Various methods of noninvasive respiratory support have been studied to reduce the risk of extubation failure in pediatric patients, but the optimal mode of postextubation respiratory support hasn't been determined. A systematic review and network meta-analysis was designed to evaluate the relative efficacy of different modes of noninvasive respiratory support, including high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP), in preventing extubation failure and other patient-centered outcomes in critically ill children.

Randomized clinical trials that included critically ill children from birth to age 18 who received invasive mechanical ventilation for more than 24 hours as well as noninvasive respiratory support were reviewed. Nine studies with a total of 1,421 participants were included in the analysis.

Compared with conventional oxygen therapy, HFNC, CPAP, and BiPAP were associated with lower rates of extubation failure. The largest absolute risk reduction (6%), with a baseline risk of extubation failure of 12%, was seen with CPAP. All three noninvasive respiratory support modes were even more effective in reducing treatment failure. Compared with conventional oxygen therapy, both HFNC and CPAP were associated with large absolute reductions in treatment failure (11% and 12%, respectively), with a baseline treatment failure rate of 18%. CPAP had the highest probability of being the best intervention to prevent extubation failure and treatment failure; HFNC was the second-ranked intervention, and BiPAP was the third. Modest increases in complications such as abdominal distention and nasal injury were seen with all three modes compared with conventional oxygen therapy.

The authors note that the results should be interpreted with caution because the risk of bias resulted in low to very low certainty of evidence in most comparisons. In addition, only two studies had a mean age older than 1 year, so the results may not be generalizable to older patient populations.