Key messages

• We found that while some methods may be better than others at preventing treatment failure and need to reinsert a breathing tube into the windpipe, the evidence is very uncertain.

• More research is needed that incorporates strict guidelines into study designs, while also comparing the different methods using the same pressures, while including more extremely premature babies born before 28 weeks of pregnancy.

What is non-invasive respiratory support?

Premature babies often need help breathing as their lungs are not fully developed. Nasal breathing support (through the nose) helps premature babies breathe without the need for breathing tubes in the windpipe. It includes several methods that deliver air or oxygen through the nose or mouth to keep the lungs open and support breathing.

What did we want to find out?

We compared seven different nasal breathing support methods to see which ones best prevented failure of treatment (when the baby's breathing worsens and extra help, such as more oxygen or a breathing tube, is needed), the need for intubation (putting in a breathing tube), and reduced the severity of long-lasting lung problems in preterm babies.

What did we do?

We reviewed studies comparing different combinations of flow rates, pressures, and timings used to support breathing in premature babies.

What did we find?

We found 61 studies (7554 premature babies).

Nasal intermittent positive pressure ventilation (using two levels of pressure with short bursts of air) or non-invasive high-frequency oscillatory ventilation (delivering tiny, rapid breaths) may lower the risk of treatment failure compared to nasal continuous positive airway pressure (a steady flow of air) or high-flow nasal cannula (air given through small nasal tubes at higher flow rates). Also, nasal intermittent positive pressure ventilation or non-invasive high-frequency oscillatory ventilation may prevent the need for a breathing tube compared to nasal continuous positive airway pressure or high-flow nasal cannula. There was no difference in the risk of developing moderate to severe long-lasting lung problems.

These findings were similar in babies born at or after 28 weeks of pregnancy, but there were no differences in babies born before 28 weeks of pregnancy, although the data in this group of babies were sparse.

What are the limitations of the evidence?

The evidence is limited for extremely premature infants born before 28 weeks of pregnancy. The studies also varied in how they compared the different methods, especially regarding airway pressure levels. This could have affected the results. Finally, we have little or no confidence in the results because of a variety of problems with how the studies were conducted.

How up to date is this evidence?

The evidence is up to date to January 2024.