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Ribeiro DDFC, Hembecker PK, Nakato AM, Fernandes BL, Nohama P. Satisfaction of Health Professionals Regarding the Short Binasal Prong Used as a Non-Invasive Ventilation Interface in Neonatology. J Multidiscip Healthc 2023; 16:2217-2229. [PMID: 37551341 PMCID: PMC10404407 DOI: 10.2147/jmdh.s415748] [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: 04/30/2023] [Accepted: 07/05/2023] [Indexed: 08/09/2023] Open
Abstract
Purpose To evaluate the health professionals' satisfaction regarding the short binasal prong used in Neonatal Intensive Care Units (NICU), evaluate the difficulties related to its use, and present possible improvements in the design of this device. Patients and Methods Observational, cross-sectional study with prospective data collection carried out in the NICU of a public hospital in southern Brazil. This research was presented into two stages. In the first stage, the Quebec User Evaluation of Satisfaction with Assistive Technology was applied with 90 health professionals to evaluate the satisfaction regarding the short binasal prong. In the second stage, the health professional's experiences and difficulties in using the binasal prongs in 14 newborns (NBs) that required non-invasive ventilation was collected. The short binasal prongs used was the Fanem® brand and the CPAP circuit was Gabisa Medical International (GMI®). Finally, improvements and recommendations were presented to optimize the device's design. Results The mean score of the health professionals' satisfaction with short binasal prongs was 3.8 ± 0.6. Ease of adjustment (3.27) and dimensions (3.62) variables had the worst scores. The main difficulties pointed out by health professionals were: circuit disconnection (57.1%), the size of the prong did not correspond to NBs' anatomical characteristics (35.7%), air leakage (21.4%), and difficulty in fixing and positioning the prong in the NB (14.28%). The improvements suggested were: appropriate prong sizes based on the anatomical characteristics of the NBs; adjustable distance between insertion and base catheters; manufactured with malleable material, however not easily foldable; curved and adjustable insertion catheters and functional system of tracheas' connection. Conclusion The dissatisfaction of health professionals with the dimensions and prongs adjustments and the difficulties faced in clinical practice indicate the need for improvements in these interfaces. The recommendations presented in this study may contribute to optimizing the design of the binasal prong in the future.
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Affiliation(s)
- Débora de Fátima Camillo Ribeiro
- Neonatal Services, Waldemar Monastier Hospital, Campo Largo, Paraná, Brazil
- Graduate Program on Health Technology, Pontifícia Universidade Católica Do Paraná, Curitiba, Paraná, Brazil
| | - Paula Karina Hembecker
- Graduate Program on Health Technology, Pontifícia Universidade Católica Do Paraná, Curitiba, Paraná, Brazil
| | - Adriane Muller Nakato
- Graduate Program on Health Technology, Pontifícia Universidade Católica Do Paraná, Curitiba, Paraná, Brazil
| | - Beatriz Luci Fernandes
- Graduate Program on Health Technology, Pontifícia Universidade Católica Do Paraná, Curitiba, Paraná, Brazil
| | - Percy Nohama
- Graduate Program on Health Technology, Pontifícia Universidade Católica Do Paraná, Curitiba, Paraná, Brazil
- Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal Do Paraná, Curitiba, Paraná, Brazil
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Ho JJ, Zakarija-Grkovic I, Lok JW, Lim E, Subramaniam P, Leong JJ. Continuous positive airway pressure (CPAP) for apnoea of prematurity. Cochrane Database Syst Rev 2023; 7:CD013660. [PMID: 37481707 PMCID: PMC10363278 DOI: 10.1002/14651858.cd013660.pub2] [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] [Indexed: 07/24/2023]
Abstract
BACKGROUND Apnoea of prematurity (AoP) is defined as a pause in breathing for 20 seconds or longer, or for less than 20 seconds when accompanied by bradycardia and hypoxaemia, in a preterm infant. An association between the severity of apnoea and neurodevelopmental delay has been reported. Continuous positive airway pressure (CPAP) is a form of non-invasive ventilatory assistance that has been shown to be relatively safe and effective in preventing and treating respiratory distress among preterm infants. It is less clear whether CPAP treatment is safe and effective in the prevention and treatment of AoP. OBJECTIVES 1. To assess the effects of CPAP on AoP in preterm infants (this may be compared to supportive care or mechanical ventilation). 2. To assess the effects of different CPAP delivery systems on AoP in preterm infants. SEARCH METHODS Searches were conducted in September 2022 in the following databases: Cochrane Library, MEDLINE, Embase, and CINAHL. We also searched clinical trial registries and the reference lists of studies selected for inclusion. SELECTION CRITERIA We included all randomised and quasi-randomised controlled trials (RCTs) in which researchers determined that CPAP was necessary for AoP in preterm infants (born before 37 weeks). Cross-over studies were also included, provided sufficient data were available for analysis. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane and Cochrane Neonatal, including independent assessment of risk of bias and extraction of data by at least two review authors. Discrepancies were resolved by involvement of a third author. We used the GRADE approach to assess the certainty of evidence for the following outcomes: 1) failed CPAP; 2) apnoea; 3) adverse effects of CPAP. MAIN RESULTS We included four single-centre trials conducted in Malaysia, Spain, Germany, and North America, involving 138 infants with a mean/median gestation of 26 to 28 weeks. Two studies were parallel-group RCTs and two were cross-over trials. None of the studies compared CPAP with supportive care. All trials compared one form of CPAP with another. Two compared a variable flow device with ventilator CPAP, one compared two different variable flow devices, and one compared a variable flow device with bubble CPAP. Interventions were administered for periods ranging between six and 48 hours, with pressures between 4 and 6 cm H2O. We assessed all trials as having a high risk of bias for blinding of participants and personnel, and two studies for blinding of outcome assessors. We found a high risk of a carry-over effect in two studies where the washout period was not adequately described, and a high risk of bias in a study that appeared to use an analysis method not generally accepted for cross-over studies. Comparison 1. CPAP and supportive care compared to supportive care alone We did not identify any study for inclusion in this comparison. Comparison 2. CPAP delivered by different types of devices 2a. Variable flow compared to ventilator CPAP Two studies were included in this comparison. We are very uncertain whether there is any difference in the incidence of failed CPAP, defined as the need for mechanical ventilation (risk ratio (RR) 0.16, 95% confidence interval (CI) 0.01 to 2.90; 1 study, 26 participants; very low-certainty). We are very uncertain whether there is any difference in the frequency of apnoea events (mean difference (MD) per four-hour interval -0.10, 95% CI -1.30 to 1.10; 1 study, 26 participants; very low-certainty). We are uncertain whether there is any difference in adverse events. Neurodevelopmental outcomes were not reported. 2b. Variable flow compared to bubble CPAP We included one study in this comparison, but it did not report our pre-specified outcomes. 2c. Infant Flow variable flow CPAP compared to Medijet variable flow CPAP We are very uncertain whether there is any difference in the incidence of failed CPAP (RR 2.62, 95% CI 0.91 to 7.53; 1 study, 80 participants; very low-certainty). The frequency of apnoea was not reported, and we do not know whether there is any difference in adverse events. Neurodevelopmental outcomes were not reported. Comparison 3. CPAP compared to mechanical ventilation We did not identify any studies for inclusion in this comparison. AUTHORS' CONCLUSIONS Due to the limited available evidence, we are very uncertain whether any CPAP device is more effective than other forms of supportive care, other CPAP devices, or mechanical ventilation for the prevention and treatment of AoP. The devices used in these studies included two types of variable flow CPAP device: bubble CPAP and ventilator CPAP. For each comparison, data were only available from a single study. There are theoretical reasons why these devices might have different effects on AoP, therefore further trials are indicated.
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Affiliation(s)
- Jacqueline J Ho
- Department of Paediatrics, RCSI & UCD Malaysia Campus (formerly Penang Medical College), George Town, Malaysia
| | | | - Jia Wen Lok
- RCSI & UCD Malaysia Campus, George Town, Malaysia
| | - Eunice Lim
- RCSI & UCD Malaysia Campus, George Town, Malaysia
| | - Prema Subramaniam
- Paediatric Department, Mount Isa Base Hospital, Mount Isa, Australia
| | - Jen Jen Leong
- Paediatric Department, Seberang Jaya Hospital, Perai, Malaysia
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Prakash R, De Paoli AG, Davis PG, Oddie SJ, McGuire W. Bubble devices versus other pressure sources for nasal continuous positive airway pressure in preterm infants. Cochrane Database Syst Rev 2023; 3:CD015130. [PMID: 37009665 PMCID: PMC10064833 DOI: 10.1002/14651858.cd015130] [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: 04/03/2023]
Abstract
BACKGROUND Several types of pressure sources, including underwater bubble devices, mechanical ventilators, and the Infant Flow Driver, are used for providing continuous positive airway pressure (CPAP) to preterm infants with respiratory distress. It is unclear whether the use of bubble CPAP versus other pressure sources is associated with lower rates of CPAP treatment failure, or mortality and other morbidity. OBJECTIVES: To assess the benefits and harms of bubble CPAP versus other pressure sources (mechanical ventilators or Infant Flow Driver) for reducing treatment failure and associated morbidity and mortality in newborn preterm infants with or at risk of respiratory distress. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2023, Issue 1); MEDLINE (1946 to 6 January 2023), Embase (1974 to 6 January 2023), Maternity & Infant Care Database (1971 to 6 January 2023), and the Cumulative Index to Nursing and Allied Health Literature (1982 to 6 January 2023). We searched clinical trials databases and the reference lists of retrieved articles. SELECTION CRITERIA We included randomised controlled trials comparing bubble CPAP with other pressure sources (mechanical ventilators or Infant Flow Driver) for the delivery of nasal CPAP to preterm infants. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of the evidence for effects on treatment failure, all-cause mortality, neurodevelopmental impairment, pneumothorax, moderate-severe nasal trauma, and bronchopulmonary dysplasia. MAIN RESULTS We included 15 trials involving a total of 1437 infants. All trials were small (median number of participants 88). The methods used to generate the randomisation sequence and ensure allocation concealment were unclear in about half of the trial reports. Lack of measures to blind caregivers or investigators was a potential source of bias in all of the included trials. The trials took place during the past 25 years in care facilities internationally, predominantly in India (five trials) and Iran (four trials). The studied pressure sources were commercially available bubble CPAP devices versus a variety of mechanical ventilator (11 trials) or Infant Flow Driver (4 trials) devices. Meta-analyses suggest that the use of bubble CPAP compared with mechanical ventilator or Infant Flow Driver CPAP may reduce the rate of treatment failure (RR 0.76, 95% confidence interval (CI) 0.60 to 0.95; (I² = 31%); RD -0.05, 95% CI -0.10 to -0.01; number needed to treat for an additional beneficial outcome 20, 95% CI 10 to 100; 13 trials, 1230 infants; low certainty evidence). The type of pressure source may not affect mortality prior to hospital discharge (RR 0.93, 95% CI 0.64 to 1.36 (I² = 0%); RD -0.01, 95% CI -0.04 to 0.02; 10 trials, 1189 infants; low certainty evidence). No data were available on neurodevelopmental impairment. Meta-analysis suggests that the pressure source may not affect the risk of pneumothorax (RR 0.73, 95% CI 0.40 to 1.34 (I² = 0%); RD -0.01, 95% CI -0.03 to 0.01; 14 trials, 1340 infants; low certainty evidence). Bubble CPAP likely increases the risk of moderate-severe nasal injury (RR 2.29, 95% CI 1.37 to 3.82 (I² = 17%); RD 0.07, 95% CI 0.03 to 0.11; number needed to treat for an additional harmful outcome 14, 95% CI 9 to 33; 8 trials, 753 infants; moderate certainty evidence). The pressure source may not affect the risk of bronchopulmonary dysplasia (RR 0.76, 95% CI 0.53 to 1.10 (I² = 0%); RD -0.04, 95% CI -0.09 to 0.01; 7 trials, 603 infants; low certainty evidence). AUTHORS' CONCLUSIONS: Given the low level of certainty about the effects of bubble CPAP versus other pressure sources on the risk of treatment failure and most associated morbidity and mortality for preterm infants, further large, high-quality trials are needed to provide evidence of sufficient validity and applicability to inform context- and setting-relevant policy and practice.
