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Yang T, Ma Y, Chen X, Yang Q, Pei J, Zhang Z, Qian X, Wang Y, Fan X, Han L. Effect of different noninvasive ventilation interfaces on the prevention of facial pressure injury: A network meta-analysis. Intensive Crit Care Nurs 2024; 81:103585. [PMID: 37977002 DOI: 10.1016/j.iccn.2023.103585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/28/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE To assess the effect of different noninvasive ventilation interfaces on preventing the facial pressure injury. METHODS This network meta-analysis was conducted following the PRISMA reporting guidelines. Seven electronic databases were systematically searched for randomised controlled trials about the comparative effectiveness of different interfaces in preventing facial pressure injury with noninvasive ventilation in adults and newborns from inception to June 2023. The acronym of PICOS was used and the keywords as well as inclusion/exclusion criteria were determined. Study selection and data extraction were performed by two independent reviewers. The Cochrane risk of bias assessment tool was used to assess the methodological quality. RESULTS A total of 78 randomised controlled trials involving 7,291 patients were included. The results of network meta-analysis showed that the effectiveness of the eight noninvasive ventilation interfaces on the prevention of facial pressure injury was in the order of: nasal cannula > full-face mask > rotation of nasal mask with nasal prongs > helmet > nasal mask > oronasal mask > nasal prongs > face mask. The use of full-face mask in adults and nasal cannula in newborns had the best effect on preventing the incidence of facial pressure injury. CONCLUSIONS The use of full-face mask in adults and nasal cannula in newborns had the most clinical advantage in preventing the incidence of facial pressure injury and were worthy promoting in clinical practice. IMPLICATIONS FOR CLINICAL PRACTICE This study provides a certain theoretical basis for the selection of appropriate interface for patients with noninvasive ventilation. Clinical practitioners should choose the appropriate interfaces based on the patient's specific condition to reduce the incidence of facial pressure injury, enhance patient comfort, and improve the effectiveness of respiratory therapy.
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Affiliation(s)
- Tingting Yang
- Evidence-based Nursing Center, School of Nursing, School of First Clinical Medical, Lanzhou University, Lanzhou, Gansu, China
| | - Yuxia Ma
- Evidence-based Nursing Center, School of Nursing, School of First Clinical Medical, Lanzhou University, Lanzhou, Gansu, China
| | - Xiaoli Chen
- Department of Pediatrics, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Qiuxia Yang
- School of First Clinical Medical, Lanzhou University, Lanzhou, Gansu, China
| | - Juhong Pei
- School of First Clinical Medical, Lanzhou University, Lanzhou, Gansu, China
| | - Ziyao Zhang
- School of Foreign Languages, Lanzhou University of Arts and Science, Lanzhou, Gansu, China
| | - Xiaoling Qian
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Yunyun Wang
- Gansu Provincial Maternity and Child Care Hospital, Lanzhou, Gansu, China
| | - Xiangping Fan
- Department of Nursing, The Third People's Hospital of Lanzhou, Lanzhou, Gansu, China
| | - Lin Han
- Department of Nursing, Gansu Provincial Hospital, Lanzhou, Gansu, China.
