经鼻间歇和持续气道正压通气治疗新生儿呼吸窘迫综合征的Meta分析

The effect of nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure in neonatal respiratory distress syndrome:a meta-analysis

目的评价经鼻间歇正压通气(NIPPV)和经鼻持续气道正压通气(NCPAP)治疗新生儿呼吸窘迫综合征(NRDS)的疗效。方法检索PubM ed、EMBASE、Ovid、Springer、中国期刊全文数据库、万方数据库和维普中文科技期刊数据库,获得NIPPV与NCPAP治疗NRDS的相关RCT文献。根据随机分配方法,分配隐藏,对研究对象、治疗方案和研究结果测量者采用盲法,结果数据的完整性,选择性报告研究结果,其他偏倚来源进行文献偏倚评价。以治疗成功率和脱机成功率为主要结局指标;以预后良好率,早产儿呼吸暂停次数,脑室内出血(IVH)、脑室周围脑白质软化(PVL)、支气管肺发育不良(BPD)和早产儿视网膜病(ROP)发生率等为次要结局指标。计数资料选取OR及其95%C I表示,计量资料以加权均数差(WMD)及其95%C I表示。结果①13篇RCT文献进入M eta分析。13篇文献均采用了正确的随机方法,均提及报告数据的完整性,均未选择性报告研究结果;12篇文献采用了分配隐藏;2篇文献提及未对研究者实施盲法。漏斗图检验未见显著发表偏倚。②M eta分析结果显示,NIPPV组治疗成功率显著高于NCPAP组,OR=0.39(95%C I:0.23~0.56),P<0.000 01。NIPPV组脱机成功率显著高于NCPAP组,OR=0.15(95%C I:0.08~0.31),P<0.000 01。③NIPPV组预后良好率显著高于NCPAP组,OR=0.30(95%C I:0.13~0.68),P=0.004。NIPPV组早产儿呼吸暂停次数显著减少,WMD=-0.48(95%C I:-0.58^-0.37),P<0.000 01。NIPPV组ROP发生率低于NCPAP组,OR=0.36(95%C I:0.15~0.87),P=0.02。NIPPV组和NCPAP组BPD(OR=0.59,95%C I:0.29~1.16)、IVH和PVL的发生率(OR=0.54,95%C I:0.24~1.20)以及住院时间(WMD=-2.97,95%C I:-11.26~5.32)差异均无统计学意义。结论 NIPPV可显著降低NRDS患儿行机械通气的比例,可显著提高机械通气拔管后脱机成功率,并可改善早产儿呼吸暂停次数和减少ROP的发生率。现有研究尚不能证实NIPPV可显著降低BPD、IVH和PVL的发生率。有关NIPPV对NRDS的远期疗效仍有待大规模、多中心的RCT研究予以明确。

Objective To compare the efficacy of nasal intermittent positive pressure ventilation（NIPPV） versus nasal continuous positive airway pressure（NCPAP） in neonatal respiratory distress syndrome（NRDS）.Methods Standard literature search strategy for the Cochrane Neonatal Review Group was performed.Searches were made in PubMed,EMBASE,Ovid,Springer and CNKI databases with the terms of newborn OR preterm AND respiratory distress syndrome AND nasal intermittent positive pressure ventilation AND nasal continuous positive airway pressure.Only RCTs or quasi-RCTs which involved NIPPV versus NCPAP were included and the rate of endotracheal ventilation,successful extubation,outcome as well as the condition of apnea of prematurity,the incidence of bronchopulmonory dysplasia（BPD）,retinopathy of prematurity（ROP）,intraventricular hemorrhage（IVH） and periventricular leukomalacia（PVL）,and length of stay were taken as the observation items.Results A total of 103 literatures were reviewed.Thirteen eligible randomized controlled trials were included.The results of quality assessment showed that 13 studies described the method of random allocation.Twelve studies mentioned allocation concealment and 2 studies did not use blinding method for participants.Included studies had no significant difference in regard to baseline when enrolled.In the meta-analysis of trial data,as compared with NCPAP,NIPPV significantly reduced the incidence of endotracheal ventilation（OR=0.39,95%CI：0.23-0.56,P0.000 01）,increased the successful rate of extubation（OR=0.15,95%CI：0.08-0.31,P0.000 01）,and had a better outcome（OR=0.30,95%CI：0.13-0.68,P=0.004）.Moreover,as compared with NCPAP,NIPPV improved apnea of prematurity（WMD=-0.48,95%CI：-0.58——0.37,P0.000 01）,decreased the incidence of ROP（OR=0.36,95%CI：0.15-0.87,P=0.02）,but there was no significant incidence reduction in BPD（OR=0.59,95%CI：0.29-1.16）,IVH and PVL（OR=0.54,95%CI：0.24-1.20）,or length of stay（WMD=-2.97,95%CI：-11.26-5.32）.Conclusions In the treatment of NRDS,NIPPV significantly reduced entracheal ventilation,increased successful extubation,improved apnea of prematurity,decreased the incidence of ROP,and had better outcome as compared with NCPAP.However,there was no evidence supporting that NIPPV could reduce the incidence of BPD,IVH and PVL.Larger sample size RCTs are needed to investigate the long-term efficacy of NIPPV in neonatal respiratory intensive care.