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Härtel C, Kribs A, Göpel W, Dargaville P, Herting E. Less Invasive Surfactant Administration for Preterm Infants - State of the Art. Neonatology 2024; 121:584-595. [PMID: 39226881 DOI: 10.1159/000540078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 06/26/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Less invasive surfactant administration (LISA) has become the preferred method of surfactant administration for spontaneously breathing babies on continuous positive airway pressure (CPAP). SUMMARY The development of LISA followed the need to combine CPAP and surfactant replacement as mainstay treatment options for respiratory distress syndrome, thereby avoided exposure to positive pressure ventilation. KEY MESSAGES This review summarises the current knowns and unknowns of LISA including the physiological concept, its relevance for short-term and long-term outcomes and the challenges for practical implementation of LISA as part of a less invasive respiratory care bundle. Further, we provide an update of the evidence on alternatives to LISA, for example, nebulised surfactant administration, pharyngeal deposition of surfactant and delivery via supraglottic airway.
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Affiliation(s)
- Christoph Härtel
- Department of Pediatrics, University of Würzburg, Würzburg, Germany,
| | - Angela Kribs
- Department of Pediatrics, University of Cologne Children's Hospital, Cologne, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University Hospital Lübeck, Lübeck, Germany
| | - Peter Dargaville
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Egbert Herting
- Department of Pediatrics, University Hospital Lübeck, Lübeck, Germany
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Bao WKJ, Feng Q, Liu KS, Ho YC. Effectiveness and safety profile of introducing less invasive surfactant administration in management of respiratory distress syndrome: A retrospective cohort study in a tertiary neonatal unit in Hong Kong. Pediatr Neonatol 2024:S1875-9572(24)00116-5. [PMID: 38991861 DOI: 10.1016/j.pedneo.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/05/2023] [Accepted: 12/13/2023] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND The objective was to evaluate the efficacy of introducing less invasive surfactant administration (LISA) for management of preterm neonates with respiratory distress syndrome (RDS). METHODS This was a retrospective cohort study identifying preterm neonates with RDS born between 2017 and 2022 in a tertiary neonatal unit, where LISA was introduced in January 2020. Time trend analysis comparing cohort of neonates born before (2017-2020) and after LISA introduction (2020-2022) was performed. The primary outcomes were incidence and severity of bronchopulmonary dysplasia (BPD). Multivariable regression models were used to estimate the association between introducing LISA to RDS management and health and safety outcomes. RESULTS In total, 261 neonates with RDS were included (114 born after LISA was introduced). Neonates receiving invasive surfactant administration had lower gestational age, birth weight, lower Apgar scores, and higher oxygen requirement, compared to those receiving LISA. In the time trend analysis, introduction of LISA was associated with lower incidence of BPD (odds ratio (95% confidence interval) 0.34 (0.16, 0.72)), and lower severity of BPD (0.31 (0.16, 0.59)). Pre- and post-LISA period showed similar treatment safety profiles. CONCLUSION Introduction of LISA was associated with improved prognosis in neonates with RDS in Hong Kong.
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Affiliation(s)
- Wing Kan Julianna Bao
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong.
| | - Qi Feng
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong; Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - King Shun Liu
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong
| | - Yok Chiu Ho
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong
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Meyer S, Bay J, Franz AR, Ehrhardt H, Klein L, Petzinger J, Binder C, Kirschenhofer S, Stein A, Hüning B, Heep A, Cloppenburg E, Muyimbwa J, Ott T, Sandkötter J, Teig N, Wiegand S, Schroth M, Kick A, Wurm D, Gebauer C, Linnemann K, Kittel J, Wieg C, Kiechl-Kohlendorfer U, Schmidt S, Böttger R, Thomas W, Brevis Nunez F, Stockmann A, Kriebel T, Müller A, Klotz D, Morhart P, Nohr D, Biesalski HK, Giannopoulou EZ, Hilt S, Poryo M, Wagenpfeil S, Haiden N, Ruckes C, Ehrlich A, Gortner L. Early postnatal high-dose fat-soluble enteral vitamin A supplementation for moderate or severe bronchopulmonary dysplasia or death in extremely low birthweight infants (NeoVitaA): a multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:544-555. [PMID: 38643780 DOI: 10.1016/s2213-2600(24)00073-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Vitamin A plays a key role in lung development, but there is no consensus regarding the optimal vitamin A dose and administration route in extremely low birthweight (ELBW) infants. We aimed to assess whether early postnatal additional high-dose fat-soluble enteral vitamin A supplementation versus placebo would lower the rate of moderate or severe bronchopulmonary dysplasia or death in ELBW infants receiving recommended basic enteral vitamin A supplementation. METHODS This prospective, multicentre, randomised, parallel-group, double-blind, placebo-controlled, investigator-initiated phase 3 trial conducted at 29 neonatal intensive care units in Austria and Germany assessed early high-dose enteral