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Affiliation(s)
- Raj Prakash
- Paediatrics, York and Scarborough Teaching Hospitals NHS Trust, York, UK
| | | | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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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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Gautam G, Gupta N, Sasidharan R, Thanigainathan S, Yadav B, Singh K, Singh A. Systematic rotation versus continuous application of 'nasal prongs' or 'nasal mask' in preterm infants on nCPAP: a randomized controlled trial. Eur J Pediatr 2023:10.1007/s00431-023-04933-1. [PMID: 36967420 PMCID: PMC10040306 DOI: 10.1007/s00431-023-04933-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/04/2023] [Accepted: 03/12/2023] [Indexed: 03/29/2023]
Abstract
To compare whether alternate rotation of nasal mask with nasal prongs every 8 h as compared to continuous use of either interface alone decreases the incidence of nasal injury in preterm infants receiving nasal Continuous Positive Airway Pressure (nCPAP). This was an open-label, three-arm, stratified randomized controlled trial where infants < 35 weeks receiving nCPAP were randomized into three groups using two different nasal interfaces (continuous prongs group, continuous mask group, and rotation group). All infants were assessed for nasal injury six hours post-removal of nCPAP using grading suggested by Fischer et al. The nursing care was uniform across all three groups. Intention-to-treat analysis was done. Fifty-seven infants were enrolled, with nineteen in each group. The incidence of nasal injury was 42.1% vs. 47.4% vs. 68.4% in the rotation group, continuous mask, and continuous prongs groups, respectively (P = 0.228). On adjusted analysis (gestational age, birth weight, and duration of nCPAP therapy), the incidence of nasal injury was significantly less in the rotation group as compared to continuous prongs group (Adjusted Odds Ratio [AOR], 95% confidence interval [CI]; 0.10 [0.01-0.69], P = 0.02) and a trend towards lesser nasal injury as compared to continuous mask group (AOR, 95% CI; 0.15 [0.02-1.08], P = 0.06). However, there was no significant difference in incidence of nasal injuries between continuous prongs versus continuous mask group (P = 0.60). The need for surfactant, nCPAP failure rate, duration of nCPAP, and common neonatal co-morbidities were similar across all three groups. Conclusion: Systematic rotation of nasal mask with nasal prongs significantly reduced nasal injury among preterm infants on nCPAP as compared to continuous use of nasal prongs alone without affecting nCPAP failure rate. Trial registration: CTRI/2019/01/017320, registered on 31/01/2019. What is Known: • Use of nasal mask as an interface for nasal Continuous Positive Airway Pressure decreases nasal injury as compared to nasal prongs. What is New: • Rotation of nasal prongs and nasal mask interfaces alternately every 8 h may reduce the nasal injury even further as compared to either interface alone.
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Affiliation(s)
- Gaurav Gautam
- Department of Paediatrics, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Neeraj Gupta
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India.
| | - Rohit Sasidharan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Sivam Thanigainathan
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Bharti Yadav
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Kuldeep Singh
- Department of Paediatrics, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
| | - Arun Singh
- Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, 342005, Rajasthan, India
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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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Prakash R, De Paoli AG, Oddie SJ, Davis PG, McGuire W. Masks versus prongs as interfaces for nasal continuous positive airway pressure in preterm infants. Cochrane Database Syst Rev 2022; 11:CD015129. [PMID: 36374241 PMCID: PMC9662142 DOI: 10.1002/14651858.cd015129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nasal masks and nasal prongs are used as interfaces for providing continuous positive airway pressure (CPAP) for preterm infants with or at risk of respiratory distress, either as primary support after birth or as ongoing support after endotracheal extubation from mechanical ventilation. It is unclear which type of interface is associated with lower rates of CPAP treatment failure, nasal trauma, or mortality and other morbidity. OBJECTIVES To assess the benefits and harms of nasal masks versus nasal prongs for reducing CPAP treatment failure, nasal trauma, or mortality and other morbidity in newborn preterm infants with or at risk of respiratory distress. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was October 2021. SELECTION CRITERIA We included randomised controlled trials comparing masks versus prongs as interfaces for delivery of nasal CPAP in newborn preterm infants (less than 37 weeks' gestation) with or at risk of respiratory distress. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. treatment failure, 2. all-cause mortality, and 3. neurodevelopmental impairment. Our secondary outcomes were 4. pneumothorax, 5. moderate-severe nasal trauma, 6. bronchopulmonary dysplasia, 7. duration of CPAP use, 8. duration of oxygen supplementation, 9. duration of hospitalisation, 10. patent ductus arteriosus receiving medical or surgical treatment, 11. necrotising enterocolitis, 12. severe intraventricular haemorrhage, and 13. severe retinopathy of prematurity. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 12 trials with 1604 infants. All trials were small (median number of participants 118). The trials occurred after 2001 in care facilities internationally, predominantly in India (eight trials). Most participants were preterm infants of 26 to 34 weeks' gestation who received nasal CPAP as the primary form of respiratory support after birth. The studied interfaces included commonly used commercially available masks and prongs. Lack of measures to blind caregivers or investigators was a potential source of performance and detection bias in all the trials. Meta-analyses suggested that use of masks compared with prongs may reduce CPAP treatment failure (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 8 trials, 919 infants; low certainty). The type of interface may not affect mortality prior to hospital discharge (RR 0.83, 95% CI 0.56 to 1.22; 7 trials, 814 infants; low certainty). There are no data on neurodevelopmental impairment. Meta-analyses suggest that the choice of interface may result in little or no difference in the risk of pneumothorax (RR 0.93, 95% CI 0.45 to 1.93; 5 trials, 625 infants; low certainty). Use of masks rather than prongs may reduce the risk of moderate-severe nasal injury (RR 0.55, 95% CI 0.44 to 0.71; 10 trials, 1058 infants; low certainty). The evidence is very uncertain about the effect on bronchopulmonary dysplasia (RR 0.69, 95% CI 0.46 to 1.03; 7 trials, 843 infants; very low certainty). AUTHORS' CONCLUSIONS The available trial data provide low-certainty evidence that use of masks compared with prongs as the nasal CPAP interface may reduce treatment failure and nasal injury, and may have little or no effect on mortality or the risk of pneumothorax in newborn preterm infants with or at risk of respiratory distress. The effect on bronchopulmonary dysplasia is very uncertain. Large, high-quality trials would be needed to provide evidence of sufficient validity and applicability to inform policy and practice.
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Affiliation(s)
- Raj Prakash
- York and Scarborough Teaching Hospitals, NHS Trust, York, UK
| | | | - Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
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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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Bamat N, Fierro J, Mukerji A, Wright CJ, Millar D, Kirpalani H. Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2021; 11:CD012778. [PMID: 34847243 PMCID: PMC8631577 DOI: 10.1002/14651858.cd012778.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Preterm infants are at risk of lung atelectasis due to various anatomical and physiological immaturities, placing them at high risk of respiratory failure and associated harms. Nasal continuous positive airway pressure (CPAP) is a positive pressure applied to the airways via the nares. It helps prevent atelectasis and supports adequate gas exchange in spontaneously breathing infants. Nasal CPAP is used in the care of preterm infants around the world. Despite its common use, the appropriate pressure levels to apply during nasal CPAP use remain uncertain. OBJECTIVES To assess the effects of 'low' (≤ 5 cm H2O) versus 'moderate-high' (> 5 cm H2O) initial nasal CPAP pressure levels in preterm infants receiving CPAP either: 1) for initial respiratory support after birth and neonatal resuscitation or 2) following mechanical ventilation and endotracheal extubation. SEARCH METHODS We ran a comprehensive search on 6 November 2020 in the following databases: CENTRAL via CRS Web and MEDLINE via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA We included RCTs, quasi-RCTs, cluster-RCTs and cross-over RCTs randomizing preterm infants of gestational age < 37 weeks or birth weight < 2500 grams within the first 28 days of life to different nasal CPAP levels. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal to collect and analyze data. We used the GRADE approach to assess the certainty of the evidence for the prespecified primary outcomes. MAIN RESULTS Eleven trials met inclusion criteria of the review. Four trials were parallel-group RCTs reporting our prespecified primary or secondary outcomes. Two trials randomized 316 infants to low versus moderate-high nasal CPAP for initial respiratory support, and two trials randomized 117 infants to low versus moderate-high nasal CPAP following endotracheal extubation. The remaining seven studies were cross-over trials reporting short-term physiological outcomes. The most common potential sources of bias were absent or unclear blinding of personnel and assessors and uncertain selective reporting. Nasal CPAP for initial respiratory support after birth and neonatal resuscitation None of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months. The remaining five outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (PMA) (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.56 to 1.85; 1 trial, 271 participants); mortality by hospital discharge (RR 1.04, 95% CI 0.51 to 2.12; 1 trial, 271 participants); BPD at 28 days of age (RR 1.10, 95% CI 0.56 to 2.17; 1 trial, 271 participants); BPD at 36 weeks' PMA (RR 0.80, 95% CI 0.25 to 2.57; 1 trial, 271 participants), and treatment failure or need for mechanical ventilation (RR 1.00, 95% CI 0.63 to 1.57; 1 trial, 271 participants). We assessed the certainty of the evidence as very low for all five outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. Nasal CPAP following mechanical ventilation and endotracheal extubation One of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. On the basis of these data, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcome of treatment failure or need for mechanical ventilation (RR 1.52, 95% CI 0.92 to 2.50; 2 trials, 117 participants; I2 = 17%; risk difference 0.15, 95% CI -0.02 to 0.32; number needed to treat for an additional beneficial outcome 7, 95% CI -50 to 3). We assessed the certainty of the evidence as very low due to risk of bias, inconsistency across the studies, and imprecise effect estimates. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months or BPD at 28 days of age. The remaining three outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants); mortality by hospital discharge (RR 2.94, 95% CI 0.12 to 70.30; 1 trial, 93 participants), and BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants). We assessed the certainty of the evidence as very low for all three outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. AUTHORS' CONCLUSIONS: There are insufficient data from randomized trials to guide nasal CPAP level selection in preterm infants, whether provided as initial respiratory support or following extubation from invasive mechanical ventilation. We are uncertain as to whether low or moderate-high nasal CPAP levels improve morbidity and mortality in preterm infants. Well-designed trials evaluating this important aspect of a commonly used neonatal therapy are needed.
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Affiliation(s)
- Nicolas Bamat
- Division of Neonatology and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie Fierro
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Amit Mukerji
- Paediatrics, McMaster University, Hamilton, Canada
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Millar
- Regional Neonatal Intensive Care Unit, Royal Jubilee Maternity Service, Belfast, UK
| | - Haresh Kirpalani
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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10
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Poets CF, Lim K, Marshall A, Jackson H, Gale TJ, Dargaville PA. Mask versus nasal prong leak and intermittent hypoxia during continuous positive airway pressure in very preterm infants. Arch Dis Child Fetal Neonatal Ed 2021; 106:81-83. [PMID: 32796057 DOI: 10.1136/archdischild-2020-319092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/09/2020] [Accepted: 06/23/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) can be applied via binasal prongs or nasal masks; both may be associated with air leak and intermittent hypoxia. We investigated whether the latter is more frequent with nasal masks or prongs. METHODS Continuous 24 hours recordings of inspired oxygen fraction (FiO2), pulse rate, respiratory rate, pulse oximeter saturation (SpO2) and CPAP level were made in preterm infants with respiratory insufficiency (n=20) managed on CPAP in the NICU at the Royal Hobart Hospital. As part of routine care, nasal interfaces were alternated 4-hourly between mask and prongs. In each recording, the first two segments containing at least 3 hours of artefact-free signal for each interface were selected. Recordings were analysed for episodes with hypoxaemia (SpO2 <80% for ≥10 s) and bradycardia (pulse rate <80/min for ≥4 s) and for episodes of pressure loss at the nasal interface. Data were compared using Wilcoxon-matched pairs test and are reported as median (IQR). RESULTS Infants had a gestational age at birth of 26 (25-27) weeks and postnatal age of 17 (14-24) days. There was no difference in %time with interface leak between prong and mask (0.9 (0-8)% vs 1.1 (0-18)%, p=0.82), %time with SpO2 <80% (0.15 (0-1.2)% vs 0.06 (0-0.8)%, p=0.74) or heart rate <80/min (0.03 (0-0.2)% vs 0 (0-0.2)%, p=0.64). Three infants had interface leak for >10% of the time with prongs and 5 with the mask. CONCLUSION Both interfaces resulted in a similarly stable provision of positive airway pressure, and there was also no difference in the occurrence of intermittent hypoxia.
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Affiliation(s)
- Christian F Poets
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Department of Neonatology, Universitatsklinikum Tubingen, Tubingen, Baden-Württemberg, Germany
| | - Kathleen Lim
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Andrew Marshall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.,School of Engineering and ICT, University of Tasmania, Hobart, Tasmania, Australia
| | - Hamish Jackson
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Timothy J Gale
- School of Engineering and ICT, University of Tasmania, Hobart, Tasmania, Australia
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia .,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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11
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Ho JJ, Subramaniam P, Davis PG. Continuous positive airway pressure (CPAP) for respiratory distress in preterm infants. Cochrane Database Syst Rev 2020; 10:CD002271. [PMID: 33058208 PMCID: PMC8094155 DOI: 10.1002/14651858.cd002271.pub3] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Respiratory distress, particularly respiratory distress syndrome (RDS), is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant has been the usual treatment, but it is invasive, potentially resulting in airway and lung injury. Continuous positive airway pressure (CPAP) has been used for the prevention and treatment of respiratory distress, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae. OBJECTIVES To determine the effect of continuous distending pressure in the form of CPAP on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress. SEARCH METHODS We used the standard strategy of Cochrane Neonatal to search CENTRAL (2020, Issue 6); Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL on 30 June 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA All randomised or quasi-randomised trials of preterm infants with respiratory distress were eligible. Interventions were CPAP by mask, nasal prong, nasopharyngeal tube or endotracheal tube, compared with spontaneous breathing with supplemental oxygen as necessary. DATA COLLECTION AND ANALYSIS We used standard methods of Cochrane and its Neonatal Review Group, including independent assessment of risk of bias and extraction of data by two review authors. We used the GRADE approach to assess the certainty of evidence. Subgroup analyses were planned on the basis of birth weight (greater than or less than 1000 g or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), timing of application (early versus late in the course of respiratory distress), pressure applied (high versus low) and trial setting (tertiary compared with non-tertiary hospitals; high income compared with low income) MAIN RESULTS: We included five studies involving 322 infants; two studies used face mask CPAP, two studies used nasal CPAP and one study used endotracheal CPAP and continuing negative pressure for a small number of less ill babies. For this update, we included one new trial. CPAP was associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.64, 95% confidence interval (CI) 0.50 to 0.82; typical risk difference (RD) -0.19, 95% CI -0.28 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 4 to 11; I2 = 50%; 5 studies, 322 infants; very low-certainty evidence), lower use of ventilatory assistance (typical RR 0.72, 95% CI 0.54 to 0.96; typical RD -0.13, 95% CI -0.25 to -0.02; NNTB 8, 95% CI 4 to 50; I2 = 55%; very low-certainty evidence) and lower overall mortality (typical RR 0.53, 95% CI 0.34 to 0.83; typical RD -0.11, 95% CI -0.18 to -0.04; NNTB 9, 95% CI 2 to 13; I2 = 0%; 5 studies, 322 infants; moderate-certainty evidence). CPAP was associated with increased risk of pneumothorax (typical RR 2.48, 95% CI 1.16 to 5.30; typical RD 0.09, 95% CI 0.02 to 0.16; number needed to treat for an additional harmful outcome (NNTH) 11, 95% CI 7 to 50; I2 = 0%; 4 studies, 274 infants; low-certainty evidence). There was no evidence of a difference in bronchopulmonary dysplasia, defined as oxygen dependency at 28 days (RR 1.04, 95% CI 0.35 to 3.13; I2 = 0%; 2 studies, 209 infants; very low-certainty evidence). The trials did not report use of surfactant, intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis and neurodevelopment outcomes in childhood. AUTHORS' CONCLUSIONS In preterm infants with respiratory distress, the application of CPAP is associated with reduced respiratory failure, use of mechanical ventilation and mortality and an increased rate of pneumothorax compared to spontaneous breathing with supplemental oxygen as necessary. Three out of five of these trials were conducted in the 1970s. Therefore, the applicability of these results to current practice is unclear. Further studies in resource-poor settings should be considered and research to determine the most appropriate pressure level needs to be considered.
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Affiliation(s)
- Jacqueline J Ho
- Department of Paediatrics, RCSI & UCD Malaysia Campus (formerly Penang Medical College), George Town, Malaysia
| | - Prema Subramaniam
- Paediatric Department, Mount Isa Base Hospital, Mount Isa, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
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12
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Vieira BSPP, Souza TR, Paschoal LN, Magalhães MR, Magalhães CM, Parreira VF. Early CPAP protocol in preterm infants with gestational age between 28 and 32 weeks: experience of a public hospital. Braz J Phys Ther 2020; 25:421-427. [PMID: 32988779 DOI: 10.1016/j.bjpt.2020.09.001] [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: 09/19/2019] [Revised: 08/18/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The use of continuous positive airway pressure (CPAP) applied early after birth improves several outcomes when compared with intubation and invasive mechanical ventilation. "Early CPAP" protocols vary in relation to the pressure level, type of interface used, and studied sample. OBJECTIVE This study compared intubation rate, exogenous surfactant use, and hospitalization length (among other variables) prior to and after adopting an "early CPAP" protocol in preterm infants with gestational age between 28 and 32 weeks, using intermediate pressures and short binasal prongs. METHODS This was a retrospective study conducted in a public university hospital in Brazil. All preterm infants with gestational age between 28 and 32 weeks were included in the study. The newborns born between January 2011 and December 2012, prior to the protocol being implemented, were considered the historical control group, and those born after implementation, between February 2013 and August 2014 were considered the intervention group. RESULTS The participants in both groups had similar baseline characteristics (p > 0.05). There were significant reductions in intubation rate (89% versus 73%, p = 0.02), exogenous surfactant use (86% versus 67%, p = 0.02), and median (Q1 - Q3) days of invasive mechanical ventilation [4 (2 - 14) versus 1 (0.15-9), p = 0.01] and length of hospital stay in days [56 (42-77) versus 42 (35-71), p = 0.02]. CONCLUSIONS The findings demonstrate positive outcomes of the early CPAP protocol. This protocol used simple and affordable equipment available in the hospital which could easily be reproduced in other centers, generating better outcomes for preterm infants and reducing hospital expenses.
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Affiliation(s)
- Bruna S P P Vieira
- Rehabilitation Sciences Graduation Program, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | - Thales R Souza
- Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil
| | | | | | | | - Verônica F Parreira
- Department of Physical Therapy, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
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13
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Weydig H, Ali N, Kakkilaya V. Noninvasive Ventilation in the Delivery Room for the Preterm Infant. Neoreviews 2020; 20:e489-e499. [PMID: 31477597 DOI: 10.1542/neo.20-9-e489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A decade ago, preterm infants were prophylactically intubated and mechanically ventilated starting in the delivery room; however, now the shift is toward maintaining even the smallest of neonates on noninvasive respiratory support. The resuscitation of very low gestational age neonates continues to push the boundaries of neonatal care, as the events that transpire during the golden minutes right after birth prove ever more important for determining long-term neurodevelopmental outcomes. Continuous positive airway pressure (CPAP) remains the most important mode of noninvasive respiratory support for the preterm infant to establish and maintain functional residual capacity and decrease ventilation/perfusion mismatch. However, the majority of extremely low gestational age infants require face mask positive pressure ventilation during initial stabilization before receiving CPAP. Effectiveness of face mask positive pressure ventilation depends on the ability to detect and overcome mask leak and airway obstruction. In this review, the current evidence on devices and techniques of noninvasive ventilation in the delivery room are discussed.
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Affiliation(s)
- Heather Weydig
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Noorjahan Ali
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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14
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Ho JJ, Subramaniam P, Zakarija-Grkovic I, Leong JJ, Lim E, Lok JW. Continuous positive airway pressure (CPAP) for apnoea of prematurity. Hippokratia 2020. [DOI: 10.1002/14651858.cd013660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jacqueline J Ho
- Department of Paediatrics; RCSI & UCD Malaysia Campus (formerly Penang Medical College); George Town Malaysia
| | | | | | | | - Eunice Lim
- RCSI & UCD Malaysia Campus; George Town Malaysia
| | - Jia Wen Lok
- RCSI & UCD Malaysia Campus; George Town Malaysia
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15
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Ribeiro DDFC, Barros FS, Fernandes BL, Nakato AM, Nohama P. Nasal Prongs: Risks, Injuries Incidence and Preventive Approaches Associated with Their Use in Newborns. J Multidiscip Healthc 2020; 13:527-537. [PMID: 32606724 PMCID: PMC7311096 DOI: 10.2147/jmdh.s252017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/14/2020] [Indexed: 11/27/2022] Open
Abstract
Purpose To assess the incidence of nasal injury in newborns submitted to non-invasive ventilation (NIV) via binasal prongs, to identify risks that come with using this interface, and to present actions for nasal injury prevention. Patients and Methods Observational and descriptive study performed in neonatal intensive care unit (NICU) of a public hospital in the south of Brazil. This research was divided into three stages. In the first one, nasal injury incidence was assessed in 148 newborns, using data collection from medical records. In the second stage, injury incidence, severity and a preliminary analysis of risks associated with the prescription of binasal prongs were analyzed in 33 newborns who required NIV. In the third stage. recommendations were presented to prevent nasal injury during NIV with short binasal prong. Results The incidence of nasal injury in the first stage was 37.16%, and 63.64% in the second one. As for severity, 68.42% of the injuries showed Stage I severity, and 31.58% Stage II. The main risks associated with the use of binasal prongs were inappropriate prong size, inappropriate prong model, interface reuse, prolonged NIV use exclusively with binasal prongs, incorrect prong position and NIV circuit pulled. A total of 17 preventive approaches were recommended: 13 related to newborns care and not dependent on prior investment. Among them: to choose appropriate prong size; to keep the prong and the NIV circuit well positioned and periodically massages with circular movements in the nasal septum and columella. Conclusion The inappropriate prong size, interface reuse, prong model, prolonged NIV use with binasal prong and incorrect prong and NIV circuit position may be associated with the high occurrence of injury in the NICU studied. Simple approaches concerning clinical staff care actions towards the newborn in NIV, which do not require a financial investment, can prevent nasal injury.
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Affiliation(s)
- Débora de Fátima Camillo Ribeiro
- Neonatal Services, Waldemar Monastier Hospital, Campo Largo, Paraná, Brazil.,Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal do Paraná, Curitiba, Paraná, Brazil.,Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Frieda Saicla Barros
- Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal do Paraná, Curitiba, Paraná, Brazil
| | - Beatriz Luci Fernandes
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Adriane Muller Nakato
- Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Percy Nohama
- Graduate Program on Biomedical Engineering, Universidade Tecnológica Federal do Paraná, Curitiba, Paraná, Brazil.,Graduate Program on Health Technology, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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16
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Nasef N, Rashed HM, Aly H. Practical aspects on the use of non-invasive respiratory support in preterm infants. Int J Pediatr Adolesc Med 2020; 7:19-25. [PMID: 32373698 PMCID: PMC7193067 DOI: 10.1016/j.ijpam.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Preterm infants frequently present with respiratory insufficiency requiring respiratory assistance. Invasive mechanical ventilation has been associated with several short and long term complications. Therefore, the practice of early use of non-invasive ventilation has been adopted. Nasal CPAP proved efficacy as an initial therapy for preterm infants. Non-invasive positive pressure ventilation is an alternative used to mitigate CPAP failure in infants with apnea or increased work of breathing. High flow nasal cannula gained popularity primarily due to the ease of its use, despite multiple prominent trials that demonstrated its inferiority. Bi-level positive airway pressure and neurally adjusted non-invasive ventilatory are used in infants with apnea and increased work of breathing. The effectiveness of non invasive ventilation tools can be augmented by having a proper protocol for initiation, weaning, skin care, positioning, and developmental care during their application.
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Affiliation(s)
- Nehad Nasef
- Neonatal Intensive Care Unit, Mansora University Children's Hospital, Mansoura, Egypt.,Department of Pediatrics, Faculty of Medicine, University of Mansoura, Egypt
| | - Hend Me Rashed
- School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
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17
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The Effect of Extended Continuous Positive Airway Pressure on Changes in Lung Volumes in Stable Premature Infants: A Randomized Controlled Trial. J Pediatr 2020; 217:66-72.e1. [PMID: 31519441 PMCID: PMC7986570 DOI: 10.1016/j.jpeds.2019.07.074] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/25/2019] [Accepted: 07/29/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare changes in lung volumes, as measured by functional residual capacity (FRC), through to discharge in stable infants randomized to 2 weeks of extended continuous positive airway pressure CPAP (eCPAP) vs CPAP discontinuation (dCPAP). STUDY DESIGN Infants born at ≤32 weeks of gestation requiring ≥24 hours of CPAP were randomized to 2 weeks of eCPAP vs dCPAP when meeting CPAP stability criteria. FRC was measured with the nitrogen washout technique. Infants were stratified by gestational age (<28 and ≥ 28 weeks) and twin gestation. A linear mixed-effects model was used to evaluate the change in FRC between the 2 groups. Data were analyzed blinded to treatment group allocation. RESULTS Fifty infants were randomized with 6 excluded, for a total of 44 infants. Baseline characteristics were similar in the 2 groups. The infants randomized to eCPAP vs dCPAP had a greater increase in FRC from randomization through 2 weeks (12.6 mL vs 6.4 mL; adjusted 95% CI, 0.78-13.47; P = .03) and from randomization through discharge (27.2 mL vs 17.1 mL; adjusted 95% CI, 2.61-17.59; P = .01). CONCLUSIONS Premature infants randomized to eCPAP had a significantly greater increase in FRC through discharge compared with those randomized to dCPAP. An increased change in FRC may lead to improved respiratory health. TRIAL REGISTRATION ClinicalTrials.gov: NCT02249143.
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18
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Ng LY, Chan AKM, Lam TWY. The use of high-flow nasal oxygen during airway management in a child with epidermolysis bullosa dystrophica and a difficult airway. Anaesth Rep 2019; 7:96-99. [PMID: 32051961 DOI: 10.1002/anr3.12031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2019] [Indexed: 11/11/2022] Open
Abstract
The role of high-flow nasal oxygen in paediatric anaesthesia has been emerging in recent years. However, literature regarding its benefits in paediatric difficult airway management is limited. In this case report, we describe the use of high-flow nasal oxygen during airway management of a child with a difficult airway due to epidermolysis bullosa dystrophica in whom the use of a facemask would have been potentially harmful. Deep sedation was achieved with propofol and remifentanil while maintaining spontaneous breathing before flexible bronchoscopic tracheal intubation was attempted. However, on attempted tracheal intubation difficulty was encountered due to poor visualisation and contact bleeding. Tracheal intubation was eventually successful after converting to videolaryngoscopy. Oxygenation was maintained throughout the process despite deep sedation and a long procedure time. Moreover, no skin abrasions or mucosal injury resulted from the use of high-flow nasal oxygen. We conclude that high-flow nasal oxygen has a valuable role during airway management for a child with a predicted difficult airway when the use of a facemask would have been potentially harmful.
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Affiliation(s)
- L Y Ng
- Department of Anaesthesia and Intensive Care Prince of Wales Hospital Hong Kong HKSAR
| | - A K M Chan
- Department of Anaesthesia and Intensive Care Prince of Wales Hospital Hong Kong HKSAR
| | - T W Y Lam
- Department of Anaesthesia and Intensive Care Prince of Wales Hospital Hong Kong HKSAR
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19
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Green EA, Dawson JA, Davis PG, De Paoli AG, Roberts CT. Assessment of resistance of nasal continuous positive airway pressure interfaces. Arch Dis Child Fetal Neonatal Ed 2019; 104:F535-F539. [PMID: 30567774 DOI: 10.1136/archdischild-2018-315838] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/21/2018] [Accepted: 11/26/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the resistance of interfaces used for the delivery of nasal continuous positive airway pressure (CPAP) in neonates, as measured by the generated system pressure at fixed gas flows, in an in vitro setting. DESIGN Gas flows of 6, 8 and 10 L/min were passed through three sizes of each of a selection of available neonatal nasal CPAP interfaces (Hudson prong, RAM Cannula, Fisher & Paykel prong, Infant Flow prong, Fisher & Paykel mask, Infant Flow mask). The expiratory limb was occluded and pressure differential measured using a calibrated pressure transducer. RESULTS Variation in resistance, assessed by mean pressure differential, was seen between CPAP interfaces. Binasal prong interfaces typically had greater resistance at the smallest assessed sizes, and with higher gas flows. However, Infant Flow prongs produced low pressures (<1.5 cmH2O) at all sizes and gas flows. RAM Cannula had a high resistance, producing a pressure >4.5 cmH2O at all sizes and gas flows. Both nasal mask interfaces had low resistance at all assessed sizes and gas flows, with recorded pressure <1 cmH2O in all cases. CONCLUSIONS There is considerable variation in measured resistance of available CPAP interfaces at gas flows commonly applied in clinical neonatal care. Use of interfaces with high resistance may result in a greater drop in delivered airway pressure in comparison to set circuit pressure, which may have implications for clinical efficacy. Device manufacturers and clinicians should consider CPAP interface resistance prior to introduction into routine clinical care.
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Affiliation(s)
| | - Jennifer Anne Dawson
- Newborn Research and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Peter G Davis
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Antonio G De Paoli
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Calum Timothy Roberts
- Monash Newborn, Monash Medical Centre, Clayton, Victoria, Australia.,Newborn Research and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
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Shi Y, De Luca D. Continuous positive airway pressure (CPAP) vs noninvasive positive pressure ventilation (NIPPV) vs noninvasive high frequency oscillation ventilation (NHFOV) as post-extubation support in preterm neonates: protocol for an assessor-blinded, multicenter, randomized controlled trial. BMC Pediatr 2019; 19:256. [PMID: 31349833 PMCID: PMC6659219 DOI: 10.1186/s12887-019-1625-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 07/12/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Various noninvasive respiratory support modalities are available in neonatal critical care in order to minimize invasive ventilation. Continuous positive airway pressure (CPAP) is the more commonly used but noninvasive positive pressure ventilation (NIPPV) seems more efficacious in the early post-extubation phase, although it is not clear if NIPPV may influence longterm outcomes. A recently introduced alternative is noninvasive high frequency oscillatory ventilation (NHFOV) which might be especially useful in babies needing high constant distending pressure. Preterm neonates may receive these respiratory supports for several weeks. Nonetheless, no data are available for the longterm use of NIPPV and NHFOV; few data exist on NHFOV and clinical outcomes, although its safety and suitability are reported in a number of preliminary short-term studies. METHODS We designed an assessor-blinded, multicenter, three-arms, parallel, pragmatic, randomized, controlled trial with a superiority design, investigating the use of CPAP vs NIPPV vs NHFOV during the whole stay in neonatal intensive care units in China. Since safety data will also be analyzed it may be considered a phase II/III trial. Moreover, subgroup analyses will be performed on patients according to prespecified criteria based on physiopathology traits: these subgroup analyses should be considered preliminary. At least 1440 neonates are supposed to be enrolled. The trial has been designed with the collaboration of international colleagues expert in NHFOV, who will also perform an interim analysis at the about 50% of the enrolment. DISCUSSION The study is applying the best trial methodology to neonatal ventilation, a field where it is often difficult to do so for practical reasons. Nonetheless, ours is also a physiology-driven trial, since interventions are applied based on physiological perspective, in order to use ventilatory techniques at their best. The pragmatic design will increase generalizability of our results but subgroup analyses according to predefined physiopathological criteria are also previewed trying to have some advantages of an explanatory design. Since not all clinicians are well versed in all respiratory techniques, the training is pivotal. We intend to apply particular care to train the participating units: a specific 3-month period and several means have been dedicated to this end. TRIAL REGISTRATION NCT03181958 (registered on June 9, 2017).
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Affiliation(s)
- Yuan Shi
- Department of Neonatology, Children’s Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014 China
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, South Paris University Hospitals, AP-HP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
- Institute of Anesthesiology and Critical Care, Catholic University of the Sacred Heart, Rome, Italy
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21
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Arsan S, Korkmaz A, Oğuz S. Turkish Neonatal Society guideline on prevention and management of bronchopulmonary dysplasia. Turk Arch Pediatr 2019; 53:S138-S150. [PMID: 31236027 PMCID: PMC6568289 DOI: 10.5152/turkpediatriars.2018.01814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Scientific and technological advances in perinatology and neonatology have led to an increased rate of survival and decreased incidences of various neonatal morbidities. However, the incidence of bronchopulmonary dysplasia has remained almost the same for years in very-low-birth-weight preterm infants. Although bronchopulmonary dysplasia is the leading cause of chronic respiratory morbidity in small preterms, no substantial improvement has been achieved in prevention and treatment strategies to date. Currently, postnatal very-low-dose corticosteroids, caffeine, and vitamin A seem to be the drugs of choice, and stem cell therapy appears to be the most promising treatment modality for the future. In this guideline, which was prepared by the Turkish Neonatal Society, recent evidence-based recommendations for the prevention and treatment of bronchopulmonary dysplasia are summarized.
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Affiliation(s)
- Saadet Arsan
- Division of Neonatology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - Ayşe Korkmaz
- Division of Neonatology, Department of Pediatrics, Acıbadem University, Faculty of Medicine, İstanbul, Turkey
| | - Suna Oğuz
- Zekai Tahir Burak Women's Health Practice and Research Center, Health Sciences University, Ankara, Turkey
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22
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Raidal SL, McKean R, Ellul PA, Nielsen SG, Quinn CT. Effects of continuous positive airway pressure on respiratory function in sedated foals. J Vet Emerg Crit Care (San Antonio) 2019; 29:269-278. [PMID: 31044526 DOI: 10.1111/vec.12816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/11/2017] [Accepted: 03/13/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To characterize the effects of continuous positive airway pressure (CPAP) delivered by a commercial human CPAP device on respiratory function in foals with pharmacologically induced respiratory suppression. DESIGN Prospective randomized, cross-over study comparing CPAP with spontaneous respiration and oxygen insufflation. SETTING University veterinary teaching hospital. ANIMALS Twelve foals born in consecutive seasons from a university teaching herd. INTERVENTIONS Foals were randomized to receive 10 minutes of respiratory support by mask oxygen supplementation or CPAP as a first treatment after induction of respiratory depression by intravenous administration of xylazine and fentanyl. Each foal received the alternate treatment after 10 minutes of breathing ambient air, and the procedure was repeated after 48 hours with treatment order reversed. MEASUREMENTS AND MAIN RESULTS The administration of xylazine and fentanyl by bolus or continuous infusion reliably induced reversible respiratory suppression and recumbency. CPAP was associated with comparable increase in PaO2 relative to mask oxygen supplementation, but with lower respiratory rate, increased oxygen extraction and increased carbon dioxide elimination. Mild increase in PaCO2 was observed during CPAP and O2 supplementation. Expiratory time increased and peak expiratory flow decreased during CPAP. CONCLUSIONS Findings of the study suggest that CPAP might represent a method for improved respiratory support compared to O2 insufflation due to increased respiratory efficiency. Care must be taken in extrapolation of these findings from foals with pharmacologically induced respiratory compromise to foals with clinical respiratory disease, and further investigation is required to better characterize the cause and impact of marginal hypercapnia observed in these studies.
