Continuous positive airway pressure versus theophylline for apnea in preterm infants

 

Abstract

Background

Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia which may be severe enough to require resuscitation including use of positive pressure ventilation. Theophylline and continuous positive airways pressure (CPAP) are two treatments that have been used to prevent apnea and its consequences.

Objectives

The main objective was to determine in preterm infants with recurrent apnea, if treatment with CPAP compared with treatment with theophylline leads to a clinically important reduction in apnea or use of mechanical ventilation, without clinically important side effects.

Search methods

Searches were made of the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2005), MEDLINE (1966 - March 2005), EMBASE (1980 - March 2005), and CINAHL (1982 - March 2005). Previous reviews including cross references were also examined. Expert informants were also questioned. Abstracts of the Society for Pediatric Research from 1996 - 2004 inclusive were searched.

Selection criteria

All trials using random or quasi-random allocation to CPAP or theophylline in preterm infants with clinical recurrent apnea/bradycardia were eligible.

Data collection and analysis

Data were extracted using standard methods of the Cochrane Collaboration and its Neonatal Review Group, with separate evaluation of trial quality and data extraction by each author and synthesis of data using relative risk.

Main results

Only one eligible trial was found. The use of mask CPAP is associated with a higher treatment failure rate as measured by less than a 50% reduction in apnea or use of an alternative treatment [RR 2.89 (95% CI 1.12, 7.47); RD 0.42 (95% CI 0.11, 0.74)]. For every 2.4 infants (95% CI 1.4, 9.5) treated with mask CPAP rather than theophylline, there results one treatment failure. In the mask CPAP group there is more use of IPPV [RR 3.09 (1.42, 6.70); RD 0.58 (95% CI 0.30, 0.86). For every 1.7 infants (95% CI 1.2, 3.3) treated with mask CPAP rather than theophylline, one infant is intubated for IPPV.

In the mask CPAP group, there are trends towards more deaths in the first year, and in death or major disability in survivors at follow up, which do not reach significance. There are no differences in rates of necrotizing enterocolitis or major disability in survivors at follow up.

Authors' conclusions

Theophylline is more effective than mask CPAP for preterm infants with apnea. Since CPAP is no longer administered by mask, the results of this review have limited importance for current clinical practice. Further evaluation of the benefits and harms of CPAP vs theophylline for preterm infants with apnea requires further trials in which CPAP is administered by current methods.

 

Plain language summary

Continuous positive airway pressure versus theophylline for apnea in preterm infants

Theophylline may be more helpful in preventing problems for preterm babies with apnea than CPAP (blowing air) through a mask. Apnea is common in preterm babies (born before 37 weeks). It is a pause in breathing of more than 20 seconds, or less than 20 seconds but with a reduced heart rate and cyanosis (a blue tinge to the skin colour indicating not enough oxygen). Resuscitation may be needed. Drugs such as theophylline can be used to stimulate breathing or continuous positive airway pressure (CPAP) which helps breathing by blowing air into the baby through a mask or tube. The review of trials found theophylline is more effective than mask CPAP for preterm infants with apnea. More research is needed.

 

摘要

背景

連續氣道正壓呼吸與茶鹼治療早產兒窒息的比較

復發性窒息常見於早產兒，特別是在極低胎齡早產兒。窒息發作造成無法有效地呼吸，可導致低氧血症和心跳過緩，進而可能嚴重到需要採取包括正壓呼吸治療的復甦措施。茶鹼(theophylline)與連續氣道正壓呼吸治療(CPAP)是兩種曾用於預防窒息及其後遺症的兩種治療方法。

目標

主要目的是確定針對復發性窒息早產兒用CPAP與茶鹼治療相比是否使在窒息發生或呼吸器治療的使用上有臨床重要意義的降低，又沒有臨床重要的副作用。

搜尋策略

對Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, 2005年第1期)，MEDLINE(1966年至2005年3月)，EMBASE(1980年至2005年3月)以及CINAHL(1982年至2005年3月)進行了檢索。還查閱以往回顧的參考文獻。還向專家詢問提供訊息。檢索包括1996年至2004年在內的兒科研究學會摘要。

選擇標準

收納所有應用隨機或半隨機法分配臨床復發性窒息/心率過緩早產兒接受CPAP或茶鹼治療的試驗

資料收集與分析

使用Cochrane Collaboration及其 Neonatal Review Group的標準方法進行數據提取，每位作者分別進行試驗質量評估和數據提取，使用相對風險(RR)進行數據綜合。

主要結論

僅有一項合格試驗。按窒息減少不到50％或換用其它替換療法為標準，使用面罩CPAP的治療失敗率較高 [RR 2.89(95％CI 1.12，7.47)RD 0.42(95％CI 0.11 ，0.74)。相比較茶鹼，用面罩CPAP治療每2.4名嬰兒(95％CI為 1.4，9.5)中有一例治療失敗。面罩CPAP的使用較多IPPV[RR 3.09(1.42，6.70)RD 0.58(95％CI 0.30，0.86)。相對茶鹼治療，面罩CPAP治療每1.7名嬰兒(95％CI 1.2，3.3)中有一名嬰兒因IPPV而插管。在使用面罩CPAP組，第一年有較高死亡及追蹤時死亡或存活者有重要失能傾向，但未達顯著意義。追蹤的壞死性腸炎發生率或存活者重大失能沒有差別。

作者結論

茶鹼治療早產兒窒息的效果優於面罩CPAP。由於CPAP已不再用面罩，所以影響本回顧結論在目前臨床應用的重要性。有必要按照目前CPAP使用方法進行進一步評估對早產兒窒息CPAP與茶鹼治療的利弊比較。

翻譯人

本摘要由臺中榮民總醫院葉惠英翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

茶鹼可能比面罩CPAP預防早產兒窒息所造成的問題。窒息常見於小於37週胎齡的早產兒。 它是停止呼吸超過20秒，或小於20秒但有心跳變慢與發疳(皮膚變藍顯示沒有足夠氧氣)。可能需要復甦措施。藥物治療像茶鹼可以刺激呼吸或用將空氣以面罩或插管吹進嬰兒的持續正壓氣道壓力(CPAP)輔助呼吸。本試驗回顧發現茶鹼比面罩CPAP對早產兒窒息更有效。需要更多的研究確定。