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Tomé MR, Orlandin EADS, Zinher MT, Dias SO, Gonçalves-Ferri WA, De Luca D, Iwashita-Lages T. NIV-NAVA versus non-invasive respiratory support in preterm neonates: a meta-analysis of randomized controlled trials. J Perinatol 2024; 44:1276-1284. [PMID: 38553605 DOI: 10.1038/s41372-024-01947-x] [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: 10/25/2023] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 09/08/2024]
Abstract
OBJECTIVE To analyze the clinical and physiological outcomes of NIV-NAVA in preterm infants compared with other non-invasive respiratory support. STUDY DESIGN We conducted a meta-analysis of RCTs and randomized crossover studies comparing NIV-NAVA to other non-invasive strategies in preterm neonates. RESULTS NIV-NAVA was superior to other non-invasive support in maximum EAdi (MD - 0.66 µV; 95% CI - 1.17 to -0.15; p = 0.01), asynchrony index (MD - 49.8%; 95% CI - 63.1 to -36.5; p < 0.01), and peak inspiratory pressure (MD - 2.2 cmH2O; 95% CI - 2.7 to -1.7; p < 0.01). However, there were no significant differences in the incidences of intubation (RR 0.91; 95% CI 0.56-1.48; p = 0.71), reintubation (RR 0.72; 95% CI 0.45-1.16; p = 0.18), or bronchopulmonary dysplasia (RR 0.77; 95% CI 0.37-1.60; p = 0.48). CONCLUSION NIV-NAVA was associated with improvements in maximum Edi, asynchrony index, and peak inspiratory pressure relative to other non-invasive respiratory strategies, without significant differences in clinical outcomes between groups.
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Affiliation(s)
- Milena R Tomé
- Federal University of Campina Grande Faculty of Medicine, Campina Grande, Brazil.
| | | | | | - Sofia O Dias
- Faculdade De Ciências Médicas de São josé dos Campos, São josé dos Campos, Brazil
| | | | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, South "A.Beclere" Medical Center, Paris, France
| | - Thaís Iwashita-Lages
- Division of Neonatal Critical Care, University of São Paulo, Ribeirão Preto, Brazil.
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Solís-García G, Bravo MC, Pellicer A. Cardiorespiratory interactions during the transitional period in extremely preterm infants: a narrative review. Pediatr Res 2024:10.1038/s41390-024-03451-6. [PMID: 39179873 DOI: 10.1038/s41390-024-03451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/03/2024] [Accepted: 07/18/2024] [Indexed: 08/26/2024]
Abstract
We aimed to review the physiology and evidence behind cardiorespiratory interactions during the transitional circulation of extremely preterm infants with fragile physiology and to propose a framework for future research. Cord clamping strategies have a great impact on initial haemodynamic changes, and appropriate transition can be facilitated by establishing spontaneous ventilation before cord clamping. Mechanical ventilation modifies preterm transitional haemodynamics, with positive pressure ventilation affecting the right and left heart loading conditions. Pulmonary vascular resistances can be minimized by ventilating with optimal lung volumes at functional residual capacity, and other pulmonary vasodilator treatments such as inhaled nitric oxide can be used to improve ventilation/perfusion mismatch. Different cardiovascular drugs can be used to provide support during transition in this population, and it is important to understand both their cardiovascular and respiratory effects, in order to provide adequate support to vulnerable preterm infants and improve outcomes. Current available non-invasive bedside tools, such as near-infrared spectroscopy, targeted neonatal echocardiography, or lung ultrasound offer the opportunity to precisely monitor cardiorespiratory interactions in preterm infants. More research is needed in this field using precision medicine to strengthen the benefits and avoid the harms associated to early neonatal interventions. IMPACT: In extremely preterm infants, haemodynamic and respiratory transitions are deeply interconnected, and their changes have a key impact in the establishment of lung aireation and postnatal circulation. We describe how mechanical ventilation modifies heart loading conditions and pulmonary vascular resistances in preterm patients, and how hemodynamic interventions such as cord clamping strategies or cardiovascular drugs affect the infant respiratory status. Current available non-invasive bedside tools can help monitor cardiorespiratory interactions in preterm infants. We highlight the areas of research in which precision medicine can help strengthen the benefits and avoid the harms associated to early neonatal interventions.
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Affiliation(s)
- Gonzalo Solís-García
- Department of Neonatology, La Paz University Hospital and IdiPaz (La Paz Hospital Institute for Health Research), Madrid, Spain.
| | - María Carmen Bravo
- Department of Neonatology, La Paz University Hospital and IdiPaz (La Paz Hospital Institute for Health Research), Madrid, Spain
- Consultant Neonatologist, Rotunda Hospital, Dublin, Ireland
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital and IdiPaz (La Paz Hospital Institute for Health Research), Madrid, Spain
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Yazdi S, Carlo WA, Nakhmani A, Boateng EO, Aban I, Ambalavanan N, Travers CP. Extended CPAP or low-flow nasal cannula for intermittent hypoxaemia in preterm infants: a 24-hour randomised clinical trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:557-561. [PMID: 38365446 PMCID: PMC11327380 DOI: 10.1136/archdischild-2023-326605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Optimal timing of continuous positive airway pressure (CPAP) cessation in preterm infants remains undetermined. We hypothesised that CPAP extension compared with weaning to low-flow nasal cannula (NC) reduces intermittent hypoxaemia (IH) and respiratory instability in preterm infants meeting criteria to discontinue CPAP. DESIGN Single-centre randomised clinical trial. SETTING Level 4 neonatal intensive care unit. PATIENTS 36 infants <34 weeks' gestation receiving CPAP≤5 cmH2O and fraction of inspired oxygen (FiO2) ≤0.30 and meeting respiratory stability criteria. INTERVENTIONS Extended CPAP was compared with weaning to low-flow NC (0.5 L/kg/min with a limit of 1.0 L/min) for 24 hours. OUTCOMES The primary outcome was IH (number of episodes with SpO2<85% lasting ≥10 s). Secondary outcomes included: coefficient of variability of SpO2, proportion of time in various SpO2 ranges, episodes (≥10 s) with SpO2<80%, median cerebral and renal oxygenation, median effective FiO2, median transcutaneous carbon dioxide and bradycardia (<100/min for≥10 s). RESULTS The median (IQR) episodes of IH per 24-hour period was 20 (6-48) in the CPAP group and 76 (18-101) in the NC group (p=0.03). Infants continued on CPAP had less bradycardia, time with SpO2 <91% and <85%, and lower FiO2 (all p<0.05). There were no statistically significant differences in IH<80%, median transcutaneous carbon dioxide or median cerebral or renal oxygenation. CONCLUSION In preterm infants meeting respiratory stability criteria for CPAP cessation, extended CPAP decreased IH, bradycardia and other hypoxaemia measures compared with weaning to low-flow NC during the 24-hour intervention. TRIAL REGISTRATION NUMBER NCT04792099.
