[Use of noninvasive high-frequency oscillatory ventilation in very low birth weight infants]

Non-invasive high-frequency ventilation in newborn infants with respiratory distress

BACKGROUND

Respiratory distress occurs in up to 7% of newborns, with respiratory support (RS) provided invasively via an endotracheal (ET) tube or non-invasively via a nasal interface. Invasive ventilation increases the risk of lung injury and chronic lung disease (CLD). Using non-invasive strategies, with or without minimally invasive surfactant, may reduce the need for mechanical ventilation and the risk of lung damage in newborn infants with respiratory distress.

OBJECTIVES

To evaluate the benefits and harms of nasal high-frequency ventilation (nHFV) compared to invasive ventilation via an ET tube or other non-invasive ventilation methods on morbidity and mortality in preterm and term infants with or at risk of respiratory distress.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and three trial registries in April 2023.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster- or quasi-RCTs of nHFV in newborn infants with respiratory distress compared to invasive or non-invasive ventilation.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials for inclusion, extracted data, assessed the risk of bias, and undertook GRADE assessment.

MAIN RESULTS

We identified 33 studies, mostly in low- to middle-income settings, that investigated this therapy in 5068 preterm and 46 term infants. nHFV compared to invasive respiratory therapy for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 0.67, 95% CI 0.20 to 2.18; 1 study, 80 infants) or the incidence of CLD (RR 0.38, 95% CI 0.09 to 1.59; 2 studies, 180 infants), both very low-certainty. ET intubation, death or CLD, severe intraventricular haemorrhage (IVH) and neurodevelopmental disability (ND) were not reported. nHFV vs nasal continuous positive airway pressure (nCPAP) used for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 1.00, 95% CI 0.41 to 2.41; 4 studies, 531 infants; very low-certainty). nHFV may reduce ET intubation (RR 0.52, 95% CI 0.33 to 0.82; 5 studies, 571 infants), but there may be little or no difference in CLD (RR 1.35, 95% CI 0.80 to 2.27; 4 studies, 481 infants); death or CLD (RR 2.50, 95% CI 0.52 to 12.01; 1 study, 68 participants); or severe IVH (RR 1.17, 95% CI 0.36 to 3.78; 4 studies, 531 infants), all low-certainty evidence. ND was not reported. nHFV vs nasal intermittent positive-pressure ventilation (nIPPV) used for initial RS nHFV may result in little to no difference in mortality before hospital discharge (RR 1.86, 95% CI 0.90 to 3.83; 2 studies, 84 infants; low-certainty). nHFV may have little or no effect in reducing ET intubation (RR 1.33, 95% CI 0.76 to 2.34; 5 studies, 228 infants; low-certainty). There may be a reduction in CLD (RR 0.63, 95% CI 0.42 to 0.95; 5 studies, 307 infants; low-certainty). A single study (36 infants) reported no events for severe IVH. Death or CLD and ND were not reported. nHFV vs high-flow nasal cannula (HFNC) used for initial RS We are very uncertain whether nHFV reduces ET intubation (RR 2.94, 95% CI 0.65 to 13.27; 1 study, 37 infants) or reduces CLD (RR 1.18, 95% CI 0.46 to 2.98; 1 study, 37 participants), both very low-certainty. There were no mortality events before hospital discharge or severe IVH. Other deaths, CLD and ND, were not reported. nHFV vs nCPAP used for RS following planned extubation nHFV probably results in little or no difference in mortality before hospital discharge (RR 0.92, 95% CI 0.52 to 1.64; 6 studies, 1472 infants; moderate-certainty). nHFV may result in a reduction in ET reintubation (RR 0.42, 95% CI 0.35 to 0.51; 11 studies, 1897 infants) and CLD (RR 0.78, 95% CI 0.67 to 0.91; 10 studies, 1829 infants), both low-certainty. nHFV probably has little or no effect on death or CLD (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 966 infants) and severe IVH (RR 0.80, 95% CI 0.57 to 1.13; 3 studies, 1117 infants), both moderate-certainty. We are very uncertain whether nHFV reduces ND (RR 0.92, 95% CI 0.37 to 2.29; 1 study, 74 infants; very low-certainty). nHFV versus nIPPV used for RS following planned extubation nHFV may have little or no effect on mortality before hospital discharge (RR 1.83, 95% CI 0.70 to 4.79; 2 studies, 984 infants; low-certainty). There is probably a reduction in ET reintubation (RR 0.69, 95% CI 0.54 to 0.89; 6 studies, 1364 infants), but little or no effect on CLD (RR 0.88, 95% CI 0.75 to 1.04; 4 studies, 1236 infants); death or CLD (RR 0.92, 95% CI 0.79 to 1.08; 3 studies, 1070 infants); or severe IVH (RR 0.78, 95% CI 0.55 to 1.10; 4 studies, 1162 infants), all moderate-certainty. One study reported there might be no difference in ND (RR 0.88, 95% CI 0.35 to 2.16; 1 study, 72 infants; low-certainty). nHFV versus nIPPV following initial non-invasive RS failure nHFV may have little or no effect on mortality before hospital discharge (RR 1.44, 95% CI 0.10 to 21.33); or ET intubation (RR 1.23, 95% CI 0.51 to 2.98); or CLD (RR 1.01, 95% CI 0.70 to 1.47); or severe IVH (RR 0.47, 95% CI 0.02 to 10.87); 1 study, 39 participants, all low- or very low-certainty. Other deaths or CLD and ND were not reported.