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Affiliation(s)
- Sharanne L Raidal
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Rosemary McKean
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Paula A Ellul
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Sharon G Nielsen
- Quantitative Consulting Unit, Research Office, Charles Sturt University, Wagga Wagga, Australia
| | - Christopher T Quinn
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, NSW, Australia
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23
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Tridente A, De Martino L, De Luca D. Porcine vs bovine surfactant therapy for preterm neonates with RDS: systematic review with biological plausibility and pragmatic meta-analysis of respiratory outcomes. Respir Res 2019; 20:28. [PMID: 30728009 PMCID: PMC6366095 DOI: 10.1186/s12931-019-0979-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/06/2019] [Indexed: 01/16/2023] Open
Abstract
Background Bovine surfactants are known to be clinically equivalent but it is unclear if porcine or bovine surfactants at their licensed dose should be preferred to treat respiratory distress syndrome in preterm neonates. Methods We performed a comprehensive review of biochemical and pharmacological features of surfactants to understand the biological plausibility of any clinical effect. We then performed a pragmatic meta-analysis comparing internationally marketed porcine and bovine surfactants for mortality and respiratory outcomes. Search for randomised controlled trials with no language/year restrictions and excluding “grey” literature, unpublished or non-peer reviewed reports was conducted, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the most recent methodological recommendations. Results Sixteen articles were included in the review and 14 in the meta-analysis (1491 neonates). 200 mg/kg poractant-α (a porcine surfactant) was associated with lower BPD/mortality (OR 0.632[95%CI:0.494, 0.809];p < 0.001),BPD (OR 0.688[95%CI:0.512, 0.925];p = 0.013), retreatment (OR 0.313[95%CI:0.187, 0.522];p < 0.0001), airleaks (OR 0.505[95%CI:0.308, 0.827];p = 0.006) and lung haemorrhage (OR 0.624[95%CI:0.388, 1];p = 0.051). Gestational age is associated with effect size for BPD (coefficient: 0.308 [95%CI:0.063, 0.554];p = 0.014) and surfactant retreatment (coefficient: -0.311 [95%CI:-0.595, − 0.028];p = 0.031). Conclusion 200 mg/kg poractant-α is associated with better respiratory outcomes compared to bovine surfactants at their licensed dose. The effect of poractant-α on BPD and surfactant retreatment is greater at lowest and highest gestational ages, respectively. Trial registration PROSPERO n.42017075251. Electronic supplementary material The online version of this article (10.1186/s12931-019-0979-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ascanio Tridente
- Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, UK.,Critical Care Unit, Whiston Hospital, St Helens and Knowsley Teaching Hospitals, Merseyside, UK
| | - Lucia De Martino
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A. Béclère", South Paris University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP) , Paris, France
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A. Béclère", South Paris University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP) , Paris, France. .,Physiopathology and Therapeutic Innovation Unit, INSERM U999, South Paris-Saclay University, Paris, France.
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24
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Bashir T, Murki S, Kiran S, Reddy VK, Oleti TP. 'Nasal mask' in comparison with 'nasal prongs' or 'rotation of nasal mask with nasal prongs' reduce the incidence of nasal injury in preterm neonates supported on nasal continuous positive airway pressure (nCPAP): A randomized controlled trial. PLoS One 2019; 14:e0211476. [PMID: 30703172 PMCID: PMC6355017 DOI: 10.1371/journal.pone.0211476] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 01/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background With increasing use of nCPAP, the safety and comfort associated with nCPAP have come into the forefront. The reported incidence of nasal injuries associated with the use of nCPAP is 20% to 60%. A recent meta-analysis concluded that the use of nasal masks significantly decreases CPAP failure and the incidence of moderate to severe nasal injury and stress the need for a well powered RCT to confirm their findings. Methods In this Open label, 3 arms, sequential, stratified randomized controlled trial, we evaluated the incidence and severity of nasal injury at removal of nCPAP when using two different nasal interfaces and in three groups (i.e. rotation group, mask continue group, prong continue group). Preterm infants with gestation ≤ 30 weeks and respiratory distress within the first 6 hours of birth and in need of CPAP were eligible for the study. Results Among the 175 newborns included in the study, incidence of nasal injury in mask continue group [n = 19/57 (33.3%)] was significantly less as compared to prong continue group [n = 55/60 (91.6%)] and rotation group [33/ 58 (56.9%), p value <0.0001]. Median maximum nasal injury score was significantly less in Mask continue group as compared to Prong continue group and Rotation group [Injury Score 0 (IQR 0–1) vs. Injury Score 3 (IQR 2–5) vs. Injury Score 1 (IQR 0–2), p value = <0.0001] respectively. The proportion of infants failing nCPAP was similar across the three groups. Conclusion nCPAP with nasal masks significantly reduces nasal injury in comparison with nasal prongs or rotation of nasal prongs and nasal masks. However, the type of interface did not affect the nCPAP failure rates.
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Affiliation(s)
- Tanveer Bashir
- Department of Neonatology, Fernandez Hospital, Hyderguda, Hyderabad, India
| | - Srinivas Murki
- Department of Neonatology, Fernandez Hospital, Hyderguda, Hyderabad, India
- * E-mail:
| | - Sai Kiran
- Department of Neonatology, Fernandez Hospital, Hyderguda, Hyderabad, India
| | | | - Tejo Pratap Oleti
- Department of Neonatology, Fernandez Hospital, Hyderguda, Hyderabad, India
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25
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King BC, Gandhi BB, Jackson A, Katakam L, Pammi M, Suresh G. Mask versus Prongs for Nasal Continuous Positive Airway Pressure in Preterm Infants: A Systematic Review and Meta-Analysis. Neonatology 2019; 116:100-114. [PMID: 31163418 DOI: 10.1159/000496462] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/24/2018] [Indexed: 11/19/2022]
Abstract
Nasal continuous positive airway pressure (NCPAP) is an effective method of respiratory support for preterm infants. Nasal masks and binasal prongs are two interfaces available to deliver NCPAP, and it is unclear if one is superior to the other. We conducted a systematic review and meta-analysis, using the methodology recommended by the Cochrane Collaboration, to compare the efficacy and safety of nasal masks versus binasal prongs to deliver NCPAP in preterm infants <37 weeks of gestation. Ovid MEDLINE, Embase, Scopus, the Cochrane database, and PubMed were searched in February 2019. Seven trials met the inclusion criteria. Among preterm infants requiring NCPAP, the use of a nasal mask, compared to nasal prongs, decreased the rate of NCPAP failure within 72 h (RR 0.72, 95% CI 0.53-0.97; number needed to treat for an additional beneficial outcome [NNTB] 12.5, 95% CI 7.1-100; 5 trials, 576 participants; low-certainty evidence) and the incidence of nasal injury (RR 0.71, 95% CI 0.59-0.85; NNTB 8.3, 95% CI 5.6-16.7; 6 trials, 665 participants; low-certainty evidence). In a subgroup of preterm infants requiring NCPAP after resuscitation at birth, the use of a nasal mask decreased the incidence of moderate-to-severe bronchopulmonary dysplasia (RR 0.47, 95% CI 0.23-0.95; NNTB 16.7, 95% CI 9.1-100; 4 trials, 395 participants; very-low-certainty evidence) and the need for subsequent surfactant administration (RR 0.78, 95% CI 0.64-0.96; NNTB 8.33, 95% CI 4.54-33.33; 4 trials, 395 participants; low-certainty evidence). The use of nasal masks for preterm infants requiring NCPAP was associated with a reduction in NCPAP failure, need for surfactant administration, and moderate-to-severe bronchopulmonary dysplasia (low- to very-low-certainty evidence). Given the potential clinical benefit and minimal risk associated with a change in patient interface, nasal masks should be considered the preferred interface for NCPAP delivery in preterm infants.
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Affiliation(s)
- Brian C King
- Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA,
| | - Bheru B Gandhi
- Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Andrea Jackson
- Outcomes and Impact Service, Texas Children's Hospital, Houston, Texas, USA
| | - Lakshmi Katakam
- Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Mohan Pammi
- Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
| | - Gautham Suresh
- Section of Neonatology, Baylor College of Medicine, Houston, Texas, USA
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26
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Fleeman N, Mahon J, Bates V, Dickson R, Dundar Y, Dwan K, Ellis L, Kotas E, Richardson M, Shah P, Shaw BN. The clinical effectiveness and cost-effectiveness of heated humidified high-flow nasal cannula compared with usual care for preterm infants: systematic review and economic evaluation. Health Technol Assess 2018; 20:1-68. [PMID: 27109425 DOI: 10.3310/hta20300] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Respiratory problems are one of the most common causes of morbidity in preterm infants and may be treated with several modalities for respiratory support such as nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive-pressure ventilation. The heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity in clinical practice. OBJECTIVES To address the clinical effectiveness of HHHFNC compared with usual care for preterm infants we systematically reviewed the evidence of HHHFNC with usual care following ventilation (the primary analysis) and with no prior ventilation (the secondary analysis). The primary outcome was treatment failure defined as the need for reintubation (primary analysis) or intubation (secondary analysis). We also aimed to assess the cost-effectiveness of HHHFNC compared with usual care if evidence permitted. DATA SOURCES The following databases were searched: MEDLINE (2000 to 12 January 2015), EMBASE (2000 to 12 January 2015), The Cochrane Library (issue 1, 2015), ISI Web of Science (2000 to 12 January 2015), PubMed (1 March 2014 to 12 January 2015) and seven trial and research registers. Bibliographies of retrieved citations were also examined. REVIEW METHODS Two reviewers independently screened all titles and abstracts to identify potentially relevant studies for inclusion in the review. Full-text copies were assessed independently. Data were extracted and assessed for risk of bias. Summary statistics were extracted for each outcome and, when possible, data were pooled. A meta-analysis was only conducted for the primary analysis, using fixed-effects models. An economic evaluation was planned. RESULTS Clinical evidence was derived from seven randomised controlled trials (RCTs): four RCTs for the primary analysis and three RCTs for the secondary analysis. Meta-analysis found that only for nasal trauma leading to a change of treatment was there a statistically significant difference, favouring HHHFNC over NCPAP [risk ratio (RR) 0.21, 95% confidence interval (CI) 0.10 to 0.42]. For the following outcomes, there were no statistically significant differences between arms: treatment failure (reintubation < 7 days; RR 0.76, 95% CI 0.54 to 1.09), bronchopulmonary dysplasia (RR 0.92, 95% CI 0.72 to 1.17), death (RR 0.56, 95% CI 0.22 to 1.44), pneumothorax (RR 0.33, 95% CI 0.03 to 3.12), intraventricular haemorrhage (grade ≥ 3; RR 0.41, 95% CI 0.15 to 1.15), necrotising enterocolitis (RR 0.41, 95% CI 0.15 to 1.14), apnoea (RR 1.08, 95% CI 0.74 to 1.57) and acidosis (RR 1.16, 95% CI 0.38 to 3.58). With no evidence to support the superiority of HHHFNC over NCPAP, a cost-minimisation analysis was undertaken, the results suggesting HHHFNC to be less costly than NCPAP. However, this finding is sensitive to the lifespan of equipment and the cost differential of consumables. LIMITATIONS There is a lack of published RCTs of relatively large-sized populations comparing HHHFNC with usual care; this is particularly true for preterm infants who had received no prior ventilation. CONCLUSIONS There is a lack of convincing evidence suggesting that HHHFNC is superior or inferior to usual care, in particular NCPAP. There is also uncertainty regarding whether or not HHHFNC can be considered cost-effective. Further evidence comparing HHHFNC with usual care is required. STUDY REGISTRATION This review is registered as PROSPERO CRD42015015978. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nigel Fleeman
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - James Mahon
- Coldingham Analytical Services, Berwickshire, UK
| | - Vickie Bates
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Rumona Dickson
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Yenal Dundar
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Kerry Dwan
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK.,Cochrane Editorial Unit, Cochrane Collaboration, London, UK
| | - Laura Ellis
- Patient representative (parent of premature infants)
| | - Eleanor Kotas
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Marty Richardson
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Prakesh Shah
- Departments of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ben Nj Shaw
- Neonatal Unit, Liverpool Women's NHS Foundation Trust, Liverpool, UK
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27
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Roberts CT, Hodgson KA. Nasal high flow treatment in preterm infants. Matern Health Neonatol Perinatol 2017; 3:15. [PMID: 28904810 PMCID: PMC5586012 DOI: 10.1186/s40748-017-0056-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 08/29/2017] [Indexed: 12/21/2022] Open
Abstract
Nasal High Flow (HF) is a mode of ‘non-invasive’ respiratory support for preterm infants, with several potential modes of action, including generation of distending airway pressure, washout of the nasopharyngeal dead space, reduction of work of breathing, and heating and humidification of inspired gas. HF has several potential advantages over continuous positive airway pressure (CPAP), the most commonly applied form of non-invasive support, such as reduced nasal trauma, ease of use, and infant comfort, which has led to its rapid adoption into neonatal care. In recent years, HF has become a well-established and commonly applied treatment in neonatal care. Recent trials comparing HF and CPAP as primary support have had differing results. Meta-analyses suggest that primary HF results in an increased risk of treatment failure, but that ‘rescue’ CPAP use in those infants with HF failure results in no greater risk of mechanical ventilation. Even in studies with higher rates of HF failure, the majority of infants were successfully treated with HF, and rates of important neonatal morbidities did not differ between treatment groups. Importantly, these studies have included only infants born at ≥28 weeks’ gestational age (GA). The decision whether to apply primary HF will depend on the value placed on its advantages over CPAP by clinicians, the approach to surfactant treatment, and the severity of respiratory disease in the relevant population of preterm infants. Post-extubation HF use results in similar rates of treatment failure, mechanical ventilation, and adverse events compared to CPAP. Post-extubation HF appears most suited to infants ≥28 weeks; there are few published data for infants below this gestation, and available evidence suggests that these infants are at high risk of HF failure, although rates of intubation and other morbidities are similar to those seen with CPAP. There is no evidence that using HF to ‘wean’ off CPAP allows for respiratory support to be ceased more quickly, but given its advantages it would appear to be a suitable alternative in infants who require ongoing non-invasive support. Safety data from randomised trials are reassuring, although more evidence in extremely preterm infants (<28 weeks’ GA) is required.
