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Meta-Analysis
. 2015 Jul 4;2015(7):CD002271.
doi: 10.1002/14651858.CD002271.pub2.

Continuous distending pressure for respiratory distress in preterm infants

Jacqueline J Ho  1 , Prema Subramaniam, Peter G Davis
Affiliations
Meta-Analysis

Continuous distending pressure for respiratory distress in preterm infants

Jacqueline J Ho et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition, but it is invasive, potentially resulting in airway and lung injury. Continuous distending pressure (CDP) has been used for the prevention and treatment of RDS, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae.

Objectives: To determine the effect of continuous distending pressure (CDP) on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress.Subgroup analyses were planned on the basis of birth weight (> or < 1000 or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), methods of application of CDP (i.e. CPAP and CNP), application early versus late in the course of respiratory distress and high versus low pressure CDP and application of CDP in tertiary compared with non-tertiary hospitals, with the need for sensitivity analysis determined by trial quality.At the 2008 update, the objectives were modified to include preterm infants with respiratory failure.

Search methods: We used the standard search strategy of the Neonatal Review Group. This included searches of the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, 2015 Issue 4), MEDLINE (1966 to 30 April 2015) and EMBASE (1980 to 30 April 2015) with no language restriction, as well as controlled-trials.com, clinicaltrials.gov and the International Clinical Trials Registry Platform of the World Health Organization (WHO).

Selection criteria: All random or quasi-random trials of preterm infants with respiratory distress 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 the lower body, compared with spontaneous breathing with oxygen added as necessary.

Data collection and analysis: We used standard methods of The Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each review author.

Main results: We included six studies involving 355 infants - two using face mask CPAP, two CNP, one nasal CPAP and one both CNP (for less ill babies) and endotracheal CPAP (for sicker babies). For this update, we included no new trials.Continuous distending pressure (CDP) is associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.52 to 0.81; typical risk difference (RD) -0.20, 95% CI -0.29 to -0.10; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; six studies; 355 infants), lower overall mortality (typical RR 0.52, 95% CI 0.32 to 0.87; typical RD -0.15, 95% CI -0.26 to -0.04; NNTB 7, 95% CI 4 to 25; six studies; 355 infants) and lower mortality in infants with birth weight above 1500 g (typical RR 0.24, 95% CI 0.07 to 0.84; typical RD -0.28, 95% CI -0.48 to -0.08; NNTB 4, 95% CI 2.00 to 13.00; two studies; 60 infants). Use of CDP is associated with increased risk of pneumothorax (typical RR 2.64, 95% CI 1.39 to 5.04; typical RD 0.10, 95% CI 0.04 to 0.17; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 17.00 to 25.00; six studies; 355 infants). We found no difference in bronchopulmonary dysplasia (BPD), defined as oxygen dependency at 28 days (three studies, 260 infants), as well as no difference in outcome at nine to 14 years (one study, 37 infants).

Authors' conclusions: In preterm infants with respiratory distress, the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax. Four out of six of these trials were done in the 1970s. Therefore, the applicability of these results to current practice is difficult to assess. Further research is required to determine the best mode of administration.

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Conflict of interest statement

