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Review
. 2023 Jul 27;7(7):CD003212.
doi: 10.1002/14651858.CD003212.pub4.

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

Brigitte Lemyre  1 , Marc-Olivier Deguise  2 , Paige Benson  3 , Haresh Kirpalani  4 , Antonio G De Paoli  5 , Peter G Davis  6   7   8
Affiliations
Review

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

Brigitte Lemyre et al. Cochrane Database Syst Rev. .

Abstract

Background: Nasal continuous positive airway pressure (NCPAP) is a useful method for providing respiratory support after extubation. Nasal intermittent positive pressure ventilation (NIPPV) can augment NCPAP by delivering ventilator breaths via nasal prongs.

Objectives: Primary objective To determine the effects of management with NIPPV versus NCPAP on the need for additional ventilatory support in preterm infants whose endotracheal tube was removed after a period of intermittent positive pressure ventilation. Secondary objectives To compare rates of abdominal distension, gastrointestinal perforation, necrotising enterocolitis, chronic lung disease, pulmonary air leak, mortality, duration of hospitalisation, rates of apnoea and neurodevelopmental status at 18 to 24 months for NIPPV and NCPAP. To compare the effect of NIPPV versus NCPAP delivered via ventilators versus bilevel devices, and assess the effects of the synchronisation of ventilation, and the strength of interventions in different economic settings.

Search methods: We used standard, extensive Cochrane search methods. The latest search date was January 2023.

Selection criteria: We included randomised and quasi-randomised trials of ventilated preterm infants (less than 37 weeks' gestational age (GA)) ready for extubation to non-invasive respiratory support. Interventions were NIPPV and NCPAP.

Data collection and analysis: We used standard Cochrane methods. Our primary outcome was 1. respiratory failure. Our secondary outcomes were 2. endotracheal reintubation, 3. abdominal distension, 4. gastrointestinal perforation, 5. necrotising enterocolitis (NEC), 6. chronic lung disease, 7. pulmonary air leak, 8. mortality, 9. hospitalisation, 10. apnoea and bradycardia, and 11. neurodevelopmental status. We used GRADE to assess the certainty of evidence.

Main results: We included 19 trials (2738 infants). Compared to NCPAP, NIPPV likely reduces the risk of respiratory failure postextubation (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.67 to 0.84; number needed to treat for an additional beneficial outcome (NNTB) 11, 95% CI 8 to 17; 19 trials, 2738 infants; moderate-certainty evidence) and endotracheal reintubation (RR 0.78, 95% CI 0.70 to 0.87; NNTB 12, 95% CI 9 to 25; 17 trials, 2608 infants, moderate-certainty evidence), and may reduce pulmonary air leaks (RR 0.57, 95% CI 0.37 to 0.87; NNTB 50, 95% CI 33 to infinite; 13 trials, 2404 infants; low-certainty evidence). NIPPV likely results in little to no difference in gastrointestinal perforation (RR 0.89, 95% CI 0.58 to 1.38; 8 trials, 1478 infants, low-certainty evidence), NEC (RR 0.86, 95% CI 0.65 to 1.15; 10 trials, 2069 infants; moderate-certainty evidence), chronic lung disease defined as oxygen requirement at 36 weeks (RR 0.93, 95% CI 0.84 to 1.05; 9 trials, 2001 infants; moderate-certainty evidence) and mortality prior to discharge (RR 0.81, 95% CI 0.61 to 1.07; 11 trials, 2258 infants; low-certainty evidence). When considering subgroup analysis, ventilator-generated NIPPV likely reduces respiratory failure postextubation (RR 0.49, 95% CI 0.40 to 0.62; 1057 infants; I2 = 47%; moderate-certainty evidence), while bilevel devices (RR 0.95, 95% CI 0.77 to 1.17; 716 infants) or a mix of both ventilator-generated and bilevel devices likely results in little to no difference (RR 0.87, 95% CI 0.73 to 1.02; 965 infants).

Authors' conclusions: NIPPV likely reduces the incidence of extubation failure and the need for reintubation within 48 hours to one-week postextubation more effectively than NCPAP in very preterm infants (GA 28 weeks and above). There is a paucity of data for infants less than 28 weeks' gestation. Pulmonary air leaks were also potentially reduced in the NIPPV group. However, it has no effect on other clinically relevant outcomes such as gastrointestinal perforation, NEC, chronic lung disease or mortality. Ventilator-generated NIPPV appears superior to bilevel devices in reducing the incidence of respiratory failure postextubation failure and need for reintubation. Synchronisation used to deliver NIPPV may be important; however, data are insufficient to support strong conclusions. Future trials should enrol a sufficient number of infants, particularly those less than 28 weeks' GA, to detect differences in death or chronic lung disease and should compare different categories of devices, establish the impact of synchronisation of NIPPV on safety and efficacy of the technique as well as the best combination of settings for NIPPV (rate, peak pressure and positive end-expiratory). Trials should strive to match the mean airway pressure between the intervention groups to allow a better comparison. Neurally adjusted ventilatory assist needs further assessment with properly powered randomised trials.

PubMed Disclaimer

Conflict of interest statement

BL was an author of an included study (Kirpalani 2013). The Canadian Institutes of Health Research funded the study. She requested data from the study for inclusion in the review (data extracted by the trial statistician, R Roberts). Roger Soll, co‐ordinating editor, Cochrane Neonatal assessed risk of bias and undertook GRADE assessment for this data. R Soll does not have any interests to disclose at this time.

PB: none.

MOD: none.

HK was involved in conducting a randomised controlled trial comparing NIPPV to NCPAP, (Nasal Ventilation in Preterm Infants (NIP) trial) published in the New England Journal of Medicine in 2013 (Kirpalani 2013). The funding source for this study was the Canadian Institutes of Health Research.

