1
|
Wu WW, Rong H, Cheng R, Yang Y, Shen F. [Risk factors for initial non-invasive ventilation failure in very low birth weight infants with gestational age <32 weeks: a multicenter retrospective study]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2024; 26:907-913. [PMID: 39267504 PMCID: PMC11404468 DOI: 10.7499/j.issn.1008-8830.2404166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
OBJECTIVES To investigate the risk factors and adverse prognosis associated with initial non-invasive ventilation (NIV) failure in very low birth weight infants (VLBWI) with gestational age <32 weeks. METHODS A retrospective collection of clinical data from preterm infants admitted to the neonatal intensive care unit (NICU) in 28 tertiary hospitals in Jiangsu Province from January 2019 to December 2021 was conducted. Based on the outcomes of initial NIV, the infants were divided into a successful group and a failure group to analyze the risk factors for NIV failure and adverse prognosis. RESULTS A total of 817 infants were included, with 453 males (55.4%) and 139 failures (17.0%). The failure group had lower gestational age, birth weight, and 1-minute and 5-minute Apgar scores compared to the successful group (P<0.05). The failure group also had a higher proportion of respiratory distress syndrome (RDS) diagnosed upon NICU admission, higher maximum positive end-expiratory pressure during NIV, and higher percentages of reaching the required maximum fraction of inspired oxygen (FiO2) ≥30%, ≥35%, and ≥40% throughout the initial NIV process compared to the successful group (P<0.05). Gestational age (OR=0.671, 95%CI: 0.581-0.772), RDS (OR=1.955, 95%CI: 1.181-3.366), and FiO2 ≥30% (OR=2.053, 95%CI: 1.106-4.044) were identified as risk factors for initial NIV failure in these infants with gestational age <32 weeks (P<0.05). The failure group had higher incidences of complications such as pulmonary infections, pneumothorax, retinopathy of prematurity, moderate to severe bronchopulmonary dysplasia, and severe intraventricular hemorrhage during hospitalization, as well as longer hospital stays and higher total costs compared to the successful group (P<0.05). CONCLUSIONS Smaller gestational age, a diagnosis of RDS in the NICU, and achieving a maximum FiO2 ≥30% during the initial NIV process are risk factors for initial NIV failure in infants with gestational age <32 weeks. Initial NIV failure significantly increases the risk of adverse outcomes in this population.
Collapse
Affiliation(s)
- Wen-Wen Wu
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Hui Rong
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Rui Cheng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Yang Yang
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| | - Fei Shen
- Department of Neonatology, Children's Hospital of Nanjing Medical University, Nanjing 210008, China
| |
Collapse
|
2
|
Welch B, Rose R, Myers J, Drayton Jackson M, Lien I, Barbato A. Decreasing early invasive mechanical ventilation exposure in preterm infants: a quality improvement initiative. J Perinatol 2024:10.1038/s41372-024-02098-9. [PMID: 39198555 DOI: 10.1038/s41372-024-02098-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 08/16/2024] [Accepted: 08/19/2024] [Indexed: 09/01/2024]
Abstract
OBJECTIVE To decrease invasive mechanical ventilation exposure in the neonatal intensive care unit (NICU) in the first week of life for preterm infants with the global aim of decreasing bronchopulmonary dysplasia (BPD). METHODS We created a quality improvement (QI) initiative to optimize early non-invasive respiratory support which launched in August 2021. Patients born at <32 weeks gestation and admitted to the NICU on non-invasive respiratory support were included. RESULTS Invasive mechanical ventilation exposure decreased from 38 to 25% with evidence of special cause variation beginning in August 2022. Infants born at ≥26 weeks were most impacted, with a 50% reduction, from 34 to 17%. While BPD rates decreased, there has not yet been evidence of special cause variation. CONCLUSION Invasive mechanical ventilation exposure for infants born at <32 weeks gestation decreased following the creation of a QI initiative focused on optimization and standardization of early non-invasive respiratory support.
Collapse
Affiliation(s)
- Blair Welch
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA.
| | - Rebecca Rose
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Jessica Myers
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Meghan Drayton Jackson
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
- Division of Hematology and Oncology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Izlin Lien
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Alana Barbato
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| |
Collapse
|
3
|
Kumar P, Yadav A, Anand P, Debata P. Predictors of CPAP failure with RAM cannula interface for primary respiratory support in preterm neonates. Med J Armed Forces India 2024; 80:60-67. [PMID: 38261886 PMCID: PMC10793224 DOI: 10.1016/j.mjafi.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background RAM cannula is used as interface for delivering nasal continuous positive airway pressure (nCPAP) in many neonatal care units though the bench to bedside evidence for its use in clinical settings in lacking. Methods In this prospective cohort study from tertiary care neonatal care unit, the primary objective was to determine the rate of CPAP failure using RAM interface, within 72 h of starting of therapy and secondary objective was to look for the incidence and severity of nasal trauma with the use of RAM interface for CPAP delivery. All inborn preterm neonates between 28 and 32 weeks of gestation and weight more than 1000 g who required non-invasive respiratory support within 6 h of life were included in the study. Results The enroled cohort of 250 neonates had mean gestational age of 30.73 ± 1.32 weeks and mean birth weight of 1410 ± 210 g. CPAP failure rate with the use of RAM interface was 31.2% (78/250) in the overall cohort. The failure rate was higher in subgroup of gestation between 28 and 30 week (52.1%) in comparison with the 31-32-week gestation (18.2%; p-value = 0.0001). Nasal trauma was present in 36 (14%) neonates; of whom 33 (91%) had mild and 2 (6%) and 1 (3%) had moderate and severe, respectively. On multivariate analysis, birth weight less than 1250 g, incomplete antenatal steroids, need for PEEP more than 5 cm & FiO2 > 30% at onset of distress and administration of surfactant were found be statistically significantly associated with CPAP failure with RAM interface. Conclusion The clinical outcomes with the use of RAM interface for CPAP administration are comparable to those with other interfaces with lesser incidence of nasal injury. The results of this study warrant future randomized trials to compare different CPAP interfaces for clinical outcomes and nasal injuries from the developing countries.