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Affiliation(s)
- Calum T Roberts
- Newborn Research Centre, The Royal Women's Hospital, Locked Bag 300, Flemington Road, Parkville 3052, Melbourne, VIC Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Kate A Hodgson
- Newborn Research Centre, The Royal Women's Hospital, Locked Bag 300, Flemington Road, Parkville 3052, Melbourne, VIC Australia
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28
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Bamat N, Fierro J, Wright CJ, Millar D, Kirpalani H. Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in very low birth weight infants. Hippokratia 2017. [DOI: 10.1002/14651858.cd012778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Nicolas Bamat
- Children's Hospital of Philadelphia; Division of Neonatology; 34th Street and Civic Center Boulevard Philadelphia Pennsylvania USA 19104
| | - Julie Fierro
- Children's Hospital of Philadelphia; Philadelphia USA
| | | | - David Millar
- Royal Jubilee Maternity Service; Regional Neonatal Intensive Care Unit; Royal Maternity Hospital Grosvenor Road Belfast Northern Ireland UK BT12 6BB
| | - Haresh Kirpalani
- University of Pennsylvania School of Medicine and Department of Clinical Epidemiology and Biostatistics, McMaster University; Department of Pediatrics; Children's Hospital of Philadelphia South 34th Street & Civic Center Blvd Philadelphia Pennsylvania USA 19104
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29
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Owen LS, Manley BJ, Davis PG, Doyle LW. The evolution of modern respiratory care for preterm infants. Lancet 2017; 389:1649-1659. [PMID: 28443559 DOI: 10.1016/s0140-6736(17)30312-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/27/2016] [Accepted: 12/19/2016] [Indexed: 10/19/2022]
Abstract
Preterm birth rates are rising, and many preterm infants have breathing difficulty after birth. Treatments for infants with prolonged breathing difficulty include oxygen therapy, exogenous surfactant, various modes of respiratory support, and postnatal corticosteroids. In this Series paper, we review the history of neonatal respiratory care and its effect on long-term outcomes, and we outline the future direction of the research field. The delivery and monitoring of oxygen therapy remains controversial, despite being in use for more than 50 years. Exogenous surfactant replacement has been used for 25 years and has dramatically reduced mortality and morbidity, but more research on when and how it is administered is needed. Methods and techniques of neonatal respiratory support are evolving. Clinicians are moving away from routine intubation and ventilation, and new modes of non-invasive support are being investigated. Postnatal corticosteroids have a limited role in infants with evolving bronchopulmonary dysplasia, but more research is needed to identify the best timing, type, dose, and method of administration. Despite advances in neonatal care in the past 50 years, bronchopulmonary dysplasia, with all its adverse short-term and long-term consequences, is still a serious problem in neonatal care. The challenge remains to support breathing in preterm infants, with special attention to risk factors in the subpopulation of infants that are at highest risk of bronchopulmonary dysplasia, without damaging their lungs or adversely affecting their long-term health.
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Affiliation(s)
- Louise S Owen
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia.
| | - Brett J Manley
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Peter G Davis
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Lex W Doyle
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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30
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Implementation of an evidence-based non-invasive respiratory support (NIRS) bundle in the NICU to decrease nasal injury complications. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.jnn.2016.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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31
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Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul VK, Deorari AK. Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates-a randomised trial. Eur J Pediatr 2017; 176:379-386. [PMID: 28091776 DOI: 10.1007/s00431-017-2851-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 01/02/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
Abstract
UNLABELLED The objective of this study was to compare the efficacy and safety of continuous positive airway pressure (CPAP) delivered using nasal masks with binasal prongs. We randomly allocated 72 neonates between 26 and 32 weeks gestation to receive bubble CPAP by either nasal mask (n = 37) or short binasal prongs (n = 35). Primary outcome was mean FiO2 requirement at 6, 12 and 24 h of CPAP initiation and the area under curve (AUC) of FiO2 against time during the first 24 h (FiO2 AUC0-24). Secondary outcomes were the incidence of CPAP failure and nasal trauma. FiO2 requirement at 6, 12 and 24 h (mean (SD); 25 (5.8) vs. 27.9 (8); 23.8 (4.5) vs. 25.4 (6.8) and 22.6 (6.8) vs. 22.7 (3.3)) as well as FiO2 AUC0-24 (584.0 (117.8) vs. 610.6 (123.6)) were similar between the groups. There was no difference in the incidence of CPAP failure (14 vs. 20%; relative risk 0.67; 95% confidence interval 0.24-1.93). Incidence of severe nasal trauma was lower with the use of nasal masks (0 vs. 31%; p < .001). CONCLUSIONS Nasal masks appear to be as efficacious as binasal prongs in providing CPAP. Masks are associated with lower risk of severe nasal trauma. TRIAL REGISTRATION CTRI2012/08/002868 What is Known? • Binasal prongs are better than single nasal and nasopharyngeal prongs for delivering continuous positive airway pressure (CPAP) in preventing need for re-intubation. • It is unclear if they are superior to newer generation nasal masks in preterm neonates requiring CPAP. What is New? • Oxygen requirement during the first 24 h of CPAP delivery is comparable with use of nasal masks and binasal prongs. • Use of nasal masks is, however, associated with significantly lower risk of severe grades of nasal injury.
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Affiliation(s)
- Aparna Chandrasekaran
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anu Thukral
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - M Jeeva Sankar
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ramesh Agarwal
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vinod K Paul
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ashok K Deorari
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Medical Devices for Pediatric Apnea Monitoring and Therapy: Past and New Trends. IEEE Rev Biomed Eng 2017; 10:199-212. [DOI: 10.1109/rbme.2017.2757899] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Welty SE. Continuous Positive Airway Pressure Strategies with Bubble Nasal Continuous Positive Airway Pressure: Not All Bubbling Is the Same: The Seattle Positive Airway Pressure System. Clin Perinatol 2016; 43:661-671. [PMID: 27837751 DOI: 10.1016/j.clp.2016.07.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Premature neonates are predisposed to complications, including bronchopulmonary dysplasia (BPD). BPD is associated with long-term pulmonary and neurodevelopmental consequences. Noninvasive respiratory support with nasal continuous positive airway pressure (CPAP) has been recommended strongly by the American Academy of Pediatrics. However, CPAP implementation has shown at least a 50% failure rate. Enhancing nasal CPAP effectiveness may decrease the need for mechanical ventilation and reduce the incidence of BPD. Bubble nasal CPAP is better than nasal CPAP using mechanical devices and the bubbling provides air exchange in distal respiratory units. The Seattle PAP system reduces parameters that assess work of breathing.
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Affiliation(s)
- Stephen E Welty
- Department of Pediatrics, Baylor College of Medicine, 6621 Fannin Street, W1604, Houston, TX 77030, USA.
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Abstract
Continuous positive airway pressure (CPAP) systems can be broadly grouped into continuous flow or variable flow devices. Bubble CPAP (bCPAP) is a continuous flow device and has physiologic properties that could facilitate gas exchange. Its efficacy has been reported to be similar to variable flow CPAP systems when used as a primary mode of respiratory support. Post-extubation bCPAP is reported to significantly reduce extubation failure rates among preterm infants ventilated for less than 2 week when compared to Infant flow driver CPAP (variable flow). bCPAP has been successfully used in resource-poor settings. The success on CPAP is however dependant on good nursing care and clear management protocols for weaning and escalation of care.
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Affiliation(s)
- Samir Gupta
- Department of Paediatrics, University Hospital of North Tees, Durham University, Hardwick road, Stockton-on-Tees, TS19 8PE, United Kingdom.
| | - Steven M Donn
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, 1540 East Hospital Drive, Ann Arbor, MI 48109, USA
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Agarwal S, Maria A, Roy MK, Verma A. A Randomized Trial Comparing Efficacy of Bubble and Ventilator Derived Nasal CPAP in Very Low Birth Weight Neonates with Respiratory Distress. J Clin Diagn Res 2016; 10:SC09-SC12. [PMID: 27790540 DOI: 10.7860/jcdr/2016/20584.8572] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 06/14/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Continuous Positive Airway Pressure (CPAP) has an established role in the care of Very Low Birth Weight (VLBW) babies with respiratory distress. Bubble CPAP (BCPAP) is a cheap alternative for countries where resources are limited. However, data comparing efficacy of BCPAP with conventional ventilator derived (VCPAP) is limited. AIM To compare CPAP failure rates between BCPAP and VCPAP among VLBW, with moderate respiratory distress. Secondary objectives were to compare the rates of Intraventricular Haemorrhage (IVH), pulmonary air leaks and deaths between the two groups and determine the predictors of CPAP failure. MATERIALS AND METHODS VLBW babies with moderate respiratory distress (Silverman Anderson score 4-7), born or admitted in Neonatal Intensive Care Unit (NICU) within 28 days of life were randomized to receive either BCPAP (n=34) or VCPAP (n=34). CPAP failure rate in both the groups was compared. RESULTS The baseline characteristics were similar in both the groups. Five out of 34 (14.70%) babies in BCPAP group and 11 out of 34 (32.35%) in VCPAP failed CPAP (p=0.08). IVH (BCPAP group 24% and VCPAP group 9%, p= 0.10) and mortality (BCPAP group 6% and VCPAP group 9%, p=0.642) were comparable in both the groups. Factors such as gestational age <30 weeks, weight <1000 grams, Respiratory Distress Syndrome (RDS), shock, pulmonary haemorrhage, Disseminated Intravascular Coagulation (DIC) and multi-organ dysfunction were significantly associated with CPAP failure in our study. CONCLUSION The CPAP failure rates in VLBW babies with moderate respiratory distress were found to be similar whether bubble CPAP or ventilator CPAP was used. There was no difference in complication rates of IVH or mortality with either method of CPAP.
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Affiliation(s)
- Sheetal Agarwal
- Assistant Professor, Department of Pediatrics, PGIMER and Dr. RML Hospital , Delhi, India
| | - Arti Maria
- Head, Department of Neonatology, PGIMER and Dr. RML Hospital , Delhi, India
| | - Mahesh K Roy
- Senior Resident, Department of Pediatrics, PGIMER and Dr. RML Hospital , Delhi, India
| | - Ankit Verma
- Senior Resident, Department of Pediatrics, PGIMER and Dr. RML Hospital , Delhi, India
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Abstract
Continuous positive airway pressure (CPAP) has been used for respiratory support in premature infants for more than 40 years and is now a cornerstone of modern neonatal care. Clinical research on CPAP has primarily focused on understanding which devices and pressure sources best implement this therapy. In contrast, less research has examined the optimal duration over which CPAP is administered. We review this aspect of CPAP therapy.
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Abstract
Non-invasive ventilation (NIV) is used in neonates to treat extrathoracic and intrathoracic airway obstruction, parenchymal lung disease and disorders of control of breathing. Avoidance of airway intubation is associated with a reduction in the incidence of chronic lung disease among preterm infants with respiratory distress syndrome. Use of nasal continuous positive airway pressure (nCPAP) may help establish and maintain functional residual capacity (FRC), decrease respiratory work, and improve gas exchange. Other modes of non-invasive ventilation, which include heated humidified high-flow nasal cannula therapy (HHHFNC), nasal intermittent mandatory ventilation (NIMV), non-invasive pressure support ventilation (NI-PSV), and bi-level CPAP (SiPAP™), have also been shown to provide additional benefit in improving breathing patterns, reducing work of breathing, and increasing gas exchange when compared with nCPAP. Newer modes, such as neurally adjusted ventilatory assist (NAVA), hold the promise of improving patient-ventilator synchrony and so might ultimately improve outcomes for preterm infants with respiratory distress.