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Affiliation(s)
- Siamak Yazdi
- Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Waldemar A Carlo
- Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Arie Nakhmani
- Department of Electrical and Computer Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ernestina O Boateng
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Immaculada Aban
- Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Namasivayam Ambalavanan
- Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Colm P Travers
- Department of Pediatrics, The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
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Wang K, Yue G, Gao S, Li F, Ju R. Non-invasive high-frequency oscillatory ventilation (NHFOV) versus nasal continuous positive airway pressure (NCPAP) for preterm infants: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2024; 109:397-404. [PMID: 38228382 DOI: 10.1136/archdischild-2023-325681] [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: 04/10/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE To compare the efficacy and safety of non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) in preterm infants. DESIGN The study conducted a comprehensive analysis across three databases, namely EMBASE, MEDLINE and Cochrane Central, to identify randomised controlled trials comparing NHFOV and NCPAP. Statistical analysis was performed using Review Manager V.5.3 software. MAIN OUTCOMES MEASURES The primary outcomes of the study were the intubation or reintubation rate in the NHFOV and NCPAP groups. Additionally, secondary outcomes included the partial pressure of carbon dioxide levels and major complications associated with non-invasive respiratory support ventilation. RESULTS Ten randomised controlled studies, involving 2031 preterm infants, were included in this meta-analysis. When compared with NCPAP, NHFOV demonstrated a significant reduction in the intubation or reintubation rate (p<0.01, relative risk=0.45, 95% CI 0.37 to 0.55), and there was no statistical difference in related complications. CONCLUSION In preterm infants, NHFOV appears to be an effective intervention for decreasing the intubation or reintubation rate compared with NCPAP, with no increase in associated complications. TRIAL REGISTRATION NUMBER CRD42023403968.
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Affiliation(s)
- Kaixu Wang
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Guang Yue
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Shuqiang Gao
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Fang Li
- Chongqing Health Center for Women and Children, Chongqing, China
| | - Rong Ju
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
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Kuitunen I, Räsänen K, Gualano MR, De Luca D. Blinding Assessments in Neonatal Ventilation Meta-Analyses: A Systematic Meta-Epidemiological Review. Neonatology 2024:1-8. [PMID: 38861954 DOI: 10.1159/000539203] [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: 02/25/2024] [Accepted: 04/27/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Randomization and blinding are generally important in randomized trials. In neonatology, blinding of ventilation strategies is unfeasible if not impossible and we hypothesized that its importance has been overestimated, while the peculiarities of the neonatal patient and the specific outcomes have not been considered. METHODS For this meta-epidemiological review, we searched PubMed and Scopus databases in November 2023. We included all meta-analyses focusing on ventilation, published in past 5 years, and reporting either mortality or bronchopulmonary dysplasia (BPD) as an outcome. We extracted the information about how the authors had analyzed risk of bias and evidence certainty. RESULTS We screened 494 abstracts and included 40 meta-analyses. Overall, 13 of the 40 reviews assessed blinding properly. Australian and European authors were most likely to perform correct assessment of the blinding (p = 0.03) and the use of RoB 2.0 tool was also associated with proper assessment (p < 0.001). In multivariate regression, the use of RoB 2.0 was the only factor associated with a proper assessment (Beta 0.57 [95% confidence interval: 0.29-0.99]). GRADE ratings were performed in 25 reviews, and the authors downgraded the evidence certainty due to risk of bias in 19 of these and none of these reviews performed the blinding assessment correctly. CONCLUSION In past neonatal evidence syntheses, the role of blinding has been mostly overestimated, which has led to downgrading of evidence certainty. Objective outcomes (such as mortality and BPD) do not need to be downgraded due to lack of blinding, as the knowledge of the received intervention does not influence the outcome assessment.
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Affiliation(s)
- Ilari Kuitunen
- University of Eastern Finland, Institute of Clinical Medicine and Department of Pediatrics, Kuopio, Finland
- Kuopio University Hospital, Department of Pediatrics, Kuopio, Finland
| | - Kati Räsänen
- University of Eastern Finland, Institute of Clinical Medicine and Department of Pediatrics, Kuopio, Finland
- Kuopio University Hospital, Department of Pediatrics, Kuopio, Finland
| | - Maria Rosaria Gualano
- UniCamillus - Saint Camillus International University of Health Sciences, Rome, Italy
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A. Beclere" Hospital, APHP-Paris Saclay University, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, Paris Saclay University, Paris, France
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Foster J, Pathrose SP, Briguglio L, Trajkovski S, Lowe P, Muirhead R, Jyoti J, Ng L, Blay N, Spence K, Chetty N, Broom M. Scoping review of systematic reviews of nursing interventions in a neonatal intensive care unit or special care nursery. J Clin Nurs 2024; 33:2123-2137. [PMID: 38339771 DOI: 10.1111/jocn.17053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024]
Abstract
AIM(S) To identify, synthesise and map systematic reviews of the effectiveness of nursing interventions undertaken in a neonatal intensive care unit or special care nursery. DESIGN This scoping review was conducted according to the JBI scoping review framework. METHODS Review included systematic reviews that evaluated any nurse-initiated interventions that were undertaken in an NICU or SCN setting. Studies that reported one or more positive outcomes related to the nursing interventions were only considered for this review. Each outcome for nursing interventions was rated a 'certainty (quality) of evidence' according to the Grading of Recommendations, Assessment, Development and Evaluations criteria. DATA SOURCES Systematic reviews were sourced from the Cochrane Database of Systematic Reviews and Joanna Briggs Institute Evidence Synthesis for reviews published until February 2023. RESULTS A total of 428 articles were identified; following screening, 81 reviews underwent full-text screening, and 34 articles met the inclusion criteria and were included in this review. Multiple nursing interventions reporting positive outcomes were identified and were grouped into seven categories. Respiratory 7/34 (20%) and Nutrition 8/34 (23%) outcomes were the most reported categories. Developmental care was the next most reported category 5/34 (15%) followed by Thermoregulation, 5/34 (15%) Jaundice 4/34 (12%), Pain 4/34 (12%) and Infection 1/34 (3%). CONCLUSIONS This review has identified nursing interventions that have a direct positive impact on neonatal outcomes. However, further applied research is needed to transfer this empirical knowledge into clinical practice. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE Implementing up-to-date evidence on effective nursing interventions has the potential to significantly improving neonatal outcomes. PATIENT OR PUBLIC CONTRIBUTION No patient or public involvement in this scoping review.
