Extubation from low-rate intermittent positive airway pressure versus extubation after a trial of endotracheal continuous positive airway pressure in intubated preterm infants

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Abstract
Failure of extubation and subsequent reintubation may result in additional stress and trauma to the premature infant. Testing infants about to be extubated with a period of endotracheal CPAP has been suggested as a method of demonstrating readiness for extubation. However, this process has been criticized as increasing the neonate's work of breathing and perhaps increasing the likelihood of extubation failure. In premature infants having their endotracheal tube removed, is direct extubation from low rate intermittent positive pressure ventilation (IPPV) more successful than that following a period of endotracheal continuous positive airway pressure (CPAP)? The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE, previous reviews including cross references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching mainly in the English language. All trials using random or quasi-random allocation of premature infants to endotracheal CPAP or direct extubation following a period of IPPV were included. Data were extracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk. Direct extubation from low rate ventilation is associated with a trend to increased chance of successful extubation when compared to extubation after a period of endotracheal CPAP, RR 0.45 (0.19,1.07), RD -0.103 (-0.200,-0.006), NNT 10 (5,167). When only truly randomized trials are considered, this result becomes both statistically significant and clinically important, RR 0.10 (0.01,0.78), RD -0.201 (-0.319,-0.083), NNT 5 (3, 12). Similar differences are seen for the secondary outcome, apnea. Preterm infants no longer requiring endotracheal intubation and IPPV should be directly extubated without a trial of ETT CPAP.