Efficacy of noninvasive respiratory support modes for primary respiratory support in preterm neonates with respiratory distress syndrome: Systematic review and network meta-analysis.

Viraraghavan Vadakkencherry Ramaswamy,Prathik Bandiya,Sushma Nangia,Kiran More,Charles Christoph Roehr

doi:10.1002/ppul.25011

Abstract

To compare the efficacy of different noninvasive respiratory support (NRS) modes for primary respiratory support of preterm infants with respiratory distress syndrome (RDS). Systematic review and network meta-analysis using the Bayesian random-effects approach. MEDLINE, EMBASE, and CENTRAL were searched. High flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), bilevel CPAP (BiPAP), noninvasive positive pressure ventilation (NIPPV). Requirement of invasive mechanical ventilation (MV), any treatment failure. A total of 35 studies including 4078 neonates were included. NIPPV was more effective in decreasing the requirement of MV than CPAP (risk ratios [95% credible interval]: 0.60 [0.44, 0.77]) and HFNC [0.66 (0.43, 0.97)]. Surface under the cumulative ranking curve (SUCRA) for NIPPV, BiPAP, HFNC, and CPAP were 0.95, 0.59, 0.32, and 0.13. For the outcome of treatment failure, both NIPPV and BiPAP were more efficacious compared to CPAP and HFNC (0.56 [0.44, 0.71] {NIPPV vs CPAP}, 0.69 [0.51, 0.93] {BiPAP vs CPAP}, 0.42 [0.30, 0.63] {NIPPV vs HFNC}, 0.53 [0.35, 0.81] {BiPAP vs HFNC}). The SUCRA for NIPPV, BiPAP, CPAP, and HFNC were 0.96, 0.70, 0.32, and 0.01. NIPPV was associated with a reduced risk of air leak compared to BiPAP and CPAP (0.36 [0.16, 0.73]; 0.54 [0.30, 0.87], respectively). NIPPV resulted in lesser incidence of bronchopulmonary dysplasia or mortality when compared to CPAP (0.74 [0.52, 0.98]). Nasal injury was lesser with HFNC compared to CPAP (0.15 [0.01, 0.60]). Most effective primary mode of NRS in preterm neonates with RDS was NIPPV.

Highlights

The introduction of surfactant had a major impact on improving the outcomes of preterm neonates with respiratory distress syndrome (RDS).[1]
noninvasive positive pressure ventilation (NIPPV) was more effective in decreasing the requirement of mechanical ventilation (MV) than continuous positive airway pressure (CPAP) and High flow nasal cannula (HFNC) [0.66 (0.43, 0.97)]
Newer modalities of noninvasive respiratory support (NRS) strategies that have come into practice in neonatal medicine in the past two decades, include heated and humidified high flow cannula (HFNC), noninvasive positive pressure ventilation (NIPPV), bilevel CPAP (BiPAP) as well as nasal high‐frequency oscillation ventilation.[4,5]

Summary

Introduction

The introduction of surfactant had a major impact on improving the outcomes of preterm neonates with respiratory distress syndrome (RDS).[1]. Several systematic reviews compared different NRS strategies in pair‐wise meta‐analysis, only one network meta‐analysis (NMA) evaluated different NRS strategies in preterm neonates with RDS.[6,7,8,9,10] The NMA by Isamaya et al[10] included different modalities of surfactant instillation (Less Invasive Surfactant Administration [LISA], Intubate Surfactant and Rapid Extubation [INSURE] and mechanical ventilation [MV] following surfactant) along with CPAP and NIPPV.[10]

Objectives

Results

Conclusion