Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. About one in ten live births around the world are preterm and many very preterm babies will develop respiratory distress soon after birth and require help with their breathing. Various strategies are available for this and an updated Cochrane review from July 2023 provides the latest evidence on the early use of nasal intermittent positive pressure ventilation compared with nasal continuous positive airway pressure. We asked one of the authors, Marc-Olivier Deguise from the Children's Hospital of Eastern Ontario in Canada to tell us about the findings, and he used ElevenLabs to make this recording.

Marco: It's well-known that providing invasive respiratory support via a tube can be harmful to the developing lung of preterm babies and can contribute to the development of chronic lung disease, which is the most common serious morbidity amongst preterm infants and there is currently no treatment for it. Because of this, providers of neonatal care have worked towards limiting the time that babies spend on mechanical ventilation and multiple non-invasive respiratory support strategies are available.
For example, continuous positive airway pressure, or CPAP, has become a popular option. This offers a continuous distending pressure to maintain an open airway, without the need for a tube. Another strategy is called bilevel positive airway pressure, or BiPAP, or nasal intermittent positive pressure ventilation, which abbreviates to NIPPV. This offers additional superimposed inflations to set peak pressure at a regular set rate over a baseline distending pressure, as is provided with CPAP.
Because it's unclear if NIPPV is better than CPAP in preterm infants with respiratory distress syndrome, or RDS, we aimed to compare babies with RDS who were supported with CPAP or NIPPV, started within 6 hours of life; to see the effects on respiratory failure and the need for respiratory support with a breathing tube, and on secondary outcomes, including chronic lung disease and mortality.
We found 17 randomized trials, most of which were small but in total, they included nearly 2000 infants. We found moderate certainty evidence that NIPPV likely reduces the risk of both respiratory failure and the need for respiratory support via a breathing tube. This appeared to be dependent on the delivery system, with a clear benefit when NIPPV was provided via ventilator rather than the bi-level device.
There was also low certainty evidence that NIPPV may reduce chronic lung disease compared to CPAP and there was no benefit or harm observed in other secondary outcomes, including mortality.
It's important to note that most trials enrolled infants with a gestational age of approximately 28 to 32 weeks and as such, the results of this review may not apply to extremely preterm infants who are most at risk of needing mechanical ventilation or developing chronic lung disease. This is a major limitation of the current evidence and clinicians taking care of extremely preterm infants should be aware that limited data are available for this group. They should also be cautious about the applicability of the evidence we did find because there was so much variability across the trials.
In summary, we can say that NIPPV likely reduces the risk of respiratory failure and the need for intubation and tube ventilation in very preterm infants, born at 28 weeks gestation or later who have RDS, or are at risk of RDS. This is mostly noted when NIPPV is provided via a ventilator as opposed to a bilevel device, meaning that neonatal units with limited access to ventilators should take this into account, because bilevel devices lead to little or no benefit in the primary outcome of this review. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population, including extremely preterm infants, as well as to compare these modes of ventilation when mean airway pressure is matched between the devices.

Mike: If you would like to look into these results in more detail and watch for future updates of this review if those additional studies become available, you can find it online. Just go to Cochrane Library dot com and search 'early NIPPV for preterm infants' to get a link to it.