Collapse
Affiliation(s)
- Pradeep Kumar
- Senior Resident (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Anita Yadav
- Associate Professor (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Pratima Anand
- Chief Medical Officer (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Pradeep Debata
- Professor (Pediatrics), Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| |
Collapse
|
4
|
van Kaam AH, Niemarkt HJ, Onland W. Timing of surfactant treatment in respiratory distress syndrome. Semin Fetal Neonatal Med 2023; 28:101495. [PMID: 38012889 DOI: 10.1016/j.siny.2023.101495] [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: 11/29/2023]
Abstract
The introduction of exogenous surfactant in the 1980s has resulted in an improved survival of very preterm infants with respiratory distress syndrome (RDS). Randomized controlled trials conducted before 2000 have shown that the magnitude of this beneficial effect strongly depends on the timing of surfactant treatment, i.e. the earlier surfactant is administered after birth the better. However, the initial mode of respiratory support in infants with RDS has changed dramatically over the last decades, moving from invasive to non-invasive support. Furthermore, new, less invasive techniques to administer surfactant have been introduced to match this non-invasive approach. This review summarizes the evidence on how these practice changes impacted the effect of surfactant timing on mortality and morbidity in preterm infants with RDS.
Collapse
Affiliation(s)
- Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Hendrik J Niemarkt
- Department of Neonatology, Maxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands.
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| |
Collapse
|
5
|
Glaser K, Bamat NA, Wright CJ. Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature. Arch Dis Child Fetal Neonatal Ed 2023; 108:554-560. [PMID: 36600473 PMCID: PMC10246486 DOI: 10.1136/archdischild-2022-324530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today's neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIV and early surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.
Collapse
Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Nicolas A Bamat
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
6
|
Bhandari V, Black R, Gandhi B, Hogue S, Kakkilaya V, Mikhael M, Moya F, Pezzano C, Read P, Roberts KD, Ryan RM, Stanford RH, Wright CJ. RDS-NExT workshop: consensus statements for the use of surfactant in preterm neonates with RDS. J Perinatol 2023; 43:982-990. [PMID: 37188774 PMCID: PMC10400415 DOI: 10.1038/s41372-023-01690-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To provide the best clinical practice guidance for surfactant use in preterm neonates with respiratory distress syndrome (RDS). The RDS-Neonatal Expert Taskforce (RDS-NExT) initiative was intended to add to existing evidence and clinical guidelines, where evidence is lacking, with input from an expert panel. STUDY DESIGN An expert panel of healthcare providers specializing in neonatal intensive care was convened and administered a survey questionnaire, followed by 3 virtual workshops. A modified Delphi method was used to obtain consensus around topics in surfactant use in neonatal RDS. RESULT Statements focused on establishing RDS diagnosis and indicators for surfactant administration, surfactant administration methods and techniques, and other considerations. After discussion and voting, consensus was achieved on 20 statements. CONCLUSION These consensus statements provide practical guidance for surfactant administration in preterm neonates with RDS, with a goal to contribute to improving the care of neonates and providing a stimulus for further investigation to bridge existing knowledge gaps.
Collapse
Affiliation(s)
- Vineet Bhandari
- The Children's Regional Hospital at Cooper/Cooper Medical School of Rowan University, Camden, NJ, USA.
| | | | - Bheru Gandhi
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | | | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Fernando Moya
- Division of Wilmington Pediatric Subspecialists, Department of Pediatrics, UNC School of Medicine, Wilmington, NC, USA
| | - Chad Pezzano
- Department of Cardio-Respiratory Services Pediatric -Albany Medical Center, Albany, NY, USA
| | - Pam Read
- AESARA Inc., Chapel Hill, NC, USA
| | | | - Rita M Ryan
- UH Rainbow Babies and Children's Hospital -Case Western Reserve University, Cleveland, OH, USA
| | | | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
7
|
Hysinger EB, Ahlfeld SK. Respiratory support strategies in the prevention and treatment of bronchopulmonary dysplasia. Front Pediatr 2023; 11:1087857. [PMID: 36937965 PMCID: PMC10018229 DOI: 10.3389/fped.2023.1087857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
Neonates who are born preterm frequently have inadequate lung development to support independent breathing and will need respiratory support. The underdeveloped lung is also particularly susceptible to lung injury, especially during the first weeks of life. Consequently, respiratory support strategies in the early stages of premature lung disease focus on minimizing alveolar damage. As infants grow and lung disease progresses, it becomes necessary to shift respiratory support to a strategy targeting the often severe pulmonary heterogeneity and obstructive respiratory physiology. With appropriate management, time, and growth, even those children with the most extreme prematurity and severe lung disease can be expected to wean from respiratory support.
