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A Randomized, Controlled Trial Comparing Two Different Continuous
Positive Airway Pressure Systems for the Successful Extubation of
Extremely Low Birth Weight Infants
Beatrice M. Stefanescu, MD*; W. Paul Murphy, MD‡; Brenda J. Hansell, RT, CCRC*; Mamta Fuloria, MD*;
Timothy M. Morgan, PhD§; and Judy L. Aschner, MD*
ABSTRACT. Objective. To determine whether the use
of the Infant Flow continuous positive airway pressure
(IF CPAP) system reduces the rate of extubation failure
among extremely low birth weight (ELBW) infants (in-
fants with birth weight <1000 g) when compared with
conventional CPAP delivered with a conventional venti-
lator and nasal prongs.
Methods. A prospective, unmasked, randomized,
controlled clinical trial was conducted in 162 eligible
intubated ELBW infants who were hospitalized in 2 in-
tensive care nurseries in Winston-Salem, North Carolina,
between July 1997 and November 2000. Successful extu-
bation was defined as no need for reintubation for any
reason for at least 7 days after the first extubation at-
tempt.
Results. The individual extubation success rates were
61.9% (52 of 84) in the conventional CPAP group and
61.5% (48 of 78) in the IF CPAP group. There were no
significant differences in the extubation success rate in
any birth weight subset between the 2 cohorts. The most
common cause of extubation failure was apnea/bradycar-
dia. Infants who were randomized to IF CPAP had fewer
days on supplemental O
2
and shorter hospital stays.
Conclusions. Extubation failure is a common prob-
lem, occurring in nearly 40% of ELBW infants who re-
quire mechanical ventilation. IF CPAP was as effective
but no more effective than conventional CPAP in pre-
venting extubation failure among ELBW infants. New
strategies are needed to identify predictors of extubation
success and to treat apnea/bradycardia, the most common
cause of extubation failure, thereby reducing the likeli-
hood of prolonged intubation in this high-risk cohort of
premature infants. Pediatrics 2003;112:1031–1038; contin-
uous positive airway pressure, extremely low birth weight,
extubation, Infant Flow CPAP.
ABBREVIATIONS. ELBW, extremely low birth weight; BPD,
bronchopulmonary dysplasia; NCPAP, nasal continuous positive
airway pressure; IF, Infant Flow; BW, birth weight; Fio
2
, fraction
of inspired oxygen; NIPPV, nasal intermittent positive pressure
ventilation.
P
rolonged intubation and mechanical ventila-
tion of extremely low birth weight (ELBW)
infants is associated with upper airway trauma
and development of bronchopulmonary dysplasia
(BPD).
1
Extubation of ELBW infants to nasal contin-
uous positive airway pressure (NCPAP) has been
shown to decrease the need for reintubation, thereby
reducing these ventilator-associated risks.
2–4
CPAP
has also been shown to reduce atelectasis, improve
ventilation-perfusion matching, and reduce apnea of
prematurity.
5,6
Various systems for delivering CPAP are avail-
able, but there is little evidence for the superiority of
one system over another.
7–10
The Infant Flow (IF)
CPAP system (Electro Medical Equipment Ltd, Sus-
sex, England), invented in Sweden in the 1980s by
Moa and Nielson and approved for use in the United
States in 1995, uses a dedicated driver and generator
with unique fluid mechanics to adjust the gas flow
throughout the respiratory cycle. The fluid flip action
of the IF generator has been reported to assist spon-
taneous breathing and reduce the work of breathing
by reducing expiratory resistance and maintaining a
stable airway pressure throughout respiration.
11–14
However, published reports on the efficacy or supe-
riority of IF CPAP have been confined to laboratory
studies using a test lung or clinical studies of brief
duration with measurements of pulmonary function
as the only endpoints.
11–17
Nevertheless, this techno-
logically novel device is gaining widespread accep-
tance in European and North American nurseries
18
without supporting evidence from randomized, con-
trolled clinical trials of the efficacy or superiority of
IF CPAP versus other CPAP delivery systems for
facilitating extubation or preventing the need for
mechanical ventilation.
The present study was designed to test the hypoth-
esis that the use of the IF CPAP system will reduce
the extubation failure rate, defined as no need for
reintubation within 7 days of extubation, among
ELBW infants by 50% (from 40% to 20%) when com-
pared with conventional CPAP delivered by a me-
chanical ventilator and INCA prongs (Ackrad Labo-
ratories, Inc, Cranford, NJ). Secondary outcome
measures included death, survival without BPD, and
the length of hospital stay.
