Noninvasive High Frequency Oscillatory Ventilation Versus Nasal Intermittent Mandatory Ventilation After Extubation in Neonates

Overview

The goal of this clinical trial is to learn which breathing support works better after removing a newborn's breathing tube. Researchers will study newborns born at 26 weeks of gestation or later. Each newborn will have received breathing support through a tube for at least 24 hours. The main questions it aims to answer are: Does noninvasive high-frequency oscillatory ventilation (nHFOV) lower the need to replace the breathing tube within 72 hours? What breathing, feeding, or other medical problems occur with each type of support? Researchers will compare nHFOV with nasal intermittent mandatory ventilation (NIMV). nHFOV provides very rapid pressure waves through the nose. NIMV provides regular, timed breaths through the nose. The researchers will compare these methods to see which works better after breathing tube removal. Participants will: Be assigned by chance to receive either nHFOV or NIMV Receive the assigned breathing support immediately after tube removal Have their breathing, oxygen level, and general condition closely monitored Have blood tests at 1, 12, and 24 hours post extubation to assess their breathing Be monitored for breathing pauses, feeding problems, and other medical problems during hospitalization

Extubation failure, defined as the need to replace an endotracheal breathing tube after planned removal, is associated with longer hospitalization and increased illness and death in newborns. Noninvasive respiratory support may help newborns transition safely from invasive mechanical ventilation. Nasal intermittent mandatory ventilation (NIMV) delivers regular positive pressure breaths through a nasal interface. Noninvasive high frequency oscillatory ventilation (nHFOV) delivers rapid pressure oscillations through a nasal interface and may improve carbon dioxide removal without requiring synchronization with the newborn's breathing. Although both methods are used in neonatal care, evidence directly comparing them in Pakistan is limited. NOV-A is a prospective, single center, open label, parallel group superiority randomized clinical trial. It will evaluate whether nHFOV lowers extubation failure compared with NIMV after the first planned extubation. Participants will be assigned in a 1:1 ratio using stratified permuted block randomization based on gestational age. An independent biostatistician will generate the allocation sequence. Allocation will remain concealed in sequentially numbered, opaque, sealed envelopes until eligibility and parental consent are confirmed. Blinding of the treating clinicians is not possible because the two respiratory support methods use different ventilator settings. To limit bias, prespecified clinical and laboratory criteria will guide decisions to replace the breathing tube. The biostatistician will remain unaware of group identities until the primary analysis is complete. The primary analysis will follow the intention to treat principle. The treatment effect will be reported as the difference between the proportions of participants requiring replacement of the breathing tube, with a two sided 95% confidence interval. A per protocol analysis will be conducted as a sensitivity analysis. An independent Data Safety Monitoring Board will review safety information after approximately 25%, 50%, and 75% of planned enrollment.