Collapse
Affiliation(s)
- Erik B. Hysinger
- Division of Pulmonary Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Correspondence: Erik B. Hysinger
| | - Shawn K. Ahlfeld
- Division of Neonatology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| |
Collapse
|
8
|
Boix H, Fernández C, Serrano Martín MDM, Arruza L, Concheiro A, Gimeno A, Sánchez A, Rite S, Jiménez F, Méndez P, Agüera JJ. Failure of early non-invasive ventilation in preterm infants with respiratory distress syndrome in current care practice in Spanish level-III neonatal intensive care units - a prospective observational study. Front Pediatr 2023; 11:1098971. [PMID: 36896404 PMCID: PMC9989254 DOI: 10.3389/fped.2023.1098971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Despite advances in respiratory distress syndrome (RDS) management over the past decade, non-invasive ventilation (NIV) failure is frequent and associated with adverse outcomes. There are insufficient data on the failure of different NIV strategies currently used in clinical practice in preterm infants. Methods This was a prospective, multicenter, observational study of very preterm infants [gestational age (GA) <32 weeks] admitted to the neonatal intensive care unit for RDS that required NIV from the first 30 min after birth. The primary outcome was the incidence of NIV failure, defined as the need for mechanical ventilation for <72 h of life. Secondary outcomes were risk factors associated with NIV failure and complication rates. Results The study included 173 preterm infants with a median GA of 28 (IQR 27-30) weeks and a median birth weight of 1,100 (IQR 800-1,333) g. The incidence of NIV failure was 15.6%. In the multivariate analysis, lower GA (OR, 0.728; 95% CI, 0.576-0.920) independently increased the risk of NIV failure. Compared to NIV success, NIV failure was associated with higher rates of unfavorable outcomes, including pneumothorax, intraventricular hemorrhage, periventricular leukomalacia, pulmonary hemorrhage, and a combined outcome of moderate-to-severe bronchopulmonary dysplasia or death. Conclusion NIV failure occurred in 15.6% of the preterm neonates and was associated with adverse outcomes. The use of LISA and newer NIV modalities most likely accounts for the reduced failure rate. Gestational age remains the best predictor of NIV failure and is more reliable than the fraction of inspired oxygen during the first hour of life.
Collapse
Affiliation(s)
- Hector Boix
- Division of Neonatology, Hospital Universitario Dexeus, Barcelona, Spain
| | - Cristina Fernández
- Department of Neonatology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Luis Arruza
- Department of Neonatology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ana Concheiro
- Department of Neonatology, Álvaro Cunqueiro University Hospital, Vigo, Spain
| | - Ana Gimeno
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Ana Sánchez
- Department of Neonatology, Hospital Universitario La Paz, Madrid, Spain
| | - Segundo Rite
- Division of Neonatology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Francisco Jiménez
- Department of Neonatology and Neonatal Intensive Care Unit, Hospital Infantil Universitario Virgen del Rocio, Seville, Spain
| | - Paula Méndez
- Division of Paediatrics, Section of Neonatology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Juan José Agüera
- Department of Paediatrics, Neonatology Section, Virgen de la Arrixaca, University Hospital, Murcia, Spain
| | | |
Collapse
|
9
|
Samim SK, Debata PK, Yadav A, Kumar J, Anand P, Garg M. RAM cannula versus short binasal prongs for nasal continuous positive airway pressure delivery in preterm infants: a randomized, noninferiority trial from low-middle-income country. Eur J Pediatr 2022; 181:4111-4119. [PMID: 36114831 DOI: 10.1007/s00431-022-04620-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 12/26/2022]
Abstract
UNLABELLED To determine if RAM cannula is non-inferior to short binasal prongs (SBP) in providing nasal continuous positive airway pressure (CPAP) in preterm infants with respiratory distress syndrome (RDS). In this randomized, open-label, noninferiority trial from a low-middle-income country, we enrolled 254 preterm infants (28-34 weeks gestational age) with RDS who needed CPAP as primary respiratory support. The eligible infants were randomized to either RAM cannula or SBP interface groups. The primary outcome was CPAP failure (defined as the need for intubation or non-invasive positive pressure ventilation) within 72 h of randomization. The noninferiority margin was defined as a 10% or less absolute difference in CPAP failure rates. The secondary outcomes included nasal trauma and adverse events. We analyzed by per-protocol (primary) and intention to treat. CPAP failure has been seen in 25 infants (19.7%) in the RAM cannula group versus 22 (17.3%) in the SBP group (RD -2.36%; 95% CI -11.9 to 7.2 [beyond inferiority margin]; p = 0.6). Moderate and severe nasal trauma was less in RAM cannula (2.4 vs. 8.7%; RR 0.27; 95% CI 0.08-0.95; p 0.028). Duration of CPAP was also significantly shorter in the RAM cannula group (MD -12.4 h; 95% CI -20.34 to -4.46, p 0.017). There were no differences in other adverse events. CONCLUSIONS RAM cannula was not non-inferior to SBP in providing CPAP to preterm infants with respiratory distress syndrome. TRIAL REGISTRATION Registered at Clinical Trial Registry of India (CTRI/2020/03/024097). WHAT IS KNOWN • RAM cannula is used for providing supplemental oxygen therapy. There is conflicting evidence on its efficacy in delivering CPAP support in preterm infants. WHAT IS NEW • RAM cannula was not non-inferior to SBP in providing CPAP to preterm infants with respiratory distress syndrome. • RAM cannula causes less nasal trauma than short binasal prongs.