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Affiliation(s)
- Jann Foster
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
- School of Nursing and Midwifery, University of Canberra, Canberra, Australian Capital Territory, Australia
- Ingham Research Institute, Liverpool, New South Wales, Australia
- NSW Centre for Evidence Based Health Care: A JBI Affiliated Group, Penrith, New South Wales, Australia
| | - Sheeja Perumbil Pathrose
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
- NSW Centre for Evidence Based Health Care: A JBI Affiliated Group, Penrith, New South Wales, Australia
| | - Laura Briguglio
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
- Neonatology, Centenary Hospital for Women and Children, Canberra, Australian Capital Territory, Australia
| | - Suza Trajkovski
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
| | - Patricia Lowe
- Australian College of Nursing, Sydney, New South Wales, Australia
- School of Nursing and Midwifery, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Renee Muirhead
- Neonatal Critical Care Unit, Mater Mothers' Hospital, Brisbane, Queensland, Australia
- School of Nursing, Midwifery and Social Work, University of Queensland, St. Lucia, Queensland, Australia
| | - Jeewan Jyoti
- Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Linda Ng
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- School of Nursing and Midwifery, University of Southern Queensland, Ipswich, Queensland, Australia
| | - Nicole Blay
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
| | - Kaye Spence
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
- Australasian NIDCAP Training Centre, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Natasha Chetty
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Margaret Broom
- School of Nursing and Midwifery, Western Sydney University, Sydney, New South Wales, Australia
- School of Nursing and Midwifery, University of Canberra, Canberra, Australian Capital Territory, Australia
- Neonatology, Centenary Hospital for Women and Children, Canberra, Australian Capital Territory, Australia
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Tamai K, Matsumoto N, Yorifuji T, Takeuchi A, Nakamura M, Nakamura K, Kageyama M. Delivery room intubation and neurodevelopment among extremely preterm infants. Pediatr Res 2024; 95:1897-1902. [PMID: 38212388 DOI: 10.1038/s41390-023-02993-5] [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: 05/15/2023] [Revised: 11/08/2023] [Accepted: 11/18/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND The impact of delivery room intubation (DRI) on neurodevelopment in extremely preterm infants remains unclear. METHODS We retrospectively analyzed data for infants born at 24-27 gestational weeks between 2003 and 2018. The primary outcome was neurodevelopmental impairment (NDI), defined as cerebral palsy or hearing, visual, or cognitive impairment at age 3 years. Secondary outcomes were NDI components and death before and after discharge from the neonatal intensive care unit. We conducted robust Poisson regression analyses, adjusting for perinatal confounders. RESULTS The full cohort included 4397 infants with NDI data, of whom 3703 were intubated in the delivery room and 694 were not intubated in the delivery room. The mean gestational age and birth weight were 26.0 ± 1.1 weeks and 778 ± 184 g for infants with DRI and 26.6 ± 1.0 weeks and 873 ± 184 g for infants without DRI. Compared with infants without DRI, those with DRI had a higher risk for NDI (32.4% vs. 23.3%; adjusted risk ratio 1.18, 95% confidence interval: 1.01-1.37). There were no differences in secondary outcomes between infants with and without DRI. CONCLUSIONS DRI was associated with an increased risk for NDI at age 3 years among extremely preterm infants. IMPACT Few studies have examined the impact of delivery room intubation on neurodevelopment in infants born extremely preterm, and the results have been inconsistent. A total of 4397 infants born at 24-27 gestational weeks who had neurodevelopmental data at age 3 years were included in the present study. The present study found that delivery room intubation was associated with an increased risk for neurodevelopmental impairment at age 3 years among extremely preterm infants.
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Affiliation(s)
- Kei Tamai
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan.
