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Bezirganoglu H, Okur N, Buyuktiryaki M, Oguz SS, Dizdar EA, Sari FN. Comparison of Assist/Control Ventilation with and without Volume Guarantee in Term or Near-Term Infants. Am J Perinatol 2024; 41:e174-e179. [PMID: 35613941 DOI: 10.1055/a-1862-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES This study aimed to compare the effects of volume guarantee (VG) combined with assist/control (AC) ventilation to AC alone on hypocarbia episodes and extubation success in infants born at or near term. METHODS In this prospective cohort study, infants >34 weeks of gestation at birth, who were born in our hospital supported by synchronized, time-cycled, pressure limited, assist/control ventilation (AC) or assist-controlled VG mechanical ventilation (ACâ+âVG) were included. After admission, infants received either AC or VGâ+âAC using by Leoni Plus ventilator. The ventilation mode was left to the clinician. In the AC group, peak airway pressure was set clinically. In the VGâ+âAC group, desired tidal volume was set at 5âmL/kg, with the ventilator adjusting peak inspiratory pressure to deliver this volume. The study was completed once the patient extubated. RESULTS There were 35 patients in each group. Incidence of hypocarbia was lower in the VGâ+âAC compared with AC (%17.1 and 22.8%, respectively) but statistically not significant. Out-of-range partial pressure of carbon dioxide (PCO2) levels were lower in the VGâ+âAC group and it reached borderline statistical significance (pâ=â0.06). The median extubation time was 70 (42-110) hours in the VGâ+âAC group, 89.5 (48.5-115.5) hours in the AC group, and it did not differ between groups (pâ=â0.47). CONCLUSION We found combining AC and VG ventilation compared with AC ventilation alone yielded similar hypocarbia episodes and extubation time for infants of >34 gestational weeks with borderline significance lower out-of-range PCO2 incidence. KEY POINTS · Underlying lung pathology requiring mechanical ventilation support in term infant is heterogeneous.. · VG ventilation compared with conventional modes yielded similar hypocarbia episodes in term infants.. · Combining VG ventilation lead to borderline significance lower out-of-range PCO2 incidence..
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Affiliation(s)
- Handan Bezirganoglu
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, Ankara, TĂŒrkiye
- Division of Neonatology, Trabzon Kanuni Training and Research Hospital, Trabzon, TĂŒrkiye
| | - Nilufer Okur
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, Ankara, TĂŒrkiye
- Division of Neonatology, Diyarbakir Gazi Yasargil Training and Research Hospital, Diyarbakir, TĂŒrkiye
| | - Mehmet Buyuktiryaki
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, Ankara, TĂŒrkiye
- Division of Neonatology, Department of Pediatrics, Ä°stanbul Medipol University Medical School, Ä°stanbul, TĂŒrkiye
| | - Serife S Oguz
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, Ankara, TĂŒrkiye
| | - Evrim A Dizdar
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, Ankara, TĂŒrkiye
| | - Fatma N Sari
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, Ankara, TĂŒrkiye
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Nagaraj YK, Balushi SA, Robb C, Uppal N, Dutta S, Mukerji A. Peri-extubation settings in preterm neonates: a systematic review and meta-analysis. J Perinatol 2024; 44:257-265. [PMID: 38216677 DOI: 10.1038/s41372-024-01870-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVE To systematically review: 1) peri-extubation settings; and 2) association between peri-extubation settings and outcomes in preterm neonates. STUDY DESIGN In this systematic review, studies were eligible if they reported patient-data on peri-extubation settings (objective 1) and/or evaluated peri-extubation levels in relation to clinical outcomes (objective 2). Data were meta-analyzed when appropriate using random-effects model. RESULTS Of 9681 titles, 376 full-texts were reviewed and 101 included. The pooled means of peri-extubation settings were summarized. For objective 2, three experimental studies were identified comparing post-extubation CPAP levels. Meta-analyses revealed lower odds for treatment failure [pooled OR 0.46 (95% CI 0.27-0.76); 3 studies, 255 participants] but not for re-intubation [pooled OR 0.66 (0.22-1.97); 3 studies, 255 participants] with higher vs. lower CPAP. CONCLUSIONS Summary of peri-extubation settings may guide clinicians in their own practices. Higher CPAP levels may reduce extubation failure, but more data on peri-extubation settings that optimize outcomes are needed.
