Interventions to improve the rate of successful extubation in preterm infants: a meta-analysis_West China Medical Journal

Authors：

MU Yuju ,  WANG Hua , MU Dezhi

Department of Neonatology, West China Second University Hospital, Sichuan University / Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan 610041, P. R. China;

Corresponding author：

WANG Hua, Email: wanghua@scu.edu.cn

Keywords：

Preterm infants; Noninvasive respiratory support; Caffeine; Extubation; Meta-analysis

DOI：

10.7507/1002-0179.202011167

Video：

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Objective To systematically review the effectiveness and safety of interventions which target to improve the rate of successful extubation in preterm infants.Methods PubMed, Web of Science, Cochrane Library, Chongqing VIP database, China National Knowledge Infrastructure, and Wanfang Database were searched for articles published from the dates of establishment of databases to August 2020, which compared different noninvasive respiratory support models or different doses of caffeine to improve the rate of successful extubation in preterm infants in randomized controlled trials. The references of included articles were also retrieved. And then a meta-analysis was performed by using RevMan 5.3 software.Results A total of 33 randomized controlled trials involving 4 536 preterm infants were included. Compared with nasal continuous positive airway pressure (NCPAP), high-flow nasal cannula (HFNC) reduced the nose injury rate [odds ratio (OR)=0.29, 95% confidence interval (CI) (0.15, 0.57), P=0.000 3] and the pneumothorax rate [OR=0.18, 95%CI (0.06, 0.55), P=0.003]; nasal intermittent positive pressure ventilation (NIPPV) reduced the extubation failure rate [OR=0.33, 95%CI (0.23, 0.48), P<0.000 01], the reintubation rate [OR=0.36, 95%CI (0.20, 0.65), P=0.000 7], the respiratory failure rate [OR=0.33, 95%CI (0.17, 0.64), P=0.000 9], and the pneumothorax rate [OR=0.29, 95%CI (0.12, 0.70), P=0.006]; and biphasic positive airway pressure (BiPAP) reduced the reintubation rate [OR=0.21, 95%CI (0.09, 0.46), P=0.000 1]. Compared with low-dose caffeine, high-dose caffeine reduced the extubation failure rate [OR=0.44, 95%CI (0.32, 0.60), P<0.000 01] and the bronchopulmonary dysplasia rate [OR=0.69, 95%CI (0.48, 0.99), P=0.04], but increased the rate of tachycardia [OR=1.99, 95%CI (1.22, 3.25), P=0.006].Conclusion According to the current evidence, compared with NCPAP, NIPPV and BiPAP could be used to improve the rate of successful extubation in preterm infants, HFNC could be used to decrease the risk of nose injury and pneumothorax; the optimal dose of caffeine should be chosen after evaluating the risk of adverse reactions such as tachycardia.

Citation： MU Yuju, WANG Hua, MU Dezhi. Interventions to improve the rate of successful extubation in preterm infants: a meta-analysis. West China Medical Journal, 2021, 36(8): 1083-1092. doi: 10.7507/1002-0179.202011167 Copy

