Comparison of heated humidified high-flow nasal cannula and nasal continuous positive airway pressure in preventing extubation failure in preterm infants: a Meta-analysis

doi:10.3877/cma.j.issn.1673-5250.2019.02.008

Objective

To evaluate the efficacy and safety of heated humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (NCPAP) in preventing extubation failure in preterm infants.

Methods

The English databases including PubMed, Embase, Cochrane Library, and Chinese databases including Wanfang Data Knowledge Service Platform, VIP database, and China National Knowledge Infrastructure (CNKI) were searched to collect randomized controlled trial (RCT) researches which compared the clinical effects of HHHFNC and NCPAP in preventing extubation failure in preterm infants. Preterm infants in HHHFNC group and NCPAP group were treated with HHHFNC and NCPAP modes, respectively. Retrieval time ranged from January 1, 2000 to July 31, 2018. Two reviewers independently screened literatures, evaluated the quality of the literatures, and extracted data according to the inclusion and exclusion criteria of this research. Then, Meta-analysis was performed by using Stata 12.0 software to evaluate the efficacy and safety of HHHFNC and NCPAP in preventing extubation failure in preterm infants. The main outcome measurements included efficacy indexes (rates of treatment failure and reintubation) and safety indexes (incidence rates of nasal trauma and frequent hemorrhoid). The secondary outcome measurements included in-hospital mortality rate and incidence rates of bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), patent ductus arteriosus (PDA), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP), and the duration of reaching full enteral feedings.

Results

A total of 8 eligible RCT research literatures involving 1 037 preterm infants were included in the Meta analysis. Among them, there were 518 cases in HHHFNC group and 519 cases in NCPAP group. Meta-analysis showed the following results. ①In terms of efficacy, there were no significant differences between two groups in the treatment failure rate (OR=1.18, 95%CI: 0.87-1.59, P=0.286) and reintubation rate (OR=0.93, 95%CI: 0.67-1.30, P=0.687). While in terms of safety, HHHFNC had a significant advantage over NCPAP in reducing the incidence rates of nasal trauma (OR=0.17, 95%CI: 0.11-0.26, P<0.001), and frequent hemorrhoid (OR=0.24, 95%CI: 0.09-0.63, P=0.003). ②In terms of secondary outcome measurements, there were no significant differences between two groups in the in-hospital mortality rate (OR=0.93, 95%CI: 0.40-2.13, P=0.857), and incidence rates of BPD (OR=0.82, 95%CI: 0.60-1.11, P=0.202), IVH (OR=0.76, 95%CI: 0.46-1.27, P=0.299), ROP (OR=1.09, 95%CI: 0.69-1.73, P=0.713), PDA (OR=0.89, 95%CI: 0.62-1.28, P=0.524), and duration of reaching full enteral feedings (SMD=0.47, 95%CI: -0.35-1.29, P=0.264). HHHFNC had a significant advantage over NCPAP in reducing the incidence rates of NEC (OR=0.56, 95%CI: 0.33-0.95, P=0.032).

Conclusions

HHHFNC appears to be similar to NCPAP in efficacy of preventing extubation failure in preterm infants. It is associated with significantly lower odds of nasal trauma, frequent hemorrhoid and NEC. However, it is recommended to be cautious as a preferred non-invasive ventilation mode to prevent extubation failure in preterm infants.

Key words: Continuous positive airway pressure, Randomized controlled trial, Heated humidified high-flow nasal cannula, Nasal continuous positive airway pressure, Extubation, Meta-analysis, Infant, premature

表1 纳入研究的8篇随机对照试验研究文献的基本情况

纳入文献(第一作者，文献发表年)	国家	早产儿例数(例)		早产儿性别(男/女，例)		早产儿胎龄(周，?±s)		观察指标
纳入文献(第一作者，文献发表年)	国家	HHHFNC组	NCPAP组	HHHFNC组	NCPAP组	HHHFNC组	NCPAP组	观察指标
Collins，2013^[4]	澳大利亚	67	65	33/43	41/24	27.9±1.95	27.6±1.97	①②③④⑤⑥⑦⑧⑨
Kadivar，2016^[5]	伊朗	27	27	14/13	14/13	31.3^a	31.5^a	②④⑦⑩
Manley，2013^[6]	澳大利亚	152	151	89/63	72/69	27.7±2.1	27.5±1.9	①②③④⑤⑥⑦⑨⑩?
Soonsawad，2017^[7]	泰国	24	25	11/13	17/8	27.5(26, 30)^b	28(25,29.5)^b	①②④⑤⑦⑨⑩?
Yoder，2013^[8]	美国	75	75	未说明	未说明	未说明	未说明	①
康文清，2016^[9]	中国	79	82	未说明	未说明	29.1±1.0	29.2±1.1	①②③④⑥⑦⑨
李恺，2014^[10]	中国	28	31	17/11	16/15	32.6±1.5	32.8±1.7	①②④⑤⑥⑦⑧⑨⑩?
陈佳，2016^[11]	中国	66	63	41/25	40/23	30.2±3.7	30.5±3.3	①②③④⑤⑧⑨⑩

