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A 7-month-old boy has remained intubated for multiple days following a tumor resection. A recent systematic review and meta-analysis analyzed the extubation failure rates with different forms of noninvasive respiratory support versus conventional oxygen therapy in pediatric patients. According to this meta-analysis, as this patient demonstrates readiness for extubation, which of the following forms of noninvasive respiratory support is MOST likely to prevent the need for reintubation?
(A) High-flow nasal cannula X(B) Continuous positive airway pressure ✔
(C) Bilevel positive airway pressure X
Gain insight on this topic, and many others, with Summaries of Emerging Evidence (SEE) 2024 – now available. The content is aggregated from 30 international medical journals to streamline your learning and improve your practice.
Reintubation in critically ill adult and pediatric patients following extubation is associated with worse outcomes. To reduce the rate of extubation failure, noninvasive forms of respiratory support can be used prophylactically following extubation. Typical forms of noninvasive respiratory support following extubation include high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP) ventilation, and bilevel positive airway pressure (BiPAP) ventilation. The optimal form of noninvasive respiratory support in the pediatric population is currently unknown.
A recent systematic review and meta-analysis was conducted to compare the efficacy of different forms of noninvasive respiratory support in preventing extubation failure in critically ill children. Extubation failure was defined as a need for reintubation within 48 to 72 hours following the initial extubation. Treatment failure was defined as a need for reintubation and a need for escalation or crossover to another form of noninvasive respiratory support. Additional clinical outcomes were also examined, including mortality, pediatric intensive care unit (PICU) length of stay, total duration of noninvasive respiratory support, hospital length of stay, pressure injuries, and abdominal distention.
A search of the MEDLINE, Embase, and CINAHL Complete databases was conducted. A total of 11,615 records were screened, and 9 randomized clinical trials met eligibility criteria. Studies that met eligibility criteria included critically ill children aged 37 weeks to 18 years who received invasive mechanical ventilation for more than 24 hours. The rates of extubation failure and treatment failure for different forms of noninvasive respiratory support and conventional oxygen therapy were determined from the eligible studies. The effect of the different forms of noninvasive respiratory support was compared to the effect of conventional oxygen therapy using a surface under the cumulative ranking curve to determine the likelihood that a given intervention was most preferred. A similar process was conducted for secondary outcomes.
All 9 studies included in this meta-analysis reported rates of extubation failure and treatment failure for conventional oxygen therapy as well as alternative forms of noninvasive respiratory support (CPAP, BiPAP, and HFNC). All forms of noninvasive respiratory support had lower rates of extubation failure and treatment failure than conventional oxygen therapy. CPAP had the greatest reduction in extubation failure (6% absolute risk reduction) and had the highest probability of being the best therapy. CPAP was also the most likely to reduce treatment failure (12% absolute risk reduction), followed by HFNC (11% absolute risk reduction). Treatment failure for patients who received noninvasive respiratory support was reduced the most for patients younger than 6 months of age.
Secondary clinical outcomes were not reported in each study included in this meta-analysis, which may limit the conclusions reached. Additionally, in some studies, noninvasive forms of respiratory support were compared among one another rather than to conventional oxygen therapy. Hospital length of stay was reduced for patients treated with HFNC (–8.7 days; 95% credible interval, –19.0 to 1.1) and CPAP (–9 days; 95% credible interval, –20.0 to 2.4) compared to those treated with conventional oxygen therapy. No difference was found in PICU length of stay or PICU mortality with any of these modalities. A modest reduction was found in overall hospital mortality rate with CPAP compared to HFNC; however, hospital mortality rate with conventional oxygen therapy or BiPAP was not studied. CPAP and HFNC had similar sedation use and rate of aspiration events.
Finally, nasal injury and abdominal distention are concerns of noninvasive respiratory support. A slight increase was found in nasal injury for all noninvasive respiratory support compared to conventional oxygen therapy: 1.3% for HFNC; 3.8% for CPAP; and 8.7% for BiPAP. A modest increase also was found in abdominal distention for all forms of noninvasive respiratory support compared to conventional oxygen therapy: 2.4% for HFNC; 2.8% for CPAP; and 3.2% for BiPAP.
Overall, this systematic review and meta-analysis demonstrated that in pediatric patients intubated for more than 24 hours, noninvasive respiratory support compared to conventional oxygen therapy following extubation reduced the rates of extubation failure and treatment failure. CPAP, followed by HFNC, had the greatest reduction in these events. However, both modalities showed a modest increase in nasal injury and abdominal distention.
Reference
Date of last update: July 9, 2024
