221 - Post-extubation use of non-invasive respiratory support in preterm infants: a network meta-analysis

Poster Number: 221
Publication Number: 221.2983

Background: Various forms of non-invasive respiratory support are increasingly used to reduce extubation failure and associated morbidities in preterm infants. However, their safety and efficacy remain uncertain.

Objective: To conduct a systematic review and meta-analyses of randomized controlled trials (RCTs) comparing different forms of non-invasive respiratory support using a network meta-analysis approach.

Design/Methods: We systematically searched multiple databases using a pre-specified search strategy for RCTs comparing two or more non-invasive support modes in preterm neonates < 37 weeks gestational age. The studied modes included continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation (NIPPV), non-invasive neurally adjusted ventilatory assist (NIV-NAVA), non-invasive high-frequency ventilation (NIHFV), high flow nasal cannula (HFNC), Biphasic CPAP, or High-CPAP. Following data extraction by two authors independently, network meta-analyses were performed using a Bayesian approach, with CPAP as the reference mode. Treatment failure, need for intubation, and moderate-severe bronchopulmonary dysplasia (BPD) were primary outcomes. Network risk ratios (nRR) with 95% credible intervals (CrI) were estimated, and the surface under the cumulative ranking (SUCRA) values were used to generate relative rankings. Certainty of evidence (CoE) was assessed using the GRADE framework, which incorporated risk of bias (ROB) assessed using Cochrane’s ROB tool, reporting bias, indirectness, imprecision, heterogeneity and incoherence.

Results: 49 RCTs were included. For treatment failure, NIPPV (nRR 0.47, 95% CrI 0.35-0.62, CoE-low) and NIHFV (nRR 0.39, 95% CrI 0.24-0.60, CoE-moderate) showed a significant difference compared to CPAP (Table 1). Similarly, for the need for intubation, NIPPV (nRR 0.51, 95% CrI 0.38-0.67, CoE-low), NIHFV (nRR 0.37, 95% CrI 0.23-0.58; CoE-moderate), NIV-NAVA (nRR 0.37, 95% CrI 0.13-0.98; CoE-low) showed a significant difference compared to CPAP (Table 2). The SUCRA estimated NIHFV as the most effective non-invasive respiratory support for treatment failure and need for intubation. None of the non-invasive respiratory support modes showed any significant difference in the risk of moderate-severe BPD compared to CPAP (Table 3).

Conclusion(s): The evidence indicates that NIPPV and NIHFV may be more effective than CPAP in reducing treatment failure. Similarly, NIPPV, NIV-NAVA, and NIHFV may be superior to CPAP in reducing the need for intubation. However, there is no difference among non-invasive respiratory support modes in reducing the risk of moderate-severe BPD.