From the Departments of *Pediatrics, ‡Anesthesia, and §Public Health
Services, Wake Forest University School of Medicine, Winston-Salem, North
Carolina.
Received for publication Jan 13, 2003; accepted Apr 24, 2003.
Reprint requests to (J.L.A.) Department of Pediatrics, Wake Forest Univer-
sity School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-
1081. E-mail: jaschner@wfubmc.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad-
emy of Pediatrics.
PEDIATRICS Vol. 112 No. 5 November 2003 1031
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METHODS
A retrospective chart review of 30 infants who had birth weight
(BW) ⱕ1000 g and were treated in 2 intensive care nurseries under
the management of neonatologists from Wake Forest University
School of Medicine demonstrated a 40% extubation failure rate,
consistent with the published literature.
3,5,19,20
Power analysis in
-
dicated that a cohort of 162 infants would be needed to demon-
strate a 50% reduction in extubation failure from 40% to 20%, with
a power of 0.8 and an
␣
-error of 0.05.
Patients, Randomization, and Study Criteria
A prospective, unmasked, randomized, controlled trial of IF
CPAP versus conventional CPAP for successful extubation was
initiated in 1997 in consecutive eligible ELBW infants in the inten-
sive care nurseries at Brenner Children’s Hospital and Forsyth
Medical Center in Winston-Salem, North Carolina. Between July
1997 and November 2000, 162 ELBW infants were assigned using
a table of random numbers and sealed opaque envelopes to either
IF CPAP or conventional CPAP and stratified into 3 BW blocks as
follows: ⱕ600 g, 601 to 800 g, and 801 to 1000 g. Randomization
occurred after informed consent had been obtained from the in-
fant’s parent or legal guardian and close to the time of the infant’s
first extubation attempt. In the rare circumstance when an infant
was randomized but not immediately extubated, the randomiza-
tion card was marked with indelible ink and kept in the study
notebook at the respiratory therapy desk in the nursery until
extubation occurred. CPAP was delivered per randomization as-
signment with either IF CPAP or “conventional CPAP” using
INCA prongs and a time-cycled, pressure-limited ventilator. Our
study design precluded crossover between the CPAP delivery
systems.
The primary endpoint was a reduction in the percentage of
infants who failed extubation, defined as no need for reintubation
for 168 hours (7 days). Secondary endpoints were death, survival
without BPD, number of days on CPAP, days on supplemental
oxygen, and length of hospitalization. Potential confounders of
extubation success, such as necrotizing enterocolitis, patent ductus
arteriosus, sepsis, and intracranial hemorrhage, were also com-
pared between the 2 groups.
Study entry criteria included BW ⱕ1000 g, need for mechanical
ventilation, first extubation attempt, and signed parental consent.
Exclusion criteria included major chromosomal anomalies, known
airway anomalies, neuromuscular disorders, other major congen-
ital malformations, and participation in a concurrent randomized
clinical trial. Regardless of gestational age or BW, the suggested
criteria for a mandatory trial of extubation included respiratory
stability for 12 to 24 hours on minimal ventilatory settings, defined
as mean airway pressure ⱕ5 cm on conventional mechanical
ventilation or ⱕ7 cm on high-frequency ventilation, with pH
ⱖ7.25, Pco
2
ⱕ65 torr, and fraction of inspired oxygen (Fio
2
) ⱕ0.3.
Infants could be extubated from higher levels of support at at-
tending discretion. The study protocol included administration of
methylxanthine therapy before extubation. Infants were extubated
to CPAP of 4 to 6 cm H
2
O and were to remain on their assigned
CPAP device for a minimum of 24 hours. CPAP was discontinued
when the infants were stable on CPAP of 4 cm H
2
O and Fio
2
ⱕ0.3
and the patient was having ⬍5 apneic episodes per day.
