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Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm
P Subramaniam1, D J Henderson-Smart, P G Davis
1NSW Centre for Perinatal Health Services Research, Queen Elizabeth II Institute for Mothers and Infants, Building DO2, University of Sydney, Sydney, NSW, Australia, 2006. dhs@mail.usyd.edu.au
Insights
Prophylactic nasal continuous positive airway pressure (CPAP) in very preterm infants did not significantly reduce the need for invasive ventilation or chronic lung disease. More research is needed due to concerning trends in adverse outcomes.
Area of Science:
- Neonatal Medicine
- Respiratory Physiology
- Clinical Trials
Background:
- Very preterm infants and very low birth weight infants are at high risk for respiratory complications.
- Chronic lung disease (CLD) is a significant concern in this vulnerable population.
- Early respiratory support strategies aim to improve outcomes and reduce morbidity.
Purpose of the Study:
- To evaluate the efficacy of prophylactic nasal continuous positive airway pressure (CPAP) initiated shortly after birth.
- To determine if prophylactic nasal CPAP reduces the need for invasive positive pressure ventilation (IPPV) and CLD incidence.
- To assess for any adverse effects associated with prophylactic nasal CPAP in very preterm infants.
Main Methods:
- A systematic literature search was conducted using standard Neonatal Review Group strategies.
- Eligible trials included very preterm infants (<32 weeks gestation or <1500g birth weight) with random or quasi-random allocation.
- The comparison was between prophylactic nasal CPAP and standard treatment methods involving CPAP or IPPV for defined respiratory conditions.
Main Results:
- A single study of 82 infants found no statistically significant differences in primary outcomes.
- There was a trend towards increased use of IPPV in the prophylactic nasal CPAP group, though not statistically significant.
- Trends suggested increased incidence of CLD, death, and intraventricular hemorrhage, with a trend towards reduced necrotizing enterocolitis.
Conclusions:
- Insufficient evidence currently exists to recommend prophylactic nasal CPAP for clinical practice in very preterm infants.
- The single study did not demonstrate a clear benefit in reducing IPPV, and observed trends of increased adverse outcomes warrant caution.
- Further multicenter randomized controlled trials are necessary to clarify the clinical role and safety of prophylactic nasal CPAP.
Background:
This section is under preparation and will be included in the next issue.
Objectives:
To determine if prophylactic nasal continuous positive airways pressure (CPAP) commenced soon after birth regardless of respiratory status in the very preterm or very low birth weight infant reduces the use of IPPV and the incidence of chronic lung disease (CLD) without adverse effects.
Search Strategy:
The standard search strategy of the Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE, previous reviews including cross references, abstracts, conferences, symposia, proceedings, expert informants, journal hand searching mainly in the English language.
Selection Criteria:
All trials using random or quasi-random patient allocation of very preterm infants < 32weeks gestation and / or < 1500 gms at birth were eligible. Comparison had to be between prophylactic nasal CPAP commencing soon after birth regardless of the respiratory status of the infant compared with "standard" methods of treatment where CPAP or IPPV is used for a defined respiratory condition.
Data Collection And Analysis:
Standard methods of the Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each author, were used. Data were analysed using relative risk (RR).
Main Results:
There are no statistically significant differences in any of the outcomes reported in the single eligible study of 82 very low birth weight infants. More infants in the prophylactic nasal CPAP group received IPPV; however, this difference is not statistically significant. There are trends towards increases in the incidence of CLD (undefined) [RR 2.27 (0.77, 6.65)], of death [RR 3.63 (0.42, 31.08)] and of intraventricular hemorrhage [RR 2.18 (0.84, 5.62)] in the treatment group. The study also found a trend towards a reduction in the incidence of necrotizing enterocolitis in the treatment group [RR 0.40 (0.13, 1.21)].
Reviewer'S Conclusions:
There is currently insufficient information to make recommendations for clinical practice. The single study reviewed showed no strong evidence of benefit in reducing the incidence of IPPV. The tendency for some adverse outcomes to be increased is of concern and more data are needed to clarify this. A multicentre randomized controlled trial comparing prophylactic nasal CPAP with "standard" methods of treatment is needed to clarify its clinical role.