Comparative effectiveness of nasal intermittent positive pressure ventilation vs continuous positive airway pressure in preterm infants with RDS: an updated systematic review and meta-analysis of randomized controlled trials

Abstract

The aim of the present systematic review was to determine whether non-invasive intermittent positive pressure ventilation (NIPPV), as initial respiratory support for preterm infants with respiratory distress syndrome (RDS), reduces the incidence of invasive ventilation (IV) and bronchopulmonary dysplasia (BPD) more effectively than nasal continuous positive airway pressure (NCPAP). We systematically searched Medline, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) for records published between 1980 and February 2022. RCTs comparing early NIPPV with NCPAP as initial respiratory support in preterm infants with RDS were included. Two reviewers independently extracted data. Pooled relative risks (RRs) with 95% confidence intervals (CI) were calculated using random-effects meta-analysis. Subgroup analyses were performed for infants receiving surfactant and stratified by gestational age (GA) or birth weight (BW). The primary outcomes were the incidence of IV and BPD. A total of 14 randomized clinical trials (RCTs) involving 1755 infants were included. Compared with NCPAP, early NIPPV significantly reduced the incidence of IV (risk ratio [RR], 0.53; 95% CI, 0.43-0.64; P < .001) and the incidence of BPD (RR, 0.48; 95% CI, 0.29-0.79; P = .004). The reduction in the incidence of IV remained statistically significant across multiple subgroups: GA > 30 weeks (RR, 0.41; 95% CI, 0.27-0.63; P < .001) and GA ≤ 30 weeks (RR, 0.31; 95% CI, 0.20-0.48; P < .001); infants treated with surfactant (RR, 0.60; 95% CI, 0.43-0.83; P = .002); BW ≤ 1500 g (RR, 0.54; 95% CI, 0.38-0.77; P < .001) and BW > 1500 g (RR, 0.53; 95% CI, 0.36-0.77; P = .001). However, the reduction in the incidence of BPD was significant only in subgroups stratified by GA: GA > 30 weeks (RR, 0.40; 95% CI, 0.18-0.90; P = .03) and GA ≤ 30 weeks (RR, 0.33; 95% CI, 0.14-0.75; P = .008).

Conclusion: Early NIPPV appears superior to NCPAP for reducing the incidence of IV and BPD in preterm infants with RDS. Nevertheless, higher-quality evidence is needed for definitive recommendations.

What is known: • Nasal intermittent positive pressure ventilation (NIPPV) delivers cyclical peak pressure support and may outperform nasal continuous positive airway pressure (NCPAP). While some randomized controlled trials (RCTs) show NIPPV reduces invasive ventilation rates compared to NCPAP, its effect on bronchopulmonary dysplasia (BPD) incidence remains inconclusive.

What is new: • NIPPV appears superior to NCPAP in reducing the incidence of IV and BPD in preterm infants with respiratory distress syndrome (RDS) as initial noninvasive respiratory support.

Keywords: Meta-analysis; Nasal continuous positive airway pressure; Nasal intermittent positive-pressure ventilation; Preterm infants; Respiratory support.