Extubation failure was defined as the need for reintubation and
mechanical ventilation for any reason within 168 hours of initial
extubation. Patients were reintubated when they exhibited arterial
hemoglobin saturations ⬍88% while receiving Fio
2
ⱖ0.50, arterial
CO
2
ⱖ65 torr with arterial pH ⬍7.25, the need for CPAP ⬎8cmof
H
2
O, or recurrent significant apnea or bradycardia requiring bag-
mask ventilation or vigorous stimulation. Infants who deterio-
rated after CPAP was discontinued were placed back on their
initially assigned CPAP system unless immediate reintubation
and mechanical ventilation was deemed necessary. Infants who
failed their initial extubation attempt and required reintubation
were extubated on subsequent attempts to the CPAP system to
which they were initially randomized.
Cranial ultrasounds were performed on all infants on days 7
and 42 of life or more frequently as clinically indicated. Cranial
ultrasounds were read by radiologists who were masked to the
infants’ randomization assignment. Radiographs, blood cultures,
and echocardiography were done when clinically indicated. Ma-
ternal and infant demographic data, birth history, chest radio-
graphs, cranial ultrasound reports, pharmacy records, and respi-
ratory data were collected.
Study Definitions
Air leaks were documented by evidence of pneumothorax,
pneumomediastinum, or pulmonary interstitial emphysema on
chest radiograph. Patent ductus arteriosus was documented by
echocardiography. Intraventricular hemorrhage was determined
according to Papile’s classification of cranial ultrasound findings
of echodensity in the germinal matrix or ventricular extension.
Periventricular leukomalacia was defined by development of
periventricular cysts identified by cranial ultrasound. Sepsis was
diagnosed by a positive blood culture or suggestive clinical and
laboratory presentation resulting in a clinical decision to treat with
antibiotics for at least 7 days despite the absence of a positive
blood culture. Necrotizing enterocolitis was defined as stage 2 or
higher as per modified Bell’s criteria.
21
Retinopathy of prematu
-
rity was defined as per the international classification.
22
BPD was
defined as an oxygen dependence at 36 weeks’ postmenstrual age
in association with characteristic radiograph changes.
Statistical Methods and Data Analysis
Patient characteristics were summarized using observed pro-
portions and means, standard deviations, and ranges. Compari-
sons between categorical outcomes and patient characteristics be-
tween the 2 CPAP groups were tested using Fisher exact test.
Comparisons between continuous measures between the 2 CPAP
groups were tested using the t test. Time to reintubation among
the infants with extubation failure in each CPAP group was de-
picted using Kaplan-Meier plots, and comparison of time on
CPAP was tested using the log-rank statistics.
Ethics
The research protocol for this study was approved by the
Institutional Review Boards of the Wake Forest University School
of Medicine and Forsyth Medical Center. The procedures followed
were in accordance with the Helsinki Declaration of 1975 as re-
vised in 1983.
RESULTS
Between July 1997 and November 2000, 500 infants
who were ⱕ1000 g at birth were admitted to the
intensive care nurseries at Brenner Children’s Hos-
pital and Forsyth Medical Center (Fig 1). Of these,
162 infants fulfilled the study entry criteria and were
enrolled in our study. Among the 338 nonenrolled
infants, 33% (n ⫽ 103) died before their first extuba-
tion attempt, 23% (n ⫽ 78) were extubated before
consent was obtained, 10% (n ⫽ 33) of parents re-
fused participation, 25% (n ⫽ 87) were ineligible
either because they were enrolled in a competing
study (15%, n ⫽ 52) or they met the other ineligibility
criteria (10%; n ⫽ 35). In 7% (n ⫽ 23), there were
other reasons for nonenrollment (study enrollment
ended before extubation, nares were too small, phy-
sician chose IF CPAP, error of enrollment, or consent
deferred because of maternal illness or unavailabil-
ity), and 4% (n ⫽ 14) of infants were transferred to
another hospital (Fig 1).
Among the 162 patients enrolled, 84 infants were
randomized to receive conventional CPAP and 78
infants were randomized to receive IF CPAP postex-
tubation. There were no statistical differences be-
tween the 2 groups with regard to any of the baseline
maternal characteristics (Table 1). Likewise, there
was no significant difference in any of the baseline
infant characteristics (Table 2).
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Per study protocol, methylxanthine administration
should have been given before the initial extubation
attempt. However, 10 infants were extubated before
methylxanthine administration. Of these 10 infants,
all 3 in the IF CPAP group and 4 of the 7 infants in
the conventional CPAP group were extubated suc-
cessfully; the remaining 3 infants in the conventional
CPAP group failed extubation because of a need for
⬎8cmH
2
O CPAP to maintain arterial hemoglobin
saturations above 88%.
