Intervention Review

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Continuous negative extrathoracic pressure or continuous positive airway pressure compared to conventional ventilation for acute hypoxaemic respiratory failure in children

  1. Prakeshkumar S Shah1,*,
  2. Arne Ohlsson2,
  3. Jyotsna P Shah3

Editorial Group: Cochrane Acute Respiratory Infections Group

Published Online: 4 NOV 2013

Assessed as up-to-date: 2 JUL 2013

DOI: 10.1002/14651858.CD003699.pub4


How to Cite

Shah PS, Ohlsson A, Shah JP. Continuous negative extrathoracic pressure or continuous positive airway pressure compared to conventional ventilation for acute hypoxaemic respiratory failure in children. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD003699. DOI: 10.1002/14651858.CD003699.pub4.

Author Information

  1. 1

    University of Toronto Mount Sinai Hospital, Department of Paediatrics and Health Policy, Management and Evaluation, Toronto, Ontario, Canada

  2. 2

    University of Toronto, Departments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada

  3. 3

    Mount Sinai Hospital, Department of Paediatrics, Markham, Ontario, Canada

*Prakeshkumar S Shah, Department of Paediatrics and Health Policy, Management and Evaluation, University of Toronto Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario, M5G 1XB, Canada. pshah@mtsinai.on.ca.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 4 NOV 2013

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Characteristics of included studies [ordered by study ID]
Cam 2002

MethodsSingle-centre study in Vietnam


ParticipantsInclusion criteria: children with dengue fever who had acute respiratory failure as defined by failure to respond to 40% oxygen given via nasal cannula as evidenced by (a) cyanosis, oxygen saturation < 93 or PaO2 < 70 mm Hg; (b) respiratory rate > 50 breaths/minute; or (c) severe chest retraction and nasal flaring. The management of infants in both groups remained similar except for the intervention. The outcomes reported were stabilisation of the patient with PaO2 > 80 mm Hg after 30 minutes of treatment


InterventionsContinuous positive airway pressure (CPAP) was started at 6 cm water pressure delivered through a Beneviste valve connected to binasal prongs at a FiO2 of 60%. The oxygen mask group received oxygen via a face mask with reservoir bag at a flow rate of 6 to 8 l/min resulting in a FiO2 of 60% to 80%


OutcomesThe outcome reported was stabilisation of the patient with PaO2 > 80 mm Hg after 30 minutes of treatment
Secondary outcomes included: respiratory rate, PaO2 and SaO2


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomly numbered sealed envelopes

Allocation concealment (selection bias)Low riskRandomly numbered sealed envelopes

Blinding (performance bias and detection bias)
All outcomes
High riskUnblinded study

Incomplete outcome data (attrition bias)
All outcomes
Low riskReported outcomes on all randomised participants

Selective reporting (reporting bias)Unclear riskProtocol not available for checking

Other biasUnclear riskInsufficient information to assess

Hartmann 1994a

MethodsSingle-centre study in the UK


ParticipantsInclusion criteria: infants less than 1 year of age. Bronchiolitis diagnosed on a clinical basis and requirement of greater than or equal to 40% oxygen to maintain SaO2 between 96% to 99%


InterventionsControl group: n = 18, 9 males
Post-menstrual age at study median 48 (range 40 to 61) weeks
CNEP group: n = 15, 7 males
Post-menstrual age at study median 45 (range 41 to 56) weeks
CNEP was started at -6 cm of water in the intervention group


OutcomesFiO2 less than 0.3 within 1 hour after start of the therapy
Need for IPPV
Need for nasal CPAP


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskOnly abstract is available which is lacking in information

Allocation concealment (selection bias)Unclear riskOnly abstract is available which is lacking in information

Blinding (performance bias and detection bias)
All outcomes
High riskOnly abstract is available which is lacking in information

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskOnly abstract is available which is lacking in information

Selective reporting (reporting bias)Unclear riskOnly abstract is available which is lacking in information

Other biasHigh riskOnly abstract is available which is lacking in information

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Carretero 2008Not a RCT

Chidini 2010Not a RCT

Codazzi 2006Not a RCT

Essouri 2008Not a RCT

Katz 2004Not a RCT

Linney 1997Not a RCT

Padman 2004Not a RCT

Palombini 2004Not a RCT

Prado 2005Not a RCT

Rodriguez 2002RCT of CPAP for post-extubation laryngitis. The patients did not have hypoxaemic respiratory failure

Samuels 1989Not a RCT

Sanabria 2008Randomised trial of 2 methods of CPAP

Shime 2006Not a RCT

Stucki 2009Not a RCT

Thia 2007RCT of CPAP versus standard treatment in children with bronchiolitis but the inclusion criteria included mild hypercapnia. There was no hypoxaemic respiratory failure

Thill 2004RCT but children included in the study did not meet the criteria for acute hypoxaemic respiratory failure specified a priori for this review

 
Comparison 1. Oxygen requirement

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Less than 30% FiO2 after one hour of therapy133Risk Ratio (M-H, Fixed, 95% CI)10.69 [0.62, 183.85]

 
Comparison 2. Need for assisted ventilation (intermittent positive pressure ventilation or CPAP)

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Intermittent positive pressure ventilation during hospital stay133Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.02, 9.06]

 2 CPAP during hospital stay133Risk Ratio (M-H, Fixed, 95% CI)0.40 [0.02, 9.06]

 
Summary of findings for the main comparison. Continuous negative extrathoracic pressure ventilation compared with control for acute hypoxaemic respiratory failure in children

Continuous negative extrathoracic pressure ventilation compared with control for acute hypoxaemic respiratory failure in children

Patient or population: children with acute hypoxaemic respiratory failure

Settings: hospital

Intervention: continuous negative extrathoracic pressure

Comparison: control

OutcomesRelative effect
(95% CI)
No. of participants
(studies)
Quality of the evidence
(GRADE)

Less than 30% FiO2 after 1 hour of therapyRR 10.69 (0.62 to 183.85)33 (1)⊕⊝⊝⊝
very low 1,2

Intermittent positive pressure ventilation during hospital stayRR 0.40 (0.02 to 9.06)33 (1)⊕⊝⊝⊝
very low 1,3

CPAP during hospital stayRR 0.40 (0.02 to 9.06)33 (1)⊕⊝⊝⊝
very low 1,3

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 CPAP = continuous positive extrathoracic pressure
FiO2 = fraction of inspired oxygen
RR = randomised controlled trial
1 = Very wide confidence intervals
2= The outcome is only reported after one hour of treatment which is a very short period for any clinically meaningful assessment
3= Limitation in study design as the results are reported in an abstract and it was not possible to assess the study adequately (see assessment of risk of biases)