vitamin A supplementation (5000 international units [IU]/kg per day) or placebo (peanut oil) for 28 days in ELBW infants. Eligible infants had a birthweight of more than 400 g and less than 1000 g; gestational age at birth of 32+0 weeks postmenstrual age or younger; and the need for mechanical ventilation, non-invasive respiratory support, or supplemental oxygen within the first 72 h of postnatal age after admission to the neonatal intensive care unit. Participants were randomly assigned by block randomisation with variable block sizes (two and four). All participants received basic vitamin A supplementation (1000 IU/kg per day). The composite primary endpoint was moderate or severe bronchopulmonary dysplasia or death at 36 weeks postmenstrual age, analysed in the intention-to-treat population. This trial was registered with EudraCT, 2013-001998-24. FINDINGS Between March 2, 2015, and Feb 27, 2022, 3066 infants were screened for eligibility at the participating centres. 915 infants were included and randomly assigned to the high-dose vitamin A group (n=449) or the control group (n=466). Mean gestational age was 26·5 weeks (SD 2·0) and mean birthweight was 765 g (162). Moderate or severe bronchopulmonary dysplasia or death occurred in 171 (38%) of 449 infants in the high-dose vitamin A group versus 178 (38%) of 466 infants in the control group (adjusted odds ratio 0·99, 95% CI 0·73-1·55). The number of participants with at least one adverse event was similar between groups (256 [57%] of 449 in the high-dose vitamin A group and 281 [60%] of 466 in the control group). Serum retinol concentrations at baseline, at the end of intervention, and at 36 weeks postmenstrual age were similar in the two groups. INTERPRETATION Early postnatal high-dose fat-soluble enteral vitamin A supplementation in ELBW infants was safe, but did not change the rate of moderate or severe bronchopulmonary dysplasia or death and did not substantially increase serum retinol concentrations. FUNDING Deutsche Forschungsgemeinschaft and European Clinical Research Infrastructures Network (ECRIN).
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Affiliation(s)
- Sascha Meyer
- Clinical Centre Karlsruhe, Franz-Lust Clinic for Paediatrics, Karlsruhe, Germany.
| | - Johannes Bay
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Axel R Franz
- University Hospital Tübingen, Neonatology and Center for Paediatric Clinical Studies, Department for Paediatrics, Tübingen, Germany
| | - Harald Ehrhardt
- Department of Paediatrics and Adolescent Medicine, Division of Neonatology and Pediatric Intensive Care Medicine, University Medical Center Ulm, Ulm, Germany
| | - Lars Klein
- Department of General Paediatrics and Neonatology, Justus-Liebig-Universität, Giessen, Germany
| | - Jutta Petzinger
- Department of General Paediatrics and Neonatology, Justus-Liebig-Universität, Giessen, Germany
| | - Christoph Binder
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Susanne Kirschenhofer
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Anja Stein
- University Hospital Essen, Clinic for Paediatrics I, Department for Neonatology, Essen, Germany
| | - Britta Hüning
- University Hospital Essen, Clinic for Paediatrics I, Department for Neonatology, Essen, Germany
| | - Axel Heep
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Eva Cloppenburg
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Julia Muyimbwa
- Clinical Centre Oldenburg, Clinic for Neonatology, Paediatric Intensive Care, Paediatric Cardiology, Paediatric Pneumonology and Allergology, Oldenburg, Germany
| | - Torsten Ott
- University Hospital Münster, Clinic for Paediatrics, Department for Neonatology, Münster, Germany
| | - Julia Sandkötter
- University Hospital Münster, Clinic for Paediatrics, Department for Neonatology, Münster, Germany
| | - Norbert Teig
- University Hospital Bochum, Children's Hospital-St Josef-Hospital, Department for Neonatology and Paediatric Intensive Care, Bochum, Germany
| | - Susanne Wiegand
- University Hospital Bochum, Children's Hospital-St Josef-Hospital, Department for Neonatology and Paediatric Intensive Care, Bochum, Germany
| | - Michael Schroth
- Cnopf'sche Kinderklinik, Clinic for Neonatology and Paediatric Intensive Care, Nürnberg, Germany
| | - Andrea Kick
- Cnopf'sche Kinderklinik, Clinic for Neonatology and Paediatric Intensive Care, Nürnberg, Germany
| | - Donald Wurm
- Clinical Centre Saarbrücken, Clinic for Paediatrics, Saarbrücken, Germany
| | - Corinna Gebauer
- University Hospital Leipzig, Center of Paediatrics, Department for Neonatology, Leipzig, Germany
| | - Knud Linnemann
- University Hospital Greifswald, Center for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Greifswald, Germany
| | - Jochen Kittel
- Barmherzige Brüder Hospital Regensburg, Clinic St Hedwig, Clinic for Paediatrics, Regensburg, Germany
| | - Christian Wieg
- Clinical Centre Aschaffenburg-Alzenau, Clinic for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Aschaffenburg, Germany
| | | | - Susanne Schmidt
- LMU Clinic for Paediatrics, Haunersches Kinderspital, Munich, Germany
| | - Ralf Böttger
- University Hospital Magdeburg, Clinic for Paediatrics, Magdeburg, Germany
| | - Wolfgang Thomas
- Hospital Mutterhaus der Borromäerinnen, Clinic for Paediatrics, Trier, Germany
| | - Francisco Brevis Nunez
- Sana Hospital Duisburg, Clinic for Paediatrics, Department of Paediatric Intensive Care, Duisburg, Germany
| | - Antje Stockmann
- Evangelical Hospital Oberhausen, Center of Paediatrics, Department of Neonatology, Oberhausen, Germany
| | - Thomas Kriebel
- Westpfalz-Klinikum Kaiserslautern, Department of Paediatrics, Kaiserslautern, Germany