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Mukerji A, Read B, Yang J, Baczynski M, Ng E, Dunn M, Ethier G, Abou Mehrem A, Beltempo M, Drolet C, da Silva O, Louis D, Lemyre B, Afifi J, Singh B, Sherlock R, Stavel M, Masse E, Kanungo J, Wong J, Bodani J, Khurshid F, Lee KS, Augustine S, de Oliveira CB, Makary H, Newman A, Ojah C, Shah PS. CPAP Versus NIPPV Postextubation in Preterm Neonates: A Comparative-Effectiveness Study. Pediatrics 2024; 153:e2023064045. [PMID: 38511227 DOI: 10.1542/peds.2023-064045] [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] [Accepted: 01/05/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Nasal intermittent positive pressure ventilation (NIPPV) has been shown to be superior to nasal continuous positive airway pressure (CPAP) postextubation in preterm neonates. However, studies have not permitted high CPAP pressures or rescue with other modes. We hypothesized that if CPAP pressures >8 cmH2O and rescue with other modes were permitted, CPAP would be noninferior to NIPPV. METHODS We conducted a pragmatic, comparative-effectiveness, noninferiority study utilizing network-based real-world data from 22 Canadian NICUs. Centers self-selected CPAP or NIPPV as their standard postextubation mode for preterm neonates <29 weeks' gestation. The primary outcome was failure of the initial mode ≤72 hours. Secondary outcomes included failure ≤7 days, and reintubation ≤72 hours and ≤7 days. Groups were compared using a noninferiority adjusted risk-difference (aRD) margin of 0.05, and margin of no difference. RESULTS A total of 843 infants extubated to CPAP and 974 extubated to NIPPV were included. CPAP was not noninferior (and inferior) to NIPPV for failure of the initial mode ≤72 hours (33.0% vs 26.3%; aRD 0.07 [0.03 to 0.12], Pnoninferiority(NI) = .86), and ≤7 days (40.7% vs 35.8%; aRD 0.09 [0.05 to 0.13], PNI = 0.97). However, CPAP was noninferior (and equivalent) to NIPPV for reintubation ≤72 hours (13.2% vs 16.1%; aRD 0.01 [-0.05 to 0.02], PNI < .01), and noninferior (and superior) for reintubation ≤7 days (16.4% vs 22.8%; aRD -0.04 [-0.07 to -0.001], PNI < .01). CONCLUSIONS CPAP was not noninferior to NIPPV for failure ≤72 hours postextubation; however, it was noninferior to NIPPV for reintubation ≤72 hours and ≤7 days. This suggests CPAP may be a reasonable initial postextubation mode if alternate rescue strategies are available.
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Affiliation(s)
- Amit Mukerji
- McMaster Children's Hospital, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Brooke Read
- London Health Sciences Centre, London, Ontario, Canada
| | - Junmin Yang
- Mount Sinai Hospital, Department of Pediatrics
| | | | - Eugene Ng
- Sunnybrook Health Sciences Centre, Department of Pediatrics
| | - Michael Dunn
- Sunnybrook Health Sciences Centre, Department of Pediatrics
| | - Guillaume Ethier
- CHU Sainte-Justine, Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Ayman Abou Mehrem
- Foothills Medical Centre, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Marc Beltempo
- Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Christine Drolet
- CHU de Quebec, Department of Pediatrics, Laval University, Quebec, Quebec City, Canada
| | - Orlando da Silva
- London Health Sciences Centre, Department of Pediatrics, Western University, London, Ontario, Canada
| | - Deepak Louis
- Health Sciences Centre and St. Boniface Hospital, Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brigitte Lemyre
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | | | | | - Edith Masse
- CIUSSSE-CHUS, Department of Pediatrics, University of Sherbrooke, Quebec, Canada
| | - Jaideep Kanungo
- Royal Victoria Hospital, University of Victoria, Victoria, British Columbia, Canada
| | - Jonathan Wong
- BC Women's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaya Bodani
- Regina General Hospital, Department of Pediatrics, University of Regina, Regina, Saskatchewan, Canada
| | - Faiza Khurshid
- Kingston General Hospital, Queen's University, Kingston, Ontario, Canada
| | - Kyong-Soon Lee
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Alana Newman
- Saint John Regional Hospital, Saint John, New Brunswick, Department of Pediatrics, Dalhousie University, Halifax, Novia Scotia, Canada
| | - Cecil Ojah
- Saint John Regional Hospital, Saint John, New Brunswick, Department of Pediatrics, Dalhousie University, Halifax, Novia Scotia, Canada
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Mukerji A, Keszler M. Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures were Equivalent? Am J Perinatol 2024. [PMID: 38211631 DOI: 10.1055/a-2242-7391] [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] [Indexed: 01/13/2024]
Abstract
Respiratory support for preterm neonates in modern neonatal intensive care units is predominantly with the use of noninvasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of noninvasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application versus the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing noninvasive respiratory support modes at equal mean airway pressures. KEY POINTS: · Most current literature on CPAP vs. NIPPV in preterm neonates is confounded by use of higher mean airway pressures during NIPPV.. · In this review, we summarize existing evidence on CPAP vs. NIPPV at equivalent mean airway pressures.. · We call for future research on noninvasive support modes to account for mean airway pressures..
