Strategies used for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants

Nasal continuous positive airway pressure (NCPAP) is a form of respiratory support commonly used in the treatment of preterm infants. Potential risks of NCPAP include damage to the nose and leaking of air from the lungs. Infants on NCPAP require more nursing care and the use of extra equipment. However, potential complications of removing NCPAP from babies too early include increasing episodes of forgetting to breathe, increased oxygen needs, increased effort of breathing, the need to restart NCPAP and the need for a breathing tube with mechanical ventilation. Any of these complications can be seen as a "failure" and are potentially distressing to staff and family. The best way to withdraw NCPAP once it has been started is unknown. Options include simply stopping, weaning the pressure, increasing the time off NCPAP each day or combinations of both. A recent study has suggested that stopping the NCPAP all together once compared to having periods of time off NCPAP decreases the incidence of chronic neonatal lung disease and the length of hospital stay.

We aimed to determine the benefits and risks of different strategies used for the withdrawal of NCPAP in preterm infants who are stable and may be ready to have NCPAP withdrawn. This review identified three studies but, due to differences in the studies and the limited data available, the results could not be combined.

Infants who have their NCPAP pressure weaned to a predefined level and then stop NCPAP completely have less total time on NCPAP and shorter durations of oxygen therapy and hospital stay compared with those that have NCPAP removed for a predetermined number of hours each day. Clear criteria need to be established for the definition of stability prior to attempting to withdraw NCPAP and for the definition of failure to withdraw.

Authors' conclusions: 

Infants who have their NCPAP pressure weaned to a predefined level and then stop NCPAP completely have less total time on NCPAP and shorter durations of oxygen therapy and hospital stay compared with those that have NCPAP removed for a predetermined number of hours each day. Future trials of withdrawing NCPAP should compare proposed strategies with weaning NCPAP pressure to a predefined level and then stopping NCPAP completely. Clear criteria need to be established for the definition of stability prior to attempting to withdraw NCPAP.

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Background: 

While indications for the use of nasal continuous positive airway pressure (NCPAP) and its associated risks and benefits are extensively investigated, the best strategy for the withdrawal of NCPAP remains unknown. In a survey of Australian and New Zealand Neonatologists, 56% stated that their approach to NCPAP weaning was "ad hoc" (Jardine 2008). At what point an infant is considered stable enough to attempt to start withdrawing their NCPAP is not clearly established. The criteria for a failed attempt at NCPAP withdrawal is also not clear.

Objectives: 

To determine the risks and benefits of different strategies used for the withdrawal of NCPAP in preterm infants.

Search strategy: 

Searches were made of the Cochrane Neonatal Review Group Specialised Register, MEDLINE from 1966 to June 2010, CINAHL from 1982 to June 2010, and the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 2). Previous reviews (including cross references) were also searched.

Selection criteria: 

We included all randomised and quasi-randomised controlled trials in which either individual newborn infants or clusters of infants (such as separate neonatal units) were randomised to different NCPAP withdrawal strategies (from the first time they come off NCPAP and any subsequent weaning and/or withdrawal attempt).

Data collection and analysis: 

We used standard methods of The Cochrane Collaboration and its Neonatal Review Group.

Main results: 

We identified four potentially eligible studies. Three studies are included in this review. One study showed a significant decrease in the duration of oxygen therapy and a significantly decreased length of stay for babies randomised to a weaning strategy where NCPAP is simply stopped when infants met predefined stability criteria.

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