%)]
30 (88) 25 (83) .35
Chorio [n(%)] 8 (24) 3 (10) .19 ANS [n(%)] 28 (82) 21 (70) .38 PIH [n(%)] 7 (21) 6 (20) 1.0 Surfactant doses* 1.3⫾0.2 1.1⫾0.2 .35 BW indicates birth weight; Chorio, choroamnionitis; ANS, ante-natal steroids; PIH, pregnancy-induced hypertension.
* Mean⫾standard error of the mean.
TABLE 2. Respiratory Profile of Infants Parameter SNIPPV
(n⫽34)
NCPAP (n⫽30)
P
Value
Weight at study (g)* 1110⫾55 1200⫾75 .32 Age at study (d)† 4 (1–83) 2.5 (1–106) .95 Pre-extubation MAP
(cm H2O)*
4.9⫾0.2 5.1⫾0.2 .38
Pre-extubation Fio2* 0.3⫾0.02 0.3⫾0.01 .84
RAWE(cm H2O/L/s)* 169⫾16 205⫾21 .18
CDYN(ml/kg/cm H2O)* 0.8⫾0.09 0.92⫾0.14 .48
Postextubation pH* 7.36⫾0.03 7.34⫾0.02 .14 Postextubation CO2
(mmHg)*
37⫾1 40⫾2 .06
Apnea (n)* 2.24⫾0.80 2.03⫾0.70 .84 Successful extubation
[n(%)]
32 (94) 18 (60) ⬍.01
extubation within the SNIPPV and NCPAP groups on the basis of birth weight categories as per the randomization protocol. In all 3 birth weight cate-gories, more infants on SNIPPV remained success-fully extubated: in infants with birth weight of⬍750 g, 5 (100%) of 5 on SNIPPV versus 4 (57%) of 7 on NCPAP (P⫽.2); in infants with birth weight of 750 to 999 g, 10 (83%) of 12 on SNIPPV versus 3 (27%) of 11 on NCPAP (P⫽.01); and for those weighing⬎999 g, 17 (100%) of 17 on SNIPPV versus 11 (92%) of 12 on NCPAP (P⫽.41). We evaluated further the NICU outcome in the 3 birth weight categories. The groups were similar; however, the number of infants in each birth weight category were too small for definite conclusions. No adverse effects of either therapy (SNIPPV or NCPAP) were noted during the hospital stay of the infants.
DISCUSSION
In this prospective, randomized, controlled study, we showed that infants who were extubated to the SNIPPV mode had a significantly higher success rate compared with the NCPAP group (94% vs 60%;P⬍
.01) at 72 hours postextubation. The study patients were well matched in terms of birth weight, GA, and severity of RDS (using doses of surfactant as a sur-rogate marker) as shown in Table 1. The age and the weight at study as well as preextubation parameters were not significantly different (Table 2).
With increased survival of very low birth weight (VLBW) infants, the number of VLBW infants who require prolonged mechanical ventilation has in-creased. Increasingly, the pulmonary management of these infants is directed at minimizing the need for prolonged mechanical ventilation to reduce ventila-tor-induced trauma and oxygen toxicity. Neverthe-less, early extubation often presents difficulties be-cause of upper-airway instability, poor respiratory drive, alveolar atelectasis, and residual lung dam-age.11,26,27 CPAP, by various means, commonly is
used to wean premature infants from mechanical ventilation.
Numerous investigators have shown that NCPAP is better than oxyhood,1,2,4,6,10,11and we showed pre-viously12 that NCPAP is as efficacious as NPCPAP for successful weaning from the ventilator. Potential benefits of NCPAP include prevention of atelectasis,1 improved oxygenation,10 and decreased apnea.10 Miller et al28 speculated that NCPAP decreases su-praglottic resistance directly through mechanical splinting of the airway and that this might be the primary mechanism for reduction of obstructive ap-nea in premature infants. It has been shown that NCPAP improves thoracoabdominal motion syn-chrony, and this is suggestive of an improved breath-ing strategy.29 Recently, Kiciman et al18 showed a decrease in thoracoabdominal motion asynchrony in newborns who were ventilated with nasal IMV and that nasal IMV decreased flow resistance through the nasal prongs and improved the stability of the chest wall, resulting in improved pulmonary mechanics. We support the notion that the addition of a PIP above PEEP by using SNIPPV not only adds inter-mittent distending pressure above PEEP but also increases flow delivery in the upper airway as sug-gested by Friedlich et al.30 Furthermore, Moretti et al20found that application of SNIPPV was associated with an increase in tidal and minute volumes as compared with NCPAP in the same infant. Further-more, SNIPPV could be creating an inadvertent PEEP that would allow recruitment of alveoli and improved functional residual capacity. All of the above factors probably account for the success of SNIPPV over NCPAP in our study.
