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Continuous distending pressure for respiratory distress syndrome in preterm infants
J J Ho1, P Subramaniam, D J Henderson-Smart
1Paediatrics, Perak College of Medicine, Jalan Greeentown, Ipoh, MALAYSIA, 30450. jackie@perakmed.edu.my
Insights
Continuous distending pressure (CDP) reduces respiratory failure and mortality in preterm infants with respiratory distress syndrome (RDS). However, CDP use is linked to an increased risk of pneumothorax, necessitating further research for modern applications.
Area of Science:
- Neonatal Medicine
- Pediatric Pulmonology
- Critical Care
Background:
- Respiratory distress syndrome (RDS) is a primary cause of illness and death in preterm infants.
- Intermittent positive pressure ventilation (IPPV) is standard but invasive, causing lung injury and chronic lung disease.
- Continuous distending pressure (CDP) offers a less invasive alternative.
Purpose of the Study:
- To evaluate if continuous distending pressure (CDP) reduces the need for IPPV in spontaneously breathing preterm infants with RDS.
- To assess associated morbidities and adverse effects of CDP compared to standard care.
Main Methods:
- Systematic review of randomized and quasi-random trials of CDP (CPAP or CNP) versus standard care in newborn infants with RDS.
- Searches included major databases (MEDLINE, Cochrane Trials) and expert consultations.
- Data were independently assessed for quality and extracted by authors.
Main Results:
- CDP use was associated with lower rates of treatment failure (death or need for ventilation) and overall mortality.
- Infants weighing over 1500g showed reduced mortality with CDP.
- An increased incidence of pneumothorax was observed with CDP application.
Conclusions:
- CDP (CPAP or CNP) offers benefits in reducing respiratory failure and mortality in preterm infants with RDS.
- A significant increase in pneumothorax risk is associated with CDP.
- The applicability of findings from the 1970s is limited due to outdated methods and lack of modern interventions (surfactant, antenatal corticosteroids).
- CPAP may be valuable in resource-limited settings; further research is needed for current intensive care practices.
Background:
Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998, Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive, resulting in airway and lung injury and contributing to the development of chronic lung disease.
Objectives:
In spontaneously breathing preterm infants with RDS, to determine if continuous distending pressure (CDP) reduces the need for IPPV and associated morbidity 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 (1966-Jan. 2000), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language.
Selection Criteria:
All trials using random or quasi-random patient allocation of newborn infants with RDS were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharyngeal tube, or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and lower body, compared with standard care.
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.
Main Results:
CDP is associated with a lower rate of failed treatment (death or use of assisted ventilation), overall mortality, and mortality in infants with birthweights above 1500 g. The use of CDP is associated with an increased rate of pneumothorax.
Reviewer'S Conclusions:
In preterm infants with RDS the application of CDP either as CPAP or CNP is associated with some benefits in terms of reduced respiratory failure and reduced mortality. CDP is associated with an increased rate of pneumothorax. The applicability of these results to current practice is difficult to assess, given the outdated methods to administer CDP, low use of antenatal corticosteroids, non-availability of surfactant and the intensive care setting of the 1970s when these trials were done. Where resources are limited, such as in developing countries, CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings