Objectives: To compare the efficacy of different noninvasive respiratory support (NRS) modes for primary respiratory support of preterm infants with respiratory distress syndrome (RDS).Design: Systematic review and network meta‐analysis using the Bayesian random‐effects approach. MEDLINE, EMBASE, and CENTRAL were searched.Interventions: High flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), bilevel CPAP (BiPAP), noninvasive positive pressure ventilation (NIPPV).Main Outcome Measures: Requirement of invasive mechanical ventilation (MV), any treatment failure.Results: A total of 35 studies including 4078 neonates were included. NIPPV was more effective in decreasing the requirement of MV than CPAP (risk ratios [95% credible interval]: 0.60 [0.44, 0.77]) and HFNC [0.66 (0.43, 0.97)]. Surface under the cumulative ranking curve (SUCRA) for NIPPV, BiPAP, HFNC, and CPAP were 0.95, 0.59, 0.32, and 0.13. For the outcome of treatment failure, both NIPPV and BiPAP were more efficacious compared to CPAP and HFNC (0.56 [0.44, 0.71] {NIPPV vs CPAP}, 0.69 [0.51, 0.93] {BiPAP vs CPAP}, 0.42 [0.30, 0.63] {NIPPV vs HFNC}, 0.53 [0.35, 0.81] {BiPAP vs HFNC}). The SUCRA for NIPPV, BiPAP, CPAP, and HFNC were 0.96, 0.70, 0.32, and 0.01. NIPPV was associated with a reduced risk of air leak compared to BiPAP and CPAP (0.36 [0.16, 0.73]; 0.54 [0.30, 0.87], respectively). NIPPV resulted in lesser incidence of bronchopulmonary dysplasia or mortality when compared to CPAP (0.74 [0.52, 0.98]). Nasal injury was lesser with HFNC compared to CPAP (0.15 [0.01, 0.60]).Conclusions: Most effective primary mode of NRS in preterm neonates with RDS was NIPPV.

Neonatal hypothermia is a serious problem in both low- or middle-income and high-income countries.^1-3 The dose-response association between the severity of neonatal hypothermia and the risk of mortality is well established.^3-6 Hence, prevention of neonatal hypothermia in the delivery room is touted as a cost-effective, high-impact intervention to reduce neonatal mortality. The 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations reiterated its previous advice to use additional thermal care interventions, such as maintaining delivery room temperature at 23 to 25 °C and using warm blankets, plastic wraps without drying, thermal mattresses, and caps for neonates born at less than 32 weeks’ gestation.⁷ However, authors of the 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations stressed the weakness of the previous guidance on the basis of very low certainty of evidence and indicated the need for an updated systematic review.⁷ Apart from assessing the benefits of the interventions, establishing the safety of these interventions is also essential, given that some studies have shown an increased risk of hyperthermia with their use.^8-10

Background: There are no evidence-based recommendations for surfactant use in late preterm (LPT) and term infants with respiratory distress syndrome (RDS). Objective: To investigate the safety and efficacy of surfactant in LPT and term infants with RDS. Methods: Systematic review, meta-analysis and evidence grading. Interventions: Surfactant therapy versus standard of care. Main outcome measures: Mortality and requirement for invasive mechanical ventilation (IMV). Results: Of the 7970 titles and abstracts screened, 17 studies (16 observational studies and 1 randomised controlled trial (RCT)) were included. Of the LPT and term neonates with RDS, 46% (95% CI 40% to 51%) were treated with surfactant. We found moderate certainty of evidence (CoE) from observational studies evaluating infants supported with non-invasive respiratory support (NRS) or IMV that surfactant use may be associated with a decreased risk of mortality (OR 0.45, 95% CI 0.32 to 0.64). Very low CoE from observational trials in which surfactant was administered at FiO₂ >0.30–0.40 to infants on Continuous Positive Airway Pressure (CPAP) indicated that surfactant did not decrease the risk of IMV (OR 1.20, 95% CI 0.40 to 3.56). Very low to low CoE from the RCT and observational trials showed that surfactant use was associated with a significant decrease in risk of air leak, persistent pulmonary hypertension of the newborn (PPHN), duration of IMV, NRS and hospital stay. Conclusions: Current evidence base on surfactant therapy in LPT and term infants with RDS indicates a potentially decreased risk of mortality, air leak, PPHN and duration of respiratory support. In view of the low to very low CoE and widely varying thresholds for deciding on surfactant replacement in the included studies, further trials are needed.

Moving from an era of invasive ventilation to that of non-invasive respiratory support, various modalities have emerged resulting in improved neonatal outcomes. Respiratory distress is the commonest problem seen both in preterm and term neonates, and the use of appropriate respiratory support could be lifesaving. This article reviews the currently available non-invasive ventilation (NIV) strategies in neonates including nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation (NIPPV), bi-level CPAP, heated humidified high flow nasal cannula, nasal high-frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Though multiple systematic reviews and meta-analyses have indicated the superiority of synchronized NIPPV over the other forms of non-invasive respiratory support in neonates, there is no single NIV modality that universally suits all. Hence, the choice of NIV for a neonate should be individualized based on its efficacy, the disease pathology, resource settings, the clinician's familiarity and parental values. Future studies should evaluate emerging modalities such as NIV-NAVA and NHFV in the respiratory management of neonates as the evidence pertaining to these is insufficient.