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Affiliation(s)
| | | | - Courtney Robb
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Nikhil Uppal
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Sourabh Dutta
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
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Tang J, Gong L, Xiong T, Chen C, Tian K, Wang A, Huang Y, Liu W, Zhou R, Zhu J, Mu D. Volume-targeted ventilation vs pressure-controlled ventilation for very low birthweight infants: a protocol of a randomized controlled trial. Trials 2023; 24:536. [PMID: 37587501 PMCID: PMC10428577 DOI: 10.1186/s13063-023-07564-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is essential in the management of critically ill neonates, especially preterm infants. However, inappropriate or prolonged use of invasive MV may result in ventilator-associated lung injury. A systemic review comparing pressure control ventilation (PCV) with volume-targeted ventilation mode (VTV) approved that VTV reduces the incidence of death or bronchopulmonary dysplasia (BPD) in neonates; however, this study did not analyze subgroups of very low birthweight (VLBW) infants. Therefore, the aim of this study was to compare the use of VTV and PCV in VLBW infants and to provide clinical evidence for reducing mortality and complications of MV in VLBW infants. METHOD A single-center randomized controlled trial will be performed. All eligible infants will be randomized and assigned to either VTV or PCV group with 1:1 ratio using sealed envelopes. Death or BPD at 36Â weeks' postmenstrual age will be used as the primary outcome. Secondary outcomes include BPD, death, length of invasive MV, noninvasive mechanical ventilation, and oxygen use, length of hospital stay, failure of conventional MV, rate of using high-frequency oscillatory ventilation (HFOV) as rescue therapy, rate of reintubation within 48Â h, and hospital expenses. DISCUSSION Systemic review suggested that VTV decreases the incidence of death or BPD in neonates compared to PLV; however, this study did not specifically analyze subgroups of VLBW infants. We designed this single-center randomized controlled trials (RCT) to add a significant contribution regarding the benefits of VTV for VLBW patients.
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Affiliation(s)
- Jun Tang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Renmin South Road #16, Wuhou District, Chengdu, China
| | - Lingyue Gong
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Tao Xiong
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Chao Chen
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Ke Tian
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Aoyu Wang
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Yi Huang
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Wenli Liu
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Rong Zhou
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Jun Zhu
- West China Second University Hospital, Sichuan University, Renmin South Road #20, Wuhou District, Chengdu, China
| | - Dezhi Mu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second University Hospital, Sichuan University, Renmin South Road #16, Wuhou District, Chengdu, China
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Implementing Volume-targeted Ventilation to Decrease Hypocarbia in Extremely Low Birth Weight Infants during the First Week of Life: A Quality Improvement Project. Pediatr Qual Saf 2021; 6:e398. [PMID: 33977188 PMCID: PMC8104191 DOI: 10.1097/pq9.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 10/22/2020] [Indexed: 11/27/2022] Open
Abstract
Hypocarbia in neonates increases the risk of poor neurodevelopmental outcomes. Volume-targeted ventilation (VTV) is associated with decreased hypocarbia and other respiratory morbidities. We noticed a high incidence of hypocarbia in extremely low birth weight (ELBW; <1,000âg) neonates in our Neonatal Intensive Care Unit. Thus, we undertook a quality improvement project to decrease the incidence of hypocarbia (the occurrence of PCO2 < 35âmm Hg) in ELBW neonates during the first week of life by 50% over 1 year. Methods Our major interventions were employing VTV as the primary mode of mechanical ventilation in neonates less than 28 weeks of gestation or ELBW at birth and increasing staff knowledge regarding hypocarbia. The baseline period spanned May-August 2016. We implemented the interventions in October 2016 and tracked the use of VTV and the incidence of hypocarbia during the first week of life for 12 months. Results We analyzed data on 28 and 77 patients in the baseline and postintervention periods, respectively. The use of VTV increased from 39% to 65%. However, the incidence of hypocarbia was not reduced (57% preintervention vs. 64% postintervention). In the postintervention cohort, the incidence of hypocarbia was comparable between VTV and other modes (60% vs. 70%; 95% confidence interval: -32%, 12%; P = 0.367), but we noted decreased blood gas sampling and earlier extubation in the VTV group (P = 0.002 and P = 0.046, respectively). Conclusions Successfully increasing VTV in our Neonatal Intensive Care Unit did not decrease hypocarbia during the first week of life. However, we observed the safety of VTV and obtained other desirable results.
