Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

Abstract

Objective To assess the role of nasal continuous positive airway pressure (CPAP) initiated at birth for prevention of death and bronchopulmonary dysplasia in very preterm infants. Design Systematic review.Data sources PubMed, Embase, the Cochrane Central Register of Controlled Trials, and online Pediatric Academic Society abstracts from the year of inception to June 2013.Eligibility criteria for selecting studies Randomised controlled trials evaluating the effect of nasal CPAP compared with intubation in preterm infants born at less than 32 weeks' gestation and presenting the outcomes of either death or bronchopulmonary dysplasia, or both (defined as the need for oxygen support or mechanical ventilation at 36 weeks corrected gestation), during hospital stay.Results Four randomised controlled trials (2782 participants) met the inclusion criteria, with 1296 infants in the nasal CPAP group and 1486 in the intubation group. All the trials reported bronchopulmonary dysplasia independently at 36 weeks corrected gestation, with borderline significance in favour of the nasal CPAP group (relative risk 0.91, 95% confidence interval 0.82 to 1.01, risk difference −0.03, 95% confidence interval −0.07 to 0.01). No difference in death was observed (relative risk 0.88, 0.68 to 1.14, risk difference −0.02, −0.04 to 0.01, respectively). Pooled analysis showed a significant benefit for the combined outcome of death or bronchopulmonary dysplasia, or both, at 36 weeks corrected gestation for babies treated with nasal CPAP (relative risk 0.91, 0.84 to 0.99, risk difference −0.04, -0.07 to 0.00), number needed to treat of 25). ConclusionOne additional infant could survive to 36 weeks without bronchopulmonary dysplasia for every 25 babies treated with nasal CPAP in the delivery room rather than being intubated.

Nasal Bilevel Versus Continuous Positive Airway Pressure in Preterm Infants: A Randomized Controlled Trial

“…It is used in several clinical circumstances and it includes different modes that can be applied. A recent meta-analysis performed by Schmolzer et al showed that nCPAP initiated in the delivery room compared with intubation reduces death or bronchopulmonary dysplasia in very preterm babies [11].…”

“…Some studies showed that there was no clear demonstration of a reduction of bronchopulmonary dysplasia (BPD) with the use of noninvasive ventilation [7][8][9][10]. However, recent meta-analysis made by Schmolzer [11] and Fischer [12] demonstrated that there is a statistically significant advantage in the use of non-invasive ventilation regarding death and BPD.…”

Safety and Efficacy of High-Flow Nasal Cannula Therapy in Preterm Infants: A Meta-analysis

“…In our opinion, this is an important distinction to make, as overall the neonatal community seems to be moving toward increased use of NIV, which has shown clinical benefit. 5 A time-based definition of failure has its own disadvantages, as some infants continue to "fail" even after the defined study period, 51 especially the extreme preterm group.…”

“…More recently, randomized controlled clinical trials have established the benefits of primary noninvasive ventilation (NIV) support, especially for nasal continuous positive airway pressure (nCPAP) 3,4 when compared with MV. 5 After extubation from MV, nCPAP is already established as an effective mode of support. 6 Other modes of NIV in preterm infants include bilevel nCPAP (BiPAP)/noninvasive positive pressure ventilation (NIPPV) and heated humidified high-flow nasal cannula (HHHFNC) therapy.…”

Admission to NICU in air is more likely if nasal High Flow is used for stabilisation in preterm babies compared to face mask CPAP

“…Whilst the latest guidance supports the use of nasal Continuous Positive Airway Pressure (CPAP), (1,2) with evidence of improved outcomes compared with routine invasive respiratory support, (3,4) we recently demonstrated the feasibility of the use of nasal high flow (nHF) in the stabilisation of premature babies (23 to 29+6 weeks gestation) in the delivery room prior to transfer to Neonatal Intensive Care Unit (NICU). (5) Although several large studies have previously demonstrated that nHF is generally as effective as nCPAP for postextubation support, (6)(7)(8) there remains a paucity of literature on the use of nHF in the DR. Our previous study showed that stabilisation on nHF reduced the rate of DR intubation and surfactant administration compared to our prior practice.…”