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Li J, Deng N, He WJA, Yang C, Liu P, Albuainain FA, Ring BJ, Miller AG, Rotta AT, Guglielmo RD, Milési C. The effects of flow settings during high-flow nasal cannula oxygen therapy for neonates and young children. Eur Respir Rev 2024; 33:230223. [PMID: 38537946 PMCID: PMC10966474 DOI: 10.1183/16000617.0223-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/18/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND During neonatal and paediatric high-flow nasal cannula therapy, optimising the flow setting is crucial for favourable physiological and clinical outcomes. However, considerable variability exists in clinical practice regarding initial flows and subsequent adjustments for these patients. Our review aimed to summarise the impact of various flows during high-flow nasal cannula treatment in neonates and children. METHODS Two investigators independently searched PubMed, Embase, Web of Science, Scopus and Cochrane for in vitro and in vivo studies published in English before 30 April 2023. Studies enrolling adults (≥18 years) or those using a single flow setting were excluded. Data extraction and risk of bias assessments were performed independently by two investigators. The study protocol was prospectively registered with PROSPERO (CRD42022345419). RESULTS 38 406 studies were identified, with 44 included. In vitro studies explored flow settings' effects on airway pressures, humidity and carbon dioxide clearance; all were flow-dependent. Observational clinical studies consistently reported that higher flows led to increased pharyngeal pressure and potentially increased intrathoracic airway pressure (especially among neonates), improved oxygenation, and reduced respiratory rate and work of breathing up to a certain threshold. Three randomised controlled trials found no significant differences in treatment failure among different flow settings. Flow impacts exhibited significant heterogeneity among different patients. CONCLUSION Individualising flow settings in neonates and young children requires consideration of the patient's peak inspiratory flow, respiratory rate, heart rate, tolerance, work of breathing and lung aeration for optimal care.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
- These authors contributed equally
| | - Ni Deng
- Department of Respiratory Care, West China Hospital of Sichuan University, Chengdu, China
- These authors contributed equally
| | - Wan Jia Aaron He
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- These authors contributed equally
| | - Cui Yang
- Department of Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- These authors contributed equally
| | - Pan Liu
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, China
- These authors contributed equally
| | - Fai A Albuainain
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
- Department of Respiratory Care, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Jubail, Saudi Arabia
| | - Brian J Ring
- Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
- Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert D Guglielmo
- Division of Pediatric Critical Care, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Christophe Milési
- Pediatric Intensive Care Unit, University of Montpellier I, Montpellier, France
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Scholten AWJ, van Leuteren RW, de Waal CG, Kraaijenga JV, de Jongh FH, van Kaam AH, Hutten GJ. Diaphragmatic electromyography in infants: an overview of possible clinical applications. Pediatr Res 2024; 95:52-58. [PMID: 37660179 DOI: 10.1038/s41390-023-02800-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 09/04/2023]
Abstract
Preterm infants often experience breathing instability and a hampered lung function. Therefore, these infants receive cardiorespiratory monitoring and respiratory support. However, the current respiratory monitoring technique may be unreliable for especially obstructive apnea detection and classification and it does not provide insight in breathing effort. The latter makes the selection of the adequate mode and level of respiratory support difficult. Electromyography of the diaphragm (dEMG) has the potential of monitoring heart rate (HR) and respiratory rate (RR), and it provides additional information on breathing effort. This review summarizes the available evidence on the clinical potential of dEMG to provide cardiorespiratory monitoring, to synchronize patient-ventilator interaction, and to optimize the mode and level of respiratory support in the individual newborn infant. We also try to identify gaps in knowledge and future developments needed to ensure widespread implementation in clinical practice. IMPACT: Preterm infants require cardiorespiratory monitoring and respiratory support due to breathing instability and a hampered lung function. The current respiratory monitoring technique may provide unreliable measurements and does not provide insight in breathing effort, which makes the selection of the optimal respiratory support settings difficult. Measuring diaphragm activity could improve cardiorespiratory monitoring by providing insight in breathing effort and could potentially have an important role in individualizing respiratory support in newborn infants.
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Affiliation(s)
- Anouk W J Scholten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Juliette V Kraaijenga
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Faculty of Science and Technology, University of Twente, Drienerlolaan 5, Enschede, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.