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Volume guarantee ventilation in neonates treated with hypothermia for hypoxic-ischemic encephalopathy during interhospital transport. J Perinatol 2021; 41:528-534. [PMID: 32989219 PMCID: PMC7520879 DOI: 10.1038/s41372-020-00823-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We investigated if volume guarantee (VG) ventilation in babies with hypoxic-ischemic encephalopathy (HIE) during interhospital transport decreases tidal volumes and prevents hypocapnia. STUDY DESIGN We computationally collected and analyzed ventilator data of babies ventilated with synchronized intermittent mandatory ventilation (SIMV) with VG (nâ=â28) or without VG (nâ=â8). RESULT The expiratory tidal volume of ventilator inflations was lower with SIMV-VG (median [IQR]: 4.9 [4.6-5.3]âmL/kg) than with SIMV only (median [IQR]: 7.1 [5.3-8.0]âmL/kg, pâ=â0.01). Babies receiving SIMV-VG had lower peak inflating pressures (median: 10.7âcmH2O, versus 17.5âcmH2O, pâ=â0.01). There was no significant difference in minute ventilation or in pCO2. Babies with strong spontaneous breathing had a mean PIPâ<â10âcmH2O but this did not result in adverse events or worsening of acidosis. CONCLUSIONS The use of VG ventilation in babies with HIE reduces tidal volumes and frequently results in very low inflating pressures without affecting pCO2.
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Vervenioti A, Fouzas S, Tzifas S, Karatza AA, Dimitriou G. Work of Breathing in Mechanically Ventilated Preterm Neonates. Pediatr Crit Care Med 2020; 21:430-436. [PMID: 32365285 DOI: 10.1097/pcc.0000000000002277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To compare the imposed work of breathing by means of pressure-time product of the diaphragm in newborn infants receiving different modes of mechanical ventilation. DESIGN Prospective observational crossover study. SETTING Tertiary care neonatal unit. PATIENTS Forty preterm newborns (gestational age †37âwk) in the phase of weaning from mechanical ventilation. INTERVENTIONS Participants were ventilated in assist control, synchronized intermittent mandatory ventilation, and intermittent mandatory ventilation mode, in a crossover manner. The combination synchronized intermittent mandatory ventilation-pressure support (SIMV-PS) at 50% (SIMV-PS50) and 75% (SIMV-PS75) of the difference between peak inflating and positive end-expiratory pressure, was also applied in a subset of infants (n = 11). Each mode was maintained for 30 minutes. Transdiaphragmatic pressure was obtained by digital subtraction of esophageal from gastric pressure (both measured using a dual pressure-tipped catheter), and pressure-time product of the diaphragm was computed by integration of transdiaphragmatic pressure over inspiratory time. MEASUREMENTS AND MAIN RESULTS The pressure-time product of the diaphragm was 224.2â±â112.8 in the intermittent mandatory ventilation mode, 165.8â±â58.8 in the synchronized intermittent mandatory ventilation mode, and 125.5â±â61.8âcm H2O Ă s Ă min in the assist control mode; all values were significantly different to each other (p < 0.0001). The pressure-time product of the diaphragm difference between assist control and intermittent mandatory ventilation, and assist control and synchronized intermittent mandatory ventilation was negatively related to postmenstrual age (regression coefficient, -0.365; p = 0.020 and -0.341; p = 0.031, respectively). In the SIMV-PS subcohort, the pressure-time product of the diaphragm was significantly higher in the intermittent mandatory ventilation mode as compared with assist control (p < 0.0001) or SIMV-PS75 (p = 0.0027), and in the synchronized intermittent mandatory ventilation mode as compared with assist control (p = 0.0301). CONCLUSIONS In preterm infants, patient-triggered ventilation modalities result in lower work of breathing than intermittent mandatory ventilation, while the assist control mode is also associated with lower pressure-time product of the diaphragm compared with synchronized intermittent mandatory ventilation. The difference in the imposed diaphragmatic workload between these ventilation modalities was inversely related to postmenstrual age, implying that less mature infants benefit more from assist control-based ventilation strategies.