| | - Andreas Müller
- University Hospital Bonn, Eltern-Kind-Zentrum (ELKI), Neonatology/Paediatric Intensive Care, Bonn, Germany
| | - Daniel Klotz
- University Hospital Freiburg, Centre for Paediatrics, Department for Neonatology and Paediatric Intensive Care, Freiburg, Germany
| | - Patrick Morhart
- Center of Paediatrics, Department for Neonatology and Paediatric Intensive Care, Erlangen, Germany
| | | | | | - Eleni Z Giannopoulou
- University Hospital Ulm, Clinic for Paediatrics, Paediatric Endocrinology and Diabetology, Ulm, Germany
| | - Susanne Hilt
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Martin Poryo
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatric Cardiology, Homburg, Germany
| | - Stefan Wagenpfeil
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
| | - Nadja Haiden
- Medical University Wien, Center of Paediatrics, Department of Neonatology, Paediatric Intensive Care and Neuropaediatrics, Vienna, Austria
| | - Christian Ruckes
- Interdisziplinäres Zentrum Klinische Studien (IZKS), Universitätsmedizin Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Anne Ehrlich
- Interdisziplinäres Zentrum Klinische Studien (IZKS), Universitätsmedizin Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Ludwig Gortner
- University Hospital Homburg, Saarland University Medical Center, Clinic for Paediatrics and Neonatology, Homburg, Germany
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Chan CS, Chiu M, Ariyapadi S, Brown LS, Burchfield P, Simcik V, Garcia K, Mazioniene K, Jaleel MA, Wyckoff MH, Kapadia VS, Kakkilaya V. Evaluation of a respiratory care protocol including less invasive surfactant administration in preterm infants. Pediatr Res 2024; 95:1603-1610. [PMID: 38097721 DOI: 10.1038/s41390-023-02963-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND Respiratory care protocol including less invasive śsurfactant administration (LISA) in ≤29 weeks' gestational age (GA) infants introduced in October 2018. METHODS Retrospective study of infants admitted on continuous positive airway pressure (CPAP) October 2018 to December 2021. Maternal and neonatal variables were compared between infants managed on CPAP with and without LISA. Infants who received LISA and subsequently required mechanical ventilation (MV) within 72 h of life (HOL) [LISA failure (LF)] were compared with those who required no MV [LISA success (LS)]. RESULTS 249 infants were admitted on CPAP, 5 were intubated prior to LISA, 143 required LISA and 101 remained on CPAP without surfactant. Of those receiving LISA, 108 were LS and 35 were LF. Compared to LS, LF infants were of lower GA and birth weight, required higher fractional inspired oxygen (FiO2), and CPAP level at birth, admission, one HOL, and an hour after LISA. Moreover, LF infants had higher mortality and morbidity. Together GA ≤ 25 weeks' and FiO2 ≥ 0.3 an hour after LISA best predicted LF. CONCLUSIONS Over 80% of infants admitted on CPAP avoided MV within 72 HOL. Early predictors of LF provide targets for future interventions to decrease need for MV in preterm infants. IMPACT Less invasive surfactant administration (LISA) decreases the need for mechanical ventilation (MV) and improves outcomes. However, some infants require MV within 72 h of life (HOL) despite LISA (LISA failure). Over 80% of ≤29 weeks' gestational age (GA) infants can be successfully managed on CPAP with or without surfactant in the first 72 HOL. A combination of factors including ≤25 weeks' GA and fraction of inspired oxygen ≥0.3 an hour after LISA predict LISA failure. Evaluation of a noninvasive respiratory support strategy including LISA provides targets for intervention to decrease need for MV in preterm infants.
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Affiliation(s)
- Christina S Chan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Melody Chiu
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Swathi Ariyapadi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Patti Burchfield
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kristi Garcia
- Parkland Health and Hospital System, Dallas, TX, USA
| | | | | | - Myra H Wyckoff
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vishal S Kapadia
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Klein R, Fastnacht L, Kribs A, Kuehne B, Mehler K. LISA Eligibility and LISA Success in Extremely Preterm Infants: A Single-Center Experience. Neonatology 2024; 121:530-535. [PMID: 38599191 PMCID: PMC11318578 DOI: 10.1159/000537904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/15/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION Less invasive surfactant application (LISA) is associated with improved short-term outcomes in preterm infants. Data on LISA eligibility and success for infants <28 weeks of gestation are lacking. METHODS Preterm infants <28 weeks of gestation who were born and actively treated in our tertiary care center in 2018 were included in the retrospective study. We assessed baseline characteristics, delivery room (DR) management, LISA success and complications, and short-term outcome. RESULTS In total, 57 infants received LISA in the DR. LISA eligibility was 73% at 22 weeks, 88% at 23 weeks, and >90% at gestational ages >24 weeks. LISA was successful in 63% of infants. LISA failure was associated with increased risk for high-grade IVH (OR 17.88), death (OR 10.94), and a reduced chance for survival without complications (OR 8.75). CONCLUSION Our report justifies LISA as a mode for surfactant application in preterm infants. It contributes to the call for studies to define risk factors for LISA failure.
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Affiliation(s)
- Ruth Klein
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Laura Fastnacht
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Angela Kribs
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Benjamin Kuehne
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Katrin Mehler
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Guthrie SO, Roberts KD. Less invasive surfactant administration methods: Who, what and how. J Perinatol 2024; 44:472-477. [PMID: 37737494 DOI: 10.1038/s41372-023-01778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/14/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023]
Abstract
Surfactant administration via an endotracheal tube (ETT) has been the standard of care for infants with respiratory distress syndrome for decades. As non-invasive ventilation has become commonplace in the NICU, methods for administering surfactant without use of an ETT have been developed. These methods include thin catheter techniques (LISA, MIST), aerosolization/ nebulization, and surfactant administration through laryngeal (LMA) or supraglottic airways (SALSA). This review will describe these methods and discuss considerations and implementation into clinical practice.
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Affiliation(s)
- S O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - K D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, USA.
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Bruns N, Dohna-Schwake C, Olivieri M, Urschitz MS, Blomenkamp S, Frosch C, Lieftüchter V, Tomidis Chatzimanouil MK, Hoffmann F, Brenner S. Pediatric intensive care unit admissions network-rationale, framework and method of operation of a nationwide collaborative pediatric intensive care research network in Germany. Front Pediatr 2024; 11:1254935. [PMID: 38269291 PMCID: PMC10806156 DOI: 10.3389/fped.2023.1254935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
The Pediatric Intensive Care Unit Admissions (PIA) network aims to establish a nationwide database in Germany to gather epidemiological, clinical, and outcome data on pediatric critical illness. The heterogeneity of pediatric patients in intensive care units (PICU) poses challenges in obtaining sufficient case numbers for reliable research. Multicentered approaches, such as patient registries, have proven effective in collecting large-scale data. However, Germany lacks a systematic registration system for pediatric intensive care admissions, hindering epidemiological and outcome assessments. The PIA network intends to address these gaps and provide a framework for clinical and epidemiological research in pediatric intensive care. The network will interconnect PICUs across Germany and collect structured data on diagnoses, treatment, clinical course, and short-term outcomes. It aims to identify areas for improvement in care, enable disease surveillance, and potentially serve as a quality control tool. The PIA network builds upon the existing infrastructure of the German Pediatric Surveillance Unit ESPED and utilizes digitalized data collection techniques. Participating units will complete surveys on their organizational structure and equipment. The study population includes patients aged ≥28 days admitted to participating PICUs, with a more detailed survey for cases meeting specific criteria. Data will be collected by local PIA investigators, anonymized, and entered into a central database. The data protection protocol complies with regulations and ensures patient privacy. Quarterly data checks and customized quality reports will be conducted to monitor data completeness and plausibility. The network will evaluate its performance, data collection feasibility, and data quality. Eligible investigators can submit proposals for data analyses, which will be reviewed and analyzed by trained statisticians or epidemiologists. The PIA network aims to improve pediatric intensive care medicine in Germany by providing a comprehensive understanding of critical illness, benchmarking treatment quality, and enabling disease surveillance.
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Affiliation(s)
- Nora Bruns
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christian Dohna-Schwake
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Olivieri
- Pediatric Intensive Care Unit, Dr. von Hauner Childreńs Hospital, LMU Munich, Munich, Germany
| | - Michael S. Urschitz
- Division of Pediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Susanne Blomenkamp
- Division of Pediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology, and Informatics, University Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - Clara Frosch
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care Medicine, and Pediatric Neurology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- TNBS, Centre for Translational Neuro- and Behavioural Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Victoria Lieftüchter
- Pediatric Intensive Care Unit, Dr. von Hauner Childreńs Hospital, LMU Munich, Munich, Germany
| | - Markos K. Tomidis Chatzimanouil
- Pediatric Intensive Care Medicine, Department of Pediatrics, University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Florian Hoffmann
- Pediatric Intensive Care Unit, Dr. von Hauner Childreńs Hospital, LMU Munich, Munich, Germany
| | - Sebastian Brenner
- Pediatric Intensive Care Medicine, Department of Pediatrics, University Clinic Carl Gustav Carus, TU Dresden, Dresden, Germany
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Kribs A, Roberts KD, Trevisanuto D, O' Donnell C, Dargaville PA. Alternative routes of surfactant application - An update. Semin Fetal Neonatal Med 2023; 28:101496. [PMID: 38040586 DOI: 10.1016/j.siny.2023.101496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Non-invasive modes of respiratory support have been shown to be the preferable way of primary respiratory support of preterm infants with respiratory distress syndrome (RDS). The avoidance of invasive mechanical ventilation can be beneficial for preterm infants in reduction of morbidity and even mortality. However, it is well-established that some infants managed with non-invasive respiratory support from the outset have symptomatic RDS to a degree that warrants surfactant administration. Infants for whom non-invasive respiratory support ultimately fails are prone to adverse outcomes, occurring at a frequency on par with the group intubated primarily. This raises the question how to combine non-invasive respiratory support with surfactant therapy. Several methods of less or minimally invasive surfactant therapy have been developed to address the dilemma between avoidance of mechanical ventilation and administration of surfactant. This paper describes the different methods of less invasive surfactant application, reports the existing evidence from clinical studies, discusses the limitations of each of the methods and the open and future research questions.