Ryan et al,14 in a crossover study that evaluated the frequency of apnea/bradycardia for 6 hours after extubation, did not find any advantage of NIPPV over NCPAP. Similarly, we found no difference in the incidence of apnea in both of our study groups during 72 hours. Lin et al,16 in their study of 34 infants, concluded that NIPPV is more effective than NCPAP in reducing the frequency of apneic episodes during a 4-hour observation period. In the present study, overall, only 41% of infants had apnea (14 and 11 infants in the NCPAP and SNIPPV groups, re-spectively), and we had a low frequency of apnea in both groups (Table 2) during the study period (72 hours). Lin et al14themselves pointed out that they had a higher incidence of apnea as compared with Ryan et al.16Our lower incidence of apnea could be attributable to a different patient population, thera-peutic levels of aminophylline, higher hematocrit, or better respiratory support.
Recently, Derleth15reported his clinical experience with NIPPV in 7 premature infants. Five of the 7 infants were treated successfully with NIPPV and avoided reintubation. Barrington et al19in their trial found that nasal synchronized IMV was more effec-tive than NCPAP in preventing extubation failure in 54 VLBW infants in the first 72 hours after extuba-tion. Our results support those of previous stud-ies15,17,19,20in that nasal ventilation can be beneficial to preterm neonates. Similarly, Friedlich et al30 also concluded that nasal synchronized IMV is more
ef-TABLE 3. NICU Course
Parameter SNIPPV (n⫽34)
NCPAP (n⫽30)
P
Value
fective than NPCPAP in decreasing extubation fail-ure.
Visveshwara et al,17 in a nonrandomized trial, re-ported that using expiratory resistance of ⬍225 cm H2O/L/s as a cutoff value could predict successful weaning to SNIPPV with a sensitivity of 87% and a specificity of 71%. Using the same cutoff value as the above mentioned study,17we found a sensitivity of 71% and a specificity of 54%. In the present study, with the use of a combination of RAWEof ⱕ70 cm H2O/L/s and CDYN of ⱖ.5 mL/kg/cm H2O, the sensitivity was 86% and the specificity was 16%. Interestingly, even with poor lung function (RAWE ⬎70 cm H2O/L/s and CDYN⬍0.5 mL/kg/cm H2O), successful extubation was seen in 27 of 29 (93%) infants on SNIPPV versus 15 of 25 (40%) on NCPAP (P⬍.01). As was true in the present trial, PFT alone may not be useful in determining optimal timing of extubation in premature infants.31
There were no adverse effects of therapy noted or differences in NICU outcome in both groups. It is intriguing to note that infants who were on SNIPPV (vs NCPAP) had less ROP (ⱖstage II; 32% vs 57%;
P ⫽ .08) and decreased CLD (35% vs 53%;P ⫽ .2) (Table 3). Because our study was not designed to evaluate specifically whether SNIPPV could decrease ROP or CLD, we can only speculate that infants who were on SNIPPV had decreased ventilator-induced trauma and oxygen toxicity.
CONCLUSION
We found SNIPPV to be more effective than NCPAP in weaning infants with RDS from mechan-ical ventilation. PFT may be used to aid in predicting successful extubation. In concurrence with the re-sults of other investigators,12,14,17,19 we recommend that SNIPPV be used as the primary mode of extu-bation, even in infants with poor lung function. Fur-thermore, a prospective randomized trial should be conducted to ascertain whether SNIPPV has an im-pact in decreasing ROP and CLD.
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DOI: 10.1542/peds.108.1.13
2001;108;13
Pediatrics
M. Nabeel Khalaf, Nancy Brodsky, John Hurley and Vineet Bhandari
Airway Pressure as Modes of Extubation
Intermittent Positive Pressure Ventilation Versus Nasal Continuous Positive
A Prospective Randomized, Controlled Trial Comparing Synchronized Nasal
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DOI: 10.1542/peds.108.1.13
2001;108;13
Pediatrics
M. Nabeel Khalaf, Nancy Brodsky, John Hurley and Vineet Bhandari
Airway Pressure as Modes of Extubation
Intermittent Positive Pressure Ventilation Versus Nasal Continuous Positive
A Prospective Randomized, Controlled Trial Comparing Synchronized Nasal
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