1.	Ferguson KN, Roberts CT, Manley BJ, et al. Interventions to improve rates of successful extubation in preterm infants: a systematic review and meta-analysis. JAMA Pediatr, 2017, 171(2): 165-174.
2.	Costa AC, Schettino Rde C, Ferreira SC. Predictors of extubation failure and reintubation in newborn infants subjected to mechanical ventilation. Rev Bras Ter Intensiva, 2014, 26(1): 51-56.
3.	Hermeto F, Bottino MN, Vaillancourt K, et al. Implementation of a respiratory therapist-driven protocol for neonatal ventilation: impact on the premature population. Pediatrics, 2009, 123(5): e907-e916.
4.	Al Mandhari H, Finelli M, Chen S, et al. Effects of an extubation readiness test protocol at a tertiary care fully outborn neonatal intensive care unit. Can J Respir Ther, 2019, 55: 81-88.
5.	Andrade LB, Melo TM, Morais DF, et al. Spontaneous breathing trial evaluation in preterm newborns extubation. Rev Bras Ter Intensiva, 2010, 22(2): 159-165.
6.	Chawla S, Natarajan G, Gelmini M, et al. Role of spontaneous breathing trial in predicting successful extubation in premature infants. Pediatr Pulmonol, 2013, 48(5): 443-448.
7.	Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0. (2011-03-01)[2018-11-03]. http://handbook.cochrane.org.
8.	Campbell DM, Shah PS, Shah V, et al. Nasal continuous positive airway pressure from high flow cannula versus infant flow for preterm infants. J Perinatol, 2006, 26(9): 546-549.
9.	Yoder BA, Stoddard RA, Li M, et al. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics, 2013, 131(5): e1482-e1490.
10.	Manley BJ, Owen LS, Doyle LW, et al. High-flow nasal cannulae in very preterm infants after extubation. N Engl J Med, 2013, 369(15): 1425-1433.
11.	Kadivar MM, Mosayebi ZM, Razi NM, et al. High flow nasal cannulae versus nasal continuous positive airway pressure in neonates with respiratory distress syndrome managed with INSURE method: a randomized clinical trial. Iran J Med Sci, 2016, 41(6): 494-500.
12.	Collins CL, Holberton JR, Barfield C, et al. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J Pediatr, 2013, 162(5): 949-954.
13.	Soonsawad S, Swatesutipun B, Limrungsikul A, et al. Heated humidified high-flow nasal cannula for prevention of extubation failure in preterm infants. Indian J Pediatr, 2017, 84(4): 262-266.
14.	潘健崧, 陈宏香, 温园香. 湿化高流量鼻导管通气预防超低出生体质量儿拔管失败临床分析. 深圳中西医结合杂志, 2017, 27(3): 77-79.
15.	郑红玲. 加温湿化经鼻导管高流量通气预防超低出生体重早产儿拔管失败的临床观察. 医药论坛杂志, 2017, 38(7): 88-89.
16.	魏贤, 甘斌, 何源, 等. HHFNC和NCPAP在早产儿机械通气撤机中的应用. 河南医学研究, 2018, 27(4): 594-597.
17.	Friedlich P, Lecart C, Posen R, et al. A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol, 1999, 19(6 Pt 1): 413-418.
18.	Barrington KJ, Bull D, Finer NN. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics, 2001, 107(4): 638-641.
19.	Khalaf MN, Brodsky N, Hurley J, et al. A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics, 2001, 108(1): 13-17.
20.	Moretti C, Giannini L, Fassi C, et al. Nasal flow-synchronized intermittent positive pressure ventilation to facilitate weaning in very low-birthweight infants: unmasked randomized controlled trial. Pediatr Int, 2008, 50(1): 85-91.
21.	Khorana M, Paradeevisut H, Sangtawesin V, et al. A randomized trial of non-synchronized nasopharyngeal intermittent mandatory ventilation (nsNIMV) vs. nasal continuous positive airway pressure (NCPAP) in the prevention of extubation failure in pre-term< 1, 500 grams. J Med Assoc Thai, 2008, 91(Suppl 3): S136-S142.
22.	O’Brien K, Campbell C, Brown L, et al. Infant flow biphasic nasal continuous positive airway pressure (BP-NCPAP) vs. infant flow NCPAP for the facilitation of extubation in infants’ ≤ 1, 250 grams: a randomized controlled trial. BMC Pediatr, 2012, 12: 43.
23.	Kirpalani H, Millar D, Lemyre B, et al. A trial comparing noninvasive ventilation strategies in preterm infants. N Engl J Med, 2013, 369(7): 611-620.