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Affiliation(s)
- Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Faculty of Medicine, Cologne, Germany.
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Colm O' Donnell
- School of Medicine, University College Dublin, Dublin, Ireland; Department of Neonatology, National Maternity Hospital, Dublin, Ireland.
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
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Katheria A, Ines F, Banerji A, Hopper A, Uy C, Chundu A, Coughlin K, Hutson S, Morales A, Sauberan J, Poeltler D, Dorner R, Rich W, Finer N. Caffeine and Less Invasive Surfactant Administration for Respiratory Distress Syndrome of the Newborn. NEJM EVIDENCE 2023; 2:EVIDoa2300183. [PMID: 38320499 DOI: 10.1056/evidoa2300183] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Management strategies for preterm neonates with respiratory distress syndrome include early initiation of continuous positive airway pressure (CPAP) and titration of fractional inspired oxygen and may include the use of less invasive surfactant administration (LISA) to avoid the need for endotracheal intubation. This randomized trial investigated whether early administration of caffeine and LISA would decrease the need for endotracheal intubation in the first 72 hours of life (HoL) compared with caffeine and CPAP alone. METHODS: Eligible neonates born at 24 weeks 0 days to 29 weeks 6 days of gestational age were randomly assigned to receive intravenous caffeine in the first 2 HoL followed by surfactant administration via the LISA method (intervention) or caffeine followed by CPAP (control). The primary outcome was the frequency of neonates requiring endotracheal intubation or meeting respiratory failure criteria between groups (caffeine and LISA vs. caffeine and CPAP) within the first 72 HoL. Multivariable logistic regression modeling was used to adjust for gestational age strata in normally distributed primary and secondary outcomes. RESULTS: Enrollment occurred between January 2020 and December 2022. Endotracheal intubation or meeting respiratory failure criteria within the first 72 HoL occurred in 21 (23%) of 92 neonates randomly assigned to receive caffeine and LISA compared with 47 (53%) of 88 neonates in the caffeine and CPAP group (odds ratio, 0.258; 95% confidence interval, 0.136 to 0.490; P<0.001), which remained significant after adjusting for gestational age strata (odds ratio, 0.227; 95% confidence interval, 0.112 to 0.460; P<0.001). Adverse events were similar between groups, except bronchopulmonary dysplasia, which occurred in 26% of the LISA group and 39% of the control group (P=0.049). CONCLUSIONS: In preterm neonates supported with CPAP, early caffeine and LISA resulted in a lower frequency of endotracheal intubation within the first 72 HoL. (Funded by Chiesi USA; ClinicalTrials.gov number, NCT04209946.)
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Affiliation(s)
- Anup Katheria
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Felix Ines
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | | | - Andrew Hopper
- Loma Linda University Children's Hospital, Loma Linda, CA
| | - Cherry Uy
- University of California Irvine Medical Center, Irvine, CA
| | - Anupama Chundu
- University of California Irvine Medical Center, Irvine, CA
| | | | - Shandee Hutson
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Ana Morales
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Jason Sauberan
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Debra Poeltler
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Rebecca Dorner
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Wade Rich
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
| | - Neil Finer
- Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA
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10
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Glaser K, Bamat NA, Wright CJ. Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature. Arch Dis Child Fetal Neonatal Ed 2023; 108:554-560. [PMID: 36600473 PMCID: PMC10246486 DOI: 10.1136/archdischild-2022-324530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today's neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIV and early surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Nicolas A Bamat
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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11
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Tanaka K, Hayashi R, Ariyama Y, Takahashi N, Namba F. Management of bronchopulmonary dysplasia in Japan: A nationwide survey. Early Hum Dev 2023; 186:105867. [PMID: 37788509 DOI: 10.1016/j.earlhumdev.2023.105867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/21/2023] [Accepted: 09/23/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND The incidence of bronchopulmonary dysplasia (BPD) and respiratory management practices for extremely low birth weight infants (ELBWIs) widely vary among institutions and countries. AIMS To clarify the variation and characteristics of the current practices of Japanese neonatologists managing patients with BPD. STUDY DESIGN Questionnaire-based survey. PARTICIPANTS Level II and III perinatal centers certified by the Japan Society of Perinatal and Neonatal Medicine. OUTCOME MEASURES Policies of the neonatal intensive care units (NICUs) regarding respiratory care and medications for BPD prevention and treatment. RESULTS A total of 76 % of facilities (207/274) responded to our survey. The response rates of level III and II facilities were 91 % (102/112) and 35 % (105/296), respectively. INtubation-SURfactant-Extubation and Less Invasive Surfactant Administration methods were performed in 23 % (47/206) and 1 % (3/206) of facilities, respectively. For the prophylactic purpose, systemic and inhaled steroids were administered "frequently" or "occasionally" in 14 % (28/205) and 42 % (86/204) of NICUs, respectively. For the therapeutic purpose, systemic and inhaled steroids were administered "frequently" or "occasionally" in 84 % (171/204) and 29 % (59/204) of NICUs, respectively. Approximately half of the NICUs (99/202) used volume-targeted ventilation (VTV) "frequently" or "occasionally" in progressing BPD. High-frequency oscillation ventilation (HFOV) was used for progressing BPD "frequently" and "occasionally" in 89 % (180/202) of the facilities. CONCLUSIONS Our study provided an overview and characteristics of BPD management in Japan in recent years. Noninvasive approaches with surfactant administration remain not widely used in Japan. HFOV is a widely accepted management for progressing BPD.
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Affiliation(s)
- Kosuke Tanaka
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.
| | - Ryo Hayashi
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Yuta Ariyama
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Naoto Takahashi
- Department of Pediatrics, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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12
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Kribs A, Roberts KD, Trevisanuto D, O'Donnell C, Dargaville PA. Surfactant delivery strategies to prevent bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151813. [PMID: 37805275 DOI: 10.1016/j.semperi.2023.151813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/09/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the most devastating morbidities of preterm infants. Antenatal factors like growth restriction and inflammation are risk factors for its development. Use of oxygen and positive pressure ventilation, which are often necessary to treat respiratory distress syndrome (RDS), increase the risk for development of BPD. Continuous positive airway pressure (CPAP) as primary respiratory support allows for avoidance of positive pressure ventilation in many cases but may lead to a delay of surfactant administration which is a proven therapy for RDS. Several alternative surfactant delivery strategies, including nebulization of surfactant, pharyngeal instillation of surfactant, delivery of surfactant via supraglottic airway device or surfactant delivery via a thin endotracheal catheter have been described which allow for the benefit of surfactant therapy while on CPAP. This review reports available data and discusses the existing evidence of their value in preventing BPD as well as further research directions.
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Affiliation(s)
- Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Faculty of medicine, Cologne, Germany.
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Colm O'Donnell
- School of Medicine, University College Dublin, Dublin, Ireland; Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
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13
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Bhandari V, Black R, Gandhi B, Hogue S, Kakkilaya V, Mikhael M, Moya F, Pezzano C, Read P, Roberts KD, Ryan RM, Stanford RH, Wright CJ. RDS-NExT workshop: consensus statements for the use of surfactant in preterm neonates with RDS. J Perinatol 2023; 43:982-990. [PMID: 37188774 PMCID: PMC10400415 DOI: 10.1038/s41372-023-01690-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To provide the best clinical practice guidance for surfactant use in preterm neonates with respiratory distress syndrome (RDS). The RDS-Neonatal Expert Taskforce (RDS-NExT) initiative was intended to add to existing evidence and clinical guidelines, where evidence is lacking, with input from an expert panel. STUDY DESIGN An expert panel of healthcare providers specializing in neonatal intensive care was convened and administered a survey questionnaire, followed by 3 virtual workshops. A modified Delphi method was used to obtain consensus around topics in surfactant use in neonatal RDS. RESULT Statements focused on establishing RDS diagnosis and indicators for surfactant administration, surfactant administration methods and techniques, and other considerations. After discussion and voting, consensus was achieved on 20 statements. CONCLUSION These consensus statements provide practical guidance for surfactant administration in preterm neonates with RDS, with a goal to contribute to improving the care of neonates and providing a stimulus for further investigation to bridge existing knowledge gaps.
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Affiliation(s)
- Vineet Bhandari
- The Children's Regional Hospital at Cooper/Cooper Medical School of Rowan University, Camden, NJ, USA.
| | | | - Bheru Gandhi
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | | | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Fernando Moya
- Division of Wilmington Pediatric Subspecialists, Department of Pediatrics, UNC School of Medicine, Wilmington, NC, USA
| | - Chad Pezzano
- Department of Cardio-Respiratory Services Pediatric -Albany Medical Center, Albany, NY, USA
| | - Pam Read
- AESARA Inc., Chapel Hill, NC, USA
| | | | - Rita M Ryan
- UH Rainbow Babies and Children's Hospital -Case Western Reserve University, Cleveland, OH, USA
| | | | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
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14
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Hojnicki M, Zapata HA, Kaluarachchi DC, Fort P, Minton S, Albert G, Ross A, Wilding GE, Guthrie SO. Predictors of successful treatment of respiratory distress with aerosolized calfactant. J Perinatol 2023; 43:991-997. [PMID: 37433969 DOI: 10.1038/s41372-023-01722-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/14/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Predictors for successful aerosolized surfactant treatment are not well defined. OBJECTIVE To identify predictors for successful treatment in the AERO-02 trial and the AERO-03 expanded access program. METHODS Neonates receiving nasal continuous positive airway pressure (NCPAP) at the time of first aerosolized calfactant administration were included in this analysis. Associations between demographic and clinical predictors to need for intubation were examined using univariate testing and multivariate logistic regression analyses. RESULTS Three hundred and eighty infants were included in the study. Overall, 24% required rescue by intubation. Multivariate modeling revealed that the predictors of successful treatment were a gestational age ≥31 weeks, a respiratory severity score (RSS) of <1.9, and <2 previous aerosol treatments. CONCLUSION Gestational age, number of aerosols, and RSS are predictive of successful treatment. These criteria will help select patients most likely to benefit from aerosolized surfactant.
