Ho J J, Subramaniam P, Henderson-Smart D J, Davis P G
Dept Paediatrics, Perak College of Medicine, Greentown, Ipoh, Malaysia, 30450.
Cochrane Database Syst Rev. 2002(2):CD002271. doi: 10.1002/14651858.CD002271.
Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998, Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive, resulting in airway and lung injury and contributing to the development of chronic lung disease.
In spontaneously breathing preterm infants with RDS, to determine if continuous distending pressure (CDP) reduces the need for IPPV and associated morbidity without adverse effects.
The standard search strategy of the Neonatal Review group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002), MEDLINE (1966-January 2002), and EMBASE (1980-January 2002), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language.
All trials using random or quasi-random allocation of preterm infants with RDS were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharyngeal tube, or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and lower body, compared with standard care.
Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used, including independent assessment of trial quality and extraction of data by each author.
CDP is associated with a lower rate of failed treatment (death or use of assisted ventilation) [summary RR 0.70 (0.55, 0.88), RD -0.22 (-0.35, -0.09), NNT 5 (3, 11)], overall mortality [summary RR 0.52 (0.32, 0.87), RD -0.15 (-0.26, -0.04), NNT 7 (4, 25)], and mortality in infants with birthweights above 1500 g [summary RR 0.24 (0.07, 0.84), RD -0.281 (-0.483, -0.078), NNT 4 (2, 13)]. The use of CDP is associated with an increased rate of pneumothorax [summary RR 2.36 (1.25, 5.54), RD 0.14 (0.04, 0.23), NNH 7 (4, 24)].
REVIEWER'S CONCLUSIONS: In preterm infants with RDS the application of CDP either as CPAP or CNP is associated with benefits in terms of reduced respiratory failure and reduced mortality. CDP is associated with an increased rate of pneumothorax. The applicability of these results to current practice is difficult to assess, given the intensive care setting of the 1970s when four out of five of these trials were done. Where resources are limited, such as in developing countries, CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings
呼吸窘迫综合征（RDS）是早产儿发病和死亡的最重要单一原因（Greenough，1998年；Bancalari，1992年）。使用表面活性剂的间歇正压通气（IPPV）是该病的标准治疗方法。IPPV的主要困难在于它具有侵入性，会导致气道和肺部损伤，并促使慢性肺病的发展。
对于患有RDS的自主呼吸早产儿，确定持续扩张压（CDP）是否能减少对IPPV的需求及相关发病率，且无不良反应。
采用新生儿综述组的标准检索策略。这包括检索牛津围产期试验数据库、Cochrane对照试验注册库（《Cochrane图书馆》，2002年第1期）、MEDLINE（1966年 - 2002年1月）和EMBASE（1980年 - 2002年1月），以及以往的综述，包括交叉参考文献、摘要、会议和研讨会论文集、专家提供的信息，主要通过手工检索英文期刊。
所有采用随机或准随机分配患有RDS的早产儿的试验均符合条件。干预措施为持续扩张压，包括通过面罩、鼻导管、鼻咽管或气管内导管进行持续气道正压通气（CPAP），或通过包裹胸部和下半身的腔室进行持续负压通气（CNP），并与标准护理进行比较。
采用Cochrane协作网及其新生儿综述组的标准方法，包括由每位作者独立评估试验质量并提取数据。
CDP与较低的治疗失败率（死亡或使用辅助通气）相关[汇总相对危险度RR 为0.70（0.55，0.88），风险差RD为 -0.22（-0.35，-0.09），需治疗人数NNT为5（3，11）]、总体死亡率[汇总RR 0.52（0.32，0.87），RD -0.15（-0.26，-0.04），NNT 7（4，25）]以及出生体重超过1500克的婴儿死亡率[汇总RR 0.24（0.07，0.84），RD -0.281（-0.483，-0.078），NNT 4（2，13）]。使用CDP与气胸发生率增加相关[汇总RR 2.36（1.25，5.54），RD 0.14（0.04，0.23），需伤害人数NNH 7（4，24）]。
对于患有RDS的早产儿，应用CDP（无论是CPAP还是CNP）在减少呼吸衰竭和降低死亡率方面具有益处。CDP与气胸发生率增加相关。鉴于这些试验中有五分之四是在20世纪70年代的重症监护环境下进行的，很难评估这些结果对当前实践的适用性。在资源有限的地区，如发展中国家，CPAP用于治疗RDS可能具有临床作用。需要进一步研究以确定最佳给药方式及其在现代重症监护环境中的作用。
