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Meta-Analysis
. 2020 Oct 15;10(10):CD002271.
doi: 10.1002/14651858.CD002271.pub3.

Continuous positive airway pressure (CPAP) for respiratory distress in preterm infants

Jacqueline J Ho  1 , Prema Subramaniam  2 , Peter G Davis  3   4   5
Affiliations
Meta-Analysis

Continuous positive airway pressure (CPAP) for respiratory distress in preterm infants

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

Abstract

Background: Respiratory distress, particularly 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 has been the usual treatment, but it is invasive, potentially resulting in airway and lung injury. Continuous positive airway pressure (CPAP) has been used for the prevention and treatment of respiratory distress, 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 in the form of CPAP on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress.

Search methods: We used the standard strategy of Cochrane Neonatal to search CENTRAL (2020, Issue 6); Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL on 30 June 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

Selection criteria: All randomised or quasi-randomised trials of preterm infants with respiratory distress were eligible. Interventions were CPAP by mask, nasal prong, nasopharyngeal tube or endotracheal tube, compared with spontaneous breathing with supplemental oxygen as necessary.

Data collection and analysis: We used standard methods of Cochrane and its Neonatal Review Group, including independent assessment of risk of bias and extraction of data by two review authors. We used the GRADE approach to assess the certainty of evidence. Subgroup analyses were planned on the basis of birth weight (greater than or less than 1000 g or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), timing of application (early versus late in the course of respiratory distress), pressure applied (high versus low) and trial setting (tertiary compared with non-tertiary hospitals; high income compared with low income) MAIN RESULTS: We included five studies involving 322 infants; two studies used face mask CPAP, two studies used nasal CPAP and one study used endotracheal CPAP and continuing negative pressure for a small number of less ill babies. For this update, we included one new trial. CPAP was associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.64, 95% confidence interval (CI) 0.50 to 0.82; typical risk difference (RD) -0.19, 95% CI -0.28 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 4 to 11; I2 = 50%; 5 studies, 322 infants; very low-certainty evidence), lower use of ventilatory assistance (typical RR 0.72, 95% CI 0.54 to 0.96; typical RD -0.13, 95% CI -0.25 to -0.02; NNTB 8, 95% CI 4 to 50; I2 = 55%; very low-certainty evidence) and lower overall mortality (typical RR 0.53, 95% CI 0.34 to 0.83; typical RD -0.11, 95% CI -0.18 to -0.04; NNTB 9, 95% CI 2 to 13; I2 = 0%; 5 studies, 322 infants; moderate-certainty evidence). CPAP was associated with increased risk of pneumothorax (typical RR 2.48, 95% CI 1.16 to 5.30; typical RD 0.09, 95% CI 0.02 to 0.16; number needed to treat for an additional harmful outcome (NNTH) 11, 95% CI 7 to 50; I2 = 0%; 4 studies, 274 infants; low-certainty evidence). There was no evidence of a difference in bronchopulmonary dysplasia, defined as oxygen dependency at 28 days (RR 1.04, 95% CI 0.35 to 3.13; I2 = 0%; 2 studies, 209 infants; very low-certainty evidence). The trials did not report use of surfactant, intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis and neurodevelopment outcomes in childhood.

Authors' conclusions: In preterm infants with respiratory distress, the application of CPAP is associated with reduced respiratory failure, use of mechanical ventilation and mortality and an increased rate of pneumothorax compared to spontaneous breathing with supplemental oxygen as necessary. Three out of five of these trials were conducted in the 1970s. Therefore, the applicability of these results to current practice is unclear. Further studies in resource-poor settings should be considered and research to determine the most appropriate pressure level needs to be considered.

PubMed Disclaimer

Conflict of interest statement

JJH: none.

PS: none.

PGD's institution has a grant pending from the Australian National Health and Medical Research Council.

Figures

1
1
Study flow diagram: review update. RCT: randomised controlled trial.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Continuous positive airway pressure (CPAP) versus supplemental oxygen, outcome: 1.1 Treatment failure (by death and use of additional ventilatory assistance, by blood gas criteria or by transfer to a neonatal intensive care unit).
5
5
Forest plot of comparison: 1 Continuous positive airway pressure (CPAP) versus supplemental oxygen, outcome: 1.5 Use of assisted ventilation.
6
6
Forest plot of comparison: 1 Continuous positive airway pressure (CPAP) versus supplemental oxygen, outcome: 1.8 Mortality.
1.1
1.1. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, 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: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 2: Treatment failure (death or use of additional ventilatory support by early or late application of CPAP)
1.3
1.3. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 3: Treatment failure (death or additional ventilatory support by level of care (tertiary vs non‐tertiary))
1.4
1.4. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 4: Treatment failure (death or use of assisted ventilation) by resource setting
1.5
1.5. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 5: Use of assisted ventilation
1.6
1.6. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 6: Respiratory failure by blood gas criteria
1.7
1.7. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 7: Transfer to a NICU
1.8
1.8. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 8: Mortality
1.9
1.9. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 9: Mortality by birthweight
1.10
1.10. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 10: Duration of supplemental oxygen
1.11
1.11. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 11: Any pneumothorax
1.12
1.12. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 12: Pneumothorax occurring after allocation
1.13
1.13. Analysis
Comparison 1: Continuous positive airway pressure (CPAP) versus supplemental oxygen, Outcome 13: Bronchopulmonary dysplasia at 28 days
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References

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