Collapse
Affiliation(s)
- S K Samim
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Pradeep Kumar Debata
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India.
| | - Anita Yadav
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Jogender Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Pratima Anand
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| | - Mehak Garg
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, 110029, India
| |
Collapse
|
10
|
Wright CJ, Glaser K, Speer CP, Härtel C, Roehr CC. Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools? J Pediatr 2022; 247:138-146. [PMID: 35429507 DOI: 10.1016/j.jpeds.2022.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/27/2021] [Accepted: 04/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Charles C Roehr
- Southmead Hospital, North Bristol NHS Trust, University of Bristol, Dept. Pediatrics, Faculty of Health Science, Bristol, UK; National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford Oxfordshire, UK.
| |
Collapse
|
11
|
Schulzke SM, Stoecklin B. Update on ventilatory management of extremely preterm infants-A Neonatal Intensive Care Unit perspective. Paediatr Anaesth 2022; 32:363-371. [PMID: 34878697 PMCID: PMC9300007 DOI: 10.1111/pan.14369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/03/2021] [Accepted: 12/06/2021] [Indexed: 12/11/2022]
Abstract
Extremely preterm infants commonly suffer from respiratory distress syndrome. Ventilatory management of these infants starts from birth and includes decisions such as timing of respiratory support in relation to umbilical cord management, oxygenation targets, and options of positive pressure support. The approach of early intubation and surfactant administration through an endotracheal tube has been challenged in recent years by primary noninvasive respiratory support and newer methods of surfactant administration via thin catheters. Available data comparing the thin catheter method to endotracheal tube and delayed extubation in extremely preterm infants born before 28 weeks of gestation did not show differences in survival free of bronchopulmonary dysplasia. Data from numerous randomized trials comparing conventional ventilation with high-frequency oscillatory ventilation did not show differences in meaningful outcomes. Among conventional modes of ventilation, there is good evidence to favor volume-targeted ventilation over pressure-limited ventilation. The former reduces the combined risk of bronchopulmonary dysplasia or death and several important secondary outcomes without an increase in adverse events. There are no evidence-based guidelines to set positive end-expiratory pressure in ventilated preterm infants. Recent research suggests that the forced oscillation technique may help to find the lowest positive end-expiratory pressure at which lung recruitment is optimal. Benefits and risks of the various modes of noninvasive ventilation depend on the clinical setting, degree of prematurity, severity of lung disease, and competency of staff in treating associated complications. Respiratory care after discharge includes home oxygen therapy, lung function monitoring, weaning from medication started in the neonatal unit, and treatment of asthma-like symptoms.
Collapse
Affiliation(s)
- Sven M. Schulzke
- Department of NeonatologyUniversity Children's Hospital Basel UKBBBaselSwitzerland,Faculty of MedicineUniversity of BaselBaselSwitzerland
| | - Benjamin Stoecklin
- Department of NeonatologyUniversity Children's Hospital Basel UKBBBaselSwitzerland
| |
Collapse
|
12
|
Kakkilaya VB, Weydig HM, Smithhart WE, Renfro SD, Garcia KM, Brown CM, He H, Wagner SA, Metoyer GC, Brown LS, Kapadia VS, Savani RC, Jaleel MA. Decreasing Continuous Positive Airway Pressure Failure in Preterm Infants. Pediatrics 2021; 148:peds.2020-014191. [PMID: 34552000 DOI: 10.1542/peds.2020-014191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks' gestational age (GA). METHODS A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks' GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre-OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). RESULTS Of the 216 infants ≤29 weeks' GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks' GA (46% vs 3%; P < .01). CONCLUSIONS Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.
