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- Title
Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis.
- Authors
Iyer, Narayan Prabhu; Rotta, Alexandre T.; Essouri, Sandrine; Fioretto, Jose Roberto; Craven, Hannah J.; Whipple, Elizabeth C.; Ramnarayan, Padmanabhan; Abu-Sultaneh, Samer; Khemani, Robinder G.
- Abstract
Key Points: Question: What is the most effective postextubation noninvasive respiratory support modality in children? Findings: In this systematic review and network meta-analysis, extubation failure and treatment failure rates were lower with continuous positive airway pressure (CPAP), high-flow nasal cannula (HFNC), and bilevel positive airway pressure (BiPAP) compared to conventional oxygen therapy (COT). Based on bayesian ranking probabilities, CPAP was reported to be the most effective of the evaluated noninvasive respiratory support modes for the prevention of extubation failure and treatment failure. Meaning: The results suggest that CPAP, HFNC, and BiPAP were more effective than COT for providing postextubation NRS in a pediatric population. This systematic review and network meta-analysis evaluates 3 noninvasive respiratory support modes for preventing extubation failure in children compared with conventional oxygen therapy. Importance: Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support (NRS) to prevent EF is unknown. Objective: To study the reported relative efficacy of different modes of NRS (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and bilevel positive airway pressure [BiPAP]) compared to conventional oxygen therapy (COT). Data Sources: MEDLINE, Embase, and CINAHL Complete through May 2022. Study Selection: Randomized clinical trials that enrolled critically ill children receiving invasive mechanical ventilation for more than 24 hours and compared the efficacy of different modes of postextubation NRS. Data Extraction and Synthesis: Random-effects models were fit using a bayesian network meta-analysis framework. Between-group comparisons were estimated using odds ratios (ORs) or mean differences with 95% credible intervals (CrIs). Treatment rankings were assessed by rank probabilities and the surface under the cumulative rank curve (SUCRA). Main Outcomes and Measures: The primary outcome was EF (reintubation within 48 to 72 hours). Secondary outcomes were treatment failure (TF, reintubation plus NRS escalation or crossover to another NRS mode), pediatric intensive care unit (PICU) mortality, PICU and hospital length of stay, abdominal distension, and nasal injury. Results: A total of 11 615 citations were screened, and 9 randomized clinical trials with a total of 1421 participants were included. Both CPAP and HFNC were found to be more effective than COT in reducing EF and TF (CPAP: OR for EF, 0.43; 95% CrI, 0.17-1.0 and OR for TF 0.27, 95% CrI 0.11-0.57 and HFNC: OR for EF, 0.64; 95% CrI, 0.24-1.0 and OR for TF, 0.34; 95% CrI, 0.16- 0.65). CPAP had the highest likelihood of being the best intervention for both EF (SUCRA, 0.83) and TF (SUCRA, 0.91). Although not statistically significant, BiPAP was likely to be better than COT for preventing both EF and TF. Compared to COT, CPAP and BiPAP were reported as showing a modest increase (approximately 3%) in nasal injury and abdominal distension. Conclusions and Relevance: The studies included in this systematic review and network meta-analysis found that compared with COT, EF and TF rates were lower with modest increases in abdominal distension and nasal injury. Of the modes evaluated, CPAP was associated with the lowest rates of EF and TF.
- Subjects
CINAHL database; MEDICAL information storage &; retrieval systems; META-analysis; AIRWAY (Anatomy); CONTINUOUS positive airway pressure; CRITICALLY ill; PATIENTS; GUTTMAN scale; EXTUBATION; TREATMENT effectiveness; CONCEPTUAL structures; OXYGEN therapy; RESEARCH funding; DESCRIPTIVE statistics; MEDLINE; CATHETERIZATION; ODDS ratio
- Publication
JAMA Pediatrics, 2023, Vol 177, Issue 8, p774
- ISSN
2168-6203
- Publication type
Article
- DOI
10.1001/jamapediatrics.2023.1478