| | - Naomi Matsumoto
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihito Takeuchi
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Makoto Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Kazue Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misao Kageyama
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
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Abdel-Latif ME, Tan O, Fiander M, Osborn DA. Non-invasive high-frequency ventilation in newborn infants with respiratory distress. Cochrane Database Syst Rev 2024; 5:CD012712. [PMID: 38695628 PMCID: PMC11064768 DOI: 10.1002/14651858.cd012712.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Respiratory distress occurs in up to 7% of newborns, with respiratory support (RS) provided invasively via an endotracheal (ET) tube or non-invasively via a nasal interface. Invasive ventilation increases the risk of lung injury and chronic lung disease (CLD). Using non-invasive strategies, with or without minimally invasive surfactant, may reduce the need for mechanical ventilation and the risk of lung damage in newborn infants with respiratory distress. OBJECTIVES To evaluate the benefits and harms of nasal high-frequency ventilation (nHFV) compared to invasive ventilation via an ET tube or other non-invasive ventilation methods on morbidity and mortality in preterm and term infants with or at risk of respiratory distress. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and three trial registries in April 2023. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster- or quasi-RCTs of nHFV in newborn infants with respiratory distress compared to invasive or non-invasive ventilation. DATA COLLECTION AND ANALYSIS Two authors independently selected the trials for inclusion, extracted data, assessed the risk of bias, and undertook GRADE assessment. MAIN RESULTS We identified 33 studies, mostly in low- to middle-income settings, that investigated this therapy in 5068 preterm and 46 term infants. nHFV compared to invasive respiratory therapy for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 0.67, 95% CI 0.20 to 2.18; 1 study, 80 infants) or the incidence of CLD (RR 0.38, 95% CI 0.09 to 1.59; 2 studies, 180 infants), both very low-certainty. ET intubation, death or CLD, severe intraventricular haemorrhage (IVH) and neurodevelopmental disability (ND) were not reported. nHFV vs nasal continuous positive airway pressure (nCPAP) used for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 1.00, 95% CI 0.41 to 2.41; 4 studies, 531 infants; very low-certainty). nHFV may reduce ET intubation (RR 0.52, 95% CI 0.33 to 0.82; 5 studies, 571 infants), but there may be little or no difference in CLD (RR 1.35, 95% CI 0.80 to 2.27; 4 studies, 481 infants); death or CLD (RR 2.50, 95% CI 0.52 to 12.01; 1 study, 68 participants); or severe IVH (RR 1.17, 95% CI 0.36 to 3.78; 4 studies, 531 infants), all low-certainty evidence. ND was not reported. nHFV vs nasal intermittent positive-pressure ventilation (nIPPV) used for initial RS nHFV may result in little to no difference in mortality before hospital discharge (RR 1.86, 95% CI 0.90 to 3.83; 2 studies, 84 infants; low-certainty). nHFV may have little or no effect in reducing ET intubation (RR 1.33, 95% CI 0.76 to 2.34; 5 studies, 228 infants; low-certainty). There may be a reduction in CLD (RR 0.63, 95% CI 0.42 to 0.95; 5 studies, 307 infants; low-certainty). A single study (36 infants) reported no events for severe IVH. Death or CLD and ND were not reported. nHFV vs high-flow nasal cannula (HFNC) used for initial RS We are very uncertain whether nHFV reduces ET intubation (RR 2.94, 95% CI 0.65 to 13.27; 1 study, 37 infants) or reduces CLD (RR 1.18, 95% CI 0.46 to 2.98; 1 study, 37 participants), both very low-certainty. There were no mortality events before hospital discharge or severe IVH. Other deaths, CLD and ND, were not reported. nHFV vs nCPAP used for RS following planned extubation nHFV probably results in little or no difference in mortality before hospital discharge (RR 0.92, 95% CI 0.52 to 1.64; 6 studies, 1472 infants; moderate-certainty). nHFV may result in a reduction in ET reintubation (RR 0.42, 95% CI 0.35 to 0.51; 11 studies, 1897 infants) and CLD (RR 0.78, 95% CI 0.67 to 0.91; 10 studies, 1829 infants), both low-certainty. nHFV probably has little or no effect on death or CLD (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 966 infants) and severe IVH (RR 0.80, 95% CI 0.57 to 1.13; 3 studies, 1117 infants), both moderate-certainty. We are very uncertain whether nHFV reduces ND (RR 0.92, 95% CI 0.37 to 2.29; 1 study, 74 infants; very low-certainty). nHFV versus nIPPV used for RS following planned extubation nHFV may have little or no effect on mortality before hospital discharge (RR 1.83, 95% CI 0.70 to 4.79; 2 studies, 984 infants; low-certainty). There is probably a reduction in ET reintubation (RR 0.69, 95% CI 0.54 to 0.89; 6 studies, 1364 infants), but little or no effect on CLD (RR 0.88, 95% CI 0.75 to 1.04; 4 studies, 1236 infants); death or CLD (RR 0.92, 95% CI 0.79 to 1.08; 3 studies, 1070 infants); or severe IVH (RR 0.78, 95% CI 0.55 to 1.10; 4 studies, 1162 infants), all moderate-certainty. One study reported there might be no difference in ND (RR 0.88, 95% CI 0.35 to 2.16; 1 study, 72 infants; low-certainty). nHFV versus nIPPV following initial non-invasive RS failure nHFV may have little or no effect on mortality before hospital discharge (RR 1.44, 95% CI 0.10 to 21.33); or ET intubation (RR 1.23, 95% CI 0.51 to 2.98); or CLD (RR 1.01, 95% CI 0.70 to 1.47); or severe IVH (RR 0.47, 95% CI 0.02 to 10.87); 1 study, 39 participants, all low- or very low-certainty. Other deaths or CLD and ND were not reported. AUTHORS' CONCLUSIONS For initial RS, we are very uncertain if using nHFV compared to invasive respiratory therapy affects clinical outcomes. However, nHFV may reduce intubation when compared to nCPAP. For planned extubation, nHFV may reduce the risk of reintubation compared to nCPAP and nIPPV. nHFV may reduce the risk of CLD when compared to nCPAP. Following initial non-invasive respiratory support failure, nHFV when compared to nIPPV may result in little to no difference in intubation. Large trials, particularly in high-income settings, are needed to determine the role of nHFV in initial RS and following the failure of other non-invasive respiratory support. Also, the optimal settings of nHVF require further investigation.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Discipline of Neonatology, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, ACT, Australia
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Olive Tan
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia
| | | | - David A Osborn
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
- Department of Neonatology, Royal Prince Alfred Hospital, Camperdown, Australia
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Tamai K, Matsumoto N, Yorifuji T, Takeuchi A, Nakamura M, Nakamura K, Kageyama M. Delivery room intubation and severe intraventricular hemorrhage in extremely preterm infants without low Apgar scores: A Japanese retrospective cohort study. Sci Rep 2023; 13:14990. [PMID: 37696821 PMCID: PMC10495461 DOI: 10.1038/s41598-023-41010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023] Open
Abstract
The purpose of this study was to assess the associations between delivery room intubation (DRI) and severe intraventricular hemorrhage (IVH), as well as other neonatal outcomes, among extremely preterm infants without low Apgar scores using data from a large-scale neonatal registry data in Japan. We analyzed data for infants born at 24-27 gestational weeks between 2003 and 2019 in Japan using robust Poisson regression. Infants with low Apgar scores (≤ 1 at 1 min or ≤ 3 at 5 min) were excluded. The primary outcome was severe IVH. Secondary outcomes were other neonatal morbidities and mortality. The full cohort included 16,081 infants (intubation cohort, 13,367; no intubation cohort, 2714). The rate of DRI increased over time (78.6%, 2003-2008; 83.4%, 2009-2014; 87.8%, 2015-2019), while the rate of severe IVH decreased (7.1%, 2003-2008; 5.7%, 2009-2014; 5.3%, 2015-2019). Infants with DRI had a higher risk of severe IVH than those without DRI (6.8% vs. 2.3%; adjusted risk ratio, 1.86; 95% confidence interval, 1.33-2.58). The results did not change substantially when stratified by gestational age. Despite conflicting changes over time in DRI and severe IVH, DRI was associated with an increased risk of severe IVH among extremely preterm infants in Japan.
