HFOV as Effective as Conventional Ventilation in Preterm Infants
HFOV as Effective as Conventional Ventilation in Preterm Infants
June 3, 2010 — High-frequency oscillatory ventilation (HFOV) seems to be as effective as conventional ventilation in preterm infants, according to the results of a systematic review and meta-analysis published online June 1 in The Lancet.
"Population and study design heterogeneity has confounded previous meta-analyses, leading to uncertainty about effectiveness and safety of elective ...HFOV in preterm infants," write Filip Cools, MD, from Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium, and colleagues from the PreVILIG collaboration. "We assessed effectiveness of elective HFOV versus conventional ventilation in this group."
The reviewers performed a meta-analysis of individual patients' data from 3229 participants in 10 randomized controlled trials. Inclusion criteria for trials were those with primary outcomes of any of the following: mortality or bronchopulmonary dysplasia at 36 weeks' postmenstrual age, death, or severe adverse neurologic event.
Relative risk (RR) for death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age for infants ventilated with HFOV was 0.95 (95% confidence interval [CI], 0.88 - 1.03). For death or severe adverse neurologic event, the RR was 1.00 (95% CI, 0.88 - 1.13), and for any of these outcomes, the RR was 0.98 (95% CI, 0.91 - 1.05).
When infants were categorized by gestational age, birth weight for gestation, initial lung disease severity, or exposure to antenatal corticosteroids, no subgroup of infants was identified that appeared to benefit more or less from HFOV. Overall treatment effect was not affected by ventilator type or ventilation strategy.
"HFOV seems equally effective to conventional ventilation in preterm infants," the study authors write. "Our results do not support selection of preterm infants for HFOV on the basis of gestational age, birthweight for gestation, initial lung disease severity, or exposure to antenatal corticosteroids."
Limitations of this study include loss of data, preventing inclusion of individual data from 430 infants; lack of central reading of brain sonograms in some multicenter trials; and risk of missing true effects in subgroup analysis.
"Subsequent trials should investigate issues such as the optimum timing of surfactant administration in infants on HFOV and other possible roles for HFOV in the treatment of respiratory distress syndrome—for example, those infants who do not respond to initial non-invasive respiratory support," the study authors conclude.
Comment: Neonatology Implications
In an accompanying comment, Richard B. Parad, from Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts, notes that these results have broad implications for neonatology.
"Because even a small effect size can be of substantial value to these critically ill patients, randomised evidence necessitates large cohorts that often can only be accrued via many enrolment centres to recruit enough participants in an acceptable time interval," Dr. Parad writes. "Meta-analysis of individual patients' data has been done with adult trials for more than 10 years, but only recently in critical care medicine, and not until now for neonatal trials. Use of such meta-analyses on datasets derived from existing neonatal trials (eg, iNO trials) might enable answers to be generated from pre-existing datasets, which were not uncovered by primary randomised trial analyses or from subsequent traditional meta-analyses that were flawed or biased."
Nestlé Belgium, Belgian Red Cross, and Dräger International supported this study. Study author J. Jane Pillow, FRACP, has disclosed having ventilators on loan from Cardinal Health.
Dr. Parad has disclosed no relevant financial relationships.
Lancet. Published online June 1, 2010.
June 3, 2010 — High-frequency oscillatory ventilation (HFOV) seems to be as effective as conventional ventilation in preterm infants, according to the results of a systematic review and meta-analysis published online June 1 in The Lancet.
"Population and study design heterogeneity has confounded previous meta-analyses, leading to uncertainty about effectiveness and safety of elective ...HFOV in preterm infants," write Filip Cools, MD, from Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium, and colleagues from the PreVILIG collaboration. "We assessed effectiveness of elective HFOV versus conventional ventilation in this group."
The reviewers performed a meta-analysis of individual patients' data from 3229 participants in 10 randomized controlled trials. Inclusion criteria for trials were those with primary outcomes of any of the following: mortality or bronchopulmonary dysplasia at 36 weeks' postmenstrual age, death, or severe adverse neurologic event.
Relative risk (RR) for death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age for infants ventilated with HFOV was 0.95 (95% confidence interval [CI], 0.88 - 1.03). For death or severe adverse neurologic event, the RR was 1.00 (95% CI, 0.88 - 1.13), and for any of these outcomes, the RR was 0.98 (95% CI, 0.91 - 1.05).
When infants were categorized by gestational age, birth weight for gestation, initial lung disease severity, or exposure to antenatal corticosteroids, no subgroup of infants was identified that appeared to benefit more or less from HFOV. Overall treatment effect was not affected by ventilator type or ventilation strategy.
"HFOV seems equally effective to conventional ventilation in preterm infants," the study authors write. "Our results do not support selection of preterm infants for HFOV on the basis of gestational age, birthweight for gestation, initial lung disease severity, or exposure to antenatal corticosteroids."
Limitations of this study include loss of data, preventing inclusion of individual data from 430 infants; lack of central reading of brain sonograms in some multicenter trials; and risk of missing true effects in subgroup analysis.
"Subsequent trials should investigate issues such as the optimum timing of surfactant administration in infants on HFOV and other possible roles for HFOV in the treatment of respiratory distress syndrome—for example, those infants who do not respond to initial non-invasive respiratory support," the study authors conclude.
Comment: Neonatology Implications
In an accompanying comment, Richard B. Parad, from Harvard Medical School and Brigham and Women's Hospital in Boston, Massachusetts, notes that these results have broad implications for neonatology.
"Because even a small effect size can be of substantial value to these critically ill patients, randomised evidence necessitates large cohorts that often can only be accrued via many enrolment centres to recruit enough participants in an acceptable time interval," Dr. Parad writes. "Meta-analysis of individual patients' data has been done with adult trials for more than 10 years, but only recently in critical care medicine, and not until now for neonatal trials. Use of such meta-analyses on datasets derived from existing neonatal trials (eg, iNO trials) might enable answers to be generated from pre-existing datasets, which were not uncovered by primary randomised trial analyses or from subsequent traditional meta-analyses that were flawed or biased."
Nestlé Belgium, Belgian Red Cross, and Dräger International supported this study. Study author J. Jane Pillow, FRACP, has disclosed having ventilators on loan from Cardinal Health.
Dr. Parad has disclosed no relevant financial relationships.
Lancet. Published online June 1, 2010.
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