24.	Kahramaner Z, Erdemir A, Turkoglu E, et al. Unsynchronized nasal intermittent positive pressure versus nasal continuous positive airway pressure in preterm infants after extubation. J Matern Fetal Neonatal Med, 2014, 27(9): 926-929.
25.	Komatsu DF, Diniz EM, Ferraro AA, et al. Randomized controlled trial comparing nasal intermittent positive pressure ventilation and nasal continuous positive airway pressure in premature infants after tracheal extubation. Rev Assoc Med Bras (1992), 2016, 62(6): 568-574.
26.	Jasani B, Nanavati R, Kabra N, et al. Comparison of non-synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as post-extubation respiratory support in preterm infants with respiratory distress syndrome: a randomized controlled trial. J Matern Fetal Neonatal Med, 2016, 29(10): 1546-1551.
27.	丁斐, 张文雅, 赵育弘, 等. 早产儿RDS撤机后不同模式无创通气治疗的临床研究. 安徽医科大学学报, 2019, 54(12): 1982-1985.
28.	江云. 经鼻间歇指令通气与经鼻持续正压通气在早产儿撤机后的应用. 中国当代医药, 2020, 27(19): 129-132.
29.	张俊亮. 鼻式间歇正压通气用于早产儿拔管的临床研究. 广州: 南方医科大学, 2013.
30.	段景辉, 李剑芳, 官素玲. 鼻塞双水平正压通气应用于≤32周早产儿拔管的临床研究. 中国临床研究, 2015, 28(7): 926-928.
31.	Victor S, Roberts SA, Mitchell S, et al. Biphasic positive airway pressure or continuous positive airway pressure: a randomized trial. Pediatrics, 2016, 138(2): e20154095.
32.	李琳, 陈丽萍, 余曼莉, 等. nBiPAP和nCPAP在新生儿呼吸窘迫综合征中作为撤机后呼吸支持治疗的效果比较. 中国现代医生, 2019, 57(23): 66-69.
33.	余鹏程. 不同剂量咖啡因联合NIPPV辅助极低出生体重儿拔管研究. 黑龙江医药, 2020, 33(1): 92-94.
34.	Gray PH, Flenady VJ, Charles BG, et al. Caffeine citrate for very preterm infants: effects on development, temperament and behaviour. J Paediatr Child Health, 2011, 47(4): 167-172.
35.	Mohammed S, Nour I, Shabaan AE, et al. High versus low-dose caffeine for apnea of prematurity: a randomized controlled trial. Eur J Pediatr, 2015, 174(7): 949-956.
36.	Steer PA, Flenady VJ, Shearman A, et al. Periextubation caffeine in preterm neonates: a randomized dose response trial. J Paediatr Child Health, 2003, 39(7): 511-515.
37.	Steer P, Flenady V, Shearman A, et al. High dose caffeine citrate for extubation of preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed, 2004, 89(6): F499-F503.
38.	范莉莉, 王婷, 王佐. 不同剂量咖啡因治疗早产儿原发性呼吸暂停的临床疗效研究. 中国全科医学, 2017, 20(10): 1204-1207.
39.	胡晓明, 米荣, 李驰, 等. 枸橼酸咖啡因剂量差异对呼吸暂停早产儿拔管失败率、并发症及不良反应的影响. 中国妇幼保健, 2018, 33(13): 2979-2982.
40.	王娟, 姜善雨, 周勤, 等. 高维持剂量枸橼酸咖啡因对极超低出生体重儿呼吸暂停的临床作用研究. 东南大学学报(医学版), 2018, 37(5): 872-876.
41.	Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Database Syst Rev, 2000(2): CD000143.
42.	Wilkinson D, Andersen C, O’Donnell CP, et al. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev, 2016, 2: CD006405.
43.	Hough JL, Shearman AD, Jardine LA, et al. Humidified high flow nasal cannulae: current practice in Australasian nurseries, a survey. J Paediatr Child Health, 2012, 48(2): 106-113.
44.	Nath P, Ponnusamy V, Willis K, et al. Current practices of high and low flow oxygen therapy and humidification in UK neonatal units. Pediatr Int, 2010, 52(6): 893-894.
45.	Manley BJ, Dold SK, Davis PG, et al. High-flow nasal cannulae for respiratory support of preterm infants: a review of the evidence. Neonatology, 2012, 102(4): 300-308.
46.	Conte F, Orfeo L, Gizzi C, et al. Rapid systematic review shows that using a high-flow nasal cannula is inferior to nasal continuous positive airway pressure as first-line support in preterm neonates. Acta Paediatr, 2018, 107(10): 1684-1696.
47.	Kotecha SJ, Adappa R, Gupta N, et al. Safety and efficacy of high-flow nasal cannula therapy in preterm infants: a meta-analysis. Pediatrics, 2015, 136(3): 542-553.
48.	冯宗太, 杨祖铭, 顾丹凤, 等. 加温湿化高流量鼻导管通气预防新生儿拔管失败的Meta分析. 中国当代儿科杂志, 2015, 17(12): 1327-1332.
49.	Lemyre B, Davis PG, De Paoli AG, et al. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev, 2017(2): CD003212.
50.	崔娜娜. 咖啡因治疗早产儿呼吸暂停疗效及安全性的meta分析. 洛阳: 河南科技大学, 2019.