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Affiliation(s)
- Aggeliki Vervenioti
- All authors: Neonatal Intensive Care Unit, Department of Pediatrics, University of Patras Medical School, Patras, Greece
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Ganguly A, Makkar A, Sekar K. Volume Targeted Ventilation and High Frequency Ventilation as the Primary Modes of Respiratory Support for ELBW Babies: What Does the Evidence Say? Front Pediatr 2020; 8:27. [PMID: 32117833 PMCID: PMC7025474 DOI: 10.3389/fped.2020.00027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/20/2020] [Indexed: 12/01/2022] Open
Abstract
Respiratory management of the extremely low birth weight (ELBW) newborn has evolved over time. Although non-invasive ventilation is being increasingly used for respiratory support in these ELBW infants, invasive ventilation still remains the primary mode in this population. Current ventilators are microprocessor driven and have revolutionized the respiratory support for these neonates synchronizing the baby's breath to ventilator breaths. High frequency ventilators with the delivery of tidal volumes less than the dead space have been introduced to minimize barotrauma and chronic lung disease. Despite these advances, the incidence of chronic lung disease has not decreased. There is still controversy regarding which mode is ideal as the primary mode of ventilation in ELBW infants. The most common modes seem to be pressure targeted conventional ventilation, volume targeted conventional ventilation and high frequency ventilation which includes high frequency oscillatory ventilation, high frequency jet ventilation and high frequency flow interrupter. In recent years, several randomized controlled trials and meta-analyses have compared volume vs. pressure targeted ventilation and high frequency ventilation. While volume targeted ventilation and high frequency ventilation does show promise, substantial practice variability among different centers persists. In this review, we weighed the evidence for each mode and evaluated which modes show promise as the primary support of ventilation in ELBW babies.
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Affiliation(s)
- Abhrajit Ganguly
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Abhishek Makkar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Krishnamurthy Sekar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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Katz I, Milet A, Chalopin M, Farjot G. Numerical analysis of mechanical ventilation using high concentration medical gas mixtures in newborns. Med Gas Res 2019; 9:213-220. [PMID: 31898606 PMCID: PMC7802424 DOI: 10.4103/2045-9912.273959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 07/02/2019] [Accepted: 07/23/2019] [Indexed: 11/05/2022] Open
Abstract
When administered in relatively high concentrations the mechanical properties of inhaled gas can become significantly different from air. This fact has implications in mechanical ventilation where adequate respiration and injury to the lungs or respiratory muscles can worsen morbidity and mortality. Here we use an engineering pressure loss model to analyze the administration of medical gas mixtures in newborns. The model is used to determine the pressure distribution along the gas flow path. Numerical experiments comparing medical gas mixtures with helium, nitrous oxide, argon, xenon, and medical air as a control, with and without an endotracheal tube obstruction were performed. The engineering pressure loss model was incorporated into a model of mechanical ventilation during pressure control mode, a ventilator mode that is often used for neonates. Results are presented in the form of Rohrer equations relating pressure loss to flow rate for each gas mixture with and without obstruction. These equations were incorporated into a model for mechanical ventilation resulting in pressure, flow rate, and volume curves for the inhalation-exhalation cycle. In terms of accuracy, published values of airway resistance range from 50 to 150 cmH2O/L per second for a normal 3 kg infant. With air, the current results are 55 to 80 cmH2O/L per second for 0.3 to 5 L/min. It is shown that density through inertial pressure losses has a greater influence on airway resistance than viscosity in spite of relatively low flow rates and small airway dimensions of newborns. The results indicate that the high-density xenon mixture can be problematic during mechanical ventilation. On the other hand, low density heliox (a mixture of helium and oxygen) provides a wider margin of safety for mechanical ventilation than the other gas mixtures. The argon or nitrous oxide mixtures considered are only slightly different from air in terms of mechanical ventilation performance.