AUTHORS' CONCLUSIONS

For initial RS, we are very uncertain if using nHFV compared to invasive respiratory therapy affects clinical outcomes. However, nHFV may reduce intubation when compared to nCPAP. For planned extubation, nHFV may reduce the risk of reintubation compared to nCPAP and nIPPV. nHFV may reduce the risk of CLD when compared to nCPAP. Following initial non-invasive respiratory support failure, nHFV when compared to nIPPV may result in little to no difference in intubation. Large trials, particularly in high-income settings, are needed to determine the role of nHFV in initial RS and following the failure of other non-invasive respiratory support. Also, the optimal settings of nHVF require further investigation.

Nasal high-frequency oscillatory ventilation versus nasal continuous positive airway pressure as primary respiratory support strategies for respiratory distress syndrome in preterm infants: a systematic review and meta-analysis

Nasal high-frequency oscillatory ventilation (NHFOV) is a new respiratory support strategy despite lacking of enough evidence in preterm infants with respiratory distress syndrome (RDS). The aim of the present systematic review was to explore whether NHFOV reduced the intubation rate as compared with nasal continuous positive airway pressure (NCPAP) as the primary respiratory support strategies in preterm infants with RDS. Medline, the Cochrane library, the Cochrane Controlled Trials Register, EMBASE, Chinese National Knowledge Infrastructure (CNKI), and Wanfang data Information Site were searched from inception to Jan 1, 2021(Prospero2019 CRD42019129316, date and name of registration: Apr 23,2019, The clinical effectiveness of NHFOV vs NCPAP for preterm babies with respiratory distress syndrome). Pooled data from clinically randomized controlled trials (RCTs) comparing NHFOV with NCPAP as the primary respiratory supporting strategies in preterm infants with RDS were performed using the fixed-effects models whenever no heterogeneity was shown. The primary outcome was intubation rate. Four randomized controlled trials involving 570 participants were included. Comparing with NCPAP, NHFOV resulted in less intubation (relative risk (RR) 0.44; 95% confidence interval (CI) 0.29-0.67, P = 0.0002), and heterogeneity was not found among the trials in the fixed-effects model (P = 0.78, I² = 0%). Similar result also appeared in sensitivity analysis after excluding one study with significant difference (RR 0.44; 95% CI 0.25-0.78, P = 0.005) (P = 0.58, I² = 0%).Conclusion: NHFOV decreased the intubation rate as compared with NCPAP as primary respiratory supporting strategies in preterm infants suffering from RDS. Future research should assess whether NHFOV can reduce the incidence of bronchopulmonary dysplasia (BPD) and intubation rate in preterm infants with BPD. Fund by Natural Science Foundation of Chongqing (cstc2020jcyj-msxmX0197), and "guan'ai" preterm Study Program of Renze Foundation of Beijing(K022). What is Known: • Nasal high-frequency oscillatory ventilation (NHFOV) has been described to be another advanced version of nasal continuous positive airway pressure (NCPAP). However, its beneficial effects among different studies as the primary modes in the early life of preterm infants with respiratory distress syndrome (RDS) were inconsistent. What is New: • Comparing with NCPAP, NHFOV decreases the risk of intubation as a primary respiratory supporting strategy in early life for preterm infants suffering from RDS.