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Affiliation(s)
- Kei Tamai
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan.
| | - Naomi Matsumoto
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihito Takeuchi
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Makoto Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Kazue Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misao Kageyama
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
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10
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林 梅, 张 雪, 王 亚, 朱 晓, 薛 江. [Interpretation of the key updates in the 2022 European guideline on the management of neonatal respiratory distress syndrome]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:779-784. [PMID: 37668023 PMCID: PMC10484088 DOI: 10.7499/j.issn.1008-8830.2303046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/12/2023] [Indexed: 09/06/2023]
Abstract
With the deepening of clinical research, the management of neonatal respiratory distress syndrome (RDS) needs to be optimized and improved. This article aims to introduce the 2022 European guideline on the management of neonatal RDS, focusing on its key updates. The guide has optimized the management of risk prediction for preterm birth, maternal referral, application of prenatal corticosteroids, application of lung protective ventilation strategies, and general care for infants with RDS. The guideline is mainly applicable to the management of RDS in neonates with gestational age greater than 24 weeks.
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11
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Kaltsogianni O, Dassios T, Greenough A. Neonatal respiratory support strategies-short and long-term respiratory outcomes. Front Pediatr 2023; 11:1212074. [PMID: 37565243 PMCID: PMC10410156 DOI: 10.3389/fped.2023.1212074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/11/2023] [Indexed: 08/12/2023] Open
Abstract
Mechanical ventilation (MV), although life-saving, is associated with chronic respiratory morbidity in both preterm and term born infants. New ventilation modes have been developed with the aim of minimising lung injury. These include invasive and non-invasive respiratory support strategies, techniques for less invasive surfactant administration (LISA) and closed-loop automated oxygen control (CLAC) systems. Increasingly, newborn infants with signs of respiratory distress are stabilised on continuous positive airway pressure (CPAP) and receive LISA. Early CPAP when compared to mechanical ventilation reduced the incidence of BPD and respiratory morbidity at 18 to 22 months corrected age. Nasal intermittent positive pressure ventilation reduced treatment failure rates compared to CPAP, but not bronchopulmonary dysplasia (BPD). LISA compared with intubation and surfactant delivery reduced BPD, but there is no evidence from randomised trials regarding long-term respiratory and neurodevelopmental outcomes. Synchronisation of positive pressure inflations with the infant's respiratory efforts used with volume targeting should be applied for infants requiring intubation as this strategy reduces BPD. A large RCT with long term follow up data demonstrated that prophylactic high frequency oscillatory ventilation (HFOV) improved respiratory and functional outcomes at school age, but those effects were not maintained after puberty. CLAC systems appear promising, but their effect on long term clinical outcomes has not yet been explored in randomised trials. Further studies are required to determine the role of newer ventilation modes such as neurally adjusted ventilator assist (NAVA). All such respiratory support strategies should be tested in randomised controlled trials powered to assess long-term outcomes.
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Affiliation(s)
- Ourania Kaltsogianni
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Theodore Dassios
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anne Greenough
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
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12
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Zhang EY, Bartman CM, Prakash YS, Pabelick CM, Vogel ER. Oxygen and mechanical stretch in the developing lung: risk factors for neonatal and pediatric lung disease. Front Med (Lausanne) 2023; 10:1214108. [PMID: 37404808 PMCID: PMC10315587 DOI: 10.3389/fmed.2023.1214108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/01/2023] [Indexed: 07/06/2023] Open
Abstract
Chronic airway diseases, such as wheezing and asthma, remain significant sources of morbidity and mortality in the pediatric population. This is especially true for preterm infants who are impacted both by immature pulmonary development as well as disproportionate exposure to perinatal insults that may increase the risk of developing airway disease. Chronic pediatric airway disease is characterized by alterations in airway structure (remodeling) and function (increased airway hyperresponsiveness), similar to adult asthma. One of the most common perinatal risk factors for development of airway disease is respiratory support in the form of supplemental oxygen, mechanical ventilation, and/or CPAP. While clinical practice currently seeks to minimize oxygen exposure to decrease the risk of bronchopulmonary dysplasia (BPD), there is mounting evidence that lower levels of oxygen may carry risk for development of chronic airway, rather than alveolar disease. In addition, stretch exposure due to mechanical ventilation or CPAP may also play a role in development of chronic airway disease. Here, we summarize the current knowledge of the impact of perinatal oxygen and mechanical respiratory support on the development of chronic pediatric lung disease, with particular focus on pediatric airway disease. We further highlight mechanisms that could be explored as potential targets for novel therapies in the pediatric population.
