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Continuous positive airway pressure versus theophylline for apnea in preterm infants
D J Henderson-Smart1, P Subramaniam, 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@perinatal.usyd.edu.au
Insights
Theophylline is more effective than mask continuous positive airway pressure (CPAP) for treating apnea in preterm infants. Current CPAP methods may alter these findings, necessitating further research.
Area of Science:
- Neonatal Medicine
- Pediatric Pulmonology
- Clinical Trials
Background:
- Recurrent apnea is prevalent in preterm infants, potentially causing hypoxemia and bradycardia requiring intervention.
- Theophylline and continuous positive airway pressure (CPAP) are established treatments for neonatal apnea.
Purpose of the Study:
- To compare the efficacy of CPAP versus theophylline in reducing apnea and mechanical ventilation use in preterm infants.
- To assess the clinical importance of side effects associated with CPAP and theophylline treatments for apnea.
Main Methods:
- Systematic literature search of multiple databases (MEDLINE, EMBASE, CINAHL, etc.) and trial registers up to July 2001.
- Inclusion criteria: randomized or quasi-random trials comparing CPAP and theophylline in preterm infants with recurrent apnea/bradycardia.
- Data extraction and analysis followed Cochrane Collaboration standards, synthesizing data using relative risk.
Main Results:
- One eligible trial indicated mask CPAP had a higher treatment failure rate (RR 2.89) compared to theophylline.
- Infants treated with mask CPAP showed increased use of intermittent positive pressure ventilation (IPPV) (RR 3.09).
- Trends towards increased mortality and disability with mask CPAP were observed but not statistically significant.
Conclusions:
- Theophylline demonstrated greater effectiveness than mask CPAP for preterm infant apnea in the reviewed trial.
- The study's findings have limited relevance to current practice due to outdated mask CPAP administration methods.
- Further trials are needed to evaluate current CPAP methods against theophylline for neonatal apnea.
Background:
Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia which may be severe enough to require resuscitation including use of positive pressure ventilation. Theophylline and continuous positive airways pressure (CPAP) are two treatments that have have been used to prevent apnea and its consequences.
Objectives:
The main objective was to determine in preterm infants with recurrent apnea, if treatment with CPAP compared with treatment with theophylline leads to a clinically important reduction in apnea or use of mechanical ventilation, without clinically important side effects.
Search Strategy:
Searches were made of the Oxford Database of Perinatal trials, the Cochrane Collaboration Clinical Trials Register, MEDLINE 1966 - July 2001, EMBASE 1980 - July 2001, CINAHL 1982 - July 2001(using text words 'theophylline', 'caffeine', 'CPAP', 'CDAP', 'positive pressure', 'apnea or apnoea' and MeSH term 'infant, premature'), previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, mainly in the English language. Abstracts of the Society for Pediatric Research were searched from 1996 - 2001 inclusive.
Selection Criteria:
All trials using random or quasi-random allocation to CPAP or theophylline in preterm infants with clinical recurrent apnea/bradycardia were eligible.
Data Collection And Analysis:
Data were extracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk.
Main Results:
Only one eligible trial was found. The use of mask CPAP is associated with a higher treatment failure rate as measured by less than a 50% reduction in apnea or use of an alternative treatment [RR 2.89 (95% CI 1.12, 7.47); RD 0.42 (95% CI 0.11, 0.74)]. For every 2.4 infants (95% CI 1.4, 9.5) treated with mask CPAP rather than theophylline, there results one treatment failure. In the mask CPAP group there is more use of IPPV [RR 3.09 (1.42, 6.70); RD 0.58 (95% CI 0.30, 0.86). For every 1.7 infants (95% CI 1.2, 3.3) treated with mask CPAP rather than theophylline, one infant is intubated for IPPV. In the mask CPAP group, there are trends towards more deaths in the first year, and in death or major disability in survivors at follow up, which do not reach significance. There are no differences in rates of necrotizing enterocolitis or major disability in survivors at follow up.
Reviewer'S Conclusions:
Theophylline is more effective than mask CPAP for preterm infants with apnea. Since CPAP is no longer administered by mask, the results of this review have limited importance for current clinical practice. Further evaluation of the benefits and harms of CPAP vs theophylline for preterm infants with apnea requires further trials in which CPAP is administered by current methods.