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Review
. 2016 Sep 1;9(9):CD000456.
doi: 10.1002/14651858.CD000456.pub5.

Synchronized mechanical ventilation for respiratory support in newborn infants

Anne Greenough  1 , Thomas E Rossor, Adesh Sundaresan, Vadivelam Murthy, Anthony D Milner
Affiliations
Review

Synchronized mechanical ventilation for respiratory support in newborn infants

Anne Greenough et al. Cochrane Database Syst Rev. .

Abstract

Background: During synchronised mechanical ventilation, positive airway pressure and spontaneous inspiration coincide. If synchronous ventilation is provoked, adequate gas exchange should be achieved at lower peak airway pressures, potentially reducing baro/volutrauma, air leak and bronchopulmonary dysplasia. Synchronous ventilation can potentially be achieved by manipulation of rate and inspiratory time during conventional ventilation and employment of patient-triggered ventilation.

Objectives: To compare the efficacy of:(i) synchronised mechanical ventilation, delivered as high-frequency positive pressure ventilation (HFPPV) or patient-triggered ventilation (assist control ventilation (ACV) and synchronous intermittent mandatory ventilation (SIMV)), with conventional ventilation or high-frequency oscillation (HFO);(ii) different types of triggered ventilation (ACV, SIMV, pressure-regulated volume control ventilation (PRVCV), SIMV with pressure support (PS) and pressure support ventilation (PSV)).

Search methods: We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 5), MEDLINE via PubMed (1966 to June 5 2016), EMBASE (1980 to June 5 2016), and CINAHL (1982 to June 5 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

Selection criteria: Randomised or quasi-randomised clinical trials comparing synchronised ventilation delivered as HFPPV to CMV, or ACV/SIMV to CMV or HFO in neonates. Randomised trials comparing different triggered ventilation modes (ACV, SIMV, SIMV plus PS, PRVCV and PSV) in neonates.

Data collection and analysis: Data were collected regarding clinical outcomes including mortality, air leaks (pneumothorax or pulmonary interstitial emphysema (PIE)), severe intraventricular haemorrhage (grades 3 and 4), bronchopulmonary dysplasia (BPD) (oxygen dependency beyond 28 days), moderate/severe BPD (oxygen/respiratory support dependency beyond 36 weeks' postmenstrual age (PMA) and duration of weaning/ventilation.Eight comparisons were made: (i) HFPPV versus CMV; (ii) ACV/SIMV versus CMV; (iii) SIMV or SIMV + PS versus HFO; iv) ACV versus SIMV; (v) SIMV plus PS versus SIMV; vi) SIMV versus PRVCV; vii) SIMV vs PSV; viii) ACV versus PSV. Data analysis was conducted using relative risk for categorical outcomes, mean difference for outcomes measured on a continuous scale.

Main results: Twenty-two studies are included in this review. The meta-analysis demonstrates that HFPPV compared to CMV was associated with a reduction in the risk of air leak (typical relative risk (RR) for pneumothorax was 0.69, 95% confidence interval (CI) 0.51 to 0.93). ACV/SIMV compared to CMV was associated with a shorter duration of ventilation (mean difference (MD) -38.3 hours, 95% CI -53.90 to -22.69). SIMV or SIMV + PS was associated with a greater risk of moderate/severe BPD compared to HFO (RR 1.33, 95% CI 1.07 to 1.65) and a longer duration of mechanical ventilation compared to HFO (MD 1.89 days, 95% CI 1.04 to 2.74).ACV compared to SIMV was associated with a trend to a shorter duration of weaning (MD -42.38 hours, 95% CI -94.35 to 9.60). Neither HFPPV nor triggered ventilation was associated with a significant reduction in the incidence of BPD. There was a non-significant trend towards a lower mortality rate using HFPPV versus CMV and a non-significant trend towards a higher mortality rate using triggered ventilation versus CMV. No disadvantage of HFPPV or triggered ventilation was noted regarding other outcomes.

Authors' conclusions: Compared to conventional ventilation, benefit is demonstrated for both HFPPV and triggered ventilation with regard to a reduction in air leak and a shorter duration of ventilation, respectively. In none of the trials was complex respiratory monitoring undertaken and thus it is not possible to conclude that the mechanism of producing those benefits is by provocation of synchronised ventilation. Triggered ventilation in the form of SIMV ± PS resulted in a greater risk of BPD and duration of ventilation compared to HFO. Optimisation of trigger and ventilator design with respect to respiratory diagnosis is encouraged before embarking on further trials. It is essential that newer forms of triggered ventilation are tested in randomised trials that are adequately powered to assess long-term outcomes before they are incorporated into routine clinical practice.