- Amsterdam Reproduction & Development research institute, Amsterdam, the Netherlands.
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Naples R, Fenton AC, Brodlie M, Harigopal S, O'Brien C. Diaphragm electrical activity during weaning of nasal high-flow therapy in preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 108:237-243. [PMID: 36223982 DOI: 10.1136/archdischild-2022-324112] [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: 03/08/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether electrical activity of the diaphragm (Edi) changes with weaning nasal high-flow (HF) therapy in preterm infants according to a standardised protocol. DESIGN Prospective observational cohort study. SETTING Neonatal intensive care unit. PATIENTS Preterm infants born at <32 weeks gestation, receiving nasal HF as part of routine clinical care. INTERVENTIONS Infants recruited to the study had their HF weaned according to set clinical criteria. Edi was measured using a modified gastric feeding tube serially from baseline (pre-wean) to 24-hours post-wean. MAIN OUTCOME MEASURES Change in Edi from baseline was measured at four time points up to 24 hours after weaning. Minimum Edi during expiration, maximum Edi during inspiration and amplitude of the Edi signal (Edidelta) were measured. Clinical parameters (heart rate, respiratory rate and fraction of inspired oxygen) were also recorded. RESULTS Forty preterm infants were recruited at a mean corrected gestational age of 31.6 (±2.7) weeks. Data from 156 weaning steps were analysed, 91% of which were successful. Edi did not change significantly from baseline during flow reduction steps, but a significant increase in diaphragm activity was observed when discontinuing HF (median increase in Edidelta immediately post-discontinuation 1.7 µV (95% CI: 0.6 to 3.0)) and at 24 hours 1.9 µV (95% CI: 0.7 to 3.8)). No significant difference in diaphragm activity was observed between successful and unsuccessful weaning steps. CONCLUSIONS A protocolised approach to weaning has a high probability of success. Edi does not change with reducing HF rate, but significantly increases with discontinuation of HF from 2 L/min.
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Affiliation(s)
- Rebecca Naples
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan C Fenton
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Sundeep Harigopal
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris O'Brien
- Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, 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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5
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van Leuteren RW, de Waal CG, Hutten GJ, de Jongh FH, van Kaam AH. Transcutaneous monitoring of diaphragm activity as a measure of work of breathing in preterm infants. Pediatr Pulmonol 2021; 56:1593-1600. [PMID: 33524225 PMCID: PMC8248030 DOI: 10.1002/ppul.25284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/06/2021] [Accepted: 01/13/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Monitoring work of breathing (WOB) is important to assess the pulmonary condition and adjust respiratory support in preterm infants. Conventional WOB measurement (esophageal pressure, tidal volume) is invasive and we hypothesized that monitoring diaphragm activity could be a noninvasive alternative to estimate WOB. The objective was to determine the correlation between conventional WOB measures and diaphragm activity, in preterm infants. METHODS WOB and diaphragm activity, measured with transcutaneous electromyography (dEMG), were simultaneously recorded at different nasal continuous positive airway pressure (nCPAP) levels. During a 30-s recording at each nCPAP level, dEMG parameters, inspiratory WOB (WOBi ), and pressure time product (PTPin ) were calculated per breath. The correlation coefficient between WOB- and dEMG-measures was calculated using single breaths and after aggregating all breaths into deciles of incremental WOBi . RESULTS Fifteen preterm infants were included (median gestational age, 28 weeks). Single-breath analysis showed a poor median correlation of 0.27 (interquartile range [IQR], 0.03 to 0.33) and 0.08 (IQR, -0.03 to 0.28), respectively, for WOBi and PTPin with peak diaphragmatic activity (dEMGpeak ). A modest median correlation coefficient of 0.65 (IQR, 0.13 to 0.79) and 0.43 (IQR, -0.33 to 0.69) was found for, respectively, WOBi and PTPin with dEMGpeak in the aggregated analysis. CONCLUSION Diaphragm activity showed a modest correlation with WOBi and PTPin in an aggregated analysis. This finding warrants further studies in infants with more significant lung disease.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction & Development Research Institute, Amsterdam, The Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
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