PEEP for preterm infants requiring CMV: clinicians are on their own

  • Bamat N & al.
  • Cochrane Database Syst Rev
  • 26 Feb 2019

  • curated by Jenny Blair, MD
  • Clinical Essentials
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Takeaway

  • For preterm infants requiring conventional mechanical ventilation (CMV) for respiratory distress syndrome (RDS) or bronchopulmonary dysplasia (BPD), evidence is lacking about optimal positive end-expiratory pressure (PEEP) level.
  • Some low-quality evidence suggests advantage with oxygen-guided lung recruitment maneuver (LRM) in selecting level.
  • Authors: “We do not believe that our current findings have implications for clinical practice.”
  • Randomized trials needed.

Why this matters

  • PEEP could mitigate ventilator-induced lung injury in this population.
  • Unclear what PEEP level is optimal or how to find optimum.

Key results

  • No trials of PEEP in BPD.
  • 2 crossover trials compared low vs high PEEP levels in RDS (n=28).
    • Trials did not report death or impairment.
    • Oxygenation, carbon dioxide levels: no difference. 
  • 2 randomized controlled trials compared oxygen-guided LRM vs usual care to optimize PEEP (n=44).
    • Mortality, BPD development: no difference. 
    • Favoring LRM: CMV duration; supplemental oxygen requirement; arterial/alveolar oxygen ratio.
  • All evidence low-quality. 

Study design

  • Systematic review, meta-analysis, 4 studies of PEEP for preterm infants undergoing CMV for RDS or BPD (n=72).
  • Outcomes: death by hospital discharge (RDS) or age 2 years (BPD); neurodevelopmental impairment at age 2 years.
  • Funding: Vermont Oxford Network.

Limitations

  • Very small studies.
  • In 1 trial, all participants had patent ductus arteriosus.

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