Randomised controlled trial of high‐flow nasal cannula in preterm infants after extubation

HFNC therapy is increasingly used as ‘non-invasive’ respiratory support for preterm infants. A 2016 Cochrane Review found that had similar efficacy to NCPAP infants following extubation,1 but further studies were needed, particularly in extremely born <28 weeks' gestation, who are at highest risk of extubation failure. The trial by Uchiyama et al the largest randomised post-extubation infants, and one only a few enrol (168 enrolled; 76 HFNC, 92 NCPAP/NIPPV). This multicentre non-inferiority NCPAP/NIPPV was superior (and did not satisfy criteria) primary outcome treatment failure within 7 days. Reintubation rates similar; more than 80% met criteria avoided reintubation due crossover NCPAP/NIPPV. Like previous trials2-4 intervention blinded, although objective used. In group, 149 received 47 NIPPV extubation. both groups, escalation clinician discretion. As control group could receive either or NIPPV, definition ‘treatment failure’ blurred: some before others not. It reported whether inflations synchronised with infant's breathing not, which may be important.5 design reasonable given existing evidence, sample size calculation assumed rate 9% higher NCPAP/NIPPV, chosen margin rather large. There an imbalance allocation (47%) (53%). total 378 ultimately recruited study (38 required, even inflation anticipated dropouts); however this represents 33% eligible has implications generalisability results. use stimulants prior reported. prospectively registered; however, there inconsistencies between registration published stated size, comparator outcome. starting gas flow >2 L/min, lower studies,3, 4 it unclear maximal permitted 8 L/min being determined. increasing associated increased delivered pressure,6 have contributed decreased group. Extubation important concern neonatal clinicians, optimal mode remains uncertain. results tip balance favour initial support; consistent when ‘backup’ For most immature failure, seems prudent avoid using support. authors no conflicts interest declare. https://ebneo.org/HFNC-after-extubation