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Affiliation(s)
- Ira Katz
- Medical Research & Development, Healthcare World Business Line, Air Liquide Santé International, Paris Innovation Campus, Les Loges-en-Josas, France
| | - Aude Milet
- Medical Research & Development, Healthcare World Business Line, Air Liquide Santé International, Paris Innovation Campus, Les Loges-en-Josas, France
| | - Matthieu Chalopin
- Medical Research & Development, Healthcare World Business Line, Air Liquide Santé International, Paris Innovation Campus, Les Loges-en-Josas, France
| | - GĂ©raldine Farjot
- Medical Research & Development, Healthcare World Business Line, Air Liquide Santé International, Paris Innovation Campus, Les Loges-en-Josas, France
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Optimal Conventional Mechanical Ventilation in Full-Term Newborns: A Systematic Review. Adv Neonatal Care 2018; 18:451-461. [PMID: 30036198 DOI: 10.1097/anc.0000000000000525] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Most studies examining the best mechanical ventilation strategies in newborn infants have been performed in premature infants with respiratory distress syndrome. PURPOSE To identify and synthesize the evidence regarding optimal mechanical ventilation strategies in full-term newborns. METHODS Systematic review carried out according to the methods described in the PRISMA statement. SEARCH STRATEGY Searches in MEDLINE, EMBASE, CINAHL, and the Cochrane Library in March 2017, with an updated search and hand searches of reference lists of relevant articles in August 2017. STUDY SELECTION Studies were included if they were published between 1996 and 2017, involved newborns with gestational age of 37 to 42 weeks, were randomized controlled trials, intervention or crossover studies, and addressed outcomes affecting oxygenation and/or ventilation, and/or short-term outcomes including duration of mechanical ventilation. Because of the large heterogeneity between the studies, it was not possible to synthesize the results in meta-analyses. The results are presented according to thematic analysis. RESULTS No individual study reported research exclusively in newborns 37 to 42 weeks of gestation. Eight studies fulfilled the inclusion criteria, but the population in all these studies included both premature and term newborns. Evidence about mechanical ventilation tailored exclusively to full-term newborns is scarce. IMPLICATION FOR PRACTICE Synchronized intermittent mandatory ventilation with a 6 mL/kg tidal volume and a positive end-expiratory pressure of 8 cm H2O may be advantageous in full-term newborns. IMPLICATION FOR RESEARCH There is an urgent need for high-quality studies, preferably randomized controlled trials, in full-term newborns requiring mechanical ventilation to optimize oxygenation, ventilation, and short-term outcomes, potentially stratified according to the underlying pathology.
