About one in ten live births around the world are preterm and many of these babies will develop respiratory distress and require help with their breathing. Various strategies are available for this and an updated Cochrane review from July 2023 provides the latest evidence on the comparison of nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure when a baby’s breathing tube is removed. We asked one of the authors, Marc-Olivier Deguise from the Children's Hospital of Eastern Ontario in Canada to tell us about the findings, and he used ElevenLabs to make this recording.
Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. About one in ten live births around the world are preterm and many of these babies will develop respiratory distress and require help with their breathing. Various strategies are available for this and an updated Cochrane review from July 2023 provides the latest evidence on the comparison of nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure when a baby's breathing tube is removed. We asked one of the authors, Marc-Olivier Deguise from the Children's Hospital of Eastern Ontario in Canada to tell us about the findings, and he used ElevenLabs to make this recording.
Marco: It's well-known that providing invasive respiratory support via a tube can be harmful to the developing lung of preterm babies and contribute to the development of chronic lung disease, which is the most common serious morbidity amongst preterm infants and there is currently no treatment for it. Because of this, providers of neonatal care have worked towards limiting the time that babies spend on mechanical ventilation and multiple non-invasive respiratory support strategies are available for when they come off it.
These include continuous positive airway pressure, or CPAP, which became a popular option and offers a continuous distending pressure to maintain an open airway without the need of a tube. Another strategy is called bilevel positive airway pressure, or BiPAP, or nasal intermittent positive pressure ventilation, which abbreviates to NIPPV. This offers additional superimposed inflations to set peak pressure at a regular set rate over a baseline distending pressure, as is provided with CPAP. These modes of ventilation can be used to facilitate the removal of the breathing tube while continuing to provide the baby with a form of breathing support that is less harmful to their developing lungs.
Because it's currently unclear whether NIPPV is better than CPAP in preterm infants where the endotracheal tube has been removed, we aimed to assess the rate of respiratory failure and the need to resume respiratory support via a breathing tube when infants were transitioned to CPAP or NIPPV after removal of the tube. We also looked at a variety of secondary outcomes, including pulmonary air leak, chronic lung disease and mortality.
We found 19 randomized trials, most of which were small, but, in total, they had recruited more than 2700 infants. We found moderate certainty evidence that NIPPV likely reduces the risk of respiratory failure and reintubation within a week. This appeared to be dependent on the delivery system, with a clear benefit when NIPPV was provided via ventilator rather than the bi-level device. NIPPV also likely results in little to no difference in chronic lung disease compared to CPAP and may reduce pulmonary air leaks. There was no clear benefit or harm observed in other secondary outcomes, including mortality.
It's important to note that most trials enrolled infants with a gestational age of approximately 28 to 32 weeks and as such, the results of this review may not apply to extremely preterm infants who are most at risk of needing mechanical ventilation or developing chronic lung disease. This is a major limitation of the current evidence and clinicians taking care of extremely preterm infants should be aware that limited data are available for this group. We also identified potential regional differences, where studies from low-income countries did not identify a benefit for the use of NIPPV in preventing respiratory failure post-extubation, but such countries were vastly under-represented in the included studies compared to high-income countries and it is difficult to say if our findings are applicable globally.
In summary, NIPPV likely reduces the risk of respiratory failure and the need for reintubation in very preterm infants, born at 28 weeks gestation or later whose breathing tube has been removed. This is mostly noted when NIPPV is provided via a ventilator as opposed to a bilevel device, meaning that neonatal units with limited access to ventilators should take this into account, because bilevel devices lead to little or no benefit in the primary outcome of this review. Additional studies are needed to confirm these results, to assess the safety of NIPPV compared with NCPAP alone in a larger patient population, including extremely preterm infants, and to compare these modes of ventilation when mean airway pressure is matched between the devices used.
Mike: If you would like to look into these results in more detail and watch for future updates of the review if those additional studies become available, you can find it online. Just go to Cochrane Library dot com and search 'NIPPV for preterm infants' to get a link to it.