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Affiliation(s)
- Emily Y. Zhang
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Colleen M. Bartman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
| | - Y. S. Prakash
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Christina M. Pabelick
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, United States
| | - Elizabeth R. Vogel
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, United States
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13
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Dawud AA, Abagaro AM. Low-Cost SpO2 Integrated Neonatal CPAP Device for Low Resource Setting. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2023; 16:145-156. [PMID: 37313451 PMCID: PMC10259578 DOI: 10.2147/mder.s406170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 06/01/2023] [Indexed: 06/15/2023] Open
Abstract
Introduction More than 60% of preterm births take place in South Asia and sub-Saharan Africa, making prematurity a primary cause of neonatal mortality. Even though continuous positive airway pressure (CPAP) is a popular treatment for respiratory distress syndrome (RDS) and is safe, practicable, and efficient for use in LMICs, it is crucial to ensure that neonates receive the full benefits of the therapy by monitoring their blood oxygen level. Methods A centrifugal fan, power source, control system, and sensors are all included in our design. A centrifugal fan was created to provide air at positive pressure in the range of approximately 4 cmH2O to 20 cmH2O utilizing revolving blades (impeller), a DC motor, and a fixed component. The control unit contains a microcontroller to handle sensor data. The proportional-integral (PI) controller board's external potentiometer is used to set the pressure level. Results To ascertain whether the prototype satisfies the design requirements, it was constructed and put through several iterations and testing. The proposed device's prototype was tested for accuracy, affordability, and usability. The centrifugal fan speed measurement was accurate to within 94.5%, while the oxygen concentration sensor reading was accurate to within 98.5%. Conclusion The design investigates viability of a straightforward, inexpensive, portable SpO2 integrated neonatal CPAP device for use in the delivery room in low-resource countries and to evaluates methods for measuring flows during CPAP treatment by monitoring the level of oxygen in the blood and pressure level delivered by the device using the lowest and safest setting that yields useful results.
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Affiliation(s)
- Ahmed Ali Dawud
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
| | - Ahmed Mohammed Abagaro
- School of Biomedical Engineering, Jimma Institute of Technology, Jimma University, Jimma, Ethiopia
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Abdallah Y, Mkony M, Noorani M, Moshiro R, Bakari M, Manji K. CPAP failure in the management of preterm neonates with respiratory distress syndrome where surfactant is scarce. A prospective observational study. BMC Pediatr 2023; 23:211. [PMID: 37138252 PMCID: PMC10155133 DOI: 10.1186/s12887-023-04038-6] [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: 10/03/2022] [Accepted: 04/26/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The mainstay in the management of preterm neonates with respiratory distress syndrome (RDS) include early Continuous Positive Airway Pressure (CPAP), timely surfactant replacement and mechanical ventilation. Preterm neonates with RDS who fail CPAP are at higher risk for chronic lung disease as well as death. Unfortunately, in low resource settings CPAP may be the only treatment available for these neonates. OBJECTIVE To determine the prevalence of CPAP failure among premature newborns with RDS and associated factors. METHODS We conducted a prospective observational study over the first 72 h of life on 174 preterm newborns with RDS receiving CPAP at Muhimbili National Hospital (MNH). At MNH newborns with Silverman Andersen Score (SAS) of ≥ 3 are commenced on CPAP; surfactant and mechanical ventilation are very scarce. Study newborns not maintaining oxygen saturation > 90% or with SAS score ≥ 6 despite being on 50% oxygen and PEEP of 6 cmH2O and those with > 2 episodes of apnoea needing stimulation or positive pressure ventilation in 24 h were considered as CPAP failure. The prevalence of CPAP failure was determined as a percentage and factors associated were determined by logistic regression. A p-value of < 0.05 was considered significant and 95% confidence interval was used. RESULTS Of the enrolled newborns, 48% were male and 91.4% were in-born. The mean gestational age and weight were 29 weeks (range 24-34 weeks) and 1157.7 g (range 800-1500 g) respectively. Of the mothers 44 (25%) received antenatal corticosteroids. Overall CPAP failure was 37.4% and among those weighing ≤ 1200g, it was 44.1% . Most failure occurred within the first 24 h. No factor was identified to be independently associated with CPAP failure. Mortality among those who failed CPAP was 33.8% and 12.8% among those who did not. CONCLUSIONS In resource limited settings like ours with low up take of antenatal corticosteroids and scarce surfactant replacement a significant portion of preterm neonates especially those weighing ≤ 1200 g with RDS fail CPAP therapy.
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Affiliation(s)
- Yaser Abdallah
- Department of Paediatrics and Child Health, Aga Khan University, P.o Box 38129, Dar es Salaam, Tanzania.
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Martha Mkony
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mariam Noorani
- Department of Paediatrics and Child Health, Aga Khan University, P.o Box 38129, Dar es Salaam, Tanzania
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Robert Moshiro
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed Bakari
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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15
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Razak A, Alhaidari OI, Ahmed J. Interventions for reducing late-onset sepsis in neonates: an umbrella review. J Perinat Med 2023; 51:403-422. [PMID: 36303465 DOI: 10.1515/jpm-2022-0131] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Neonatal sepsis is one of the leading causes of neonatal deaths in neonatal intensive care units. Hence, it is essential to review the evidence from systematic reviews on interventions for reducing late-onset sepsis (LOS) in neonates. METHODS PubMed and the Cochrane Central were searched from inception through August 2020 without any language restriction. Cochrane reviews of randomized clinical trials (RCTs) assessing any intervention in the neonatal period and including one or more RCTs reporting LOS. Two authors independently performed screening, data extraction, assessed the quality of evidence using Cochrane Grading of Recommendations Assessment, Development and Evaluation, and assessed the quality of reviews using a measurement tool to assess of multiple systematic reviews 2 tool. RESULTS A total of 101 high-quality Cochrane reviews involving 612 RCTs and 193,713 neonates, evaluating 141 interventions were included. High-quality evidence showed a reduction in any or culture-proven LOS using antibiotic lock therapy for neonates with central venous catheters (CVC). Moderate-quality evidence showed a decrease in any LOS with antibiotic prophylaxis or vancomycin prophylaxis for neonates with CVC, chlorhexidine for skin or cord care, and kangaroo care for low birth weight babies. Similarly, moderate-quality evidence showed reduced culture-proven LOS with intravenous immunoglobulin prophylaxis for preterm infants and probiotic supplementation for very low birth weight (VLBW) infants. Lastly, moderate-quality evidence showed a reduction in fungal LOS with the use of systemic antifungal prophylaxis in VLBW infants. CONCLUSIONS The overview summarizes the evidence from the Cochrane reviews assessing interventions for reducing LOS in neonates, and can be utilized by clinicians, researchers, policymakers, and consumers for decision-making and translating evidence into clinical practice.