AGP: none.

PD received a grant from the Australian National Health and Medical Research Council. He was involved in conducting the COIN trial (a multicentre trial conducted at his institution, The Royal Women's Hospital) by the Australian National Health and Medical Research Council. This trial is not included in this review.

Figures

1
1
PRISMA figure
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Forest plot of respiratory failure in NCPAP vs NIPPV postextubation.
5
5
Forest plot of the need for reintubation in CPAP vs NIPPV postextubation.
6
6
Forest plot of chronic lung disease in CPAP vs NIPPV postextubation.
7
7
Forest plot of mortality in CPAP vs NIPPV postextubation.
1.1
1.1. Analysis
Comparison 1: NIPPV versus NCPAP to prevent extubation failure, Outcome 1: Respiratory failure postextubation
1.2
1.2. Analysis
Comparison 1: NIPPV versus NCPAP to prevent extubation failure, Outcome 2: Respiratory failure postextubation at 72 hours versus 7 days
1.3
1.3. Analysis
Comparison 1: NIPPV versus NCPAP to prevent extubation failure, Outcome 3: Endotracheal reintubation
1.4
1.4. Analysis
Comparison 1: NIPPV versus NCPAP to prevent extubation failure, Outcome 4: Endotracheal reintubation at 72 hours versus 7 days
2.1
2.1. Analysis
Comparison 2: NIPPV versus NCPAP and gastrointestinal complications, Outcome 1: Abdominal distension requiring cessation of feeds
2.2
2.2. Analysis
Comparison 2: NIPPV versus NCPAP and gastrointestinal complications, Outcome 2: Gastrointestinal perforation
2.3
2.3. Analysis
Comparison 2: NIPPV versus NCPAP and gastrointestinal complications, Outcome 3: Necrotising enterocolitis
3.1
3.1. Analysis
Comparison 3: NIPPV versus NCPAP to improve pulmonary outcomes, Outcome 1: Chronic lung disease (oxygen supplementation at 36 weeks)
3.2
3.2. Analysis
Comparison 3: NIPPV versus NCPAP to improve pulmonary outcomes, Outcome 2: Pulmonary air leaks
4.1
4.1. Analysis
Comparison 4: NIPPV versus NCPAP and mortality, Outcome 1: Mortality
5.1
5.1. Analysis
Comparison 5: NIPPV versus NCPAP and duration of hospital admission, Outcome 1: Duration of hospital admission (days)
6.1
6.1. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 1: Respiratory failure postextubation
6.2
6.2. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 2: Endotracheal reintubation during the week postextubation
6.3
6.3. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 3: Abdominal distension requiring cessation of feeds
6.4
6.4. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 4: Gastrointestinal perforation
6.5
6.5. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 5: Necrotising enterocolitis
6.6
6.6. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 6: Chronic lung disease (oxygen supplementation at 36 weeks)
6.7
6.7. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 7: Pulmonary air leak
6.8
6.8. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 8: Duration of hospitalisation (days)
6.9
6.9. Analysis
Comparison 6: NIPPV versus NCPAP (synchronised versus non‐synchronised), Outcome 9: Mortality
7.1
7.1. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 1: Respiratory failure postextubation
7.2
7.2. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 2: Endotracheal reintubation during the week postextubation
7.3
7.3. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 3: Abdominal distension requiring cessation of feeds
7.4
7.4. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 4: Gastrointestinal perforation
7.5
7.5. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 5: Necrotising enterocolitis
7.6
7.6. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 6: Chronic lung disease (oxygen supplementation at 36 weeks)
7.7
7.7. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 7: Pulmonary air leak
7.8
7.8. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 8: Mortality
7.9
7.9. Analysis
Comparison 7: NIPPV versus NCPAP (ventilator‐generated NIPPV versus bilevel NIPPV), Outcome 9: Duration of hospitalisation (days)
8.1
8.1. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 1: Respiratory failure postextubation
8.2
8.2. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 2: Endotracheal reintubation during the week postextubation
8.3
8.3. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 3: Abdominal distension requiring cessation of feeds
8.4
8.4. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 4: Gastrointestinal perforation
8.5
8.5. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 5: Necrotising enterocolitis
8.6
8.6. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 6: Chronic lung disease (oxygen supplementation at 36 weeks)
8.7
8.7. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 7: Pulmonary air leak
8.8
8.8. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 8: Mortality
8.9
8.9. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 9: Duration of hospitalisation (days)
8.10
8.10. Analysis
Comparison 8: NIPPV versus NCPAP (economic setting), Outcome 10: Rates of apnoea (episodes/24 hours)
See this image and copyright information in PMC

Update of

References

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References to studies excluded from this review

Aguiar 2015 {published data only}
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Dursun 2019 {published data only}
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Gomez 2018 {published data only}
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Kishore 2009 {published data only}
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Kugelman 2007 {published data only}
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Kumar 2011 {published data only}
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Latremouille 2018 {published data only}
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Latremouille 2021 {published data only}
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Shi 2010 {published data only}
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Shi 2013 {published data only}
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References to studies awaiting assessment

Ding 2020 {published data only}
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Li 2022 {published data only}
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Saeedi 2012 {published data only}
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Yuan 2022 {published data only}
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References to ongoing studies

Shi 2019 {published data only}
    1. NCT03181958. A trial comparing noninvasive ventilation strategies in preterm infants following extubation. clinicaltrials.gov/ct2/show/NCT03181958 (first received 9 June 2017).
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References to other published versions of this review

Davis 2001
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Lemyre 2014
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Lemyre 2017
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