CPAP preferred respiratory support after extubation in critically ill children: JAMA

Optimizing the first-line choice of post-extubation respiratory support should reduce extubation failures and the overall duration of invasive and non-invasive respiratory support. However, the optimal first-line mode of noninvasive respiratory support following extubation of critically ill children is not known. Therefore, Dr Padmanabhan Ramnarayan and his team conducted a study to evaluate the noninferiority of high-flow nasal cannula (HFNC) therapy as the first-line mode of noninvasive respiratory support following extubation, compared with continuous positive airway pressure (CPAP), on time to liberation from respiratory support.

In this pragmatic, multicenter, randomized, noninferiority FIRST-ABC trial, the researchers included six hundred children aged 0 to 15 years clinically assessed to require noninvasive respiratory support within 72 hours of extubation. The children were randomized to start either HFNC at a flow rate based on patient weight (n = 299) or CPAP of 7 to 8 cm H2O (n = 301). The major outcome assessed was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which the child was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio (HR) of 0.75. They further assessed 6 other secondary outcomes, including mortality at day 180 and reintubation within 48 hours.

Key findings of the study:

• Upon analysis, the researchers found that HFNC failed to meet noninferiority, with a median time to the liberation of 50.5 hours vs 42.9 hours for CPAP (adjusted HR, 0.83).
• They observed similar results across prespecified subgroups.
• Among 6 prespecified secondary outcomes, they noted that 5 showed no significant difference, including the rate of reintubation within 48 hours (13.3% for HFNC vs 11.5 % for CPAP).
• However, they noted that mortality at day 180 was significantly higher for HFNC (5.6% vs 2.4% for CPAP; adjusted odds ratio, 3.07).
• They reported that the most common adverse events were abdominal distension (HFNC: 8/281 [2.8%] vs CPAP: 7/272 [2.6%]) and nasal/facial trauma (HFNC: 14/281 [5.0%] vs CPAP: 15/272 [5.5%]).

The authors concluded, "Among critically ill children requiring noninvasive respiratory support following extubation, HFNC compared with CPAP following extubation failed to meet the criterion for noninferiority for time to liberation from respiratory support."

In an accompanying editorial, Dr Christopher M. Horvat and his team wrote, " Higher mortality with HFNC compared with CPAP has been observed among children in other settings, although the reasons are unclear. That HFNC did not meet noninferiority criteria in the FIRST-ABC trial and potentially led to higher 180-day mortality may favor the use of CPAP until more evidence becomes available. The FIRST-ABC trial provides helpful information on preferred approaches to respiratory management in the PICU, although uncertainty still dominates clinical decision-making involving optimal respiratory support following extubation for pediatric patients."

For further information:

DOI: 10.1001/jama.2022.3367

Keywords: critically ill children, high-flow nasal cannula, continuous positive airway pressure, respiratory support, pediatric intensive care units, infant mortality rate, reintubation rate, FIRST-ABC trial, JAMA.