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Affiliation(s)
- Abdul Razak
- Monash Newborn, Monash Children's Hospital, Department of Paediatrics, Monash University, Clayton, VIC 3168, Australia
- Division of Neonatology, Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Omar Ibrahim Alhaidari
- Division of Neonatology, Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, ON, Canada
| | - Javed Ahmed
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, ON, Canada
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16
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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: 133] [Impact Index Per Article: 133.0] [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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Dumpa V, Avulakunta I, Bhandari V. Respiratory management in the premature neonate. Expert Rev Respir Med 2023; 17:155-170. [PMID: 36803028 DOI: 10.1080/17476348.2023.2183843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes. AREAS COVERED Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed. EXPERT OPINION Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Indirapriya Avulakunta
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper Medical School of Rowan University, the Children's Regional Hospital at Cooper, Camden, NJ, USA
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Harris C, Greenough A. The prevention and management strategies for neonatal chronic lung disease. Expert Rev Respir Med 2023; 17:143-154. [PMID: 36813477 DOI: 10.1080/17476348.2023.2183842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Survival from even very premature birth is improving, but long-term respiratory morbidity following neonatal chronic lung disease (bronchopulmonary dysplasia (BPD)) has not reduced. Affected infants may require supplementary oxygen at home, because they have more hospital admissions particularly due to viral infections and frequent, troublesome respiratory symptoms requiring treatment. Furthermore, adolescents and adults who had BPD have poorer lung function and exercise capacity. AREAS COVERED Antenatal and postnatal preventative strategies and management of infants with BPD. A literature review was undertaken using PubMed and Web of Science. EXPERT OPINION There are effective preventative strategies which include caffeine, postnatal corticosteroids, vitamin A, and volume guarantee ventilation. Side-effects, however, have appropriately caused clinicians to reduce use of systemically administered corticosteroids to infants only at risk of severe BPD. Promising preventative strategies which need further research are surfactant with budesonide, less invasive surfactant administration (LISA), neurally adjusted ventilatory assist (NAVA) and stem cells. The management of infants with established BPD is under-researched and should include identifying the optimum form of respiratory support on the neonatal unit and at home and which infants will most benefit in the long term from pulmonary vasodilators, diuretics, and bronchodilators.
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Affiliation(s)
- Christopher Harris
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
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Boix H, Fernández C, Serrano Martín MDM, Arruza L, Concheiro A, Gimeno A, Sánchez A, Rite S, Jiménez F, Méndez P, Agüera JJ. Failure of early non-invasive ventilation in preterm infants with respiratory distress syndrome in current care practice in Spanish level-III neonatal intensive care units - a prospective observational study. Front Pediatr 2023; 11:1098971. [PMID: 36896404 PMCID: PMC9989254 DOI: 10.3389/fped.2023.1098971] [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: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Despite advances in respiratory distress syndrome (RDS) management over the past decade, non-invasive ventilation (NIV) failure is frequent and associated with adverse outcomes. There are insufficient data on the failure of different NIV strategies currently used in clinical practice in preterm infants. Methods This was a prospective, multicenter, observational study of very preterm infants [gestational age (GA) <32 weeks] admitted to the neonatal intensive care unit for RDS that required NIV from the first 30 min after birth. The primary outcome was the incidence of NIV failure, defined as the need for mechanical ventilation for <72 h of life. Secondary outcomes were risk factors associated with NIV failure and complication rates. Results The study included 173 preterm infants with a median GA of 28 (IQR 27-30) weeks and a median birth weight of 1,100 (IQR 800-1,333) g. The incidence of NIV failure was 15.6%. In the multivariate analysis, lower GA (OR, 0.728; 95% CI, 0.576-0.920) independently increased the risk of NIV failure. Compared to NIV success, NIV failure was associated with higher rates of unfavorable outcomes, including pneumothorax, intraventricular hemorrhage, periventricular leukomalacia, pulmonary hemorrhage, and a combined outcome of moderate-to-severe bronchopulmonary dysplasia or death. Conclusion NIV failure occurred in 15.6% of the preterm neonates and was associated with adverse outcomes. The use of LISA and newer NIV modalities most likely accounts for the reduced failure rate. Gestational age remains the best predictor of NIV failure and is more reliable than the fraction of inspired oxygen during the first hour of life.
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Affiliation(s)
- Hector Boix
- Division of Neonatology, Hospital Universitario Dexeus, Barcelona, Spain
| | - Cristina Fernández
- Department of Neonatology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Luis Arruza
- Department of Neonatology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ana Concheiro
- Department of Neonatology, Álvaro Cunqueiro University Hospital, Vigo, Spain
| | - Ana Gimeno
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Ana Sánchez
- Department of Neonatology, Hospital Universitario La Paz, Madrid, Spain
| | - Segundo Rite
- Division of Neonatology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Francisco Jiménez
- Department of Neonatology and Neonatal Intensive Care Unit, Hospital Infantil Universitario Virgen del Rocio, Seville, Spain
| | - Paula Méndez
- Division of Paediatrics, Section of Neonatology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Juan José Agüera
- Department of Paediatrics, Neonatology Section, Virgen de la Arrixaca, University Hospital, Murcia, Spain
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Mamidi RR, MacDonald KD, Brumbach BH, Go MDA, McEvoy CT. Nasal continuous positive airway pressure practices in preterm infants: A survey of neonatal providers. J Neonatal Perinatal Med 2023; 16:611-617. [PMID: 38043019 DOI: 10.3233/npm-230006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
BACKGROUND The standard of care for respiratory support of preterm infants is nasal continuous positive airway pressure (CPAP), yet practices are not standardized. Our aim was to survey CPAP practices in infants < 32 weeks gestation among the American Academy of Pediatrics Neonatal-Perinatal section. METHODS A US, web-based survey inquired about the initiation, management, and discontinuation of CPAP, and chinstrap use and oral feedings on CPAP. RESULTS 857 providers consented. Regarding criteria to discontinue/wean CPAP: 69% use specific respiratory stability criteria; 22% a specific post-menstrual age; 8% responded other. 64% did not have guidelines for CPAP discontinuation; 54% did not have guidelines for CPAP initiation. 66% believe chinstraps improve CPAP efficacy; however, 11% routinely apply a chinstrap. 22% allow oral feeds on CPAP in certain circumstances. CONCLUSION There are meaningful variabilities in CPAP practices among neonatal providers across the US. Given the potential long-term implications this can have on the growth and development of the preterm lung, further evidence-based research is needed in relation to respiratory outcomes to optimize and standardize CPAP strategies.
