High-Flow Nasal Cannula Versus Nasal Continuous Positive Airway Pressure for Post-Extubation Support in Preterm Infants: A Meta-Analysis

Abstract

Introduction: Extubation failure is common in mechanically ventilated preterm infants. Nasal continuous positive airway pressure (NCPAP) is standard post-extubation support, but high-flow nasal cannula (HFNC) is increasingly used due to perceived ease of application. Whether HFNC is non-inferior to NCPAP remains controversial.

Methods: We searched MEDLINE, CENTRAL, and CINAHL for RCTs comparing HFNC versus NCPAP in preterm infants (<32 weeks) after planned extubation. Primary outcome: extubation failure within 72 hours (reintubation or severe apnea). Secondary outcomes: nasal trauma, air leak syndromes, bronchopulmonary dysplasia (BPD). Risk of bias assessed with Cochrane tool. Non-inferiority margin set at 10%.

Results: Twelve RCTs (n=2,867 infants) were included. HFNC was not inferior to NCPAP for 72-hour extubation failure (risk difference 2.1%, 95% CI –1.2% to 5.4%, below non-inferiority margin). However, conventional analysis showed higher failure rate with HFNC (RR 1.28, 95% CI 1.02–1.61, p=0.04). Nasal trauma was significantly lower with HFNC (RR 0.35, 95% CI 0.22–0.56). No differences in BPD or pneumothorax.

Discussion: While non-inferiority was statistically met, the conventional superiority analysis suggests HFNC carries a small but significant increase in extubation failure risk. This paradox highlights the clinical importance of absolute risk differences (<2% in absolute terms). Reduced nasal trauma favors HFNC for infants without severe pre-extubation respiratory failure.

Conclusions: HFNC is an acceptable alternative to NCPAP for post-extubation support in stable preterm infants, particularly when minimizing nasal injury is prioritized. For infants with frequent apneas, NCPAP remains preferable.