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Affiliation(s)
- Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Martin Keszler
- Department of Pediatrics, Brown University, Providence, Rhode Island
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Permall DL, Zhang Y, Li H, Guan Y, Chen X. A clinical study evaluating the combination of LISA and SNIPPV for the treatment of respiratory distress syndrome in preterm infants. Sci Rep 2024; 14:1429. [PMID: 38228632 PMCID: PMC10792160 DOI: 10.1038/s41598-023-50303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 12/18/2023] [Indexed: 01/18/2024] Open
Abstract
To compare the therapeutic effect of less invasive surfactant administration (LISA) followed by synchronized nasal intermittent positive pressure ventilation (SNIPPV) and traditional intubate-Surfactant-Extubate (InSurE) strategy for the treatment of neonatal respiratory distress syndrome (NRDS). A single-center, non-randomized and single- blinded study Tertiary neonatal intensive care unit 89 infants enrolled were preterm with gestational age < 366/7 weeks and clinically diagnosed with neonatal RDS (NRDS) Interventions: 32 infants were assigned to the LISA + SNIPPV group and 57 infants to the InSurE + nCPAP group. No statistically significant differences were noted in the baseline characteristics of the enrolled infants. A lower proportion of infants developed BPD in the LISA + SNIPPV group compared to the InSurE + CPAP group [10 (31.25%) vs. 21 (36.84%), P > 0.05]; however, there was no statistically significant difference. The number needed to treat (NNT) with LISA + SNIPPV to prevent BPD development is 18. The mortality rate was not significant between our study arms [1 (3.13%) vs 2 (3.51%), P > 0.05]. There were no statistically significant differences in the durations (days) of MV [(12.18 ± 13.89) vs. (11.35 ± 11.61), P > 0.05], oxygen therapy [(35.03 ± 19.13) vs. (39.75 ± 17.91), P > 0.05] and re-intubation rates [(0.19 ± 0.40) vs. (0.21 ± 0.45), P > 0.05] between the two study groups. In terms of complications, the incidence of patent ductus arteriosus (PDA) [24 (75.00%) vs. 27 (47.37%), P < 0.05] was higher and a lower rate of disturbed liver function [1 (3.23%) vs. 19 (33.33%), P < 0.05] were observed in the LISA + SNIPPV group. Acid-base imbalances were reportedly significantly higher in the InSurE group (P < 0.05). No significant differences in other complications were noted. In the interventional group, FiO2 requirements were significantly lower up until the 3rd week of treatment [FiO2 at day 0, (30.75 ± 4.78) vs. (34.66 ± 9.83), P < 0.05; FiO2 at day 21, (25.32 ± 3.74) vs. (29.11 ± 8.17), P < 0.05], as was RSS on days 2 [(0.77 ± 0.38) vs. (1.94 ± 0.75), P < 0.05] and 3 [(0.66 ± 0.33) vs. (1.89 ± 0.82), P < 0.05] after treatment. Additionally, infants in the standard group had a significantly prolonged hospital stay (days) [(45.97 ± 16.93) vs. (54.40 ± 16.26), P < 0.05]. The combination of LISA and SNIPPV for NRDS can potentially lower the rate of BPD, FiO2 demand and shorten the length of hospitalization.
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Affiliation(s)
| | - Yuhan Zhang
- Nanjing Medical University, Nanjing, Jiangsu, China
| | - Hanyue Li
- Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yafei Guan
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaoqing Chen
- Department of Pediatrics, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.
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Zhou R, Xiong T, Tang J, Huang Y, Liu W, Zhu J, Chen C, Gong L, Tian K, Wang A, Mu D. High-flow nasal cannula (HFNC) vs continuous positive airway pressure (CPAP) vs nasal intermittent positive pressure ventilation as primary respiratory support in infants of ≥ 32 weeks gestational age (GA): study protocol for a three-arm multi-center randomized controlled trial. Trials 2023; 24:647. [PMID: 37803402 PMCID: PMC10557210 DOI: 10.1186/s13063-023-07665-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/20/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Health problems in neonates with gestational age (GA) ≥ 32 weeks remain a major medical concern. Respiratory distress (RD) is one of the common reasons for admission of neonates with GA ≥ 32 weeks. Noninvasive ventilation (NIV) represents a crucial approach to treat RD, and currently, the most used NIV modes in neonatal intensive care unit include high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and nasal intermittent positive pressure ventilation. Although extensive evidence supports the use of NIPPV in neonates with a GA < 32 weeks, limited data exist regarding its effectiveness in neonates with GA ≥ 32 weeks. Therefore, the aim of this study is to compare the clinical efficacy of HFNC, CPAP, and NIPPV as primary NIV in neonates with GA ≥ 32 weeks who experience RD. METHODS This trial is designed as an assessor-blinded, three-arm, multi-center, parallel, randomized controlled trial, conducted in neonates ≥ 32 weeks' GA requiring primary NIV in the first 24 h of life. The neonates will be randomly assigned to one of three groups: HFNC, CPAP or NIPPV group. The effectiveness, safety and comfort of NIV will be evaluated. The primary outcome is the occurrence of treatment failure within 72 h after enrollment. Secondary outcomes include death before discharge, surfactant treatment within 72 h after randomization, duration of both noninvasive and invasive mechanical ventilation, duration of oxygen therapy, bronchopulmonary dysplasia, time to achieve full enteral nutrition, necrotizing enterocolitis, duration of admission, cost of admission, air leak syndrome, nasal trauma, and comfort score. DISCUSSION Currently, there is a paucity of data regarding the utilization of NIPPV in neonates with GA ≥ 32 weeks. This study will provide clinical evidence for the development of respiratory treatment strategies in neonates at GA ≥ 32 weeks with RD, with the aim of minimizing the incidence of tracheal intubation and reducing the complications associated with NIV. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR2300069192. Registered on March 9, 2023, https://www.chictr.org.cn/showproj.html?proj=171491 .