None.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 CDP vs standard care, Outcome 1 Treatment failure (by death and use of additional ventilatory assistance, by blood gas criteria or by transfer to a neonatal intensive care unit).
1.2
1.2. Analysis
Comparison 1 CDP vs standard care, Outcome 2 Use of additional ventilatory assistance.
1.3
1.3. Analysis
Comparison 1 CDP vs standard care, Outcome 3 Transfer to a neonatal intensive care unit.
1.4
1.4. Analysis
Comparison 1 CDP vs standard care, Outcome 4 Mortality.
1.5
1.5. Analysis
Comparison 1 CDP vs standard care, Outcome 5 Mortality ≤ 1500 g.
1.6
1.6. Analysis
Comparison 1 CDP vs standard care, Outcome 6 Mortality > 1500 g.
1.7
1.7. Analysis
Comparison 1 CDP vs standard care, Outcome 7 Duration of supplemental oxygen (days).
1.8
1.8. Analysis
Comparison 1 CDP vs standard care, Outcome 8 Any pneumothorax.
1.9
1.9. Analysis
Comparison 1 CDP vs standard care, Outcome 9 Pneumothorax occurring after allocation.
1.10
1.10. Analysis
Comparison 1 CDP vs standard care, Outcome 10 Use of surfactant.
1.11
1.11. Analysis
Comparison 1 CDP vs standard care, Outcome 11 Bronchopulmonary dysplasia at 28 days in survivors.
1.12
1.12. Analysis
Comparison 1 CDP vs standard care, Outcome 12 Death or severe disability.
1.13
1.13. Analysis
Comparison 1 CDP vs standard care, Outcome 13 Severe disability.
1.14
1.14. Analysis
Comparison 1 CDP vs standard care, Outcome 14 Any disability.
1.15
1.15. Analysis
Comparison 1 CDP vs standard care, Outcome 15 Cerebral palsy.
2.1
2.1. Analysis
Comparison 2 CNP vs standard care, Outcome 1 Failure (death or use of additional ventilatory assistance).
2.2
2.2. Analysis
Comparison 2 CNP vs standard care, Outcome 2 Use of additional ventilatory assistance.
2.3
2.3. Analysis
Comparison 2 CNP vs standard care, Outcome 3 Mortality.
2.4
2.4. Analysis
Comparison 2 CNP vs standard care, Outcome 4 Pneumothorax after allocation.
2.5
2.5. Analysis
Comparison 2 CNP vs standard care, Outcome 5 Bronchopulmonary dysplasia at 28 days in survivors.
2.6
2.6. Analysis
Comparison 2 CNP vs standard care, Outcome 6 Death or severe disability.
2.7
2.7. Analysis
Comparison 2 CNP vs standard care, Outcome 7 Severe disability.
2.8
2.8. Analysis
Comparison 2 CNP vs standard care, Outcome 8 Any disability.
2.9
2.9. Analysis
Comparison 2 CNP vs standard care, Outcome 9 Cerebral palsy.
3.1
3.1. Analysis
Comparison 3 CPAP vs standard care, Outcome 1 Treatment failure (by death or use of additional ventilatory assistance).
3.2
3.2. Analysis
Comparison 3 CPAP vs standard care, Outcome 2 Use of additional ventilatory assistance.
3.3
3.3. Analysis
Comparison 3 CPAP vs standard care, Outcome 3 Mortality.
3.4
3.4. Analysis
Comparison 3 CPAP vs standard care, Outcome 4 Mortality ≤ 1500 g.
3.5
3.5. Analysis
Comparison 3 CPAP vs standard care, Outcome 5 Mortality > 1500 g.
3.6
3.6. Analysis
Comparison 3 CPAP vs standard care, Outcome 6 Any pneumothorax.
3.7
3.7. Analysis
Comparison 3 CPAP vs standard care, Outcome 7 Pneumothorax occurring after allocation.
4.1
4.1. Analysis
Comparison 4 Early application of CDP vs standard care, Outcome 1 Failure (death or use of additional ventilatory assistance).
4.2
4.2. Analysis
Comparison 4 Early application of CDP vs standard care, Outcome 2 Mortality.
5.1
5.1. Analysis
Comparison 5 CDP vs standard care ‐ excluding Rhodes (quasi‐random), Outcome 1 Failure (death or use of additional ventilatory assistance).
5.2
5.2. Analysis
Comparison 5 CDP vs standard care ‐ excluding Rhodes (quasi‐random), Outcome 2 Mortality.
6.1
6.1. Analysis
Comparison 6 CDP vs standard care ‐ excluding Belenky (low quality), Outcome 1 Failure (death or use of additional ventilatory assistance).
6.2
6.2. Analysis
Comparison 6 CDP vs standard care ‐ excluding Belenky (low quality), Outcome 2 Mortality.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Belenky 1976 {published and unpublished data}
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Colnaghi 2008 {published data only}
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Tooley 2003 {published data only}
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References to other published versions of this review

Ho 2000
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