PubMed Disclaimer

Conflict of interest statement

AG received no grants or speaker fees for the three years prior to the publication of this review.

TER has no interest to declare

AS has no interest to declare

VM has no interest to declare

ADM has no interest to declare

Figures

1
1
Study flow diagram: review update
1.1
1.1. Analysis
Comparison 1: HFPPV vs CMV, Outcome 1: Death
1.2
1.2. Analysis
Comparison 1: HFPPV vs CMV, Outcome 2: Air leaks
1.3
1.3. Analysis
Comparison 1: HFPPV vs CMV, Outcome 3: Total air leak
1.4
1.4. Analysis
Comparison 1: HFPPV vs CMV, Outcome 4: BPD (oxygen dependency at 28 days)
1.5
1.5. Analysis
Comparison 1: HFPPV vs CMV, Outcome 5: IVH
2.1
2.1. Analysis
Comparison 2: ACV/SIMV vs CMV, Outcome 1: Death
2.2
2.2. Analysis
Comparison 2: ACV/SIMV vs CMV, Outcome 2: Air leaks
2.3
2.3. Analysis
Comparison 2: ACV/SIMV vs CMV, Outcome 3: Duration of ventilation (hours)
2.4
2.4. Analysis
Comparison 2: ACV/SIMV vs CMV, Outcome 4: Extubation failure
2.5
2.5. Analysis
Comparison 2: ACV/SIMV vs CMV, Outcome 5: Severe IVH
2.6
2.6. Analysis
Comparison 2: ACV/SIMV vs CMV, Outcome 6: BPD (oxygen dependency at 28 days)
2.7
2.7. Analysis
Comparison 2: ACV/SIMV vs CMV, Outcome 7: Moderate/Severe BPD (oxygen dependent at 36 weeks PCA)
3.1
3.1. Analysis
Comparison 3: SIMV or SIMV + PS vs HFOV, Outcome 1: Death
3.2
3.2. Analysis
Comparison 3: SIMV or SIMV + PS vs HFOV, Outcome 2: BPD: oxygen requirement at 28 days
3.3
3.3. Analysis
Comparison 3: SIMV or SIMV + PS vs HFOV, Outcome 3: Moderate/ Severe BPD: Oxygen requirement at 36 weeks PCA
3.4
3.4. Analysis
Comparison 3: SIMV or SIMV + PS vs HFOV, Outcome 4: Death or BPD
3.5
3.5. Analysis
Comparison 3: SIMV or SIMV + PS vs HFOV, Outcome 5: Duration of mechanical ventilation
3.6
3.6. Analysis
Comparison 3: SIMV or SIMV + PS vs HFOV, Outcome 6: Air leaks
3.7
3.7. Analysis
Comparison 3: SIMV or SIMV + PS vs HFOV, Outcome 7: IVH Grade 3/4
4.1
4.1. Analysis
Comparison 4: ACV vs SIMV, Outcome 1: Duration of weaning (hours)
4.2
4.2. Analysis
Comparison 4: ACV vs SIMV, Outcome 2: Weaning failure
4.3
4.3. Analysis
Comparison 4: ACV vs SIMV, Outcome 3: Extubation failure
4.4
4.4. Analysis
Comparison 4: ACV vs SIMV, Outcome 4: Air leaks
5.1
5.1. Analysis
Comparison 5: PS + SIMV versus SIMV, Outcome 1: Death
5.2
5.2. Analysis
Comparison 5: PS + SIMV versus SIMV, Outcome 2: Air leaks
5.3
5.3. Analysis
Comparison 5: PS + SIMV versus SIMV, Outcome 3: BPD
5.4
5.4. Analysis
Comparison 5: PS + SIMV versus SIMV, Outcome 4: Severe IVH (grade III and IV)
6.1
6.1. Analysis
Comparison 6: PRVCV vs SIMV, Outcome 1: Death prior to discharge
6.2
6.2. Analysis
Comparison 6: PRVCV vs SIMV, Outcome 2: BPD: oxygen requirement at 36 weeks in survivors
6.3
6.3. Analysis
Comparison 6: PRVCV vs SIMV, Outcome 3: Air leak
6.4
6.4. Analysis
Comparison 6: PRVCV vs SIMV, Outcome 4: Severe IVH
7.1
7.1. Analysis
Comparison 7: PSV vs SIMV, Outcome 1: Duration of weaning
7.2
7.2. Analysis
Comparison 7: PSV vs SIMV, Outcome 2: Extubation failure
7.3
7.3. Analysis
Comparison 7: PSV vs SIMV, Outcome 3: Air leaks (total)
7.4
7.4. Analysis
Comparison 7: PSV vs SIMV, Outcome 4: Moderate/Severe BPD: oxygen requirement at 36 weeks PCA
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD000456.pub4