Use of NHFOV vs. NIPPV for the respiratory support of preterm newborns after extubation: A meta-analysis

OBJECTIVES

This meta-analysis evaluated and compared the efficacy and safety of noninvasive high-frequency oscillatory ventilation (NHFOV) and nasal intermittent positive-pressure ventilation (NIPPV) for preterm newborns after extubation.

METHODS

We searched the PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, Wanfang and VIP databases from inception to August 28, 2022. Randomized controlled trials (RCTs) that evaluated and compared the efficacy and safety of NHFOV and NIPPV in newborns were included in the review and meta-analysis, which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines.

RESULTS

Eight studies involving 1,603 patients were included. Compared with NIPPV, NHFOV could reduce the reintubation rates (RR = 0.68, 95% CI 0.53, 0.86, P = 0.002). Subgroup analysis showed that the significant difference was found in reintubation rates within 72 h (RR = 0.48, 95% CI 0.32, 0.73, P = 0.0005). NHFOV also could decrease the duration of non-invasive ventilation (standard mean difference (SMD) = -1.52, 95% CI -2.58, -0.45, P = 0.005). However, all included studies had a high risk of bias, and the overall quality of the evidence of the outcomes was low or very low.

CONCLUSION

In our study, compared with NIPPV, NHFOV seems to reduce the reintubation rates without increasing adverse outcomes. Nevertheless, definite recommendations cannot be made based on the quality of the published evidence.

Non-invasive high-frequency oscillatory ventilation in preterm infants after extubation: a randomized, controlled trial

OBJECTIVE

To investigate the effectiveness and safety of non-invasive high-frequency oscillatory ventilation (NHFOV) in post-extubation preterm infants.

METHODS

This was a randomized, controlled trial. A total of 149 preterm infants aged between 25 to 34 weeks' gestational age with a birth weight of <1500 g who required invasive mechanical ventilation on admission were included. After extubation, they were randomized to the NHFOV group (n = 47), nasal intermittent positive pressure ventilation (NIPPV) group (n = 51), or nasal continuous positive airway pressure (NCPAP) group (n = 51). We compared the effectiveness and safety among these three groups.

RESULTS

A total of 139 preterm infants finally completed the study. The reintubation rate was significantly lower in the NHFOV group than in the other groups. The duration of non-invasive ventilation and the length of hospital stay in the NHFOV and NIPPV groups were significantly shorter than those in the NCPAP group. The incidence of bronchopulmonary dysplasia in the NHFOV and NIPPV groups was significantly lower than that in the NCPAP group. The NHFOV group had significantly less nasal injury than the NCPAP group.

CONCLUSION

As post-extubation respiratory support in preterm infants, NHFOV has a lower reintubation rate compared with NCPAP and NIPPV, without increasing the rate of complications.

Nasal High-Frequency Oscillatory Ventilation in Preterm Infants with Moderate Respiratory Distress Syndrome: A Multicenter Randomized Clinical Trial

OBJECTIVE

To determine whether nasal high-frequency oscillatory ventilation (NHFOV) as a primary mode of respiratory support as compared with nasal continuous airway pressure (NCPAP) will reduce the need for invasive mechanical ventilation in preterm infants (260/7-336/7 weeks of gestational age [GA]) with respiratory distress syndrome (RDS).