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Affiliation(s)
- Rong Zhou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China.
| | - Jun Tang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - Yi Huang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Wenli Liu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Jun Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Chao Chen
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Lingyue Gong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Ke Tian
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Aoyu Wang
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, Section Three, South Renmin Road, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
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Sahni M, Bhandari V. Invasive and non-invasive ventilatory strategies for early and evolving bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151815. [PMID: 37775369 DOI: 10.1016/j.semperi.2023.151815] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
In the age of surfactant and antenatal steroids, neonatal care has improved outcomes of preterm infants dramatically. Since the early 2000's neonatologists have strived to decrease bronchopulmonary dysplasia (BPD) by decreasing ventilator-associated lung injury and utilizing many novel modes of non-invasive respiratory support. After the initial success with nasal continuous positive airway pressure, it was established that discontinuing invasive ventilation early in favor of non-invasive respiratory support is the most effective way to reduce the incidence of BPD. In this review, we discuss the management of the preterm lung from the time of delivery, through the phases of respiratory distress syndrome (early BPD) and then evolving BPD. The goal remains to optimize respiratory support of the preterm lung while minimizing ventilator-associated lung injury and oxygen toxicity. A multidisciplinary approach involving the medical team and family is quintessential in reaching this goal and involves adequate respiratory support, optimizing nutrition and fluid balance as well as preventing infections.
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Affiliation(s)
- Mitali Sahni
- Pediatrix Medical Group, Sunrise Children's Hospital, Las Vegas, NV, United States; University of Nevada, Las Vegas, NV, United States
| | - Vineet Bhandari
- Neonatology Research Laboratory (Room #206), Education and Research Building, Cooper University Hospital, Camden, NJ, United States; The Children's Regional Hospital at Cooper, Cooper Medical School of Rowan University, Camden, NJ, United States.
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Lavizzari A, Zannin E, Klotz D, Dassios T, Roehr CC. State of the art on neonatal noninvasive respiratory support: How physiological and technological principles explain the clinical outcomes. Pediatr Pulmonol 2023; 58:2442-2455. [PMID: 37378417 DOI: 10.1002/ppul.26561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/26/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023]
Abstract
Noninvasive respiratory support has gained significant popularity in neonatal units because of its potential to reduce lung injury associated with invasive mechanical ventilation. To minimize lung injury, clinicians aim to apply for noninvasive respiratory support as early as possible. However, the physiological background and the technology behind such support modes are not always clear, and many open questions remain regarding the indications of use and clinical outcomes. This narrative review discusses the currently available evidence for various noninvasive respiratory support modes applied in Neonatal Medicine in terms of physiological effects and indications. Reviewed modes include nasal continuous positive airway pressure, nasal high-flow therapy, noninvasive high-frequency oscillatory ventilation, nasal intermittent positive pressure ventilation (NIPPV), synchronized NIPPV and noninvasive neurally adjusted ventilatory assist. To enhance clinicians' awareness of each support mode's strengths and limitations, we summarize technical features related to the functioning mechanisms of devices and the physical properties of the interfaces commonly used for providing noninvasive respiratory support to neonates. We finally address areas of current controversy and suggest possible areas of research for implementing noninvasive respiratory support in neonatal intensive care units.
