系统评价胎龄小于32周早产儿预防性经鼻持续气道正压通气的作用

Prophylactic nasal continuous positive airways pressure used in preterm infants of ≤32 weeks gestation:a systemic review

目的评价早产儿早期应用经鼻持续气道正压通气(NCPAP)预防呼吸窘迫综合征(RDS),减少呼吸机应用、病死率和并发症的发生。方法以(prophylactic nasal CPAP OR early nasal CPAP)AND(preterm infants OR low birth weightinfants),经鼻持续气道正压通气AND(早产儿OR低出生体重儿)为英中文关键词,检索PubMed、EMBASE、Cochrane临床对照试验库、维普中文科技期刊数据库、中国知网和万方数据库,检索时间均从建库至2011年12月,并辅以手工检索。应用RevMan5.0软件进行Meta分析,根据异质性结果选择相应的效应模型分析;无法进行Meta分析时采用描述性分析。结果 8篇RCT文献进入分析。Meta分析结果显示:NCPAP组未能显著降低早产儿气管插管呼吸机应用率(RR=-0.09,95%CI:-0.19～0.02,P=0.09)、RDS发生率(RR=0.81,95%CI:0.59～1.1,P=0.18)和病死率(RR=0.88,95%CI:0.72～1.09,P=0.25);NCPAP组能显著减少早产儿肺表面活性物质应用率(RR=0.72,95%CI:0.64～0.80,P﹤0.00001)。NCPAP组未能显著减少气管插管呼吸机通气时间(MD=-1.91d,95%CI:-6.47～4.45d,P=0.72)及氧气应用时间(MD=-0.46d,95%CI:-6.55～5.63d,P=0.88)。NCPAP组除增加气胸的发生率外,并未明显增加支气管肺发育不良、颅内出血、早产儿视网膜病、败血症、新生儿坏死性小肠结肠炎和动脉导管未闭等并发症的发生率。结论目前的证据表明早期应用NCPAP可减少肺表面活性物质应用,但增加了气胸的发生率;未能减少早产儿呼吸机应用、RDS发生率和病死率,未增加除气胸外的其他并发症发生率。

Objective To assess prophylactic nasal continuous positive airways pressure （CPAP） used soon after birth regardless of respiratory status in infants who were preterm or with very low birth weight to reduce the use of mechanical ventilation （MV） and the incidence of respiratory distress syndrome （RDS） , bronchopulmonary dysplasia（BPD） and adverse outcomes of nasal CPAP. Methods We searched the Cochrane Central Register of Controlled Trials （CENTRAL） , EMBASE, PubMed, CNKI, Wanfang Chinese periodical Database and VIP Chinese periodical Database from the establishment of the database to December 2011, using the terms （prophylactic nasal CPAP OR early nasal CPAP） AND （preterm infants OR low birth weight infants）. All trials using randomized or quasi-randomized patient allocation of preterm infants ≤ 32 weeks gestation were eligible. Two review authors independently assessed the potential risk of bias in included studies according to the Cochrane Collaboration＇s recommendations including sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting and other sources of bias. Risk ratios （RR） and 95% confidence intervals （CI） as the effect measures for dichotomous data were synthesized. The mean difference （MD） and 95% CI were used as the metrics of effect size for continuous outcomes. The meta-analysis was performed using the Cochrane statistical package RevMan 5.0. Results Eight trials in preterm infants who were treated with prophylactic nasal CPAP were included. NCPAP group failed to significantly reduce the utilization rate of trachealintubation （ RR = - 0.09,95 % CI ： - 0.19 - 0.02, P = 0.09 ）, incidence of RDS （ RR = 0.81,95 % C1：0.59 - 1.1, P = 0.18 ） and fatality （RR =0.88,95% CI：0.72 -1.09,P =0.25） in preterm infants. The use of prophylactic nasal CPAP resulted in a reduction in the outcome of surfactant administration （ RR =0.72, 95% CI： 0.64 -0.80, P 〈0.000 01 ）. NCPAP group failed to significantly reduce the time of tracheal intubation （MD = -1.91 d,95% CI： -6.47 -4.45 d, P = 0.72） and the time of oxygen （MD = -0.46 d,95% CI： -6.55 -5.63 d, P = 0.88 ）. There were no statistically significant differences in the incidence of BPD, IVH, retinopathy of prematurity, necrotizing enterocolitis, and ROP between NCPAP group and control group. Conclusions Recent evidences indicate significant effects of prophylactic nasal CPAP in reducing the outcome of surfactant administration and increasing the incidence of pneumothorax. Further multi-center randomized controlled trials are still expected to evaluate the effectiveness of prophylactic nasal CPAP for reducing the incidence of RDS, death and increasing the incidence of some adverse outcomes.