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Affiliation(s)
- Michelle Hojnicki
- Johns Hopkins All Children's Hospital, Maternal, Fetal and Neonatal Institute, St. Petersburg, FL, USA
| | - Henry A Zapata
- Department of Pediatrics, Division of Neonatology and Newborn Nursery, University of Wisconsin-Madison, Madison, WI, USA
| | - Dinushan C Kaluarachchi
- Department of Pediatrics, Division of Neonatology and Newborn Nursery, University of Wisconsin-Madison, Madison, WI, USA
| | - Prem Fort
- Johns Hopkins All Children's Hospital, Maternal, Fetal and Neonatal Institute, St. Petersburg, FL, USA
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Ann Ross
- Department of Neonatology, K Hovnanian Children's Hospital, Hackensack Meridian Health, Neptune, NJ, USA
| | - Gregory E Wilding
- Department of Biostatistics, University at Buffalo, Buffalo, NY, USA
| | - Scott O Guthrie
- Department of Pediatrics, Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN, USA.
- Jackson-Madison County General Hospital, Jackson, TN, USA.
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15
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Pichler K, Kuehne B, Dekker J, Stummer S, Giordano V, Berger A, Kribs A, Klebermass-Schrehof K. Assessment of Comfort during Less Invasive Surfactant Administration in Very Preterm Infants: A Multicenter Study. Neonatology 2023; 120:473-481. [PMID: 37311430 PMCID: PMC10614453 DOI: 10.1159/000530333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/10/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION This study was set up to investigate if and to what extent non-pharmacological analgesia is able to provide comfort to very preterm infants (VPI) during less invasive surfactant administration (LISA). METHODS This was a prospective non-randomized multicenter observational study performed in level IV NICUs. Inborn VPI with a gestational age between 220/7 and 316/7 weeks, signs of respiratory distress syndrome, and the need for surfactant replacement were included. Non-pharmacological analgesia was performed in all infants during LISA. In case of failure of the first LISA attempt, additional analgosedation could be administered. COMFORTneo scores during LISA were assessed. RESULTS 113 VPI with a mean gestational age of 27 weeks (+/- 2.3 weeks) and mean birth weight of 946 g (+/- 33 g) were included. LISA was successful at the first laryngoscopy attempt in 81%. COMFORTneo scores were highest during laryngoscopy. At this time point, non-pharmacological analgesia provided adequate comfort in 61% of the infants. 74.4% of lower gestational aged infants (i.e., 220-266 weeks) were within the comfort zone during laryngoscopy compared to 51.6% of higher gestational aged infants (i.e., 270-320 weeks) (p = 0.016). The time point of surfactant administration did not influence the COMFORTneo scores during the LISA procedure. CONCLUSION Non-pharmacological analgesia provided comfort in as much as 61% of the included VPI during LISA. Further research is needed to both develop strategies to identify infants who, despite receiving non-pharmacological analgesia, are at high risk for experiencing discomfort during LISA and define patient-tailored dosage and choice of analgosedative drugs.
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Affiliation(s)
- Karin Pichler
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria,
| | - Benjamin Kuehne
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Stummer
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Vito Giordano
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Katrin Klebermass-Schrehof
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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16
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Balázs G, Balajthy A, Seri I, Hegyi T, Ertl T, Szabó T, Röszer T, Papp Á, Balla J, Gáll T, Balla G. Prevention of Chronic Morbidities in Extremely Premature Newborns with LISA-nCPAP Respiratory Therapy and Adjuvant Perinatal Strategies. Antioxidants (Basel) 2023; 12:1149. [PMID: 37371878 DOI: 10.3390/antiox12061149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/22/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
Less invasive surfactant administration techniques, together with nasal continuous airway pressure (LISA-nCPAP) ventilation, an emerging noninvasive ventilation (NIV) technique in neonatology, are gaining more significance, even in extremely premature newborns (ELBW), under 27 weeks of gestational age. In this review, studies on LISA-nCPAP are compiled with an emphasis on short- and long-term morbidities associated with prematurity. Several perinatal preventative and therapeutic investigations are also discussed in order to start integrated therapies as numerous organ-saving techniques in addition to lung-protective ventilations. Two thirds of immature newborns can start their lives on NIV, and one third of them never need mechanical ventilation. With adjuvant intervention, these ratios are expected to be increased, resulting in better outcomes. Optimized cardiopulmonary transition, especially physiologic cord clamping, could have an additively beneficial effect on patient outcomes gained from NIV. Organ development and angiogenesis are strictly linked not only in the immature lung and retina, but also possibly in the kidney, and optimized interventions using angiogenic growth factors could lead to better morbidity-free survival. Corticosteroids, caffeine, insulin, thyroid hormones, antioxidants, N-acetylcysteine, and, moreover, the immunomodulatory components of mother's milk are also discussed as adjuvant treatments, since immature newborns deserve more complex neonatal interventions.
