Non invasive ventilation for respiratory distress syndrome: a randomized controlled trial

Noninvasive ventilation has been increasingly used to reduce mechanical ventilation (MV) in preterm infants and subsequently lower the incidence of bronchopulmonary dysplasia (BPD). In particular, nasal continuous positive airway pressure (NCPAP) has become an established practice in many centers for the treatment of preterm infants with respiratory distress syndrome.
Evidence supports the combination of early surfactant treatment with transient intubation (the INSURE approach) followed by NCPAP to further reduce the risk of invasive ventilation. However, not all infants receiving early NCPAP can be successfully managed and the use of nasal intermittent positive-pressure ventilation (NIPPV) has been suggested to reduce these failure rates.
NIPPV is noninvasive ventilation that increases the beneficial effects of NCPAP by combining it with ventilatory inflations, thus decreasing the need for MV. The results of two randomized controlled trials indicated that early NIPPV reduces the need for endotracheal intubation within the first 72 hours of life when compared with NCPAP. However, further evidence is required to clarify the role of these procedures.
On this basis, a Brazilian group has conducted a single-center, prospective randomized controlled trial using standardized protocols for intubation and surfactant therapy. The primary outcome of the study was the need for intubation within the first 72 hours of life after random assignment to early NIPPV or NCPAP.
In total, 200 infants were enrolled (26 to 336/7 weeks). Rates of the primary outcome did not differ significantly between the NIPPV (25%) and NCPAP (34%) groups (relative risk [RR]: 0.71 [95% confidence interval (CI): 0.48 –1.14]). In a posthoc analysis, conducted from 24 to 72 hours of life, significantly more infants in the NIPPV group remained extubated compared with those in the NCPAP groups (10 vs 22%; RR: 0.45 [95% CI: 0.22– 0.91]). This difference was also noted in the group of infants who required surfactant. Among infants with a birthweight >1000g NIPPV failure was significantly lower as compared to NCPAP (P=0.03). No significant difference was found in the overall rate of BPD between groups.
In conclusion, the results of this study suggest that NIPPV is feasible and safe and may have beneficial effects, especially in infants with a birthweight >1000g, when compared with NCPAP in terms of reduction of the need of MV in the first 72 hours of life. Findings of previous studies suggest that the main advantage of NIPPV over NCPAP might be that of stimulating breathing to avoid apnea and hypercapnia that could have an important role in avoiding failure of noninvasive ventilation. Further multicenter randomized controlled trials with adequate power, and especially targeted to infants <1000g, are needed to assess if NIPPV and/or NCPAP as the first (soon after birth) or primary (i.e., after a brief intubation and early surfactant administration) mode of noninvasive respiratory support can affect BPD and long-term outcomes.

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