A Trial Comparing Noninvasive Ventilation Strategies in Preterm Infants

BackgroundTo reduce the risk of bronchopulmonary dysplasia in extremely-low-birth-weight infants, clinicians attempt to minimize the use of endotracheal intubation by the early introduction of less invasive forms of positive airway pressure. MethodsWe randomly assigned 1009 infants with a birth weight of less than 1000 g and a gestational age of less than 30 weeks to one of two forms of noninvasive respiratory support nasal intermittent positive-pressure ventilation (IPPV) or nasal continuous positive airway pressure (CPAP) at the time of the first use of noninvasive respiratory support during the first 28 days of life. The primary outcome was death before 36 weeks of postmenstrual age or survival with bronchopulmonary dysplasia. ResultsOf the 497 infants assigned to nasal IPPV for whom adequate data were available, 191 died or survived with bronchopulmonary dysplasia (38.4%), as compared with 180 of 490 infants assigned to nasal CPAP (36.7%) (adjusted odds ratio, 1.09; 95% confidence interval, 0.83 to 1.43; P=0.56). The frequencies of air leaks and necrotizing enterocolitis, the duration of respiratory support, and the time to full feedings did not differ significantly between treatment groups. ConclusionsAmong extremely-low-birth-weight infants, the rate of survival to 36 weeks of postmenstrual age without bronchopulmonary dysplasia did not differ significantly after noninvasive respiratory support with nasal IPPV as compared with nasal CPAP. (Funded by the Canadian Institutes of Health Research; NIPPV ClinicalTrials.gov number, NCT00433212; Controlled-Trials.com number, ISRCTN15233270.) In a randomized trial involving extremely-low-birth-weight infants eligible for noninvasive ventilation, the survival rate without bronchopulmonary dysplasia after nasal intermittent positive-pressure ventilation was similar to the rate after nasal continuous positive airway pressure. In extremely-low-birth-weight infants, bronchopulmonary dysplasia remains a leading cause of early death,(1) a strong predictor of later neurologic impairment,(2) and a major reason for resource use(3) and rehospitalization during the first year of life.(4) Improvements in survival rates among such infants have led to rates of bronchopulmonary dysplasia of up to 60% at the lowest gestational ages.(1),(5),(6) Tracheal intubation and mechanical ventilation are associated with ventilator-induced lung injury and airway inflammation, leading to bronchopulmonary dysplasia.(7),(8) Prolonged duration of intubation and mechanical ventilation in extremely-low-birth-weight infants is associated with an increased risk of death or survival with neurologic ...