To address other potential confounders of extuba-
tion failure, we compared the rates of other compli-
cations of prematurity. As shown in Table 3, the 2
groups were comparable with respect to their clinical
outcomes. Fewer infants received bronchodilators in
the IF CPAP group (8%) compared with conven-
tional CPAP group (19%), which did reach statistical
significance (P ⫽ .04).
The overall extubation success rate in the com-
bined cohort was 61.7%. There were no significant
differences between the infants who were random-
ized to the IF system and the conventionally deliv-
ered CPAP system with respect to the primary out-
come variable of successful extubation. Among the
infants in the IF CPAP group, 61.5% (48 of 78 pa-
tients) remained extubated, whereas in the conven-
tional CPAP group, 61.9% (52 of 84 patients) were
extubated successfully. Both of these results approx-
Fig 1. Flow diagram of ELBW infants who were screened and randomly assigned to the IF CPAP and conventional CPAP groups,
adapted from the Consort Statement.
23
The number of infants excluded and the reasons for nonenrollment are provided. Two infants in
the IF CPAP group did not receive the allocated treatment (1 infant died after randomization but before extubation, and 1 was extubated
directly to nasal cannula). Statistical analysis was by “intention to treat.”
TABLE 1. Maternal Baseline Characteristics
Maternal Characteristics Conventional CPAP
(n ⫽ 84)
IF CPAP
(n ⫽ 78)
Age (y)
Mean ⫾ SD 26.7 ⫾ 6.2 25.5 ⫾ 6
Range 14–40 14–39
Ethnicity (n [%])
White 39 (46%) 46 (59%)
Black 38 (45%) 28 (36%)
Asian 1 (0.1%) 1 (0.1%)
Hispanic 4 (0.5%) 2 (0.2%)
Other 2 (0.2%) 1 (0.1%)
Antenatal steroids (n [%])
Complete 38 (45.2%) 36 (46.1%)
Incomplete 21 (25.0%) 16 (20.5%)
None 22 (26.2%) 21 (26.9%)
Unknown 3 (3.6%) 5 (6.4%)
Chorioamnionitis (%) 12 (15%) 11 (13%)
Preeclampsia/eclampsia (n [%]) 22 (26%) 16 (20%)
Cesarean section (n [%]) 46 (54.7%) 49 (62.8%)
SD indicates standard deviation.
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imated our historical control finding of a 40% extu-
bation failure rate among infants with BW ⱕ1000 g.
Figure 2 is a Kaplan-Meier curve depicting the time
to reintubation among the infants who failed extu-
bation in each CPAP group. There were no signifi-
cant differences in the time to reintubation among
the 2 groups.
Figure 3 shows the percentage of infants who were
extubated successfully as a function of BW. We did
not find any statistical differences between the 2
CPAP groups among the 3 BW categories: ⱕ600 g,
601 to 800 g, and 801 to 1000 g. The mean weight at
extubation was higher among infants in the conven-
tional CPAP group (828 ⫾ 195 g vs 781 ⫾ 135 g in the
IF CPAP group), and infants in the conventional
CPAP group were slightly older (mean age at extu-
bation: 16.6 ⫾ 19.1 days in the conventional CPAP
group and 13 ⫾ 13.3 days in the IF CPAP group),
although these differences were not statistically sig-
nificant.
We found no significant differences between the 2
CPAP groups as a function of extubation weight (Fig
4). Infants who weighed ⱕ600 g were as likely to be
extubated successfully as infants who weighed 601 to
1000 g. Infants who weighed ⬎1000 g at the time of
extubation had a 92% likelihood of being extubated
successfully.
As shown in Table 4, there were no significant
Fig 2. Kaplan-Meier curve depicting the time course of extuba-
tion failure among infants in each CPAP group who required
reintubation within the first 7 days (168 hours). Approximately
40% of infants in both groups were reintubated by 168 hours.
Almost 15% of all infants, or approximately 35% of infants who
failed the first extubation attempt, required reintubation within 24
hours.
