Noninvasive Ventilation or CPAP for Postextubation Support in Small Infants

Andrew G Miller; Karan R Kumar; Bhargav S Adagarla; Kaitlyn E Haynes; Rachel M Watts; Jeanette L Muddiman; Travis S Heath; Veerajalandhar Allareddy; Alexandre T Rotta

doi:10.4187/respcare.11194

Noninvasive Ventilation or CPAP for Postextubation Support in Small Infants

Respir Care. 2023 Jul 25;69(1):82-90. doi: 10.4187/respcare.11194. Online ahead of print.

Authors

Andrew G Miller¹, Karan R Kumar², Bhargav S Adagarla³, Kaitlyn E Haynes⁴, Rachel M Watts⁴, Jeanette L Muddiman⁴, Travis S Heath⁵, Veerajalandhar Allareddy⁶, Alexandre T Rotta⁶

Affiliations

¹ Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Andrew.g.miller@duke.edu.
² Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
³ Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
⁴ Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
⁵ Department of Pharmacy, Duke University Medical Center, Durham, North Carolina.
⁶ Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina.

PMID: 37491072
PMCID: PMC10753612 (available on 2025-01-01)
DOI: 10.4187/respcare.11194

Abstract

Background: Infants with a high risk of extubation failure are often treated with noninvasive ventilation (NIV) or CPAP, but data on the role of these support modalities following extubation are sparse. This report describes our experience using NIV or CPAP to support infants following extubation in our pediatric ICUs (PICUs).

Methods: We performed a retrospective study of children < 10 kg receiving postextubation NIV or CPAP in our PICUs. Data on demographics, medical history, type of support, vital signs, pulse oximetry, near-infrared spectroscopy (NIRS), gas exchange, support settings, and re-intubation were extracted from the electronic medical record. Support was classified as prophylactic if planned before extubation and rescue if initiated within 24 h of extubation. We compared successfully extubated and re-intubated subjects using chi-square test for categorical variables and Mann-Whitney test for continuous variables.

Results: We studied 51 subjects, median age 44 (interquartile range 0.5-242) d and weight 3.7 (3-4.9) kg. There were no demographic differences between groups, except those re-intubated were more likely to have had cardiac surgery prior to admission (0% vs 14%, P = .040). NIV was used in 31 (61%) and CPAP in 20 (39%) subjects. Prophylactic support was initiated in 25 subjects (49%), whereas rescue support was needed in 26 subjects (51%). Twenty-two subjects (43%) required re-intubation. Re-intubation rate was higher for rescue support (58% vs 28%, P = .032). Subjects with a pH < 7.35 (4.3% vs 42.0%, P = .003) and lower somatic NIRS (39 [24-56] vs 62 [46-72], P = .02) were more likely to be re-intubated. The inspiratory positive airway pressure, expiratory positive airway pressure, and F_IO₂ were higher in subjects who required re-intubation.

Conclusions: NIV or CPAP use was associated with a re-intubation rate of 43% in a heterogeneous sample of high-risk infants. Acidosis, cardiac surgery, higher F_IO₂ , lower somatic NIRS, higher support settings, and application of rescue support were associated with the need for re-intubation.

Keywords: CPAP; children; congenital heart disease; extubation; extubation failure; infants; interfaces; noninvasive respiratory support; noninvasive ventilation; pediatric ICU; pediatric cardiac intensive care; respiratory failure.