表1 纳入研究的8篇随机对照试验研究文献的基本情况

纳入文献(第一作者，文献发表年)	国家	早产儿例数(例)		早产儿性别(男/女，例)		早产儿胎龄(周，?±s)		观察指标
纳入文献(第一作者，文献发表年)	国家	HHHFNC组	NCPAP组	HHHFNC组	NCPAP组	HHHFNC组	NCPAP组	观察指标
Collins，2013^[4]	澳大利亚	67	65	33/43	41/24	27.9±1.95	27.6±1.97	①②③④⑤⑥⑦⑧⑨
Kadivar，2016^[5]	伊朗	27	27	14/13	14/13	31.3^a	31.5^a	②④⑦⑩
Manley，2013^[6]	澳大利亚	152	151	89/63	72/69	27.7±2.1	27.5±1.9	①②③④⑤⑥⑦⑨⑩?
Soonsawad，2017^[7]	泰国	24	25	11/13	17/8	27.5(26, 30)^b	28(25,29.5)^b	①②④⑤⑦⑨⑩?
Yoder，2013^[8]	美国	75	75	未说明	未说明	未说明	未说明	①
康文清，2016^[9]	中国	79	82	未说明	未说明	29.1±1.0	29.2±1.1	①②③④⑥⑦⑨
李恺，2014^[10]	中国	28	31	17/11	16/15	32.6±1.5	32.8±1.7	①②④⑤⑥⑦⑧⑨⑩?
陈佳，2016^[11]	中国	66	63	41/25	40/23	30.2±3.7	30.5±3.3	①②③④⑤⑧⑨⑩

表2 纳入研究的8篇随机对照试验研究文献的质量评价

纳入文献(第一作者，文献发表年)	随机分组方法	分配隐藏	盲法	结果数据的完整性	选择性报告研究结果	其他偏倚	Jadad量表评分(分)
Collins，2013^[4]	计算机随机产生	是	未提及	是	否	无	5
Kadivar，2016^[5]	随机序列	否	未提及	是	否	无	3
Manley，2013^[6]	计算机随机产生	是	未提及	是	否	无	5
Soonsawad，2017^[7]	具体随机分组方法不详	是	未提及	是	否	无	4
Yoder，2013^[8]	计算机随机产生	是	未提及	是	否	无	5
康文清，2016^[9]	具体随机分组方法不详	否	未提及	是	否	无	2
李恺，2014^[10]	随机数字表法	否	未提及	是	否	无	3
陈佳，2016^[11]	具体随机分组方法不详	否	未提及	是	否	无	2

表2 纳入研究的8篇随机对照试验研究文献的质量评价

纳入文献(第一作者，文献发表年)	随机分组方法	分配隐藏	盲法	结果数据的完整性	选择性报告研究结果	其他偏倚	Jadad量表评分(分)
Collins，2013^[4]	计算机随机产生	是	未提及	是	否	无	5
Kadivar，2016^[5]	随机序列	否	未提及	是	否	无	3
Manley，2013^[6]	计算机随机产生	是	未提及	是	否	无	5
Soonsawad，2017^[7]	具体随机分组方法不详	是	未提及	是	否	无	4
Yoder，2013^[8]	计算机随机产生	是	未提及	是	否	无	5
康文清，2016^[9]	具体随机分组方法不详	否	未提及	是	否	无	2
李恺，2014^[10]	随机数字表法	否	未提及	是	否	无	3
陈佳，2016^[11]	具体随机分组方法不详	否	未提及	是	否	无	2

图1 HHHFNC组与NCPAP组早产儿治疗失败率比较的Meta分析

图2 HHHFNC组与NCPAP组早产儿再插管率比较的Meta分析结果

图3 HHHFNC组与NCPAP组早产儿鼻损伤发生率比较的Meta分析结果

图4 HHHFNC组与NCPAP组早产儿气漏发生率比较的Meta分析结果

表3 HHHFNC组与NCPAP组早产儿次要结局评价指标比较的Meta分析结果

结局指标	纳入文献篇数(篇)	HHHFNC组		NCPAP组		效应模型	Meta分析结果
结局指标	纳入文献篇数(篇)	发生例数(例)	总例数(例)	发生例数(例)	总例数(例)	效应模型	OR/SMD(95%CI)	P值
院内死亡率	4^[4,6,9,10]	11	326	12	329	固定	0.93(0.40～2.13)	0.857
BPD发生率	7^{[4,5,6,7,9,10,11]}	123	443	138	444	固定	0.82(0.66～1.11)	0.202
IVH发生率	7^{[4,5,6,7,9,10,11]}	38	443	45	444	固定	0.76(0.46～1.27)	0.299
NEC发生率	6^{[4,6,7,9,10,11]}	26	414	43	417	固定	0.56(0.33～0.95)	0.032
ROP发生率	5^{[5,6,7,10,11]}	57	297	56	306	固定	1.09(0.69～1.73)	0.713
PDA发生率	3^[6,7,11]	99	242	105	239	固定	0.89(0.62～1.28)	0.524
达到全肠道喂养时间	2^[4,10]	—	95	—	96	随机	0.47(－0.35～1.29)	0.264

表3 HHHFNC组与NCPAP组早产儿次要结局评价指标比较的Meta分析结果

结局指标	纳入文献篇数(篇)	HHHFNC组		NCPAP组		效应模型	Meta分析结果
结局指标	纳入文献篇数(篇)	发生例数(例)	总例数(例)	发生例数(例)	总例数(例)	效应模型	OR/SMD(95%CI)	P值
院内死亡率	4^[4,6,9,10]	11	326	12	329	固定	0.93(0.40～2.13)	0.857
BPD发生率	7^{[4,5,6,7,9,10,11]}	123	443	138	444	固定	0.82(0.66～1.11)	0.202
IVH发生率	7^{[4,5,6,7,9,10,11]}	38	443	45	444	固定	0.76(0.46～1.27)	0.299
NEC发生率	6^{[4,6,7,9,10,11]}	26	414	43	417	固定	0.56(0.33～0.95)	0.032
ROP发生率	5^{[5,6,7,10,11]}	57	297	56	306	固定	1.09(0.69～1.73)	0.713
PDA发生率	3^[6,7,11]	99	242	105	239	固定	0.89(0.62～1.28)	0.524
达到全肠道喂养时间	2^[4,10]	—	95	—	96	随机	0.47(－0.35～1.29)	0.264

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