Non-invasive respiratory support superior to invasive measures in preterm infants

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1. Non-invasive continuous positive airway pressure (CPAP) reduced rates of death or bronchopulmonary dysplasia compared with intubation in preterm infants. 

2. CPAP was associated with lower rates of surfactant use and mechanical ventilation. 

Evidence Rating Level: 1 (Excellent)       

Study Rundown: This systematic review and meta-analysis found that non-invasive CPAP was associated with lower rates of bronchopulmonary dysplasia and death compared with intubation in preterm infants. Results showed that treating 25 infants with CPAP instead of intubation resulted in 1 less infant experiencing death or severe morbidity from bronchopulmonary dysplasia. Infants on CPAP were also less likely to require surfactant or mechanical ventilation.

Inclusion of multiple randomized controlled trials lends credence to the results of this meta-analysis. Heterogeneity of study designs, including methodological limitations and inability to stratify results by gestational age limit interpretation of these findings. Large randomized controlled trial might solidify findings of this investigation. 

Click to read the study in BMJ

Relevant Reading: Bronchopulmonary Dysplasia in Very Low Birth Weight Subjects and Lung Function in Late Adolescence

In-Depth [systematic review]: This study analyzed data from 4 randomized controlled trials comparing the effect of nasal continuous positive airway pressure (CPAP) (n=1296) with intubation (n=1486) in preterm infants born at <32 weeks of gestation. The primary outcome was a composite of death, bronchopulmonary dysplasia (defined as the need for oxygen support or mechanical ventilation past 36 weeks) or both during the hospital stay.

Compared to intubated infants, premature infants on CPAP were significant less likely to experience death or bronchopulmonary dysplasia (RR=0.91, 95% CI 0.84-0.99), with a number needed to treat of 25. When only looking at rates of bronchopulmonary dysplasia, there was a non-significant trend in favor of CPAP over intubation (RR=0.91, 95% CI=0.82-1.01). CPAP was also associated with a reduction in requirement of surfactant (RR=0.40, CI=0.23-0.70) and mechanical ventilation (RR=0.56, CI=0.32-0.97). 

By Maren Shapiro and Leah Hawkins, MD, MPH

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