Background: Multiple non-invasive respiratory support (NRS) modalities are used for post extubation support in preterm neonates. Seven NRS modalities were compared – Constant flow CPAP (CF-CPAP) [bubble CPAP; ventilator CPAP], Variable flow CPAP (VF-CPAP), High flow nasal cannula (HFNC), Synchronized non-invasive positive pressure ventilation (S-NIPPV), Non-synchronized NIPPV (NS-NIPPV), Bilevel CPAP (BiPAP), non-invasive high frequency oscillation ventilation (nHFOV).
Design: Systematic review and network meta-analysis using the Bayesian random effects approach. MEDLINE, EMBASE, CENTRAL, WHO-ICTRP were searched.
Main outcome measure: Requirement of invasive mechanical ventilation within 7 days of extubation.
Results: 33 studies with 4080 preterm neonates were included. S-NIPPV, NS-NIPPV, nHFOV and VF-CPAP were more efficacious in preventing re-intubation than CF-CPAP [RR (95% CrI) – 0.22 (0.12, 0.35); 0.44 (0.27, 0.67); 0.42 (0.18, 0.81); 0.73 (0.52, 0.99)]. SUCRA value ranked S-NIPPV to be the best post extubation intervention (SUCRA – 0.98). S-NIPPV was more effective than NS-NIPPV, BiPAP, VF-CPAP and HFNC [RR (95% CrI) – 0.52 (0.24, 0.97); 0.32 (0.14, 0.64); 0.30 (0.16, 0.50); 0.24 (0.12, 0.41)]. NS-NIPPV resulted in lesser re-intubation compared to VF-CPAP and HFNC [RR (95% CrI) – 0.61 (0.36, 0.97); 0.49 (0.27, 0.80)]. BiPAP, VF-CPAP and HFNC had comparable efficacies. The overall quality of evidence was very low to moderate.
Conclusion: Results of this NMA indicate that S-NIPPV might be the most effective and CF-CPAP the least effective NRS modality for preventing extubation failure.