Volume-targeted Versus Pressure-limited Ventilation for Preterm Infants: A Systematic Review and Meta-Analysis

STUDY QUESTION Does Volume-Targeted Neonatal Ventilation (VTV) reduce death or Broncho-Pulmonary Dysplasia (BPD) when compared with Pressure Limited Ventilation (PLV) METHODS Eligibility All randomized trials comparing VTV and PLV were included. Exclusion Crossover studies that were only able to assess short-term outcomes were excluded. Outcomes The outcomes were death, BPD, air leak, incidence of hypocarbia, duration of ventilation, cranial ultrasound findings, and neurodevelopmental outcomes. Search Relevant trials comparing VTV and PLV were identified using the standard search strategy of the Neonatal Review Group of the Cochrane Collaboration. Trials were sought using the Medical Literature Analysis and Retrieval System Online (MEDLINE), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials. Articles published before November 2010, were included; Databases were searched using the Medical Subject Heading (MeSH) terms: 'infant, newborn' and 'respiration, artificial,' and the text word 'volume'; No language restrictions were applied; Abstracts published by the European Society for Pediatric Research were hand searched; In addition to cross-referencing, the previous reviews' expert informants were contacted, and newer additional resources such as the WHO International Clinical Trials' search portal were searched; Two authors (K.W. and C.K.) independently conducted the search and evaluated articles for eligibility, methodological quality, and risk of bias. Data collection For each trial, randomization, stratification, concealment strategies, and completeness were sought. If appropriate, the trial authors were contacted, to clarify or obtain additional prospectively collected data, including the combined outcomes for death or BPD, severe intraventricular hemorrhage (IVH) or periventricular leukomalasia (PVL), and death or neurodevelopmental impairment outcome. VTV modes: Controlled the delivery of inspiratory tidal volume by use of the VG (Volume Guarantee) mode. PLV mode: Inspired tidal volume controlled by peak inspiratory pressure (PIP) POPULATION The population comprised of preterm infants with respiratory distress syndrome (RDS) who required mechanical ventilation (MV). RESULT During MV, the relevant outcomes were reported by eight trials. VTV significantly reduced the risk of pneumothorax (NNT=17), incidence of hypocarbia (NNT=4), and duration of ventilation (≤2.4 days). No statistically significant differences were observed in the risk of pulmonary interstitial emphysema or any air leak, or in FiO 2 . During primary hospital admission, the relevant outcomes were reported by seven trials. VTV significantly reduced the combined rates of death or BPD (NNT=8), and severe IVH (grade 3 or 4) or PVL (NNT=11). There was a borderline reduction in BPD alone (P=0.05). No statistically significant difference was observed in the risk of death before discharge or severe IVH, PVL, or oxygen treatment at discharge. The follow-up outcomes were available for two trials, although neither was powered for the follow-up outcomes. The meta-analysis did not identify any significant difference between VTV and PLV in severe neurodevelopmental impairment or in the combined outcome of severe neurodevelopmental impairment or death. There was no evidence of statistical heterogeneity, except for the duration of ventilation, any IVH, and grade 3 - 4 IVH. Caution was advised in the interpretation of these results. Protection against selection and publication bias was made. The use of VTV was associated with a significant reduction in the combined outcomes of death or BPD, and in grades 3 - 4 IVH or PVL. There was reduction in the rates of hypocarbia and pneumothorax. CONCLUSION Compared with PLV, an infant ventilated by using volume-targeted ventilation had reduced death / BPD, duration of ventilation, pneumothorax, hypocarbia, and PVL / severe IVH. Further studies are needed to assess the neurodevelopmental outcomes. COMMENTARY There was no evidence of statistical heterogeneity, except for the duration of ventilation, any IVH, and grade 3 - 4 IVH. Caution is advised in the interpretation of these results. Protection against selection and publication bias was made. Patient population is more or less similar. Both VTV and PLV strategies were feasible in most NICU unit. However, our unit preference (VTV) will would be supported by these results. The use of VTV was associated with a significant reduction in the combined outcomes of death or BPD, and of grade 3 - 4 IVH or PVL. There was also a reduction in the rates of hypocarbia and pneumothorax. The meta-analysis did not identify any significant differences of neurodevelopmental outcome between the groups. However; this was applicable only to two trials, which were not powered for this outcome. Abstracted from Neonatology 2011;100:219-227 DOI: 10.1159/000326080.

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