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

  • Review
  • Intervention

Authors


Abstract

Background

Previous randomised trials and meta-analyses have shown nasal continuous positive airway pressure (NCPAP) to be a useful method of respiratory support after extubation. However, infants managed in this way sometimes "fail" and require endotracheal reintubation with its attendant risks and expense. Nasal intermittent positive pressure ventilation (NIPPV) is a method of augmenting NCPAP by delivering ventilator breaths via nasal prongs. Older children and adults with chronic respiratory failure have been shown to benefit from NIPPV and the technique has been applied to neonates. However, serious side effects including gastric perforation have been reported and clinicians remain uncertain about the role of NIPPV in the management of neonates. It has recently become possible to synchronise delivery of NIPPV with the infant's own breathing efforts, which may make this modality more useful in this patient group.

Objectives

To determine whether the use of NIPPV when compared to NCPAP decreases the rate of extubation failure without adverse effects in the preterm infant extubated following a period of intermittent positive pressure ventilation.

Search methods

MEDLINE was searched using the MeSH terms: Infant, Newborn (exp) and Positive-pressure respiration (exp) up to December 18, 2007. Other sources included the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2007), CINAHL using search terms: Infant, newborn and intermittent positive pressure ventilation, expert informants, previous reviews including cross-references and conference and symposia proceedings were used.

Selection criteria

Randomised trials comparing the use of NIPPV with NCPAP in preterm infants being extubated were selected for this review.

Data collection and analysis

Data regarding clinical outcomes including extubation failure, endotracheal reintubation, rates of apnea, gastrointestinal perforation, feeding intolerance, chronic lung disease and duration of hospital stay were extracted independently by the three review authors. The trials were analysed using relative risk (RR), risk difference (RD) and number needed to treat (NNT) for dichotomous outcomes and weighted mean difference (WMD) for continuous outcomes.

Main results

Three trials comparing extubation of infants to NIPPV or to NCPAP were identified. All trials used the synchronised form of NIPPV. Each showed a statistically significant benefit for infants extubated to NIPPV in terms of prevention of extubation failure criteria. The meta-analysis demonstrates a statistically and clinically significant reduction in the risk of meeting extubation failure criteria [typical RR 0.21 (95% CI 0.10, 0.45), typical RD -0.32 (95% CI -0.45, -0.20), NNT 3 (95% CI 2, 5)]. There were no reports of gastrointestinal perforation in any of the trials. Differences in rates of chronic lung disease approached but did not achieve statistical significance favouring NIPPV [typical RR 0.73 (95% CI 0.49, 1.07), typical RD -0.15 (95% CI -0.33, 0.03)].

Authors' conclusions

Implications for practice: NIPPV is a useful method of augmenting the beneficial effects of NCPAP in preterm infants. Its use reduces the incidence of symptoms of extubation failure more effectively than NCPAP. Within the limits of the small numbers of infants randomised to NIPPV there is a reassuring absence of the gastrointestinal side effects that were reported in previous case series.

Implications for research: Future trials should enroll a sufficient number of infants to detect differences in important outcomes such as chronic lung disease and gastrointestinal perforation. The impact of synchronisation of NIPPV on the technique's safety and efficacy should be established in future trials.

摘要

背景

鼻式間歇式正壓換氣 (NIPPV) 相較鼻式連續式正壓 (NCPAP) 用於早產兒拔管後

先前的隨機試驗及統合分析顯示鼻式連續式正壓 (NCPAP) 是在拔管後提供呼吸支持的一種有效方式,然而使用這種方法的嬰兒有時會失敗且需要再度插管並伴隨危險和代價。鼻式間歇式正壓換氣 (NIPPV) 是一種加強NCPAP的方式,可經由鼻管給予呼吸器的換氣。NIPPV對於大小孩和慢性呼吸衰竭的成人有益處,並且也應用在新生兒,然而曾被報告過一些嚴重的併發症如胃穿孔,臨床醫師仍舊不確定NIPPV在新生兒科的角色。近來NIPPV變得可與嬰兒自呼努力同步,可能使這種方法在新生兒更加實用。