TABLE 2. Infant Baseline Characteristics
Infant Characteristics Conventional CPAP
(n ⫽ 84)
IF CPAP
(n ⫽ 78)
BW (g)
Mean ⫾ SD 755 ⫾ 155 744 ⫾ 123
Range 406–1000 440–985
Gestational age (wk)
Mean ⫾ SD 25.7 ⫾ 2.0 25.9 ⫾ 1.5
Range 22–31 23–29
Male sex (n [%]) 35 (42%) 33 (42%)
Singleton (n [%]) 63 (75%) 64 (82%)
CRIB score
Mean ⫾ SD 7.4 ⫾ 4.4 7.9 ⫾ 3.8
Range 1–17 1–16
Surfactant therapy (n [%]) 82 (98%) 78 (100%)
1-minute Apgar score (mean ⫾ SD) 4.2 ⫾ 2.4 4.5 ⫾ 2.5
5-minute Apgar score (mean ⫾ SD) 6.5 ⫾ 2.1 6.3 ⫾ 2.2
CRIB indicates Clinical Risk Index for Babies.
TABLE 3. Clinical Outcomes in the Conventional CPAP and IF CPAP Groups
Outcome Conventional CPAP
(n ⫽ 84)
IF CPAP
(n ⫽ 78)
PDA treated with indomethacin (n [%]) 48 (59%) 43 (55%)
PDA ligation (n [%]) 13 (15%) 6 (8%)
Sepsis (n [%]) 70 (83%) 66 (85%)
Postnatal steroids for BPD (n [%]) 53 (63%) 44 (56%)
Diuretics (n [%]) 57 (68%) 46 (59%)
Bronchodilators (n [%]) 16 (19%) 6 (8%)
NEC (n [%]) 15 (18%) 18 (23%)
PIE (any grade; n [%]) 17 (20%) 20 (26%)
Gross air leak (n [%]) 10 (12%) 4 (5%)
ROP (n [%]) 72 (86%) 60 (77%)
Surgery (n [%]) 9 (11%) 6 (8%)
IVH (grades 1 and 2; n [%]) 17 (20%) 13 (17%)
IVH (grades 3 and 4; n [%]) 14 (17%) 11 (14%)
PVL (n [%]) 5 (6%) 3 (4%)
Ventriculomegaly (n [%]) 25 (30%) 24 (31%)
PDA indicates patent ductus arteriosus; NEC, necrotizing enterocolitis; PIE, pulmonary interstitial
emphysema; ROP, retinopathy of prematurity; IVH, intraventricular hemorrhage; PVL, periventricu-
lar leukomalacia.
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differences between the 2 CPAP groups with respect
to blood gas parameters or ventilator settings in the
hour before first extubation attempt. Eleven (13%)
infants in the conventional CPAP group and 13 (17%)
infants in the IF CPAP group were extubated directly
from high-frequency ventilation. One infant in each
group was extubated from the Bunnell Life Pulse
high-frequency jet ventilator; the other infants were
extubated directly from the SensorMedics 3100A
high-frequency oscillatory ventilator.
There were no statistical differences between the
groups with respect to the outcomes of death, sur-
vival without BPD, or total number of days on CPAP
(including initial and subsequent extubation at-
tempts) as shown in Table 5. However, infants who
were randomized to IF CPAP had fewer days on
supplemental O
2
(P ⫽ .03), and their length of hos
-
pitalization was shorter (P ⫽ .017).
The reasons for extubation failure are depicted in
Fig 5. As shown, the most common reason for extu-
bation failure was apnea and bradycardia, occurring
in almost 60% of the infants who required reintuba-
tion. Nearly equal numbers of infants required rein-
tubation because of inadequate oxygenation and in-
adequate ventilation on NCPAP (approximately 15%
in each category).
Fig 3. Successful extubation as a function of birth
weight.
Fig 4. Successful extubation as a function of
extubation weight.
TABLE 4. Ventilatory Settings and Blood Gas Parameters 1 Hour Before First Extubation Attempt
Ventilatory Settings and
Blood Gas Parameters
Conventional CPAP†
(n ⫽ 84)
IF CPAP‡
(n ⫽ 74)
Fio
2
(mean ⫾ SD)
0.33 ⫾ 0.11 0.33 ⫾ 0.10
MAP
CMV (mean ⫾ SD) 4.5 ⫾ 1.2 4.6 ⫾ 1.5
HFOV* (mean ⫾ SD) 7.5 ⫾ 27⫾ 1.5
Blood pH (mean ⫾ SD) 7.36 ⫾ 0.06 7.34 ⫾ 0.06
Blood Pco
2
(mean ⫾ SD)
46.6 ⫾ 11.9 47.2 ⫾ 11.8
MAP indicates mean airway pressure; CMV, conventional mechanical ventilation; HFOV, high-
frequency oscillatory ventilation.