Collapse
Affiliation(s)
- Venkatakrishna B Kakkilaya
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heather M Weydig
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - William E Smithhart
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Cari M Brown
- Parkland Hospital and Health System, Dallas, Texas
| | - Henry He
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Vishal S Kapadia
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rashmin C Savani
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
13
|
Claassen CC, Strand ML, Williams HL, Hillman NH. Use of the RAM Cannula with Early Bubble Continuous Positive Airway Pressure Requires Higher Pressures: Clinical and In vitro Evaluations. Am J Perinatol 2021; 38:1167-1173. [PMID: 32446255 DOI: 10.1055/s-0040-1710557] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Early bubble continuous positive airway pressure (bCPAP) in the delivery room (DR) reduces early intubation, mechanical ventilation, and bronchopulmonary dysplasia. The RAM cannula, adopted for ease of patient care, is a high resistance nasal interface that, when used with bCPAP, only transmits a portion of set pressures and attenuates the bubble effects. This study aimed to review early bCPAP pressures and bCPAP failure with the RAM cannula interface over a 6-year period. STUDY DESIGN Retrospective, single-center study of infants delivered <1,250 g from 2013 to 2018 (n = 735) begun on bCPAP in the DR with the RAM cannula. In vitro testing of bCPAP pressure transmission was also performed for multiple nasal interfaces and nasal occlusion percentages. RESULTS The percentage of infants intubated in the DR decreased over time (59 to 42%), while the average bCPAP pressure increased from 5.3 to 6.8 cmH2O. A total of 355 infants (48%) were admitted to the neonatal intensive care unit (NICU) from the DR on BCPAP. The failure rate for bCPAP in NICU within 72 hours decreased from 45 to 24% as the maximum CPAP increased from 5.8 to 7.6 cmH2O. Pneumothorax rates did not change. CPAP pressure transmission decreased with all sizes of the RAM cannula. CONCLUSION When utilizing the RAM cannula for bCPAP, higher CPAP levels were associated with decreases in DR intubations and CPAP failure within the first 72 hours. If clinicians choose to use the RAM cannula for bCPAP, they will need higher set pressures to achieve lung inflation and the beneficial oscillatory effect will be diminished. KEY POINTS · The transmission of the pressure oscillations from bubble CPAP is diminished with the RAM cannula.. · Increasing set CPAP pressures was associated with a decreased delivery room intubation rate and a decreased CPAP failure rate within 72 hours.. · Clinicians using the RAM cannula for bCPAP will need to increase pressures to obtain adequate lung inflation or change to a nasal interface designed for bCPAP..
Collapse
Affiliation(s)
- Colleen C Claassen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Marya L Strand
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| | - Howard L Williams
- SSM Health Systems, SSM Health Cardinal Glennon Children's Hospital, St. Louis, Missouri
| | - Noah H Hillman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, Missouri
| |
Collapse
|
14
|
Ackermann BW, Glaser K. Lung recruitment prior to IN-SUR-E procedure-Safe and effective? Acta Paediatr 2021; 110:1971-1972. [PMID: 33729597 DOI: 10.1111/apa.15820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/14/2021] [Accepted: 02/24/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Benjamin W. Ackermann
- Division of Neonatology Department of Women’s and Children’s Health University of Leipzig Medical Center Leipzig Germany
| | - Kirsten Glaser
- Division of Neonatology Department of Women’s and Children’s Health University of Leipzig Medical Center Leipzig Germany
| |
Collapse
|
15
|
Kidman AM, Manley BJ, Boland RA, Davis PG, Bhatia R. Predictors and outcomes of extubation failure in extremely preterm infants. J Paediatr Child Health 2021; 57:913-919. [PMID: 33486799 DOI: 10.1111/jpc.15356] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 10/15/2020] [Accepted: 12/13/2020] [Indexed: 11/28/2022]
Abstract
AIM To determine predictors and outcomes of extubation failure in extremely preterm (EP) infants born <28 weeks' gestational age (GA). METHODS Retrospective clinical audit across two tertiary-level neonatal intensive care units in Melbourne, Australia. Two-hundred and four EP infants who survived to their first extubation from mechanical ventilation. Extubation failure (re-intubation) within 7 days after the first extubation. RESULTS Lower GA (odds ratio [OR] 0.71, 95% confidence interval (CI), 0.61-0.89, P < 0.001) and higher pre-extubation measured mean airway pressure (MAP) on the mechanical ventilator (OR 1.9 [95% CI 1.41-2.51], P < 0.001) predicted extubation failure. The area under a receiver operating characteristic curve for GA and MAP was 0.77 (95% CI 0.70-0.82). After adjustment for GA, infants who experienced extubation failure had higher rates of bronchopulmonary dysplasia (P < 0.001), post-natal systemic corticosteroid treatment (P < 0.001), airway trauma (P < 0.003), longer durations of treatment with mechanical ventilation (P < 0.001), non-invasive respiratory support (P < 0.001), supplemental oxygen therapy (P = 0.05) and longer hospitalisation (P = 0.025). CONCLUSIONS Lower GA and higher pre-extubation measured MAP were predictive of extubation failure within 7 days in extremely preterm infants. Extubation failure was associated with increased morbidity and extended periods of respiratory support and hospitalisation.
Collapse
Affiliation(s)
- Anna Madeline Kidman
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Rosemarie A Boland
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Paediatric Infant Perinatal Emergency Retrieval at Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Risha Bhatia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
16
|
Glaser K, Wright CJ. Indications for and Risks of Noninvasive Respiratory Support. Neonatology 2021; 118:235-243. [PMID: 33902052 PMCID: PMC8178193 DOI: 10.1159/000515818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 01/20/2023]
Abstract
Within the last decades, therapeutic advances have significantly improved the survival of extremely preterm infants. In contrast, the incidence of major neonatal morbidities, including bronchopulmonary dysplasia, has not declined. Given the well-established relationship between exposure to invasive mechanical ventilation and neonatal lung injury, neonatologists have sought for effective strategies of noninvasive respiratory support in high-risk infants. Continuous positive airway pressure has replaced invasive mechanical ventilation for the initial stabilization and the treatment of respiratory distress syndrome. Today, noninvasive respiratory support has been adopted even in the tiniest babies with the highest risk of lung injury. Moreover, different modes of noninvasive respiratory support supplemented by a number of adjunctive measures and rescue strategies have entered clinical practice with the goal of preventing intubation or reintubation. However, does this unquestionably important paradigm shift to strategies focused on noninvasive support lull us into a false sense of security? Can we do better in (i) identifying those very immature preterm infants best equipped for noninvasive stabilization, can we improve (ii) determinants of failure of noninvasive respiratory support in the individual infant and underlying etiology, and can we enhance (iii) success of noninvasive respiratory support and (iv) better prevent ultimate harm to the developing lung? With increased survival of infants at the highest risk of developing lung injury and an unchanging burden of bronchopulmonary dysplasia, we should question indiscriminate use of noninvasive respiratory support and address the above issues.