METHODS

This multicenter randomized controlled trial was conducted in 18 tertiary neonatal intensive care units in China. A total of 302 preterm infants born at a GA of 260/7-336/7 weeks with a diagnosis of RDS were randomly assigned to either the NCPAP (n = 150) or the NHFOV (n = 152) group. The primary outcome was the need for invasive mechanical ventilation during the first 7 days after birth.

RESULTS

Treatment failure occurred in 15 of 152 infants (9.9%) in the -NHFOV group and in 26 of 150 infants (17.3%) in the NCPAP group (95% CI of risk difference: -15.2 to 0.4, p = 0.06). In the subgroup analysis, NHFOV resulted in a significantly lower rate of treatment failure than did NCPAP in the strata of 26+0/7-29+6/7weeks of GA (11.9 vs. 32.4%, 95% CI of risk difference: -39.3 to -1.7, p = 0.03) and birth weight <1,500 g (10.4 vs. 29.6%, 95% CI of risk difference: -33.8 to -4.6, p = 0.01). The rate of thick secretions causing an airway obstruction was higher in the NHFOV group than in the NCPAP group (13.8 vs. 5.3%, 95% CI of risk difference: 1.9-15.1, p = 0.01). No significant differences in other secondary outcomes were found between the NHFOV and NCPAP groups.

CONCLUSIONS

NHFOV was not superior to NCPAP with regard to the primary outcome when applied as the primary respiratory support for RDS in infants between 26+0/7 and 33+6/7 weeks of GA. In the subgroup analysis, NHFOV seemed to improve effectiveness than NCPAP in preterm infants <30 weeks of GA.

Three non-invasive ventilation strategies for preterm infants with respiratory distress syndrome: a propensity score analysis

INTRODUCTION

The present study was designed and conducted to compare the efficacy between nasal continuous positive airway pressure (NCPAP), nasal intermittent positive-pressure ventilation (NIPPV), and noninvasive high-frequency oscillatory ventilation (NHFOV) as the primary noninvasive ventilation in preterm infants with respiratory distress syndrome (RDS).

MATERIAL AND METHODS

This multicenter retrospective cohort study was performed using data from four tertiary neonatal intensive care units (NICUs) in China between 2016 and 2018. 512 preterm infants with RDS who received early non-invasive ventilation (NIV) were analyzed. Propensity score analysis with 1 : 1 matching was performed with the nearest neighbor matching method using calipers of width equal to 0.1 of the standard deviation of the logit of the propensity score. The primary outcome was the need for intubation and invasive mechanical ventilation (IMV) within the first 7 days after birth. Secondary outcomes were days of hospitalization, predischarge mortality, rate of retinopathy of prematurity (ROP) > stage II, rate of bronchopulmonary dysplasia (BPD) at 36 weeks post-menstrual age, rate of air leaks, rate of intraventricular hemorrhage (IVH) ≥ grade 3, and rate of necrotizing enterocolitis (NEC) ≥ stage II.

RESULTS

Propensity score matching identified 126 infants in each cohort (NHFOV vs. NIPPV), 96 infants in each cohort (NHFOV vs. NCPAP), 134 infants in each cohort (NIPPV vs. NCPAP) respectively. The need for IMV was significantly lower in the NHFOV as compared with NCPAP and NIPPV groups respectively (13/126 vs. 27/126, p = 0.016; 9/96 vs. 20/96, p = 0.027), while no difference was observed between NIPPV and NCPAP groups (25/134 vs. 25/134, p = 0.805). However, the number of days of hospitalization in NIPPV was significantly lower than that of the NCPAP group (24.8 ±14.6 days vs. 33.2 ±20.2 days p = 0.002). In subgroup analyses, the need for IMV was significantly lower in the NHFOV group than in the NCPAP and NIPPV group (7 : 79 vs. 15 : 74; 95% CI: 1.00-6.836; p = 0.044 and 11 : 102 vs. 22 : 98; 95% CI: 1.092-5.251; p = 0.026), and there was no difference between NIPPV and NCPAP in the preterm infants at ≤ 32 weeks' gestational age. There were no significant differences among three groups (p > 0.05 respectively) regarding secondary outcomes.