目標

比較NIPPV與NCPAP用於使用間歇式正壓換氣一段時間拔管後的早產兒,NIPPV是否可減少拔管失敗率且無副作用

搜尋策略

搜尋MEDLINE至2003年4月14止,使用MeSH terms:Infants、Newborn (exp) 和Positivepressure respiration (exp) ,其他資源包括Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1, 2003) 、CINAHL使用搜尋名詞包括Infant、newborn和 intermittent positive pressure ventilation,也搜尋專業資料、先前的回顧文章包括交互參考資料和會議及研討會紀錄。

選擇標準

這篇回顧文章選錄比較NIPPV與NCPAP治療用於拔管後的早產兒的隨機試驗

資料收集與分析

與臨床結果有關的資料由三位檢閱者各自分別選錄,包括拔管失敗、再度插管、呼吸暫停的發生率、腸胃穿孔、餵食不耐、慢性肺疾病和住院長短。這些試驗使用相對危險性 (RR) 、危險差 (RD) 和需要治療的數量 (NNT) 分析二分結果,並使用加權平均差異 (WMD) 分析持續性結果。

主要結論

三個比較拔管的嬰兒使用NIPPV及NCPAP的試驗被找出,三個試驗都是用同步化的NIPPV,每個都顯示嬰兒拔管後使用NIPPV從預防拔管失敗的角度有統計上顯著的益處,統合分析也顯示有對臨床重要的效果[RR 0.21 (0.10, 0.45), RD −0.32 (−0.45, −0.20), NNT 3 (2, 5)]。這些試驗沒有任何報告有腸胃道穿孔,慢性肺病的發生率差異顯示NIPPV較佳,結果接近但未為達統計上有意義[RR 0.73 (0.49, 1.07), RD −0.15 (−0.33, 0.03)]。

作者結論

實行的涵義:對早產兒, NIPPV是一種加強NCPAP益處的的方式,它的使用減少拔管失敗症狀的發生率比NCPAP更有效。在隨機使用NIPPV數目有限的病人中,再度確認沒有發生先前病例系列報告的腸胃道併發症。研究的涵意:將來的試驗應包含足夠的嬰兒以查出重要預後的差別例如慢性肺疾病和腸胃穿孔,同步化NIPPV對於技術安全和效果的影響應在將來的試驗被建立。

翻譯人

本摘要由馬偕醫院王臻誼翻譯。

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

總結

在早產兒不需要氣管內管後,有些證據顯示鼻式間歇性正壓換氣 (NIPPV) 增進鼻式連續式正壓 (NCPAP) 的效果,有呼吸問題的早產兒經常需要呼吸器的幫忙,從氣管內管提供規則呼吸,拔管的過程不一定順利,且若是嬰兒無法靠自己呼吸得很好,管子可能需要再放回去。NCPAP和NIPPV是支持嬰兒呼吸較不侵入性的方法,使用的管子較短只放到鼻子,造成的傷害也較小。NCPAP和NIPPV可以在拔管後使用,以減少再度被插管的嬰兒數目。NCPAP提供穩定的壓力到鼻子再傳到肺部,幫助他們呼吸更好,NIPPV提供一樣的支持外也提供呼吸器呼吸。這三篇研究比較NCPAP和NIPPV,每篇都顯示NIPPV減少再度插管的需要,需要更進一步的努力確保NIPPV的安全。

Plain language summary

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

There is some evidence that nasal intermittent positive pressure ventilation (NIPPV) increases the effectiveness of nasal continuous positive airway pressure (NCPAP) in preterm babies who no longer need an endotracheal tube (tube in the wind pipe). Preterm babies with breathing problems often require help from a machine (ventilator) that provides regular breaths through a tube in the windpipe. The process of extubation or removal of this tube does not always go smoothly and the tube may need to go back if the baby cannot manage by him/herself. NCPAP and NIPPV are ways of supporting babies breathing in a less invasive way - the tubes are shorter and go only to the back of the nose and, therefore, cause less damage. NCPAP and NIPPV may be used after extubation to reduce the number of babies that need to have the endotracheal tube reinstituted. NCPAP provides steady pressure to the back of the nose which is transmitted to the lungs, helping the baby breath more comfortably. NIPPV provides the same support, but also adds some breaths from the ventilator. The three studies that have compared NCPAP and NIPPV each show that NIPPV reduces the need for the endotracheal tube to be reinstituted. Further studies are needed to make sure NIPPV is safe.

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