Collapse
Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| |
Collapse
|
17
|
Patel P, Houck A, Fuentes D. Examining Variations in Surfactant Administration (ENVISION): A Neonatology Insights Pilot Project. CHILDREN-BASEL 2021; 8:children8040261. [PMID: 33800603 PMCID: PMC8065748 DOI: 10.3390/children8040261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/01/2022]
Abstract
Variability in neonatal clinical practice is well recognized. Respiratory management involves interdisciplinary care and often is protocol driven. The most recent published guidelines for management of respiratory distress syndrome and surfactant administration were published in 2014 and may not reflect current clinical practice in the United States. The goal of this project was to better understand variability in surfactant administration through conduct of health care provider (HCP) interviews. Questions focused on known practice variations included: use of premedication, decisions to treat, technique of surfactant administration and use of guidelines. Data were analyzed for trends and results were communicated with participants. A total of 54 HCPs participated from June to September 2020. In almost all settings, neonatologists or nurse practitioners intubated the infant and respiratory therapists administered surfactant. The INSURE (INtubation-SURrfactant-Extubation) technique was practiced by 83% of participants. Premedication prior to intubation was used by 76% of HCPs. An FiO2 ≥ 30% was the most common threshold for surfactant administration (48%). In conclusion, clinical practice variations exist in respiratory management and surfactant administration and do not seem to be specific to NICU level or institution type. It is unknown what effects the variability in clinical practice might have on clinical outcomes.
Collapse
|
18
|
Halliday HL, Speer CP. Sharing Progress in Neonatology (SPIN): Oxygen and Surfactant, Optimal Ventilation, Pulmonary Hypertension, Diagnostic Procedures, and Definition of Bronchopulmonary Dysplasia. Neonatology 2021; 118:207-210. [PMID: 33979805 DOI: 10.1159/000516039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 11/19/2022]
|
19
|
Sood BG, Thomas R, Delaney-Black V, Xin Y, Sharma A, Chen X. Aerosolized Beractant in neonatal respiratory distress syndrome: A randomized fixed-dose parallel-arm phase II trial. Pulm Pharmacol Ther 2020; 66:101986. [PMID: 33338661 DOI: 10.1016/j.pupt.2020.101986] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/02/2020] [Accepted: 12/09/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE There is increasing research into novel techniques of administering surfactant to preterm infants (PTIs) with respiratory distress syndrome (RDS) receiving non-invasive respiratory support (NIRS). Although aerosolized surfactant (AS) is promising in PTIs receiving NIRS, the optimal surfactant dose and formulation, drug-device combination and patient profile is not known. The objective of this randomized clinical trial was to investigate the feasibility, safety, efficacy and impact of four dosing schedules of AS using two nebulizers in PTIs with RDS stratified by gestational age (GA). METHODS PTIs with RDS receiving pre-defined NIRS for ≤8 h were assigned to 4 A S dosing schedules and 2 nebulizers within three GA strata (I = 240/7-286/7, II = 290/7-326/7, III = 330/7-366/7 weeks). There was no contemporaneous control group; at the recommendation of the Data Monitoring Committee, data was collected retrospectively for control infants. RESULTS Of 149 subjects that received AS, the median age at initiation of the 1st dose and duration was 5.5 and 2.4 h respectively. There were 29 infants in stratum I, and 60 each in strata II and III. Of infants <32 weeks GA, 94% received caffeine prior to AS. Fifteen infants (10%) required intubation within 72 h; the rates were not significantly different between GA strata, dosing schedules and nebulizers for infants who received aerosolized surfactant. Compared to retrospective controls, infants who received AS were less likely to need intubation within 72 h in both the intention-to-treat (32% vs. 11%) and the per-protocol (22% vs. 10%) analyses (p < 0.05) with GA stratum specific differences. AS was well tolerated by infants and clinical caregivers. Commonest adverse events included surfactant reflux from nose and mouth (18%), desaturations (11%), and increased secretions (7%). CONCLUSIONS We have demonstrated the feasibility, absence of serious adverse events and short-term efficacy of four dosing schedules of AS in the largest Phase II clinical trial of PTIs 24-36 weeks' GA with RDS receiving NIRS (ClinicalTrials.gov NCT02294630). The commonest adverse events noted were surfactant reflux and desaturations; no serious adverse effects were observed. Infants who received AS were less likely to receive intubation within 72 h compared to historical controls. AS is a promising new therapy for PTIs with RDS.
