Heated humidified high-flow nasal cannula versus nasal continuous positive airways pressure for respiratory support in preterm neonates - A noninferiority trial at a tertiary care center

Background: In the neonatal period, respiratory failure remains a difficult challenge and is associated with high morbidity and mortality. Humidified high-flow nasal cannula (HHFNC) is being used as an alternative form of respiratory support for preterm infants with respiratory distress syndrome, apnea, and chronic lung disease. Objective: The objective was to assess the indications, frequency of usage, efficacy, and safety of heated HHFNC (HHHFNC) as compared to nasal continuous positive airway pressure (NCPAP) in providing respiratory support in preterm neonates after a period of positive pressure ventilation. (postextubation). Materials and Methods: This study was conducted in a Level II b neonatal intensive tertiary care unit in North Karnataka, India. In this study, all preterm neonates less than 37 weeks of gestation were placed on one of the respiratory supports (HHHFNC or NCPAP), immediately following extubation from mechanical ventilation. The primary outcome measures assessed were death, days on mechanical ventilation, need for reintubation (failure), air leak, nasal injury, and bronchopulmonary dysplasia (BPD). Results: There were no significant differences in major clinical outcomes including death, BPD, ventilator-days, necrotizing enterocolitis, severe intraventricular hemorrhage, retinopathy of prematurity, or time to full feeds. Failure of assigned mode of respiratory support was seen in 12% of infants on HHHFNC compared to 16% on NCPAP (P = 0.48). No significant difference in other outcome measures was seen between the groups. No nasal injury was observed in the HHHFNC group against 10% in the NCPAP group (P = 0.55). Conclusion: There was no statistically significant difference within the primary and secondary outcomes. At 5% level of significance, HHHFNC was found to be noninferior compared to NCPAP with 3.5% difference in the rates of failure of assigned mode of respiratory support. Hence, HHHFNC can be considered to be a safe, efficacious, and more easily acceptable mode of respiratory support as compared to NCPAP in preterm neonates after a period of positive pressure ventilation.