References

References to studies included in this review

Amini 2013 {published data only}
    1. Amini E, Nayeri FS, Hemati A, Esmaeilinia T, Nili F, Dalili H, et al. Comparison of High Frequency Positive Pressure Mechanical Ventilation (HFPPV) With Conventional Method in the Treatment of Neonatal Respiratory Failure. Iranian Red Crescent Medical Journal 2013;15(3):183-6. [PMID: ] - PMC - PubMed
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Reyes 2006 {published data only}
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Singh 2012 {published data only}
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References to studies excluded from this review

Abd El‐Moneim 2005 {published data only}
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Abubakar 2005 {published data only}
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Amitay 1993 {published data only}
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Bernstein 1993 {published data only}
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Bitondo 2012 {published data only}
    1. Bitondo M M, Aguirre-Bermeo H M, Moccaldo A, De Santis P, Bernini V, Tersali A, et al. Patient-ventilator asynchrony during conventional or automated pressure support ventilation in difficult-to-wean patients. Critical Care 2012;16(Suppl 1):P126. [DOI: 10.1186/cc10733] - DOI
Chan 1993b {published data only}
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Cheema 2001 {published data only}
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Clavieras 2013 {published data only}
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Dimitriou 1998 {published data only}
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Duman 2012 {published data only}
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Durand 2001 {published data only}
    1. Durand DJ, Asselin JM, Hudak ML, Aschner JL, McArtor RD, Cleary JP, et al. Early high-frequency oscillatory ventilation versus synchronized intermittent mandatory ventilation in very low birth weight infants: a pilot study of two ventilation protocols. Journal of Perinatology 2001;21(4):221-9. - PubMed
Estay 2009 {published data only}
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Firme 2005 {published data only}
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Friedlich 1999 {published data only}
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Greenough 1986 {published data only}
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Greenough 1987a {published data only}
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Greenough 1987b {published data only}
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Greenough 1988a {published data only}
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Greenough 1988b {published data only}
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Greenough 1991 {published data only}
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Gupta 2008 {published data only}
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Guthrie 2005 {published data only}
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Guven 2013 {published data only}
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Herrera 2002 {published data only}
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Hird 1990a {published data only}
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Hird 1990b {published data only}
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Hird 1991a {published data only}
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Hird 1991b {published data only}
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Hird 1991c {published data only}
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Hird 1991d {published data only}
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Hummler 1996 {published data only}
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Hummler 1997 {published data only}
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Hummler 2006 {published data only}
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Jaber 2005 {published data only}
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Jarreau 1996 {published data only}
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John 1994 {published data only}
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Kapasi 2001 {published data only}
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Keszler 2004 {published data only}
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Laubscher 1997 {published data only}
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Lista 2006 {published data only}
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Luyt 2001 {published data only}
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McCallion 2007 {published data only}
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Migliori 2003 {published data only}
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Mitchell 1989 {published data only}
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Mizuno 1994 {published data only}
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Moretti 1999 {published data only}
    1. Moretti C, Gizzi C, Papoff P, Lampariello S, Capoferri M, Calcagnini G, Bucci G. Comparing the effects of nasal synchronized intermittent positive pressure ventilation (nSIPPV) and nasal continuous positive airway pressure (nCPAP) after extubation in very low birth weight infants. Early Human Development 1999;56(2–3):167–77. - PubMed
Mrozek 2000 {published data only}
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Nacoti 2012 {published data only}
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Nafday 2005 {published data only}
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References to other published versions of this review

Greenough 1998
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Greenough 2004
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