Collapse
Affiliation(s)
- Beena G Sood
- Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA.
| | - Ronald Thomas
- Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Virginia Delaney-Black
- Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Yuemin Xin
- Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Amit Sharma
- Department of Pediatrics, Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI, 48201, USA
| | - Xinguang Chen
- Department of Epidemiology, University of Florida College of Medicine, 665 W 8th Street, Jacksonville, FL, 32209, USA
| |
Collapse
|
20
|
Krishnamurthy G, Sahni R, Leone T, Kim F, Brooks MC, Morales SV, Koziakova A, Mills C, Capaci CP, Penn A. Care of the COVID-19 exposed complex newborn infant. Semin Perinatol 2020; 44:151282. [PMID: 32819725 PMCID: PMC7373040 DOI: 10.1016/j.semperi.2020.151282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
As we confront COVID-19, the global public health emergency of our times, new knowledge is emerging that, combined with information from prior epidemics, can provide insights on how to manage this threat in specific patient populations. Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), both caused by coronaviruses, caused serious respiratory illness in pregnant women that resulted in adverse perinatal outcomes. Thus far, COVID-19 appears to follow a mild course in the vast majority of pregnant women. A significant proportion of pregnant women appear to be asymptomatic carriers of SARS-CoV-2. However, there is limited information on how COVID-19 impacts the fetus and whether vertical transmission occurs. While these knowledge gaps are addressed, it is important to recognize the highly efficient transmission characteristics of SARS-C0V-2 and its potential for causing serious disease in vulnerable individuals, including health care workers. This review provides perspectives from a single center in New York City, the epicenter of the pandemic within the United States. It offers an overview of the preparations required for deliveries of newborns of mothers with COVID-19 and the management of neonates with particular emphasis on those born with complex issues.
Collapse
Affiliation(s)
- Ganga Krishnamurthy
- Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY.
| | - Rakesh Sahni
- Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Tina Leone
- Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Faith Kim
- Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Maria Cristina Brooks
- Division of Nursing, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Sylvia Villaraza- Morales
- Division of Nursing, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Adriana Koziakova
- Division of Nursing, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Cloyde Mills
- Division of Nursing, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Chaundra Passehl Capaci
- Division of Nursing, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Anna Penn
- Division of Neonatology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
21
|
Bubble Nasal Continuous Positive Airway Pressure (bNCPAP): An Effective Low-Cost Intervention for Resource-Constrained Settings. Int J Pediatr 2020; 2020:8871980. [PMID: 33014078 PMCID: PMC7519183 DOI: 10.1155/2020/8871980] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 08/28/2020] [Indexed: 11/26/2022] Open
Abstract
Preterm birth complications are responsible for almost one-third of the global neonatal mortality burden, and respiratory distress syndrome remains the single most common cause of these preventable deaths. Since its inception, almost half a century ago, nasal continuous positive airway pressure (NCPAP) has evolved to become the primary modality for neonatal respiratory care in both the developed and developing world. Although evidence has demonstrated the effectiveness of low-cost bubble NCPAP in reducing newborn mortality, its widespread use is yet to be seen in resource-constrained settings. Moreover, many tertiary hospitals in developing countries still utilise an inexpensive locally assembled bNCPAP system of unknown efficacy and safety. This review provides a brief overview of the history, physiological benefits, indications, contraindications, and complications of bNCPAP. Evidence regarding the effectiveness of low-cost bNCPAP in the neonatal intensive care unit is also summarised. The article further details a locally assembled bNCPAP system used in resource-constrained settings and highlights the care package for neonates receiving bNCPAP, failure criteria, and strategies for weaning.
Collapse
|
22
|
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.
Collapse
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.
| |
Collapse
|
23
|
Glaser K, Speer CP, Wright CJ. Fine Tuning Non-invasive Respiratory Support to Prevent Lung Injury in the Extremely Premature Infant. Front Pediatr 2020; 7:544. [PMID: 31998672 PMCID: PMC6966957 DOI: 10.3389/fped.2019.00544] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/13/2019] [Indexed: 12/31/2022] Open
Abstract
Within the last decades, therapeutic advances, such as antenatal corticosteroids, surfactant replacement, monitored administration of supplemental oxygen, and sophisticated ventilatory support have significantly improved the survival of extremely premature infants. In contrast, the incidence of some neonatal morbidities has not declined. Rates of bronchopulmonary dysplasia (BPD) remain high and have prompted neonatologists to seek effective strategies of non-invasive respiratory support in high risk infants in order to avoid harmful effects associated with invasive mechanical ventilation. There has been a stepwise replacement of invasive mechanical ventilation by early continuous positive airway pressure (CPAP) as the preferred strategy for initial stabilization and for early respiratory support of the premature infant and management of respiratory distress syndrome. However, the vast majority of high risk babies are mechanically ventilated at least once during their NICU stay. Adjunctive therapies aiming at the prevention of CPAP failure and the support of functional residual capacity have been introduced into clinical practice, including alternative techniques of administering surfactant as well as non-invasive ventilation approaches. In contrast, the strategy of applying sustained lung inflations in the delivery room has recently been abandoned due to evidence of higher rates of death within the first 48 h of life.