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Affiliation(s)
- Gergely Balázs
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - András Balajthy
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - István Seri
- First Department of Pediatrics, School of Medicine, Semmelweis University, 1083 Budapest, Hungary
- Keck School of Medicine of USC, Children's Hospital of Los Angeles, Los Angeles, CA 90033, USA
| | - Thomas Hegyi
- Department of Pediatrics, Division of Neonatology, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ 08903, USA
| | - Tibor Ertl
- Departments of Neonatology and Obstetrics & Gynecology, University of Pécs Medical School, 7624 Pécs, Hungary
- MTA-PTE Human Reproduction Scientific Research Group, University of Pécs, 7624 Pécs, Hungary
| | - Tamás Szabó
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Röszer
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - Ágnes Papp
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - József Balla
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- ELKH-UD Vascular Pathophysiology Research Group, Hungarian Academy of Sciences, University of Debrecen, 4032 Debrecen, Hungary
| | - Tamás Gáll
- Department of Internal Medicine, Division of Nephrology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
| | - György Balla
- Department of Pediatrics, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
- ELKH-UD Vascular Pathophysiology Research Group, Hungarian Academy of Sciences, University of Debrecen, 4032 Debrecen, Hungary
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17
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Sweet DG. When to treat with surfactant? Arch Dis Child Fetal Neonatal Ed 2023:archdischild-2022-325061. [PMID: 37185271 DOI: 10.1136/archdischild-2022-325061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023]
Affiliation(s)
- David G Sweet
- Neonatal Unit, Royal Maternity Hospital, Belfast, Belfast, UK
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18
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Errors in a Figure. JAMA Netw Open 2023; 6:e2312619. [PMID: 37083673 PMCID: PMC10122163 DOI: 10.1001/jamanetworkopen.2023.12619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
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19
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Norman M, Padkaer Petersen J, Stensvold HJ, Thorkelsson T, Helenius K, Brix Andersson C, Ørum Cueto H, Domellöf M, Gissler M, Heino A, Håkansson S, Jonsson B, Klingenberg C, Lehtonen L, Metsäranta M, Rønnestad AE, Trautner S. Preterm birth in the Nordic countries-Capacity, management and outcome in neonatal care. Acta Paediatr 2023. [PMID: 36912750 DOI: 10.1111/apa.16753] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/14/2023]
Abstract
AIM Organisation of care, perinatal and neonatal management of very preterm infants in the Nordic regions were hypothesised to vary significantly. The aim of this observational study was to test this hypothesis. METHODS Information on preterm infants in the 21 greater healthcare regions of Denmark, Finland, Iceland, Norway and Sweden was gathered from national registers in 2021. Preterm birth rates, case-mix, perinatal interventions, neonatal morbidity and survival to hospital discharge in very (<32 weeks) and extremely preterm infants (<28 weeks of gestational age) were compared. RESULTS Out of 287 642 infants born alive, 16 567 (5.8%) were preterm, 2389 (0.83%) very preterm and 800 (0.28%) were extremely preterm. In very preterm infants, exposure to antenatal corticosteroids varied from 85% to 98%, live births occurring at regional centres from 48% to 100%, surfactant treatment from 28% to 69% and use of mechanical ventilation varied from 13% to 77% (p < 0.05 for all comparisons). Significant regional variations within and between countries were also seen in capacity in neonatal care, case-mix and number of admissions, whereas there were no statistically significant differences in survival or major neonatal morbidities. CONCLUSION Management of very preterm infants exhibited significant regional variations in the Nordic countries.
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Affiliation(s)
- Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jesper Padkaer Petersen
- The Danish Clinical Quality Program - National Clinical Registries (RKKP), Aarhus, Denmark
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Jørgen Stensvold
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Thordur Thorkelsson
- Department of Neonatal Medicine, Children's Hospital Iceland, Landspitali University Hospital, Reykjavík, Iceland
| | - Kjell Helenius
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Charlotte Brix Andersson
- The Danish Clinical Quality Program - National Clinical Registries (RKKP), Aarhus, Denmark
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Thisted, Denmark
| | - Heidi Ørum Cueto
- The Danish Clinical Quality Program - National Clinical Registries (RKKP), Aarhus, Denmark
| | - Magnus Domellöf
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - Mika Gissler
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Anna Heino
- Department of Knowledge Brokers, THL Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Stellan Håkansson
- Department of Clinical Sciences, Paediatrics, Umeå University, Umeå, Sweden
| | - Baldvin Jonsson
- Department of Neonatal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Claus Klingenberg
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Paediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Liisa Lehtonen
- Department of Paediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
- Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Marjo Metsäranta
- Department of Paediatrics, New Children's Hospital, Paediatric Research Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Arild E Rønnestad
- Department of Neonatal Intensive Care, Clinic of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Medical Faculty, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Simon Trautner
- The Danish Clinical Quality Program - National Clinical Registries (RKKP), Aarhus, Denmark
- Department of Intensive Care of Newborns and Small Children, University Hospital of Copenhagen, Copenhagen, Denmark
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20
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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Adaptation for life after birth: a review of neonatal physiology. ANAESTHESIA & INTENSIVE CARE MEDICINE 2022. [DOI: 10.1016/j.mpaic.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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