Nasal Intermittent Positive Pressure Ventilation versus Continuous Positive Airway Pressure and Apnea of Prematurity: A Systematic Review and Meta-Analysis

Abstract

Objective The study aimed to systematically review and analyze the impact of nasal intermittent positive pressure ventilation (NIPPV) versus continuous positive airway pressure (CPAP) on apnea of prematurity (AOP) in preterm neonates. Study Design In this systematic review and meta-analysis, experimental studies enrolling preterm infants comparing NIPPV (synchronized, nonsynchronized, and bi-level) and CPAP (all types) were searched in multiple databases and screened for the assessment of AOP. Primary outcome was AOP frequency per hour (as defined by authors of included studies). Results Out of 4,980 articles identified, 18 studies were included with eight studies contributing to the primary outcome. All studies had a high risk of bias, with significant heterogeneity in definition and measurement of AOP. There was no difference in AOPs per hour between NIPPV versus CPAP (weighted mean difference = −0.19; 95% confidence interval [CI]: −0.76 to 0.37; eight studies, 456 patients). However, in a post hoc analysis evaluating the presence of any AOP (over varying time periods), the pooled odds ratio (OR) was lower with NIPPV (OR: 0.46; 95% CI: 0.32–0.67; 10 studies, 872 patients). Conclusion NIPPV was not associated with decrease in AOP frequency, although demonstrated lower odds of developing any AOP. However, definite recommendations cannot be made based on the quality of the published evidence. Key Points

Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures Were Equivalent?

“…26 An updated systematic review identified 6 additional studies and found no difference in frequency of apnea with NIPPV vs. CPAP upon meta-analysing the available data. 27 However, the pooled odds of developing any apneas were reduced.…”

“…26 An updated systematic review identified six additional studies and found no difference in frequency of apnea with NIPPV versus CPAP upon meta-analysis of the available data. 27 However, the pooled odds of developing any apneas were reduced. No firm conclusions could be drawn due to the significant heterogeneity in study designs and outcomes, as well as the fact that apnea was a secondary outcome in most studies and selective reporting could not be ruled out.…”

“…No firm conclusions could be drawn due to the significant heterogeneity in study designs and outcomes, as well as the fact that apnea was a secondary outcome in most studies and selective reporting could not be ruled out. 27 When evaluating evidence of tidal volume delivery during NIPPV, there are limited data to support this notion. Owen et al evaluated tidal volume during NIPPV using traditional prongs and found that majority of delivered "breaths" are asynchronous with patient-efforts and when they do coincide, may only increase the tidal volume delivered by 15%.…”

ATS core curriculum 2023. Pediatric pulmonary medicine: Respiratory disorders in infants

“…85 AOP is nearly universal in infants born at <29 weeks GA and often resolves by 37 weeks PMA, although it may persist in some infants, particularly those born at <28 weeks GA. 86 Management includes methylxanthines and respiratory support with supplemental oxygen, nasal continuous positive airway pressure (nCPAP), NIPPV, or invasive ventilation. [86][87][88][89] Other general measures include maintaining thermal stability, treatment of anemia and metabolic abnormalities, and ruling-out other causes (e.g., sepsis, necrotizing enterocolitis, seizures, central nervous system pathology).…”

Apnea of prematurity (draft of clinical guidelines)

“… Ребенку с апноэ недоношенных при неэффективности медикаментозной терапии (сохранение частоты и/или тяжести эпизодов апноэ на фоне проведения терапии кофеином) с лечебной целью рекомендуется проведение неинвазивной респираторной терапии [СРАР, NCPAP, NIPPV (nasal intermittent positive pressure ventilation)] [1,23,25,58,96,[107][108][109][110].…”