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Affiliation(s)
- Stamatia Alexiou
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Howard B Panitch
- The Perelman School of Medicine at The University of Pennsylvania, Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Cardiorespiratory events in preterm infants: interventions and consequences. J Perinatol 2016; 36:251-8. [PMID: 26583943 DOI: 10.1038/jp.2015.165] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 09/29/2015] [Accepted: 10/05/2015] [Indexed: 01/09/2023]
Abstract
Stabilization of respiration and oxygenation continues to be one of the main challenges in clinical care of the neonate. Despite aggressive respiratory support including mechanical ventilation, continuous positive airway pressure, oxygen and caffeine therapy to reduce apnea and accompanying intermittent hypoxemia, the incidence of intermittent hypoxemia events continues to increase during the first few months of life. Even with improvements in clinical care, standards for oxygen saturation targeting and modes of respiratory support have yet to be identified in this vulnerable infant cohort. In addition, we are only beginning to explore the association between the incidence and pattern of cardiorespiratory events during early postnatal life and both short- and long-term morbidity including retinopathy of prematurity, growth, sleep-disordered breathing and neurodevelopmental impairment. Part 1 of this review included a summary of lung development and diagnostic methods of cardiorespiratory monitoring. In Part 2 we focus on clinical interventions and the short- and long-term consequences of cardiorespiratory events in preterm infants.
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Wilkinson D, Andersen C, O'Donnell CPF, De Paoli AG, Manley BJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 2016; 2:CD006405. [PMID: 26899543 PMCID: PMC9371597 DOI: 10.1002/14651858.cd006405.pub3] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND High flow nasal cannulae (HFNC) are small, thin, tapered binasal tubes that deliver oxygen or blended oxygen/air at gas flows of more than 1 L/min. HFNC are increasingly being used as a form of non-invasive respiratory support for preterm infants. OBJECTIVES To compare the safety and efficacy of HFNC with other forms of non-invasive respiratory support in preterm infants. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 1 January 2016), EMBASE (1980 to 1 January 2016), and CINAHL (1982 to 1 January 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised or quasi-randomised trials comparing HFNC with other non-invasive forms of respiratory support in preterm infants immediately after birth or following extubation. DATA COLLECTION AND ANALYSIS The authors extracted and analysed data, and calculated risk ratio, risk difference and number needed to treat for an additional beneficial outcome. MAIN RESULTS We identified 15 studies for inclusion in the review. The studies differed in the interventions compared (nasal continuous positive airway pressure (CPAP), nasal intermittent positive pressure ventilation (NIPPV), non-humidified HFNC, models for delivering HFNC), the gas flows used and the indications for respiratory support (primary support from soon after birth, post-extubation support, weaning from CPAP support). When used as primary respiratory support after birth compared to CPAP (4 studies, 439 infants), there were no differences in the primary outcomes of death (typical risk ratio (RR) 0.36, 95% CI 0.01 to 8.73; 4 studies, 439 infants) or chronic lung disease (CLD) (typical RR 2.07, 95% CI 0.64 to 6.64; 4 studies, 439 infants). HFNC use resulted in longer duration of respiratory support, but there were no differences in other secondary outcomes. One study (75 infants) showed no differences between HFNC and NIPPV as primary support. Following extubation (total 6 studies, 934 infants), there were no differences between HFNC and CPAP in the primary outcomes of death (typical RR 0.77, 95% CI 0.43 to 1.36; 5 studies, 896 infants) or CLD (typical RR 0.96, 95% CI 0.78 to 1.18; 5 studies, 893 infants). There was no difference in the rate of treatment failure (typical RR 1.21, 95% CI 0.95 to 1.55; 5 studies, 786 infants) or reintubation (typical RR 0.91, 95% CI 0.68 to 1.20; 6 studies, 934 infants). Infants randomised to HFNC had reduced nasal trauma (typical RR 0.64, 95% CI 0.51 to 0.79; typical risk difference (RD) -0.14, 95% CI -0.20 to -0.08; 4 studies, 645 infants). There was a small reduction in the rate of pneumothorax (typical RR 0.35, 95% CI 0.11 to 1.06; typical RD -0.02, 95% CI -0.03 to -0.00; 5 studies 896 infants) in infants treated with HFNC. Subgroup analysis found no difference in the rate of the primary outcomes between HFNC and CPAP in preterm infants in different gestational age subgroups, though there were only small numbers of extremely preterm and late preterm infants. One trial (28 infants) found similar rates of reintubation for humidified and non-humidified HFNC, and two other trials (100 infants) found no difference between different models of equipment used to deliver humidified HFNC. For infants weaning from non-invasive respiratory support (CPAP), two studies (149 infants) found that preterm infants randomised to HFNC had a reduced duration of hospitalisation compared with infants who remained on CPAP. AUTHORS' CONCLUSIONS HFNC has similar rates of efficacy to other forms of non-invasive respiratory support in preterm infants for preventing treatment failure, death and CLD. Most evidence is available for the use of HFNC as post-extubation support. Following extubation, HFNC is associated with less nasal trauma, and may be associated with reduced pneumothorax compared with nasal CPAP. Further adequately powered randomised controlled trials should be undertaken in preterm infants comparing HFNC with other forms of primary non-invasive support after birth and for weaning from non-invasive support. Further evidence is also required for evaluating the safety and efficacy of HFNC in extremely preterm and mildly preterm subgroups, and for comparing different HFNC devices.
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Affiliation(s)
- Dominic Wilkinson
- University of OxfordOxford Uehiro Centre for Practical EthicsOxfordUK
- University of AdelaideRobinson Research InstituteAdelaideAustralia
| | - Chad Andersen
- University of AdelaideRobinson Research InstituteAdelaideAustralia
- Women's and Children's HospitalDepartment of Neonatal Medicine72 King William RoadNorth AdelaideSouth AustraliaAustralia5006
| | - Colm PF O'Donnell
- National Maternity HospitalDepartment of NeonatologyHolles StreetDublin 2Ireland
| | | | - Brett J Manley
- The Royal Women's HospitalNeonatal Services and Newborn Research CentreMelbourneAustralia
- The University of MelbourneDepartment of Obstetrics and GynaecologyMelbourneAustralia
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Respiratory Support for Pharmacologically Induced Hypoxia in Neonatal Calves. Vet Med Int 2016; 2016:2129362. [PMID: 26998379 PMCID: PMC4779535 DOI: 10.1155/2016/2129362] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/12/2016] [Indexed: 12/04/2022] Open
Abstract
Practical methods to provide respiratory support to bovine neonates in a field setting are poorly characterised. This study evaluated the response of healthy neonatal calves with pharmacologically induced respiratory suppression to nasal oxygen insufflation and to continuous positive airway pressure (CPAP) delivered via an off-the-shelf device. Ten calves were randomised to receive either nasal oxygen insufflation (Group 1, n = 5) or CPAP (Group 2, n = 5) as a first treatment after induction of respiratory depression by intravenous administration of xylazine, fentanyl, and diazepam. Calves received the alternate treatment after 10 minutes of breathing ambient air. Arterial blood gas samples were obtained prior to sedation, following sedation, following the first and second treatment, and after breathing ambient air before and after the second treatment. Oxygen insufflation significantly increased arterial oxygen partial pressure (PaO2) but was also associated with significant hypercapnia. When used as the first treatment, CPAP was associated with significantly decreased arterial partial pressure of carbon dioxide but did not increase PaO2. These results suggest that the use of CPAP may represent a practical method for correction of hypercapnia associated with inadequate ventilation in a field setting, and further research is required to characterise the use of CPAP with increased inspired oxygen concentrations.
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CeasIng Cpap At standarD criteriA (CICADA): predicting a successful outcome. Eur J Pediatr 2016; 175:81-7. [PMID: 26231684 DOI: 10.1007/s00431-015-2603-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED This is a retrospective analysis of a multicentre randomised controlled trial (RCT) where we concluded that CeasIng Cpap At standerD criteriA (CICADA) in premature babies (PBs) <30 weeks gestational age (GA) was the significantly better method of ceasing CPAP. To identify factors that may influence the number of attempts to cease CPAP, we reviewed the records of 50 PBs from the RCT who used the CICADA method. PBs were grouped according to number of attempts to cease CPAP (fast group ≤2 attempts and slow group >2 attempts to cease CPAP). There were 26 (fast group) and 24 (slow group) PBs included in the analysis. Results showed significant differences in mean GA (27.8 ± 0.3 vs 26.9 ± 0.3 [weeks ± SE], p = 0.03) and birth weight ([Bwt]; 1080 ± 48.8 vs 899 ± 45.8 [grams ± SE], p = 0.01) between groups. Significantly fewer PBs in the fast group had a patent ductus arteriosus (PDA) compared to the slow group (5/26 (19.2%) vs 13/24 (54.2 %), p = 0.02). Bwt was a significant negative predictor of CPAP duration (r = -0.497, p = 0.03) and CPAP ceasing attempts (r = -0.290, p = 0.04). CONCLUSION PBs with a higher GA and Bwt without a PDA ceased CPAP earlier using the CICADA method. Bwt was better than GA for predicting CPAP duration and attempts to cease CPAP. WHAT IS KNOWN Our previous studies showed that CeasIng Cpap At standarD criteriA (CICADA) significantly reduces CPAP time, oxygen requirements and caffeine use. Some PBs however using the CICADA method required >2 attempts to cease CPAP ('slow CICADA' group). WHAT IS NEW PBs in the 'fast CICADA' group (<3 attempts to cease CPAP) (a) have longer gestational age and higher birth weight, (b) shorter mechanical ventilation and (c) lower incidence of patent ductus arteriosus. Attempts to cease CPAP decreased by 0.5 times per 1 week increase in GA and 0.3 times per 100-g increase in birth weight for PBs <30 weeks gestation.
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Paterson D, Shivananda S, Helou SE, Fusch C, Mukerji A. Impact of interprofessional education on noninvasive ventilation in a tertiary neonatal intensive care unit. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2016; 52:81-84. [PMID: 30123022 PMCID: PMC6073516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To evaluate the impact and effectiveness of an experiential interprofessional education workshop on noninvasive ventilation (NIV) in the setting of a neonatal intensive care unit. METHODS In the present cross-sectional study, a full-day workshop, consisting of didactic and hands-on components, was developed to assess knowledge and perceptions, and to disseminate the latest evidence and practical aspects of NIV use. All health care professionals (HCPs) were asked to participate. Pre- and post-participation questionnaires and knowledge tests were used to assess the effectiveness of knowledge transfer, and to seek participants' reflections on the utility of the workshop. RESULTS Among 214 participants, 206 (96%) and 195 (91%) completed the pre- and post-participation questionnaires, respectively. The majority agreed (14%) or strongly agreed (75%) that NIV education was important for their role. Participants scored their perceived comfort with NIV following the workshop highly (median 5 [interquartile range (IQR) 1]) on a five-point Likert scale and 96% would recommend it to a colleague. Median knowledge scores on NIV, assessed as percent correct responses, increased from 74% (IQR 16) to 86% (IQR 11) (P<0.05). CONCLUSIONS A focused, context-specific workshop helped improve understanding and comfort among HCPs while reducing misconceptions about NIV. Further research to assess optimal delivery of NIV education and impact on patient outcomes is required.