1. Ferguson KN, Roberts CT, Manley BJ, et al. Interventions to improve rates of successful extubation in preterm infants: a systematic review and meta-analysis. JAMA Pediatr, 2017, 171(2): 165-174.
2. Costa AC, Schettino Rde C, Ferreira SC. Predictors of extubation failure and reintubation in newborn infants subjected to mechanical ventilation. Rev Bras Ter Intensiva, 2014, 26(1): 51-56.
3. Hermeto F, Bottino MN, Vaillancourt K, et al. Implementation of a respiratory therapist-driven protocol for neonatal ventilation: impact on the premature population. Pediatrics, 2009, 123(5): e907-e916.
4. Al Mandhari H, Finelli M, Chen S, et al. Effects of an extubation readiness test protocol at a tertiary care fully outborn neonatal intensive care unit. Can J Respir Ther, 2019, 55: 81-88.
5. Andrade LB, Melo TM, Morais DF, et al. Spontaneous breathing trial evaluation in preterm newborns extubation. Rev Bras Ter Intensiva, 2010, 22(2): 159-165.
6. Chawla S, Natarajan G, Gelmini M, et al. Role of spontaneous breathing trial in predicting successful extubation in premature infants. Pediatr Pulmonol, 2013, 48(5): 443-448.
7. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0. (2011-03-01)[2018-11-03]. http://handbook.cochrane.org.
8. Campbell DM, Shah PS, Shah V, et al. Nasal continuous positive airway pressure from high flow cannula versus infant flow for preterm infants. J Perinatol, 2006, 26(9): 546-549.
9. Yoder BA, Stoddard RA, Li M, et al. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics, 2013, 131(5): e1482-e1490.
10. Manley BJ, Owen LS, Doyle LW, et al. High-flow nasal cannulae in very preterm infants after extubation. N Engl J Med, 2013, 369(15): 1425-1433.
11. Kadivar MM, Mosayebi ZM, Razi NM, et al. High flow nasal cannulae versus nasal continuous positive airway pressure in neonates with respiratory distress syndrome managed with INSURE method: a randomized clinical trial. Iran J Med Sci, 2016, 41(6): 494-500.
12. Collins CL, Holberton JR, Barfield C, et al. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J Pediatr, 2013, 162(5): 949-954.
13. Soonsawad S, Swatesutipun B, Limrungsikul A, et al. Heated humidified high-flow nasal cannula for prevention of extubation failure in preterm infants. Indian J Pediatr, 2017, 84(4): 262-266.
14. 潘健崧, 陈宏香, 温园香. 湿化高流量鼻导管通气预防超低出生体质量儿拔管失败临床分析. 深圳中西医结合杂志, 2017, 27(3): 77-79.
15. 郑红玲. 加温湿化经鼻导管高流量通气预防超低出生体重早产儿拔管失败的临床观察. 医药论坛杂志, 2017, 38(7): 88-89.
16. 魏贤, 甘斌, 何源, 等. HHFNC和NCPAP在早产儿机械通气撤机中的应用. 河南医学研究, 2018, 27(4): 594-597.
17. Friedlich P, Lecart C, Posen R, et al. A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol, 1999, 19(6 Pt 1): 413-418.
18. Barrington KJ, Bull D, Finer NN. Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics, 2001, 107(4): 638-641.
19. Khalaf MN, Brodsky N, Hurley J, et al. A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation. Pediatrics, 2001, 108(1): 13-17.
20. Moretti C, Giannini L, Fassi C, et al. Nasal flow-synchronized intermittent positive pressure ventilation to facilitate weaning in very low-birthweight infants: unmasked randomized controlled trial. Pediatr Int, 2008, 50(1): 85-91.
21. Khorana M, Paradeevisut H, Sangtawesin V, et al. A randomized trial of non-synchronized nasopharyngeal intermittent mandatory ventilation (nsNIMV) vs. nasal continuous positive airway pressure (NCPAP) in the prevention of extubation failure in pre-term< 1, 500 grams. J Med Assoc Thai, 2008, 91(Suppl 3): S136-S142.
22. O’Brien K, Campbell C, Brown L, et al. Infant flow biphasic nasal continuous positive airway pressure (BP-NCPAP) vs. infant flow NCPAP for the facilitation of extubation in infants’ ≤ 1, 250 grams: a randomized controlled trial. BMC Pediatr, 2012, 12: 43.
23. Kirpalani H, Millar D, Lemyre B, et al. A trial comparing noninvasive ventilation strategies in preterm infants. N Engl J Med, 2013, 369(7): 611-620.