* Excludes 1 infant in each group extubated from high-frequency jet ventilation.
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DISCUSSION
This prospective, randomized, controlled trial is
the largest published study to examine extubation
outcomes in infants with BW ⱕ1000 g. This is also
the first published randomized, controlled trial to
compare IF CPAP with conventional CPAP to facil-
itate successful extubation of ELBW infants. In this
study, we showed that infants who were extubated
to IF CPAP were as likely but no more likely to be
extubated successfully than infants who were placed
on conventional CPAP using nasal prongs and a
pressure/time-limited ventilator (61.5% vs 61.9%, re-
spectively). Similar to our retrospective analysis and
similar to the data available in the literature,
3,5,20
the
failure rate at the time of first extubation attempt for
infants with a BW ⱕ1000 g was approximately 40%.
The study patients were well matched in terms of
BW, gestational age, and sex, as well as severity of
illness (using Clinical Risk Index for Babies score as
a surrogate marker) as shown in Table 2. Although
the infants in the conventional CPAP group had a
higher mean weight at extubation (828 ⫾ 195gvs
781 ⫾ 135 g in the IF CPAP group) and were older at
the time of initial extubation attempt (16.4 ⫾ 18.8
days vs 12.9 ⫾ 13.2 days in the IF CPAP group), these
differences did not reach statistical significance. We
did not find any statistical difference in the rate of
successful extubation between the 2 CPAP groups
among 3 BW subcategories: ⱕ600 g, 601 to 800 g, and
801 to 1000 g (Fig 3). Among the infants who
weighed ⱕ600 g at the time of first extubation at-
tempt, 50% (7 of 14 infants) were extubated success-
fully, a percentage that was similar to the 60% suc-
cess rate (82 of 137 infants) among those who
weighed 601 to 1000 g (P ⫽ .77). Infants with extu-
bation weight ⬎1000 g had ⬎90% likelihood of suc-
cessful extubation (Fig 4). The ventilator settings and
blood gas parameters 1 hour before the first extuba-
tion attempt were nearly identical in both groups
(Table 4).
The number of surviving ELBW infants who re-
quire prolonged mechanical ventilation has in-
creased in the past decade.
24
Efforts to limit the
duration of intermittent positive pressure ventilation
led to attempts at early weaning of ventilatory sup-
port to decrease morbidity and mortality. Early ex-
tubation of ELBW infants is fraught with difficulties
because of upper airway instability, relatively poor
respiratory drive, compliant chest wall, alveolar at-
electasis and residual lung damage. CPAP, applied
by various means and devices,
3,7,25
is frequently used
to wean infants from mechanical ventilation. Many
studies have shown that NCPAP is more beneficial
than oxyhood
2,4,9,25–28
by preventing atelectasis, de
-
creasing the frequency of apnea/bradycardia epi-
sodes, and improving lung function. However, the
use of endotracheal CPAP before extubation proved
to be more deleterious than extubation directly to
NCPAP,
27,29,30
particularly among the smallest in
-
fants.
Several published studies have investigated the
efficacy of weaning infants from mechanical ventila-
tion to nasal intermittent positive pressure ventila-
tion (NIPPV) compared with NCPAP. Most studies
that evaluated NIPPV had a small sample size.
6,20
Ryan et al,
31
when studying the advantages of
Fig 5. Reasons for extubation failure.
TABLE 5. Secondary Outcomes of Death Survival Without BPD, Days on CPAP, and Days on
Supplemental Oxygen
Secondary Outcome Conventional CPAP
(n ⫽ 84)
IF CPAP
(n ⫽ 78)
P Value
Death (n [%]) 3 (4%) 8 (10%) .12
Survival without BPD (n [%]) 31 (37%) 30 (38%) .87
Days on CPAP
Mean ⫾ SD 10.17 ⫾ 8.53 8.74 ⫾ 8.04 .27
Range 0.06–37.79 0–36.32
Supplemental O
2
(d)
Mean ⫾ SD 77.2 ⫾ 35.1 65.7 ⫾ 31.4 .03
Range 0.5–224 3–147
Length of stay (d)
Mean ⫾ SD 86.3 ⫾ 37.34 73.7 ⫾ 28.7 .017
Range 16–269 13–147
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NIPPV over NCPAP, showed no benefit of NIPPV in
the treatment of apnea of prematurity. However, the
study endpoint encompassed only a short time pe-
riod of 6 hours after extubation. Lin et al
6
found
decreased apnea in infants who were on NIPPV dur-
ing a 4-hour observation period.