CONCLUSIONS

In this multicenter retrospective cohort study, NHFOV significantly reduced the need for IMV within the first 7 days as compared to NCPAP and NIPPV in the treatment of preterm infants with RDS without increasing the incidence of adverse events. However, NIPPV was not found to be superior to NCPAP for decreasing the need for IMV in the treatment of preterm infants with RDS.

Noninvasive high-frequency oscillatory ventilation as respiratory support in preterm infants: a meta-analysis of randomized controlled trials

BACKGROUND

Noninvasive high-frequency oscillatory ventilation (nHFOV), a relatively new modality, is gaining popularity despite scarce evidence. This meta-analysis was designed to evaluate the efficacy and safety of nHFOV as respiratory support in premature infants.

METHODS

We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL from inception of the database to January 2019. All published randomized controlled trials (RCTs) evaluating the effect of nHFOV therapy with nasal continuous positive airway pressure (nCPAP) or biphasic nCPAP (BP-CPAP) in newborns for respiratory support were included. All meta-analyses were performed using Review Manager 5.3.

RESULTS

A total of 8 RCTs involving 463 patients were included. The meta-analysis estimated a lower risk of intubation (relative risk = 0.50, 95% confidence interval of 0.36 to 0.70) and more effective clearance of carbon dioxide (weighted mean difference = - 4.61, 95% confidence interval of - 7.94 to - 1.28) in the nHFOV group than in the nCPAP/BP-CPAP group.

CONCLUSIONS

Our meta-analysis of RCTs suggests that nHFOV, as respiratory support in preterm infants, significantly remove carbon dioxide and reduce the risk of intubation compared with nCPAP/BP-CPAP. The appropriate parameter settings for different types of noninvasive high-frequency ventilators, the effect of nHFOV in extremely preterm infants, and the long-term safety of nHFOV need to be assessed in large trials.

Non-invasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: Study protocol for a multi-center prospective randomized controlled trial

BACKGROUND

Invasive mechanical ventilation (IMV) is associated with the development of adverse pulmonary and non-pulmonary outcomes in very premature infants. Various modes of non-invasive respiratory support are increasingly being used to decrease the incidence of bronchopulmonary dysplasia. The aim of this trial is to compare the effect of non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) in preterm infants with respiratory distress syndrome (RDS) as a primary non-invasive ventilation support mode.

METHODS/DESIGN

In this multi-center randomized controlled trial, 300 preterm infants born at a gestational age of 266/7 to 336/7 weeks with a diagnosis of RDS will be randomized to NHFOV or NCPAP as a primary mode of non-invasive respiratory support. The study will be conducted in 18 tertiary neonatal intensive care units in China. The primary outcome is the need for IMV during the first 7 days after enrollment in preterm infants randomized to the two groups. The prespecified secondary outcomes include days of hospitalization, days on non-invasive respiratory support, days on IMV, days on supplemental oxygen, mortality, need for a surfactant, severe retinopathy of prematurity requiring laser treatment or surgery, patent ductus arteriosus needing ligation, bronchopulmonary dysplasia, abdominal distention, air leak syndromes, intraventricular hemorrhage (≥ grade 3), spontaneous intestinal perforation, necrotizing enterocolitis (≥II stage), and nasal trauma. Other secondary outcomes include Bayley Scales of Infant Development at 18-24 months of corrected age.

DISCUSSION

In recent decades, several observational studies have compared the effects of NHFOV and NCPAP in neonates as a rescue mode or during weaning from IMV. To our knowledge, this will be the first multi-center prospective, randomized controlled trial to evaluate NHFOV as a primary mode in preterm infants with RDS in China or any other part of the world. Our trial may help to establish guidelines for NHFOV in preterm infants with RDS to minimize the need for IMV, and to decrease the significant pulmonary and non-pulmonary morbidities associated with IMV.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03099694 . Registered on 4 April 2017.