Current data on the use of noninvasive ventilation (NIV) with continuous positive airway pressure (CPAP) in children with acute respiratory infections has low overall certainty and is inconclusive regarding a mortality benefit. However, the occurrence of adverse events (AEs) reported with CPAP NIV is low. A systemic review and meta-analysis on the topic was conducted in low-income and middle-income countries (LMICs). Results of the study were published in Archives of Disease in Childhood.

The investigators sought to determine NIV CPAP outcomes for pediatric respiratory distress in LMICs. The meta-analysis included all studies published in peer-reviewed journals on NIV efficacy or safety in the population of interest. A total of 2174 studies were screened, with 20 included in the systematic review. Of these 20 studies, there were 5 randomized controlled trials (RCTs), 1 cluster RCT, 1 nonrandomized comparative study, and 13 observational studies. Further, 3 studies were included in 2 separate meta-analyses of mortality and AEs.

Most of the studies evaluated the use of bubble CPAP or conventional CPAP and were small. Ten of the studies also included neonates. Overall, 16 studies were conducted at tertiary referral or provincial hospitals that included intensive care or high acuity units.

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Studies that were considered suitable for meta-analyses on the efficacy of CPAP against mortality and AEs were RCTs conducted in Bangladesh, Ghana, and Malawi. The combined risk ratio (RR) of CPAP compared with the use of low-flow oxygen was 0.75 (95% CI, 0.33-1.72), demonstrating no conclusive mortality benefit. Regarding AEs, the combined RR of CPAP vs low-flow oxygen was 1.52 (95% CI, 0.71-3.26), similarly inconclusive for AE risk. The certainty of evidence was thus downgraded to “low” with respect to both mortality and AE outcomes because of discrepancies in design issues in results across RCTs.

The researchers concluded that the current literature is beneficial in understanding the setting in which CPAP can be used safely as part of the overall management of pediatric patients with acute respiratory infections. Their review provides key evidence-based recommendations for hospitals in LMICs that have already implemented CPAP NIV for the treatment of nonneonate patients with severe respiratory illnesses.

Disclosure: None of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies.  


Sessions KL, Smith AG, Holmberg PJ, et al. Continuous positive airway pressure for children in resource-limited settings, effect on mortality and adverse events: systematic review and meta-analysis. Arch Dis Child. Published online December 8, 2021. doi:10.1136/archdischild-2021-323041