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Sustained Inflation vs Standard Resuscitation for Preterm Infants: A Systematic Review and Meta-analysis
Elizabeth E Foglia1, Arjan B Te Pas2, Haresh Kirpalani1
1Division of Neonatology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
Insights
Sustained inflation did not reduce hospital mortality in preterm infants compared to standard respiratory support. This meta-analysis found no benefit and suggests against routine use of sustained inflation for neonates.
Area of Science:
- Neonatal Medicine
- Respiratory Physiology
- Evidence-Based Pediatrics
Background:
- Preterm infants often require respiratory support for lung aeration.
- Standard therapies include intermittent positive pressure ventilation and continuous positive airway pressure.
- Initial sustained inflation is an alternative resuscitation strategy.
Purpose of the Study:
- To systematically review and meta-analyze the efficacy of sustained inflation versus standard respiratory support.
- To evaluate the prevention of hospital mortality and morbidity in preterm infants.
Main Methods:
- Systematic review and meta-analysis of randomized clinical trials.
- Searched MEDLINE, Embase, CINAHL, and Cochrane Central Register through June 2019.
- Included trials comparing sustained inflation (>5 seconds) to standard ventilation/CPAP in preterm infants (<37 weeks gestation).
Main Results:
- Nine studies (1406 infants) were included. No significant difference in hospital mortality between sustained inflation (11.5%) and standard therapy (9.3%).
- Sustained inflation showed an increased risk of death within the first 2 days (Risk Difference 3.1%).
- Low quality of evidence due to risk of bias and imprecision.
Conclusions:
- No difference in the primary outcome of death before hospital discharge.
- No evidence of efficacy for sustained inflation in preventing secondary outcomes.
- Findings do not support the routine use of sustained inflation for preterm infants.
Importance:
Most preterm infants require respiratory support to establish lung aeration after birth. Intermittent positive pressure ventilation and continuous positive airway pressure are standard therapies. An initial sustained inflation (inflation time >5 seconds) is a widely practiced alternative strategy.
Objective:
To conduct a systematic review and meta-analysis of sustained inflation vs intermittent positive pressure ventilation and continuous positive airway pressure for the prevention of hospital mortality and morbidity for preterm infants.
Data Sources:
MEDLINE (through PubMed), Embase, the Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials were searched through June 24, 2019.
Study Selection:
Randomized clinical trials of preterm infants born at less than 37 weeks' gestation that compared sustained inflation (inflation time >5 seconds) vs standard resuscitation with either intermittent positive pressure ventilation or continuous positive airway pressure were included. Studies including other cointerventions were excluded.
Data Extraction And Synthesis:
Two reviewers assessed the risk of bias of included studies. Meta-analysis of pooled outcome data used a fixed-effects model specific to rarer events. Subgroups were based on gestational age and study design (rescue vs prophylactic sustained inflation).
Main Outcomes And Measures:
Death before hospital discharge.
Results:
Nine studies recruiting 1406 infants met inclusion criteria. Death before hospital discharge occurred in 85 of 736 infants (11.5%) treated with sustained inflation and 62 of 670 infants (9.3%) who received standard therapy for a risk difference of 3.6% (95% CI, -0.7% to 7.9%). Although analysis of the primary outcome identified important heterogeneity based on gestational age subgroups, the 95% CI for the risk difference included 0 for each individual gestational age subgroup. There was no difference in the primary outcome between subgroups based on study design. Sustained inflation was associated with increased risk of death in the first 2 days after birth (risk difference, 3.1%; 95% CI, 0.9%-5.3%). No differences in the risk of other secondary outcomes were identified. The quality-of-evidence assessment was low owing to risk of bias and imprecision.
Conclusions And Relevance:
There was no difference in the risk of the primary outcome of death before hospital discharge, and there was no evidence of efficacy for sustained inflation to prevent secondary outcomes. These findings do not support the routine use of sustained inflation for preterm infants after birth.
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