Collapse
Affiliation(s)
- Kirsten Glaser
- University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Christian P. Speer
- University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| |
Collapse
|
24
|
A trial comparing continuous positive airway pressure (CPAP) devices in preterm infants. J Perinatol 2020; 40:1193-1201. [PMID: 32433510 PMCID: PMC7375950 DOI: 10.1038/s41372-020-0690-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/06/2020] [Accepted: 05/07/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To test the hypothesis that infants born <30 weeks' gestation supported by Seattle-PAP will have lower rates of continuous positive airway pressure (CPAP) failure than infants supported with conventional, Fisher&Paykel-CPAP (FP-CPAP). STUDY DESIGN Randomized trial (3/2017-01/2019) at 5 NICUs. The primary outcome was CPAP failure; subgroup analyses (gestational age, receipt antenatal corticosteroids) were performed. RESULTS A total of 232 infants were randomized. Infants in the Seattle-PAP and FP-CPAP groups had mean gestational ages of 27.0 and 27.2 weeks, respectively. We observed no differences in rates of treatment failure between Seattle-PAP (40/112, 35.7%) and FP-CPAP (38/120, 31.7%; risk difference, 4.1%; 95% CI, -8.1-16.2; P = 0.51). Subgroup analysis indicated no differences in rates of CPAP failure. We observed no differences between the two groups in frequencies of adverse events or duration of respiratory support. CONCLUSIONS Among infants born <30 weeks' gestation, rates of CPAP failure did not differ between Seattle-PAP and FP-CPAP.
Collapse
|
25
|
Early predictors of continuous positive airway pressure failure in preterm neonates. J Perinatol 2019; 39:1081-1088. [PMID: 31089256 DOI: 10.1038/s41372-019-0392-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To develop a prediction model to identify infants admitted on continuous positive airway pressure (CPAP) requiring intubation within seventy-two hours of life (HOL). STUDY DESIGN Infants born ≤29 weeks' gestational age between 2013 and April 2018 were randomly assigned to either a modeling cohort (MC) or a validation cohort (VC) in a 2:1 ratio. Variables available within two HOL were compared between the CPAP failure group (CFG) and the CPAP success group (CSG). RESULTS Of the 189 infants in the MC, 50% failed CPAP. Compared to CSG, infants in the CFG had lower antenatal steroid exposure, birth weight, higher radiographic severe respiratory distress syndrome (RDS) and fraction of inspired oxygen (FiO2). A forward stepwise logistic regression modeling in both MC and VC showed that FiO2 >0.3 and radiographic severe RDS predicted CPAP failure. CONCLUSION FiO2 >0.3 within two HOL and radiographic severe RDS predicts CPAP failure in preterm infants.
Collapse
|
26
|
Hussain WA, Marks JD. Approaches to Noninvasive Respiratory Support in Preterm Infants: From CPAP to NAVA. Neoreviews 2019; 20:e213-e221. [PMID: 31261062 DOI: 10.1542/neo.20-4-e213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Endotracheal intubation and invasive mechanical ventilation have been mainstays in respiratory care of neonates with respiratory distress syndrome. Together with antenatal steroids and surfactant, this approach has accounted for significant reductions in neonatal mortality. However, with the increased survival of very low birthweight infants, the incidence of bronchopulmonary dysplasia (BPD), the primary respiratory morbidity of prematurity, has also increased. Arrest of alveolar growth and development and the abnormal development of the pulmonary vasculature after birth are the primary causes of BPD. However, invasive ventilation-associated lung inflammation and airway injury have long been believed to be important contributors. In fact, discontinuing invasive ventilation in favor of noninvasive respiratory support has been considered the single best approach that neonatologists can implement to reduce BPD. In this review, we present and discuss the mechanisms, efficacy, and long-term outcomes of the four main approaches to noninvasive respiratory support of the preterm infant currently in use: nasal continuous positive airway pressure, high-flow nasal cannula, nasal intermittent mandatory ventilation, and neurally adjusted ventilatory assist. We show that noninvasive ventilation can decrease rates of intubation and the need for invasive ventilation in preterm infants with respiratory distress syndrome. However, none of these noninvasive approaches decrease rates of BPD. Accordingly, noninvasive respiratory support should be considered for clinical goals other than the reduction of BPD.
Collapse
Affiliation(s)
- Walid A Hussain
- Section of Neonatology, Department of Pediatrics, University of Chicago, Chicago, IL
| | - Jeremy D Marks
- Section of Neonatology, Department of Pediatrics, University of Chicago, Chicago, IL.,Committee on Neurobiology, Department of Neurology, University of Chicago, Chicago, IL
| |
Collapse
|
27
|
Affiliation(s)
- Alan H Jobe
- Division of Neonatology, Perinatal and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| |
Collapse
|
28
|
Abstract
Respiratory failure affects a significant percentage of critically ill children, necessitating both invasive and non-invasive respiratory support. As the outcomes of these patients have improved, children with higher acuity and more complex respiratory pathophysiology require mechanical ventilation. Despite growing understanding of lung-protective strategies and ventilation induced lung injury, certain patients still require harmful ventilatory settings with conventional mechanical ventilation (CMV). High frequency ventilation, neurally adjusted ventilatory assist, and airway pressure release ventilation offer feasible alternatives to CMV. In addition to minimizing the risk of ventilatory induced lung injury when used appropriately, they provide a unique environment to facilitate operations on certain neonates and older children. Finally, non-invasive ventilation is now commonly employed in children with surgical conditions.
Collapse
Affiliation(s)
- Ana Ruzic
- Department of Surgery, UK Healthcare Kentucky Children's Hospital, 800 Rose St, Lexington KY 40536, USA.
| |
Collapse
|