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Affiliation(s)
- R R Mamidi
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
| | - K D MacDonald
- Division of Pediatric Pulmonology, Oregon Health & Science University, Portland, OR, USA
| | - B H Brumbach
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - M D A Go
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
| | - C T McEvoy
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
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21
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Boel L, Hixson T, Brown L, Sage J, Kotecha S, Chakraborty M. Non-invasive respiratory support in preterm infants. Paediatr Respir Rev 2022; 43:53-59. [PMID: 35562288 DOI: 10.1016/j.prrv.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 12/25/2022]
Abstract
Survival of preterm infants has increased steadily over recent decades, primarily due to improved outcomes for those born before 28 weeks of gestation. However, this has not been matched by similar improvements in longer-term morbidity. One of the key long-term sequelae of preterm birth remains bronchopulmonary dysplasia (also called chronic lung disease of prematurity), contributed primarily by the effect of early pulmonary inflammation superimposed on immature lungs. Non-invasive modes of respiratory support have been rapidly introduced providing modest success in reducing the incidence of bronchopulmonary dysplasia when compared with invasive mechanical ventilation, and improved clinical practice has been reported from population-based studies. We present a comprehensive review of the key modes of non-invasive respiratory support currently used in preterm infants, including their mechanisms of action and evidence of benefit from clinical trials.
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Affiliation(s)
- Lieve Boel
- Neonatal Intensive Care Unit, Queen Alexandra Hospital, Portsmouth, UK
| | - Thomas Hixson
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Lisa Brown
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Jayne Sage
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Mallinath Chakraborty
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK; Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, UK.
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22
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Ekhaguere OA, Okonkwo IR, Batra M, Hedstrom AB. Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022. Front Pediatr 2022; 10:961509. [PMID: 35967574 PMCID: PMC9372546 DOI: 10.3389/fped.2022.961509] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023] Open
Abstract
The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.
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Affiliation(s)
- Osayame A. Ekhaguere
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ikechukwu R. Okonkwo
- Department of Pediatrics, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Maneesh Batra
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| | - Anna B. Hedstrom
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
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23
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Continuing interventions in a quality improvement bundle to reduce bronchopulmonary dysplasia. World J Pediatr 2022; 18:278-282. [PMID: 35179711 DOI: 10.1007/s12519-021-00508-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 10/19/2022]
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Zhang H, Li J, Zeng L, Gao Y, Zhao W, Han T, Tong X. A multicenter, randomized controlled, non-inferiority trial, comparing nasal continuous positive airway pressure with nasal intermittent positive pressure ventilation as primary support before minimally invasive surfactant administration for preterm infants with respiratory distress syndrome (the NIV-MISA-RDS trial): Study protocol. Front Pediatr 2022; 10:968462. [PMID: 35967549 PMCID: PMC9372355 DOI: 10.3389/fped.2022.968462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Non-invasive ventilation (NIV) treatment has been developed to minimize lung damage and to avoid invasive mechanical ventilation (IMV) in preterm infants, especially in those with a gestational age of <30 weeks. Our hypothesis is that for preterm infants <30 weeks with potential to develop respiratory distress syndrome (RDS), nasal continuous positive airway pressure (NCPAP) is non-inferior to the nasal intermittent positive pressure ventilation (NIPPV) as primary respiratory support before minimal invasive surfactant administration (MISA). METHODS AND DESIGN The NIV-MISA-RDS trial is planned as an unblinded, multicenter, randomized, non-inferiority trial at 14 tertiary neonatal intensive care units (NICUs) in China. Eligible infants are preterm infants of 24-29+6 weeks of gestational age who have spontaneous breaths at birth and require primary NIV support for RDS. Infants are randomized 1:1 to treatment with either NCPAP or NIPPV once admitted into NICUs. If an infant presents progressively aggravated respiratory distress and is clinically diagnosed as having RDS, pulmonary surfactant will be supplemented by MISA in the first 2 h of life. The primary outcome is NIV treatment failure within 72 h after birth. With a specified non-inferiority margin of 10%, using a two-sided 95% CI and 80% power, the study requires 480 infants per group (in total 960 infants). DISCUSSION Current evidence shows that NIV and MISA may be the most effective strategy for minimizing IMV in preterm infants with RDS. However, there are few large randomized controlled trials to compare the effectiveness of NCPAP and NIPPV as the primary respiratory support after birth and before surfactant administration. We will conduct this trial to test the hypothesis that NCPAP is not inferior to NIPPV as the initial respiratory support in reducing the use of IMV in premature infants who have spontaneous breaths after birth and who do not require intubation in the first 2 h after birth. The study will provide clinical data for the selection of the initial non-invasive ventilation mode in preterm infants with a gestational age of <30 weeks with spontaneous breaths after birth. CLINICAL TRIAL REGISTRATION https://register.clinicaltrials.gov, identifier: NCT05137340.
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Affiliation(s)
- Hui Zhang
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Jun Li
- School of Health Humanities, Peking University, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yajuan Gao
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Wanjun Zhao
- Department of Pediatrics, Beijing Hospital, Beijing, China
| | - Tongyan Han
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
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