Mask versus Prongs for Nasal Continuous Positive Airway Pressure in Preterm Infants: A Systematic Review and Meta-Analysis

Abstract

Nasal continuous positive airway pressure (NCPAP) is an effective method of respiratory support for preterm infants. Nasal masks and binasal prongs are two interfaces available to deliver NCPAP, and it is unclear if one is superior to the other. We conducted a systematic review and meta-analysis, using the methodology recommended by the Cochrane Collaboration, to compare the efficacy and safety of nasal masks versus binasal prongs to deliver NCPAP in preterm infants <37 weeks of gestation. Ovid MEDLINE, Embase, Scopus, the Cochrane database, and PubMed were searched in February 2019. Seven trials met the inclusion criteria. Among preterm infants requiring NCPAP, the use of a nasal mask, compared to nasal prongs, decreased the rate of NCPAP failure within 72 h (RR 0.72, 95% CI 0.53–0.97; number needed to treat for an additional beneficial outcome [NNTB] 12.5, 95% CI 7.1–100; 5 trials, 576 participants; low-certainty evidence) and the incidence of nasal injury (RR 0.71, 95% CI 0.59–0.85; NNTB 8.3, 95% CI 5.6–16.7; 6 trials, 665 participants; low-certainty evidence). In a subgroup of preterm infants requiring NCPAP after resuscitation at birth, the use of a nasal mask decreased the incidence of moderate-to-severe bronchopulmonary dysplasia (RR 0.47, 95% CI 0.23–0.95; NNTB 16.7, 95% CI 9.1–100; 4 trials, 395 participants; very-low-certainty evidence) and the need for subsequent surfactant administration (RR 0.78, 95% CI 0.64–0.96; NNTB 8.33, 95% CI 4.54–33.33; 4 trials, 395 participants; low-certainty evidence). The use of nasal masks for preterm infants requiring NCPAP was associated with a reduction in NCPAP failure, need for surfactant administration, and moderate-to-severe bronchopulmonary dysplasia (low- to very-low-certainty evidence). Given the potential clinical benefit and minimal risk associated with a change in patient interface, nasal masks should be considered the preferred interface for NCPAP delivery in preterm infants.

Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design

“…Short binasal prongs or nasal masks are the recommended interface when providing CPAP to infants 21 22. Several other interfaces are widely used for CPAP treatment.…”

Nasal mask vs binasal prongs for nasal continuous positive airway pressure in preterm infants: A systematic review and meta‐analysis

“…8,12 Systematic reviews and meta-analyses of these clinical trials showed a similar benefit of reduced risk of intubation when NCPAP is provided with nasal masks compared with binasal prongs. [2][3][4] Nonetheless, these systematic reviews suffered significant limitations due to imprecision resulting from the small sample size of the clinical trials and the inability to blind the intervention. [2][3][4] As it is impractical to blind the intervention in clinical trials, the possible way to improve the certainty in the evidence is by enhancing the precision.…”

“…[2][3][4] Nonetheless, these systematic reviews suffered significant limitations due to imprecision resulting from the small sample size of the clinical trials and the inability to blind the intervention. [2][3][4] As it is impractical to blind the intervention in clinical trials, the possible way to improve the certainty in the evidence is by enhancing the precision. Hence, we undertook this systematic review to identify whether the confidence in the estimate can be improved by including the additional clinical trials.…”

Bubble Nasal Continuous Positive Airway Pressure (bNCPAP): An Effective Low-Cost Intervention for Resource-Constrained Settings

“…The reported incidence of nasal injury associated with NCPAP ranges from 6.4% to 91.6% [ 36 , 46 , 48 ] and is inversely related to the gestational age and birth weight [ 46 ]. Numerous RCTs and meta-analyses have demonstrated an association between the type of interface and nasal injury during noninvasive ventilation [ 48 – 51 ]. Short binasal prongs and nasal masks are the most widely used interfaces, but nasopharyngeal tube and nasal cannula have also been utilised [ 29 , 52 – 54 ].…”

“…The merits and demerits of these interfaces are shown in Table 2 . Nasal mask is generally associated with a significantly lower risk of nasal injury compared to binasal prongs [ 48 – 51 ]. Nasal masks apply excessive constant pressure to the nasal bridge and philtrum, reducing local tissue perfusion and causing nasal injury [ 50 ].…”