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Say B, Kanmaz Kutman HG, Oguz SS, Oncel MY, Arayici S, Canpolat FE, Uras N, Karahan S. Binasal Prong versus Nasal Mask for Applying CPAP to Preterm Infants: A Randomized Controlled Trial. Neonatology 2016; 109:258-64. [PMID: 26859512 DOI: 10.1159/000443263] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 12/10/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) is being widely used for the treatment of respiratory distress syndrome (RDS) in preterm infants. However, there are only a few studies which compare different interfaces of NCPAP delivery and their effects on respiratory outcomes. OBJECTIVE We aimed to determine whether NCPAP applied with binasal prongs compared to that with a nasal mask (NM) reduces the rate of moderate/severe bronchopulmonary dysplasia (BPD) in preterm infants. METHODS Infants between 26 and 32 weeks' gestation who suffered from RDS and were treated with NCPAP were assessed. Parallel randomization was performed to eligible infants to receive NCPAP either via binasal prongs or NM. Infants were intubated if they fulfilled the predefined failure criteria. Data were collected by using the intention-to-treat principle. RESULTS One hundred and sixty infants were screened and 149 were randomized. Seventy-five infants in the binasal prong (NP) group and 74 in the NM group were analyzed. Mean gestational ages were 29.3 ± 1.6 vs. 29.1 ± 2.0 weeks (p = 0.55), and birth weights were 1,225 ± 257 vs. 1,282 ± 312 g (p = 0.22) in the NP and NM groups, respectively. The frequency of NCPAP failure within 24 h of life was higher in the NP than the NM group (8 vs. 0%; p = 0.09). The median duration of NCPAP was significantly higher in the NP group [median 4 (1-5) vs. 2 (1-3) h, p < 0.01]. The rate of moderate and severe BPD was significantly lower in the NM (n = 2, 2.7%) when compared with the NP group (n = 11, 14.6%; p < 0.01). The BPD/death rates were not different between the 2 groups (NM group: n = 18 or 24.3%; NP group: n = 19 or 25.3%; p = 0.51). CONCLUSIONS The NM was successfully used for delivering NCPAP in preterm infants, and no NCPAP failure was observed within the first 24 h. These data show that applying NCPAP by NM yielded a shorter duration of NCPAP and statistically reduced the rates of moderate and severe BPD.
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Affiliation(s)
- Birgul Say
- Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
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Nasal Jet-CPAP (variable flow) versus Bubble-CPAP in preterm infants with respiratory distress: an open label, randomized controlled trial. J Perinatol 2015; 35:935-40. [PMID: 26270255 DOI: 10.1038/jp.2015.98] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 06/30/2015] [Accepted: 07/07/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare the failure rates between Jet continuous positive airway pressure device (J-CPAP-variable flow) and Bubble continuous positive airway device (B-CPAP) in preterm infants with respiratory distress. STUDY DESIGN Preterm newborns <34 weeks gestation with onset of respiratory distress within 6 h of life were randomized to receive J-CPAP (a variable flow device) or B-CPAP (continuous flow device). A standardized protocol was followed for titration, weaning and removal of CPAP. Pressure was monitored close to the nares in both the devices every 6 hours and settings were adjusted to provide desired CPAP. The primary outcome was CPAP failure rate within 72 h of life. Secondary outcomes were CPAP failure within 7 days of life, need for surfactant post-randomization, time to CPAP failure, duration of CPAP and complications of prematurity. An intention to treat analysis was done. RESULTS One-hundred seventy neonates were randomized, 80 to J-CPAP and 90 to B-CPAP. CPAP failure rates within 72 h were similar in infants who received J-CPAP and in those who received B-CPAP (29 versus 21%; relative risks 1.4 (0.8 to 2.3), P=0.25). Mean (95% confidence intervals) time to CPAP failure was 59 h (54 to 64) in the Jet CPAP group in comparison with 65 h (62 to 68) in the Bubble CPAP group (log rank P=0.19). All other secondary outcomes were similar between the two groups. CONCLUSION In preterm infants with respiratory distress starting within 6 h of life, CPAP failure rates were similar with Jet CPAP and Bubble CPAP.
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Mukerji A, Belik J. Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission. J Perinatol 2015; 35:716-9. [PMID: 26043417 DOI: 10.1038/jp.2015.61] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 04/24/2015] [Accepted: 04/29/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate carbon dioxide (CO2) clearance, delivered pressures and tidal volume (VT) during neonatal nasal intermittent positive pressure ventilation (NIPPV) with two commonly used interfaces. STUDY DESIGN A neonatal lung model, with either short binasal prongs (SBP) or a small caliber nasal cannula (RAM) interface, was tested over a range of clinically relevant settings. A fixed amount of CO2 was infused and the fraction remaining in the lung 100 s postinfusion was measured. Pressure transmission to the lung and VT was measured at the level of the trachea. RESULT CO2 elimination was directly proportional to the inspiratory pressure during NIPPV. At peak pressures of 22 to 34 cm H2O, CO2 clearance was greater (P<0.001) with SBP as compared with RAM. Relative to the set ventilator parameters, a substantial pressure dampening effect was documented at the lung level, which was significantly lower with RAM when compared with SBP (2.8% (0.2) versus 11.9% (1.5), P<0.0001). CO2 elimination was dependent on VT and effective despite only a small fraction of physiological VT (maximum delivered VT%: SBP 15.5 (0.7) versus RAM 6.1 (1.4), P<0.0001). CONCLUSION NIPPV promotes CO2 elimination even at low transmitted airway pressures, but less effective with RAM as compared with SBP. CO2 elimination despite small VT suggests that NIPPV may depend on a non-conventional gas-exchange mechanism.
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Affiliation(s)
- A Mukerji
- Division of Neonatology, Department of Paediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - J Belik
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Ho JJ, Subramaniam P, Davis PG. Continuous distending pressure for respiratory distress in preterm infants. Cochrane Database Syst Rev 2015; 2015:CD002271. [PMID: 26141572 PMCID: PMC7133489 DOI: 10.1002/14651858.cd002271.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition, but it is invasive, potentially resulting in airway and lung injury. Continuous distending pressure (CDP) has been used for the prevention and treatment of RDS, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae. OBJECTIVES To determine the effect of continuous distending pressure (CDP) on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress.Subgroup analyses were planned on the basis of birth weight (> or < 1000 or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), methods of application of CDP (i.e. CPAP and CNP), application early versus late in the course of respiratory distress and high versus low pressure CDP and application of CDP in tertiary compared with non-tertiary hospitals, with the need for sensitivity analysis determined by trial quality.At the 2008 update, the objectives were modified to include preterm infants with respiratory failure. SEARCH METHODS We used the standard search strategy of the Neonatal Review Group. This included searches of the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, 2015 Issue 4), MEDLINE (1966 to 30 April 2015) and EMBASE (1980 to 30 April 2015) with no language restriction, as well as controlled-trials.com, clinicaltrials.gov and the International Clinical Trials Registry Platform of the World Health Organization (WHO). SELECTION CRITERIA All random or quasi-random trials of preterm infants with respiratory distress were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharyngeal tube or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and the lower body, compared with spontaneous breathing with oxygen added as necessary. DATA COLLECTION AND ANALYSIS We used standard methods of The Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each review author. MAIN RESULTS We included six studies involving 355 infants - two using face mask CPAP, two CNP, one nasal CPAP and one both CNP (for less ill babies) and endotracheal CPAP (for sicker babies). For this update, we included no new trials.Continuous distending pressure (CDP) is associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.52 to 0.81; typical risk difference (RD) -0.20, 95% CI -0.29 to -0.10; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; six studies; 355 infants), lower overall mortality (typical RR 0.52, 95% CI 0.32 to 0.87; typical RD -0.15, 95% CI -0.26 to -0.04; NNTB 7, 95% CI 4 to 25; six studies; 355 infants) and lower mortality in infants with birth weight above 1500 g (typical RR 0.24, 95% CI 0.07 to 0.84; typical RD -0.28, 95% CI -0.48 to -0.08; NNTB 4, 95% CI 2.00 to 13.00; two studies; 60 infants). Use of CDP is associated with increased risk of pneumothorax (typical RR 2.64, 95% CI 1.39 to 5.04; typical RD 0.10, 95% CI 0.04 to 0.17; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 17.00 to 25.00; six studies; 355 infants). We found no difference in bronchopulmonary dysplasia (BPD), defined as oxygen dependency at 28 days (three studies, 260 infants), as well as no difference in outcome at nine to 14 years (one study, 37 infants). AUTHORS' CONCLUSIONS In preterm infants with respiratory distress, the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax. Four out of six of these trials were done in the 1970s. Therefore, the applicability of these results to current practice is difficult to assess. Further research is required to determine the best mode of administration.
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Affiliation(s)
- Jacqueline J Ho
- Penang Medical CollegeDepartment of Paediatrics4 Sepoy LinesPenangMalaysia10450
| | - Prema Subramaniam
- Wanganui HospitalPaediatric Department100 Heads RoadWanganuiNew Zealand30990
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Kuboi T, Okazaki K, Kusaka T, Shimada A. Congenital dacryocystoceles controlled by nCPAP via nasal mask in a neonate. Pediatr Int 2015; 57:475-7. [PMID: 26016738 DOI: 10.1111/ped.12516] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 08/01/2014] [Accepted: 09/09/2014] [Indexed: 11/29/2022]
Abstract
Congenital dacryocystocele is a relatively rare type of nasolacrimal duct obstruction that may induce respiratory distress during the early neonatal period. We encountered a case of bilateral congenital dacryocystoceles with intranasal cysts in a premature infant delivered at 34 weeks of gestation. The patient developed symptoms of respiratory failure immediately after birth, but no ophthalmologic symptoms. Treatment with nasal continuous positive airway pressure via a nasal mask, instead of a nasal prong, effectively relieved the symptoms. Early diagnosis and appropriate treatment are critical for infants with nasal obstruction.
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Affiliation(s)
- Toru Kuboi
- Department of Neonatology, Shikoku Medical Center for Children and Adults, Kagawa, Japan
| | - Kaoru Okazaki
- Department of Neonatology, Shikoku Medical Center for Children and Adults, Kagawa, Japan
| | - Takashi Kusaka
- Department of Pediatrics, Kagawa University, Kagawa, Japan
| | - Aki Shimada
- Department of Otolaryngology, University of Tokushima School of Medicine, Tokushima, Japan
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Continuous positive airway pressure in preterm neonates: An update of current evidence and implications for developing countries. Indian Pediatr 2015; 52:319-28. [DOI: 10.1007/s13312-015-0632-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Nasal high-frequency oscillation ventilation in neonates: a survey in five European countries. Eur J Pediatr 2015; 174:465-71. [PMID: 25227281 DOI: 10.1007/s00431-014-2419-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022]
Abstract
UNLABELLED Nasal high-frequency oscillation ventilation (nHFOV) is a non-invasive ventilation mode that applies an oscillatory pressure waveform to the airways using a nasal interface. nHFOV has been shown to facilitate carbon dioxide expiration, but little is known about its use in neonates. In a questionnaire-based survey, we assessed nHFOV use in neonatal intensive care units (NICUs) in Austria, Switzerland, Germany, the Netherlands, and Sweden. Questions included indications for nHFOV, equipment used, ventilator settings, and observed side effects. Of the clinical directors of 186 NICUs contacted, 172 (92 %) participated. Among those responding, 30/172 (17 %) used nHFOV, most frequently in premature infants <1500 g (27/30) for the indication nasal continuous positive airway pressure (nCPAP) failure (27/30). Binasal prongs (22/30) were the most common interfaces. The median (range) mean airway pressure when starting nHFOV was 8 (6-12) cm H2O, and the maximum mean airway pressure was 10 (7-18) cm H2O. The nHFOV frequency was 10 (6-13) Hz. Abdominal distension (11/30), upper airway obstruction due to secretions (8/30), and highly viscous secretions (7/30) were the most common nHFOV side effects. CONCLUSION In a number of European NICUs, clinicians use nHFOV. The present survey identified differences in nHFOV equipment, indications, and settings. Controlled clinical trials are needed to investigate the efficacy and side effects of nHFOV in neonates.
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Acute Neonatal Respiratory Failure. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7193706 DOI: 10.1007/978-3-642-01219-8_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute respiratory failure requiring assisted ventilation is one of the most common reasons for admission to the neonatal intensive care unit. Respiratory failure is the inability to maintain either normal delivery of oxygen to the tissues or normal removal of carbon dioxide from the tissues. It occurs when there is an imbalance between the respiratory workload and ventilatory strength and endurance. Definitions are somewhat arbitrary but suggested laboratory criteria for respiratory failure include two or more of the following: PaCO2 > 60 mmHg, PaO2 < 50 mmHg or O2 saturation <80 % with an FiO2 of 1.0 and pH < 7.25 (Wen et al. 2004).
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