Optimising bi-level non-invasive ventilation in preterm neonates: a systematic review

Bi-level non-invasive ventilation (BiPAP) can be used as a step-up from continuous positive airway pressure (CPAP) in preterm neonates to reduce the amount of time spent mechanically ventilated. Prolonged mechanical ventilation is associated with increased morbidity and mortality. MEDLINE was searched using the terms CPAP and BiPAP. Four studies reported a significant reduction in the need for mechanical ventilation when applying BiPAP compared with CPAP. Two studies reported no significant benefit. Studies which used 15/5 cm H2O or 20/5 cm H2O were more successful than those that used 6/5 cm H2O or 8/5 cm H2O. There was no discernible pattern to the effectiveness of respiratory rate, synchronisation or inspiratory time. In conclusion, BiPAP should be delivered at 15-20/5 cm H2O or 20/5 cm H2O. Key messagesBiPAP has greater efficacy than CPAP at reducing the need for mechanical ventilation in preterm neonates with respiratory distress An inspiratory pressure of at least 15 cm H2O should be employed wherever possible There is insufficient evidence to recommend any particular respiratory rate, inspiratory time or synchronisation mode over another Structured clinical questionIs BiPAP (intervention) more effective than CPAP (control) at reducing the need for mechanical ventilation in preterm neonates, and if so, what are the most effective pressures, inspiratory time, respiratory rate and synchronization mode to use? Search strategyMEDLINE was searched via Pubmed using the terms CPAP AND BiPAP. This yielded 223 results. Further references within these articles were considered. Studies were included if they compared the effect of BiPAP vs CPAP on the need for mechanical ventilation or tracheal intubation. A total of 18 relevant studies were identified, including 15 randomised controlled trials (RCT) and one meta-analysis. Eight studies were excluded because they were already reported in the meta-analysis. Two were excluded because they were retrospective. A further two were excluded due to a lack of statistical analysis in the reporting. [1, 2]. A total of six studies remained for consideration; see table.