Eduardo Banclari’s group have just published an RCT comparing success of extubation among 93 babies less than 1 kg birth weight who were put on low CPAP pressure (4 to 6) or high pressure (7 to 9 cm H2O). These were babies who were ready for extubation but still needed some oxygen (25% or more). Buzzella B, Claure N, D’Ugard C, Bancalari E: A randomized controlled trial of two nasal continuous positive airway pressure levels after extubation in preterm infants. The Journal of pediatrics 2013. There was much more extubation success with the higher pressure in this group of babies, especially among the smaller ones. Although this is a modestly sized trial, I can’t see any good reason for not using pressures of 7 to 9 when you extubate extremely low birth weight babies who are still needing some oxygen, at least until (and if) there are other studies published.
My friend Guilherme Sant’Anna at McGill has also published a study, this time looking at extubation readiness. (Kaczmarek J, Chawla S, Marchica C, Dwaihy M, Grundy L, Sant’Anna GM: Heart rate variability and extubation readiness in extremely preterm infants. Neonatology 2013, 104(1):42-48). We know there are features of heart rate variability that predict sepsis, this study used a recording of 60 minutes of the ECG just prior to extubating the baby, and found a much lower variability of the heart rate in those who failed. This needs confirmation, but it might turn out to be a useful way of predicting which babies are likely to succeed on their own.