24. Kahramaner Z, Erdemir A, Turkoglu E, et al. Unsynchronized nasal intermittent positive pressure versus nasal continuous positive airway pressure in preterm infants after extubation. J Matern Fetal Neonatal Med, 2014, 27(9): 926-929.
25. Komatsu DF, Diniz EM, Ferraro AA, et al. Randomized controlled trial comparing nasal intermittent positive pressure ventilation and nasal continuous positive airway pressure in premature infants after tracheal extubation. Rev Assoc Med Bras (1992), 2016, 62(6): 568-574.
26. Jasani B, Nanavati R, Kabra N, et al. Comparison of non-synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as post-extubation respiratory support in preterm infants with respiratory distress syndrome: a randomized controlled trial. J Matern Fetal Neonatal Med, 2016, 29(10): 1546-1551.
27. 丁斐, 张文雅, 赵育弘, 等. 早产儿RDS撤机后不同模式无创通气治疗的临床研究. 安徽医科大学学报, 2019, 54(12): 1982-1985.
28. 江云. 经鼻间歇指令通气与经鼻持续正压通气在早产儿撤机后的应用. 中国当代医药, 2020, 27(19): 129-132.
29. 张俊亮. 鼻式间歇正压通气用于早产儿拔管的临床研究. 广州: 南方医科大学, 2013.
30. 段景辉, 李剑芳, 官素玲. 鼻塞双水平正压通气应用于≤32周早产儿拔管的临床研究. 中国临床研究, 2015, 28(7): 926-928.
31. Victor S, Roberts SA, Mitchell S, et al. Biphasic positive airway pressure or continuous positive airway pressure: a randomized trial. Pediatrics, 2016, 138(2): e20154095.
32. 李琳, 陈丽萍, 余曼莉, 等. nBiPAP和nCPAP在新生儿呼吸窘迫综合征中作为撤机后呼吸支持治疗的效果比较. 中国现代医生, 2019, 57(23): 66-69.
33. 余鹏程. 不同剂量咖啡因联合NIPPV辅助极低出生体重儿拔管研究. 黑龙江医药, 2020, 33(1): 92-94.
34. Gray PH, Flenady VJ, Charles BG, et al. Caffeine citrate for very preterm infants: effects on development, temperament and behaviour. J Paediatr Child Health, 2011, 47(4): 167-172.
35. Mohammed S, Nour I, Shabaan AE, et al. High versus low-dose caffeine for apnea of prematurity: a randomized controlled trial. Eur J Pediatr, 2015, 174(7): 949-956.
36. Steer PA, Flenady VJ, Shearman A, et al. Periextubation caffeine in preterm neonates: a randomized dose response trial. J Paediatr Child Health, 2003, 39(7): 511-515.
37. Steer P, Flenady V, Shearman A, et al. High dose caffeine citrate for extubation of preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed, 2004, 89(6): F499-F503.
38. 范莉莉, 王婷, 王佐. 不同剂量咖啡因治疗早产儿原发性呼吸暂停的临床疗效研究. 中国全科医学, 2017, 20(10): 1204-1207.
39. 胡晓明, 米荣, 李驰, 等. 枸橼酸咖啡因剂量差异对呼吸暂停早产儿拔管失败率、并发症及不良反应的影响. 中国妇幼保健, 2018, 33(13): 2979-2982.
40. 王娟, 姜善雨, 周勤, 等. 高维持剂量枸橼酸咖啡因对极超低出生体重儿呼吸暂停的临床作用研究. 东南大学学报(医学版), 2018, 37(5): 872-876.
41. Davis PG, Henderson-Smart DJ. Nasal continuous positive airways pressure immediately after extubation for preventing morbidity in preterm infants. Cochrane Database Syst Rev, 2000(2): CD000143.
42. Wilkinson D, Andersen C, O’Donnell CP, et al. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev, 2016, 2: CD006405.
43. Hough JL, Shearman AD, Jardine LA, et al. Humidified high flow nasal cannulae: current practice in Australasian nurseries, a survey. J Paediatr Child Health, 2012, 48(2): 106-113.
44. Nath P, Ponnusamy V, Willis K, et al. Current practices of high and low flow oxygen therapy and humidification in UK neonatal units. Pediatr Int, 2010, 52(6): 893-894.
45. Manley BJ, Dold SK, Davis PG, et al. High-flow nasal cannulae for respiratory support of preterm infants: a review of the evidence. Neonatology, 2012, 102(4): 300-308.
46. Conte F, Orfeo L, Gizzi C, et al. Rapid systematic review shows that using a high-flow nasal cannula is inferior to nasal continuous positive airway pressure as first-line support in preterm neonates. Acta Paediatr, 2018, 107(10): 1684-1696.
47. Kotecha SJ, Adappa R, Gupta N, et al. Safety and efficacy of high-flow nasal cannula therapy in preterm infants: a meta-analysis. Pediatrics, 2015, 136(3): 542-553.
48. 冯宗太, 杨祖铭, 顾丹凤, 等. 加温湿化高流量鼻导管通气预防新生儿拔管失败的Meta分析. 中国当代儿科杂志, 2015, 17(12): 1327-1332.
49. Lemyre B, Davis PG, De Paoli AG, et al. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev, 2017(2): CD003212.
50. 崔娜娜. 咖啡因治疗早产儿呼吸暂停疗效及安全性的meta分析. 洛阳: 河南科技大学, 2019.

West China Medical Journal

Interventions to improve the rate of successful extubation in preterm infants: a meta-analysis

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