Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for apnea of prematurity

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Abstract
Apnea of prematurity is almost universal in infants who are born before 34 weeks gestation. Previous randomised trials and systematic reviews have found methylxanthines to be effective in preventing apnea of prematurity. However, recent concerns about potential long‐term side effects of methylxanthines on the neurodevelopment of low birth weight infants have led to an increased interest in alternate methods of treating apnea of prematurity. Nasal continuous positive airway pressure (NCPAP) is a useful method of respiratory support that reduces the incidence of obstructive or mixed apnea. However, apneic infants managed with NCPAP, with or without methylxanthines, sometimes require endotracheal intubation with its attendant morbidity and cost. Nasal intermittent positive pressure ventilation (NIPPV) is a simple, effective mode of respiratory support for older children and adults. It has been used to treat apnea in preterm infants but case reports of gastrointestinal perforations have limited its widespread use. To determine the effect of treatment with NIPPV compared to treatment with NCPAP on apnea and need for intubation and mechanical ventilation in preterm infants with recurrent apnea. To determine the effect of treatment with NIPPV compared to treatment with NCPAP on the incidence of gastrointestinal complications, i.e. gastric distension leading to cessation of feeds, or perforation. MEDLINE was searched (1966‐week 2 ‐ July 2007). Other sources included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007) and CINAHL (1982‐week 2, July 2007). Also used were expert informants, previous reviews including cross‐references, and conference and symposia proceedings. All randomised and quasi‐randomised trials were included. Participants included unventilated preterm infants experiencing apnea of prematurity. Interventions compared were intermittent positive pressure ventilation administered via the nasal route, either by short nasal prongs or nasopharyngeal tube, and nasal CPAP delivered by the same methods. Types of outcome measures: ‐ failure of therapy as defined by apnea that is frequent or severe requiring additional ventilatory support ‐ rates of endotracheal intubation ‐ rates of apnea and bradycardia expressed as events per hour ‐ gastrointestinal complications i.e. abdominal distension requiring cessation of feeds, or GI perforation Data were extracted independently by the three reviewers. The trials were analysed using relative risk (RR), risk difference (RD) and number needed to treat (NNT) for dichotomous data; means and weighted mean difference (WMD) were used for continuous data. Two trials enrolling 54 infants in total, fulfilled the inclusion criteria. Both reported only the short term results (4 to 6 hours) of the interventions. Only one infant (randomised to NCPAP) required intubation during this period. In a cross‐over study of 20 infants, Ryan 1989 showed no significant difference in rates of apnea (events/hr) between the two interventions [WMD ‐0.10 (‐0.53,0.33)]. Lin (1998) randomised 34 infants and demonstrated a greater reduction in frequency of apneas (events/hr) with NIPPV compared to NCPAP [WMD ‐1.19 (‐2.31,‐0.07)]. Meta‐analysis of both trials showed no difference in pC02 (mmHg) at the end of the 4‐6 hour study period [WMD 0.95 (‐3.05,4.94)]. No data were reported on gastrointestinal complications. Implications for practice: NIPPV may be a useful method of augmenting the beneficial effects of NCPAP in preterm infants with apnea that is frequent or severe. Its use appears to reduce the frequency of apneas more effectively than NCPAP. Additional safety and efficacy data are required before recommending NIPPV as standard therapy for apnea. Implications for research: Future trials with sufficient power should assess the efficacy (reduction in failure of therapy) and safety (GI complications) of NIPPV. Outcomes should be assessed throughout the entire period during which the infant requires assisted ventilation. The recent ability to synchronise NIPPV with an infant's spontaneous respirations is a promising development requiring further assessment. 鼻式間歇式正壓換氣 (NIPPV) 相較鼻式連續式正壓 (NCPAP) 用於早產兒呼吸暫停 早產兒呼吸暫停幾乎是在34週之前出生的嬰兒都會發生，先前隨機試驗及系統性回顧文章發現甲基茶鹼可有效預防早產兒呼吸暫停，然而近來擔憂使用甲基茶鹼產生的長期副作用與低出生體重早產兒的神經發展有關，引起許多人對早產兒呼吸暫停取代治療方法的興趣。鼻式連續式正壓 (Nasal continuous positive airway pressure) 是一種可降低阻塞型或混合型呼吸暫停的呼吸支持，然而使用鼻式連續式正壓的呼吸暫停嬰兒併用或不併用甲基茶鹼，有時會需要插入氣管內管，因而伴隨其合併症及花費。鼻式間歇式正壓換氣 (Nasal intermittent positive pressure ventilation) 是一種簡單有效的呼吸支持方式，用於大小孩及成人，曾被用於治療早產兒呼吸暫停，但因有造成腸胃道穿孔的病例報告，而使得廣泛的使用有限。 比較用NIPPV與NCPAP治療，對於早產兒呼吸暫停及因反覆呼吸暫停需要插管及機械式換氣的效果。比較使用NIPPV與NCPAP治療發生腸胃道的併發症的機率，如腹脹導致的餵食中斷或穿孔。 搜尋MEDLINE從1966年第二週到2007年7月,其他來源包括Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007) 和 CINAHL (從1982年第二週到2007年7月) ，也搜尋專業資料、先前的回顧性文章包括交互參考資料、及會議和研討會記錄。...