Key messages

• We found that some methods may be better than others to prevent treatment failure and the need to reinsert a breathing tube into the windpipe, but the evidence is uncertain.

• More research is needed that incorporates strict guidelines into study designs, while also comparing the different methods using the same air pressures, and including more extremely premature babies born before 28 weeks of pregnancy.

What is non-invasive respiratory support after extubation (taking the breathing tube out after the baby has been on breathing machine)?

Premature babies often need help breathing as their lungs are not fully developed. This is done by connecting a breathing tube inserted into the windpipe to a machine that breathes for the baby. As the baby's breathing and lungs improve, non-invasive breathing assistance that does not require a breathing tube is given. This is delivered through the nose (called nasal) to support the breathing.

What did we want to find out?

We compared the available information from the medical literature on seven types of nasal breathing support (each using different combinations of flow rates, pressures, and timings) to determine which is most effective in premature babies after breathing tube removal at preventing treatment failure (when the baby's breathing worsens and extra help, like more oxygen or a breathing tube, is needed), reducing the need for reinsertion of a breathing tube (to assist breathing), and lowering the severity of long-lasting lung problems.

What did we do?

We reviewed studies comparing different combinations of flow rates, pressures, and timings used to support breathing in premature babies (less than 37 weeks of pregnancy) after the breathing tube is removed.

What did we find?

We found 54 studies with 6995 premature babies to compare different types of non-invasive breathing support.

Nasal intermittent positive pressure ventilation (using two levels of pressure with short bursts of air) may lower the risk of treatment failure and may prevent the need for reinsertion of a breathing tube compared to nasal continuous positive airway pressure (a steady flow of air) or high flow nasal cannula (air given through small tubes at higher flow rates). Non-invasive high-frequency oscillatory ventilation (delivering tiny, rapid breaths) likely lowers the risk of treatment failure and likely prevents the need for reinsertion of a breathing tube compared to nasal continuous positive airway pressure (a steady flow of air) or high-flow nasal cannula (small tubes at higher flow rates). Also, non-invasive high-frequency oscillatory ventilation delivering tiny, rapid breaths may reduce the risk of long-lasting lung problems.

Our certainty in the evidence was moderate to low, and we were unable to make any firm conclusions.

These findings were similar when considering the group of babies born at 28 weeks of pregnancy or greater. In contrast, there were no differences in babies born at less than 28 weeks of pregnancy, although there were too few results in this population.

What are the limitations of the evidence?

The evidence is limited for extremely premature infants born at less than 28 weeks of pregnancy. The studies also varied in how they compared the different methods, especially regarding airway flow levels. This could have affected the results. Finally, we have little or no confidence in some of the results because of a variety of problems with how the studies were conducted.

How up to date is this evidence?

The evidence is up to date to January 2024.