Recently, in a prospective randomized study,
Khalaf et al
5
found synchronized NIPPV to be more
effective than NCPAP in weaning infants with respi-
ratory distress syndrome from mechanical ventila-
tion. The extubation success rate in the synchronized
NIPPV group was 94% at 72 hours postextubation.
Despite a higher mean gestational age and mean
weight at extubation in the Khalaf et al study, the
rate of successful extubation at 72 hours in the
NCPAP group was identical (60%) to our findings at
7 days. Although the results are encouraging, larger
prospective studies are needed to evaluate the safety
and efficacy of this technique in ELBW infants.
32
Future studies should include additional endpoints
such as survival without BPD, length of hospital
stay, incidence of complications such as gastrointes-
tinal perforation and nosocomial infections, and
long-term survival and developmental outcomes.
Despite no difference in our primary outcome of
successful initial extubation attempt or in the total
number of days on NCPAP, infants in the IF CPAP
group had fewer total days on supplemental O
2
and
shorter lengths of hospitalization. If future studies
confirm this association, then there may be a cost
advantage to the use of IF CPAP.
Extubation failure remains a common clinical
problem among ELBW infants. In our study, apnea/
bradycardia was the most common reason for extu-
bation failure in both CPAP groups. In our combined
cohort, 58% of ELBW infants who failed extubation
did so because of apnea and bradycardia episodes.
This finding is consistent with that of another re-
ported study.
33
Methods for preventing apnea and
bradycardia have been the subject of a number of
studies. The use of prophylactic methylxanthines for
extubation in ELBW infants has been shown to re-
duce the frequency and/or severity of apnea/brady-
cardia in larger preterm infants
34,35
but does not
eliminate the problem entirely, and questions about
safety remain unresolved.
36
Several studies have
shown that NIPPV can be an effective therapeutic
tool for decreasing apnea of prematurity.
CONCLUSIONS
We found no difference in the rate of extubation
failure between the IF CPAP and conventional CPAP
groups. Innovative approaches to the postextubation
treatment of these infants are needed. Novel inter-
ventions that reduce the frequency of apnea and
bradycardia are likely to reduce extubation failure
among this population of vulnerable infants.
ACKNOWLEDGMENTS
This study was supported by the Wake Forest University
School of Medicine General Clinical Research Center (grant M01-
RR07122) and an unrestricted grant from SensorMedics Corp
(Yorba Linda, CA) and Electro Medical Equipment, Ltd (Brighton,
Sussex, England).
We acknowledge the expert data formatting assistance of Rob-
ert M. Amoroso of the General Clinical Research Center of Wake
Forest University School of Medicine.
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THE ANTISEPSIS SCAMS
“Listerine had first been marketed in the late 19th century as a proprietary
promoted to physicians and was named after Sir Joseph Lister, antiseptic surgery’s
pioneer. Touted as ‘the best antiseptic for both internal and external use,’ it was
recommended for treating gonorrhea and for ‘filling the cavity, during ovariot-
omy.’ In 1921, the ebullient Gerald Lambert, son of the founder, decided to vend
his product direct to the public in a massive way. Within a few years, the
company’s sales had spurted phenomenally, and net earnings had multiplied
40-fold. Much of Listerine’s success must be credited to ‘halitosis.’ This coined
word frightened the continent, not because bad breath was a fatal malady but
because it was a social disaster. Listerine advertising raised worrisome doubts in
each reader’s mind with telling slogans like ‘even your best friends won’t tell you,’
and ‘often a bridesmaid but never a bride.’”
Young JH. The Medical Messiahs. Princeton, NJ: Princeton University Press; 1967
Submitted by Student
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2003;112;1031Pediatrics
M. Morgan and Judy L. Aschner
Beatrice M. Stefanescu, W. Paul Murphy, Brenda J. Hansell, Mamta Fuloria, Timothy
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Airway Pressure Systems for the Successful Extubation of Extremely Low Birth
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