Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants

  • Review
  • Intervention

Authors


Abstract

Background

Cohort studies (Avery 1987; Jonsson 1997) have suggested that early post-natal nasal continuous positive airways pressure (CPAP) may be beneficial in reducing the need for intubation and intermittent positive pressure ventilation, and in preventing chronic lung disease in preterm or low birth weight infants.

Objectives

To determine if prophylactic nasal CPAP commenced soon after birth regardless of respiratory status in the very preterm or very low birth weight infant reduces the use of IPPV and the incidence of chronic lung disease (CLD) without adverse effects.

Search methods

The search was updated in April 2005. The standard search strategy of the Neonatal Review Group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Library Issue 1 2005, MEDLINE 1966-April 2005, previous reviews including cross references, abstracts, conferences, symposia, proceedings, expert informants, journal hand searching mainly in the English language.

Selection criteria

All trials using random or quasi-random patient allocation of very preterm infants < 32 weeks gestation and / or < 1500 gms at birth were eligible. Comparison had to be between prophylactic nasal CPAP commencing soon after birth regardless of the respiratory status of the infant compared with "standard" methods of treatment where CPAP or IPPV is used for a defined respiratory condition.

Data collection and analysis

Standard methods of the Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each author, were used. Data were analysed using relative risk (RR). Meta-analysis was performed using a fixed effects model.

Main results

There are no statistically significant differences in any of the outcomes studied in either of the eligible trials (Han 1987; Sandri 2004) reporting on 82 and 230 infants respectively. In Han 1987 there are trends towards increases in the incidence of BPD at 28 days [RR 2.27 (0.77, 6.65)], death [RR 3.63 (0.42, 31.08)] and any IVH [RR 2.18 (0.84, 5.62)] in the CPAP group. In Sandri 2004 there is a trend towards an increase in IVH grade 3 or 4 [RR 3.0 (0.96, 28.42)] in the CPAP group. No outcome was significantly different in any of the meta-analyses.

Authors' conclusions

There is currently insufficient information to evaluate the effectiveness of prophylactic nasal CPAP in very preterm infants. Neither of the included studies reviewed showed evidence of benefit in reducing the use of IPPV. The tendency for some adverse outcomes to be increased is of concern and further multicentre randomized controlled trials are needed to clarify this.

摘要

背景

在非常早產的嬰兒身上,採用預防式的經鼻腔持續性呼吸道正壓來預防死亡與罹病等情況

世代研究(Avery 1987;Jonsson 1997)認為,在早產或是低出生體重的嬰兒身上,在出生後的早期就使用經鼻腔持續性呼吸道正壓(CPAP),或許可幫助來降低器管插管與使用間斷性正壓呼吸器 (IPPV) 之需求,及幫助預防慢性肺部疾病。

目標

對於非常早產或是出生時體重非常輕的嬰兒而言,不論其呼吸狀況為何,在出生後馬上就使用預防性的經鼻腔CPAP,在不產生副作用的情況下,來確認是否可以減少IPPV的使用,並且讓慢性肺部疾病(CLD)的發生率下降。

搜尋策略

本次搜尋日期為2005年4月,採用Neonatal Review Group 標準搜尋策略,包含搜尋 Oxford Database of Perinatal Trials、Cochrane Library Issue 1 2005、MEDLINE 1966年2005年4月、先前的文獻回顧,包括交叉對照參考資料、摘要、研討會及座談會手冊、專家意見,並且人工搜尋英文期刊。

選擇標準

對於出生時的妊娠週數 <32週以及/或是出生時體重 <1500克的非常早產嬰兒,進行隨機或半隨機的病患分配之試驗納入合格的條件。在不考慮嬰兒之呼吸狀況下,對於出生後馬上就使用預防性的經鼻腔CPAP,與有規範過呼吸狀況的情況時才使用CPAP或是IPPV時來做比較。

資料收集與分析

我們使用的是Cochrane Collaboration以及其Neonatal Review Group的標準方法,其中包括了由每1位作者獨立完成的試驗品質評估與資料擷取。我們使用了相對風險(RR)來進行資料分析。我們也使用了固定效果模型來進行統合分析。

主要結論

在分別針對82名與230名嬰兒所進行的合格試驗(Han 1987;Sandri 2004)當中,對於當中的任何1份試驗來說,就內容中曾經研究過的任何預後看來,都沒有發現統計學上的顯著差異。在 Han 1987的研究顯示,在CPAP的那組,位於第28天的BPD (慢性肺部疾病) 發生率「RR 2.27(0.77,6.65)」、死亡情況「RR 3.63(0.42,31.08),以及任何的IVH (腦室出血) 「RR 2.18(0.84,5.62)」,都有增加的趨勢。在 Sandri 2004的研究顯示,在CPAP的那組,產生第3或第4等級的IVH「RR 3.0(0.96,28.42)」會有增加的趨勢。不論任何1種統合分析,都看不出有任何具有顯著差異的預後。

作者結論

要在非常早產之嬰兒身上評估預防性的經鼻腔CPAP之功效,目前的資訊還是不足的。在這些被納入的研究當中,經過檢審之後,對於要減少IPPV的使用,並沒有任何1份研究可以顯示證據來加以支持。針對某些不良的預後而言,呈現出了增加的趨勢,而這就是值得關注的事情,未來還需要有更深入的多中心隨機對照試驗,以釐清這樣的現象。

翻譯人

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

總結

在早產兒身上,透過鼻子使用的持續性呼吸道正壓(CPAP)而言,並沒有足夠的證據顯示可以預防呼吸症狀。早產兒(在37週之前出生)可能會需要協助才能夠正常地進行呼吸。可藉由某根放置在他們氣管當中的管子(間歇正壓通氣,IPPV)來提供間歇式的空氣氣流,就可以用機械式的呼吸方式來幫助這些嬰兒,但是這樣的方式屬於侵入式的行為,而且還可能會帶來許多併發症。我們也可以藉由控制進入鼻腔中之氣體壓力的方式,在他們的呼吸道中給予他們連續性的壓力。針對使用預防性的經鼻腔CPAP來預防需要用到IPPV等呼吸症狀,本篇回顧並沒有從這些試驗當中發現到足夠的證據能夠顯示出它的影響。更多的研究是需要的。

Plain language summary

Prophylactic nasal continuous positive airways pressure for preventing morbidity and mortality in very preterm infants

There is not enough evidence to show the effect of continuous positive airways pressure (CPAP) applied through the nose to prevent respiratory problems in preterm babies. Preterm babies (born before 37 weeks) may need help to breathe properly. These babies can be helped to breathe mechanically by intermittent airflow via a tube placed in their windpipe (Intermittent Positive Pressure Ventilation, IPPV) but this is invasive and may be associated with complications. They can also be given continuous pressure in their airways by controlling the pressure of the gas entering the nose. The review did not find enough evidence from trials to show the effect of using prophylactic nasal CPAP to prevent respiratory problems requiring IPPV. More research is needed.

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