Meta-analysis of elective high frequency ventilation in preterm infants with respiratory distress syndrome

Abstract

Aim - To summarise the evidence on the efficacy of elective high frequency ventilation compared with conventional ventilation in preterm infants with respiratory distress syndrome. Methods - A search from 1987 onwards was made on Embase, Medline, and the Cochrane Library. A questionnaire was also circulated during an international meeting on high frequency ventilation. To be included in the data synthesis, studies had to be randomised controlled trials comparing elective high frequency ventilation with conventional ventilation in preterm infants with respiratory failure due to respiratory distress syndrome; indices of mortality, chronic pulmonary morbidity, and other clinically relevant outcomes were compared. Studies were assessed for methodological validity according to explicit criteria. Results - Ten studies (a total number of 1345 preterm infants) were considered for data synthesis. No difference in mortality at 28 or 30 days, nor in oxygen dependency at 28 days was found between both types of ventilation. Reduced oxygen dependency at the postconceptional age of 36 weeks (RR 0.50, 95% CI 0.32-0.78) was found, but so was an increase in grades 3 and 4 intraventricular haemorrhage (IVH) (RR 1.31, 95% CI 1.04-1.66). Those studies using a high lung volume ventilatory strategy showed a significant decrease in oxygen dependency at the postconceptional age of 36 weeks (RR 0.44, 95% CI 0.27-0.73), but no increase in severe IVH (RR 0.78, 95% CI 0.45-1.37). Conclusions - Although high frequency ventilation reduces chronic lung disease, it seems to increase the risk of severe IVH. These results are dominated by an early study where the absence of benefit on pulmonary outcomes, and the increase in adverse neurological events, could be related to the low volume ventilatory strategy used. Recent studies, using a high lung volume approach, show better pulmonary outcomes without any increase in intracranial morbidity. Still, uncertainty remains about long term pulmonary and neurodevelopmental outcome.