High-Flow Nasal Cannulae in Very Preterm Infants after Extubation

BackgroundThe use of high-flow nasal cannulae is an increasingly popular alternative to nasal continuous positive airway pressure (CPAP) for noninvasive respiratory support of very preterm infants (gestational age, <32 weeks) after extubation. However, data on the efficacy or safety of such cannulae in this population are lacking. MethodsIn this multicenter, randomized, noninferiority trial, we assigned 303 very preterm infants to receive treatment with either high-flow nasal cannulae (5 to 6 liters per minute) or nasal CPAP (7 cm of water) after extubation. The primary outcome was treatment failure within 7 days. Noninferiority was determined by calculating the absolute difference in the risk of the primary outcome; the margin of noninferiority was 20 percentage points. Infants in whom treatment with high-flow nasal cannulae failed could be treated with nasal CPAP; infants in whom nasal CPAP failed were reintubated. ResultsThe use of high-flow nasal cannulae was noninferior to the use of nasal CPAP, with treatment failure occurring in 52 of 152 infants (34.2%) in the nasal-cannulae group and in 39 of 151 infants (25.8%) in the CPAP group (risk difference, 8.4 percentage points; 95% confidence interval, -1.9 to 18.7). Almost half the infants in whom treatment with high-flow nasal cannulae failed were successfully treated with CPAP without reintubation. The incidence of nasal trauma was significantly lower in the nasal-cannulae group than in the CPAP group (P=0.01), but there were no significant differences in rates of serious adverse events or other complications. ConclusionsAlthough the result for the primary outcome was close to the margin of noninferiority, the efficacy of high-flow nasal cannulae was similar to that of CPAP as respiratory support for very preterm infants after extubation. (Funded by the National Health and Medical Research Council; Australian New Zealand Clinical Trials Network number, ACTRN12610000166077.) This study compared high-flow nasal cannulae with nasal continuous positive airway pressure (CPAP) for noninvasive respiratory support of very preterm infants after extubation. The efficacy of high-flow nasal cannulae was similar to that of nasal CPAP. In the United States, approximately 75,000 infants were classified as very preterm (gestational age, <32 weeks) in 2011.(1) Very preterm infants have substantially higher mortality and morbidity than term infants, partly because they are more prone to respiratory failure and often require mechanical ventilation through an endotracheal tube after birth. Once they recover from their acute breathing problems, the best way to achieve successful extubation from mechanical ventilation is controversial. Nasal continuous positive airway pressure (CPAP) is known to be superior to no positive-pressure support(2) and is the current standard of care for noninvasive respiratory support of very preterm infants. ...