Continuous distending pressure for respiratory distress in preterm infants

Abstract

Cochrane Database of Systematic Reviews Data collection and analysis We used standard methods of The Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each review author. Main results We included six studies involving 355 infants-two using face mask CPAP, two CNP, one nasal CPAP and one both CNP (for less ill babies) and endotracheal CPAP (for sicker babies). For this update, we included no new trials. Continuous distending pressure (CDP) is associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.52 to 0.81; typical risk di erence (RD)-0.20, 95% CI-0.29 to-0.10; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; six studies; 355 infants), lower overall mortality (typical RR 0.52, 95% CI 0.32 to 0.87; typical RD-0.15, 95% CI-0.26 to-0.04; NNTB 7, 95% CI 4 to 25; six studies; 355 infants) and lower mortality in infants with birth weight above 1500 g (typical RR 0.24, 95% CI 0.07 to 0.84; typical RD-0.28, 95% CI-0.48 to-0.08; NNTB 4, 95% CI 2.00 to 13.00; two studies; 60 infants). Use of CDP is associated with increased risk of pneumothorax (typical RR 2.64, 95% CI 1.39 to 5.04; typical RD 0.10, 95% CI 0.04 to 0.17; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 17.00 to 25.00; six studies; 355 infants). We found no di erence in bronchopulmonary dysplasia (BPD), defined as oxygen dependency at 28 days (three studies, 260 infants), as well as no di erence in outcome at nine to 14 years (one study, 37 infants). Authors' conclusions In preterm infants with respiratory distress, the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax. Four out of six of these trials were done in the 1970s. Therefore, the applicability of these results to current practice is di icult to assess. Further research is required to determine the best mode of administration.

Efficacy and safety of bubble CPAP in neonatal care in low and middle income countries: a systematic review

“…These guidelines recommend the use of nasal prongs as a mechanism of delivery, and a flow rate of 0.5–1 L/min, increasing to 2 L/min in severe respiratory distress to achieve an oxygen saturation of >90%. Studies in high-income countries in the 1970s suggested a survival advantage for preterm newborns with severe respiratory distress managed with CPAP compared with standard oxygen therapy (relative risk 0.52, 95% CI 0.32 to 0.87) 21. Since then, the use of CPAP has increased and become a standard of care for preterm newborns with moderate to severe respiratory distress, in tertiary and many non-tertiary hospitals.…”

“…In high-income countries, the safety profile of bubble CPAP appears similar to that of CPAP produced by other means (eg, ventilator-driven CPAP), and the majority of reported complications can be mitigated or prevented by adequate nursing care 16 21 24…”

The Changing Landscape in Supporting Preterm Infants at Birth

“…However, as respiratory support in the delivery room includes providing support to clear airway liquid, which is not a requirement days after birth, higher CPAP levels are likely to be needed immediately after birth. Similarly, higher CPAP levels may be required to prevent return of lung liquid and maintain functional residual capacity [8, 24-27]. In recent years it has become increasingly apparent that assuming strategies that are effective in the NICU (hours to days after birth) will be equally effective in the delivery room, ignoring much of what we know about the fetal to neonatal transition.…”

Has enough evidence accumulated to consider CPAP a first-line standard of care in developing countries?

“…Together, these conclude that early CPAP results in a small but statistically significant reduction in the composite outcome of bronchopulmonary dysplasia and/or death 3–5. Additionally, these trials indicate that CPAP reduces the need for mechanical ventilation and shortens the duration of supplemental oxygen exposure 4 6…”

“…In a multicentre RCT comparing early CPAP to oxygen therapy with or without mechanical ventilation in 12 South American centres, the risk of mortality, albeit not significantly, was lower in the CPAP-treated group (RR 0.72; 95% CI 0.41 to 1.25). In a Cochrane review, CPAP use was associated with a significant reduction in mortality (RR 0.52; 95% CI 0.32 to 0.87) and none of the included trials raised concern for increased mortality risk 6. Although the majority of the studies included in the Cochrane were conducted over 30 years ago in developed countries, no significant evidence to date suggests that CPAP use will increase mortality.…”