Noninvasive neurally-adjusted ventilatory assist in preterm infants: a systematic review and meta-analysis

Noninvasive neurally-adjusted ventilatory assist (NIV-NAVA) improves patient-ventilator synchrony and may reduce treatment failure in preterm infants compared with nasal continuous positive airway pressure (NCPAP) and noninvasive positive-pressure ventilation (NIPPV). We conducted a systematic review and meta-analysis to assess the effects of NIV-NAVA in preterm infants with respiratory distress. Four investigators independently assessed the eligibility of studies in CENTRAL, CINAHL, ClinicalTrials.gov, Embase, MEDLINE, PubMed, and WHO ICTRP databases, and extracted data. The included studies were randomized controlled trials (RCTs) comparing NIV-NAVA with other noninvasive ventilation modalities in preterm infants. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The objective of the meta-analysis was to compare NIV-NAVA vs CPAP/NIPPV as a primary mode post extubation. Five RCTs which examined 279 preterm infants were included. In the subgroup of post-extubation respiratory support, NIV-NAVA decreased treatment failure compared with NCPAP/NIPPV (risk ratio 0.29; 95% confidence interval [0.10, 0.81], 2 RCTs, 96 infants, low certainty of the evidence). NIV-NAVA did not significantly reduce the risk of treatment failure in the subgroup of primary respiratory support (very low certainty of the evidence). There were no significant differences in secondary outcomes with low to very low certainty of evidence. In a small cohort with low certainty of evidence, NIV-NAVA may prevent reintubation in preterm infants. Further large-scale RCTs are needed to determine the effects and safety of NIV-NAVA in preterm infants.与经鼻持续气道正压通气（nasal continuous positive airway pressure, NCPAP）和无创正压通气（noninvasive positive-pressure ventilation, NIPPV）相比，无创神经调节通气辅助（noninvasive neurally-adjusted ventilatory assist, NIV-NAVA）可改善患者-呼吸机同步性，并可能降低早产儿的治疗失败率。本研究开展系统评价与meta分析，旨在评估NIV-NAVA对呼吸窘迫早产儿的干预效果。四名研究者独立检索了CENTRAL、CINAHL、ClinicalTrials.gov、Embase、MEDLINE、PubMed及WHO ICTRP数据库，对纳入研究的资格进行评估并提取数据。本研究纳入的均为对比NIV-NAVA与其他无创通气模式用于早产儿的随机对照试验（randomized controlled trials, RCTs），证据质量采用推荐、评估、制定与评价（Grading of Recommendations, Assessment, Development, and Evaluation, GRADE）分级法进行评价。本次meta分析的目标为比较拔管后初始通气模式采用NIV-NAVA与CPAP/NIPPV的效果。本研究共纳入5项RCTs，涉及279名早产儿。在拔管后呼吸支持亚组中，相较于NCPAP/NIPPV，NIV-NAVA可降低治疗失败风险（相对危险度0.29；95%置信区间[0.10, 0.81]，2项RCTs，96名患儿，证据质量为低等级）。在初始呼吸支持亚组中，NIV-NAVA未显著降低治疗失败风险（证据质量为极低等级）。其余次要结局指标均未出现显著差异，证据质量为低至极低等级。在一项样本量较小的队列中（证据质量低等级），NIV-NAVA或可预防早产儿再插管。未来仍需开展大规模RCTs，以明确NIV-NAVA在早产儿中的应用效果与安全性。