Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation

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Abstract
Previous randomised trials and meta‐analyses have shown nasal continuous positive airway pressure (NCPAP) to be a useful method of respiratory support after extubation. However, infants managed in this way sometimes "fail" and require endotracheal reintubation with its attendant risks and expense. Nasal intermittent positive pressure ventilation (NIPPV) is a method of augmenting NCPAP by delivering ventilator breaths via nasal prongs. Older children and adults with chronic respiratory failure have been shown to benefit from NIPPV and the technique has been applied to neonates. However, serious side effects including gastric perforation have been reported and clinicians remain uncertain about the role of NIPPV in the management of neonates. It has recently become possible to synchronise delivery of NIPPV with the infant's own breathing efforts, which may make this modality more useful in this patient group. To determine whether the use of NIPPV when compared to NCPAP decreases the rate of extubation failure without adverse effects in the preterm infant extubated following a period of intermittent positive pressure ventilation. MEDLINE was searched using the MeSH terms: Infant, Newborn (exp) and Positive‐pressure respiration (exp) up to December 18, 2007. Other sources included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2007), CINAHL using search terms: Infant, newborn and intermittent positive pressure ventilation, expert informants, previous reviews including cross‐references and conference and symposia proceedings were used. Randomised trials comparing the use of NIPPV with NCPAP in preterm infants being extubated were selected for this review. Data regarding clinical outcomes including extubation failure, endotracheal reintubation, rates of apnea, gastrointestinal perforation, feeding intolerance, chronic lung disease and duration of hospital stay were extracted independently by the three review authors. The trials were analysed using relative risk (RR), risk difference (RD) and number needed to treat (NNT) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes. Three trials comparing extubation of infants to NIPPV or to NCPAP were identified. All trials used the synchronised form of NIPPV. Each showed a statistically significant benefit for infants extubated to NIPPV in terms of prevention of extubation failure criteria. The meta‐analysis demonstrates a statistically and clinically significant reduction in the risk of meeting extubation failure criteria [typical RR 0.21 (95% CI 0.10, 0.45), typical RD ‐0.32 (95% CI ‐0.45, ‐0.20), NNT 3 (95% CI 2, 5)]. There were no reports of gastrointestinal perforation in any of the trials. Differences in rates of chronic lung disease approached but did not achieve statistical significance favouring NIPPV [typical RR 0.73 (95% CI 0.49, 1.07), typical RD ‐0.15 (95% CI ‐0.33, 0.03)]. Implications for practice: NIPPV is a useful method of augmenting the beneficial effects of NCPAP in preterm infants. Its use reduces the incidence of symptoms of extubation failure more effectively than NCPAP. Within the limits of the small numbers of infants randomised to NIPPV there is a reassuring absence of the gastrointestinal side effects that were reported in previous case series. Implications for research: Future trials should enroll a sufficient number of infants to detect differences in important outcomes such as chronic lung disease and gastrointestinal perforation. The impact of synchronisation of NIPPV on the technique's safety and efficacy should be established in future trials. 鼻式間歇式正壓換氣 (NIPPV) 相較鼻式連續式正壓 (NCPAP) 用於早產兒拔管後 先前的隨機試驗及統合分析顯示鼻式連續式正壓 (NCPAP) 是在拔管後提供呼吸支持的一種有效方式，然而使用這種方法的嬰兒有時會失敗且需要再度插管並伴隨危險和代價。鼻式間歇式正壓換氣 (NIPPV) 是一種加強NCPAP的方式，可經由鼻管給予呼吸器的換氣。NIPPV對於大小孩和慢性呼吸衰竭的成人有益處，並且也應用在新生兒，然而曾被報告過一些嚴重的併發症如胃穿孔，臨床醫師仍舊不確定NIPPV在新生兒科的角色。近來NIPPV變得可與嬰兒自呼努力同步，可能使這種方法在新生兒更加實用。 比較NIPPV與NCPAP用於使用間歇式正壓換氣一段時間拔管後的早產兒，NIPPV是否可減少拔管失敗率且無副作用 搜尋MEDLINE至2003年4月14止，使用MeSH terms：Infants、Newborn (exp) 和Positivepressure respiration (exp) ，其他資源包括Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003) 、CINAHL使用搜尋名詞包括Infant、newborn和 intermittent positive pressure ventilation，也搜尋專業資料、先前的回顧文章包括交互參考資料和會議及研討會紀錄。 這篇回顧文章選錄比較NIPPV與NCPAP治療用於拔管後的早產兒的隨機試驗 與臨床結果有關的資料由三位檢閱者各自分別選錄，包括拔管失敗、再度插管、呼吸暫停的發生率、腸胃穿孔、餵食不耐、慢性肺疾病和住院長短。這些試驗使用相對危險性 (RR) 、危險差 (RD) 和需要治療的數量 (NNT) 分析二分結果，並使用加權平均差異 (WMD) 分析持續性結果。 三個比較拔管的嬰兒使用NIPPV及NCPAP的試驗被找出，三個試驗都是用同步化的NIPPV，每個都顯示嬰兒拔管後使用NIPPV從預防拔管失敗的角度有統計上顯著的益處，統合分析也顯示有對臨床重要的效果[RR 0.21 (0.10, 0.45), RD −0.32 (−0.45, −0.20), NNT 3 (2, 5)]。這些試驗沒有任何報告有腸胃道穿孔，慢性肺病的發生率差異顯示NIPPV較佳，結果接近但未為達統計上有意義[RR 0.73 (0.49, 1.07), RD −0.15 (−0.33, 0.03)]。...

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