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Klingenberg C, Wheeler KI, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in neonates. Cochrane Database Syst Rev 2017; 10:CD003666. [PMID: 29039883 PMCID: PMC6485452 DOI: 10.1002/14651858.cd003666.pub4] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Damage caused by lung overdistension (volutrauma) has been implicated in the development of bronchopulmonary dysplasia (BPD). Modern neonatal ventilation modes can target a set tidal volume as an alternative to traditional pressure-limited ventilation (PLV) using a fixed inflation pressure. Volume-targeted ventilation (VTV) aims to produce a more stable tidal volume in order to reduce lung damage and stabilise the partial pressure of carbon dioxide (pCO2). OBJECTIVES To determine whether VTV compared with PLV leads to reduced rates of death and death or BPD in newborn infants and to determine whether use of VTV affected outcomes including air leak, cranial ultrasound findings and neurodevelopment. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 12), MEDLINE via PubMed (1966 to 13 January 2017), Embase (1980 to 13 January 2017) and CINAHL (1982 to 13 January 2017). We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. We contacted the principal investigators of studies to obtain supplementary information. SELECTION CRITERIA Randomised and quasi-randomised trials comparing VTV versus PLV in infants of less than 44 weeks' postmenstrual age and reporting clinically relevant outcomes. DATA COLLECTION AND ANALYSIS We assessed risk of bias for each trial using Cochrane methodology. We evaluated quality of evidence for each outcome using GRADE criteria. We tabulated mortality, rates of BPD, short-term clinical outcomes and long-term developmental outcomes. STATISTICS for categorical outcomes, we calculated typical estimates for risk ratios (RR), risk differences (RD) and number needed to treat for an additional beneficial outcome (NNTB). For continuous variables, we calculated typical estimates for mean differences (MD). We used 95% confidence intervals (CI) and assumed a fixed-effect model for meta-analysis. MAIN RESULTS Twenty randomised trials met our inclusion criteria; 16 parallel trials (977 infants) and four cross-over trials (88 infants). No studies were blinded and the quality of evidence for outcomes assessed varied from moderate to low.We found no difference in the primary outcome, death before hospital discharge, between VTV modes versus PLV modes (typical RR 0.75, 95% CI 0.53 to 1.07; low quality evidence). However, there was moderate quality evidence that the use of VTV modes resulted in a reduction in the primary outcome, death or BPD at 36 weeks' gestation (typical RR 0.73, 95% CI 0.59 to 0.89; typical NNTB 8, 95% CI 5 to 20) and the following secondary outcomes: rates of pneumothorax (typical RR 0.52, 95% CI 0.31 to 0.87; typical NNTB 20, 95% CI 11 to 100), mean days of mechanical ventilation (MD -1.35 days, 95% CI -1.83 to -0.86), rates of hypocarbia (typical RR 0.49, 95% CI 0.33 to 0.72; typical NNTB 3, 95% CI 2 to 5), rates of grade 3 or 4 intraventricular haemorrhage (typical RR 0.53, 95% CI 0.37 to 0.77; typical NNTB 11, 95% CI 7 to 25) and the combined outcome of periventricular leukomalacia with or without grade 3 or 4 intraventricular haemorrhage (typical RR 0.47, 95% CI 0.27 to 0.80; typical NNTB 11, 95% CI 7 to 33). VTV modes were not associated with any increased adverse outcomes. AUTHORS' CONCLUSIONS Infants ventilated using VTV modes had reduced rates of death or BPD, pneumothoraces, hypocarbia, severe cranial ultrasound pathologies and duration of ventilation compared with infants ventilated using PLV modes. Further studies are needed to identify whether VTV modes improve neurodevelopmental outcomes and to compare and refine VTV strategies.
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Affiliation(s)
- Claus Klingenberg
- University Hospital of North NorwayDepartment of PediatricsTromsĂžNorwayNâ9038
- UiT The Arctic University of NorwayPaediatric Research GroupTromsĂžNorway
| | - Kevin I Wheeler
- Royal Children's Hospital MelbourneDepartment of Neonatology50 Flemington RoadParkville, MelbourneVictoriaAustralia3052
- Murdoch Childrens Research InstituteParkvilleVictoriaAustralia
| | - Naomi McCallion
- Rotunda HospitalDepartment of PaediatricsParnell SquareDublinIreland
- Royal College of Surgeons in IrelandDepartment of PaediatricsDublin 2Ireland
| | - Colin J Morley
- University of CambridgeDepartment of Obstetrics and GynecologyCambridgeUK
| | - Peter G Davis
- The Royal Women's HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
- Murdoch Childrens Research InstituteMelbourneAustralia
- University of MelbourneDepartment of Obstetrics and GynecologyMelbourneAustralia
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