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Affiliation(s)
- Anna Lavizzari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Emanuela Zannin
- Fondazione Monza e Brianza per il Bambino e la sua Mamma, Monza, Italy
| | - Daniel Klotz
- Center for Pediatrics, Division of Neonatology, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Theodore Dassios
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Charles C Roehr
- Faculty of Health Sciences, University of Bristol, Bristol, UK
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
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Lemyre B, Deguise MO, Benson P, Kirpalani H, De Paoli AG, Davis PG. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2023; 7:CD003212. [PMID: 37497794 PMCID: PMC10374244 DOI: 10.1002/14651858.cd003212.pub4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) is a useful method for providing respiratory support after extubation. Nasal intermittent positive pressure ventilation (NIPPV) can augment NCPAP by delivering ventilator breaths via nasal prongs. OBJECTIVES Primary objective To determine the effects of management with NIPPV versus NCPAP on the need for additional ventilatory support in preterm infants whose endotracheal tube was removed after a period of intermittent positive pressure ventilation. Secondary objectives To compare rates of abdominal distension, gastrointestinal perforation, necrotising enterocolitis, chronic lung disease, pulmonary air leak, mortality, duration of hospitalisation, rates of apnoea and neurodevelopmental status at 18 to 24 months for NIPPV and NCPAP. To compare the effect of NIPPV versus NCPAP delivered via ventilators versus bilevel devices, and assess the effects of the synchronisation of ventilation, and the strength of interventions in different economic settings. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was January 2023. SELECTION CRITERIA We included randomised and quasi-randomised trials of ventilated preterm infants (less than 37 weeks' gestational age (GA)) ready for extubation to non-invasive respiratory support. Interventions were NIPPV and NCPAP. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcome was 1. respiratory failure. Our secondary outcomes were 2. endotracheal reintubation, 3. abdominal distension, 4. gastrointestinal perforation, 5. necrotising enterocolitis (NEC), 6. chronic lung disease, 7. pulmonary air leak, 8. mortality, 9. hospitalisation, 10. apnoea and bradycardia, and 11. neurodevelopmental status. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 19 trials (2738 infants). Compared to NCPAP, NIPPV likely reduces the risk of respiratory failure postextubation (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.67 to 0.84; number needed to treat for an additional beneficial outcome (NNTB) 11, 95% CI 8 to 17; 19 trials, 2738 infants; moderate-certainty evidence) and endotracheal reintubation (RR 0.78, 95% CI 0.70 to 0.87; NNTB 12, 95% CI 9 to 25; 17 trials, 2608 infants, moderate-certainty evidence), and may reduce pulmonary air leaks (RR 0.57, 95% CI 0.37 to 0.87; NNTB 50, 95% CI 33 to infinite; 13 trials, 2404 infants; low-certainty evidence). NIPPV likely results in little to no difference in gastrointestinal perforation (RR 0.89, 95% CI 0.58 to 1.38; 8 trials, 1478 infants, low-certainty evidence), NEC (RR 0.86, 95% CI 0.65 to 1.15; 10 trials, 2069 infants; moderate-certainty evidence), chronic lung disease defined as oxygen requirement at 36 weeks (RR 0.93, 95% CI 0.84 to 1.05; 9 trials, 2001 infants; moderate-certainty evidence) and mortality prior to discharge (RR 0.81, 95% CI 0.61 to 1.07; 11 trials, 2258 infants; low-certainty evidence). When considering subgroup analysis, ventilator-generated NIPPV likely reduces respiratory failure postextubation (RR 0.49, 95% CI 0.40 to 0.62; 1057 infants; I2 = 47%; moderate-certainty evidence), while bilevel devices (RR 0.95, 95% CI 0.77 to 1.17; 716 infants) or a mix of both ventilator-generated and bilevel devices likely results in little to no difference (RR 0.87, 95% CI 0.73 to 1.02; 965 infants). AUTHORS' CONCLUSIONS NIPPV likely reduces the incidence of extubation failure and the need for reintubation within 48 hours to one-week postextubation more effectively than NCPAP in very preterm infants (GA 28 weeks and above). There is a paucity of data for infants less than 28 weeks' gestation. Pulmonary air leaks were also potentially reduced in the NIPPV group. However, it has no effect on other clinically relevant outcomes such as gastrointestinal perforation, NEC, chronic lung disease or mortality. Ventilator-generated NIPPV appears superior to bilevel devices in reducing the incidence of respiratory failure postextubation failure and need for reintubation. Synchronisation used to deliver NIPPV may be important; however, data are insufficient to support strong conclusions. Future trials should enrol a sufficient number of infants, particularly those less than 28 weeks' GA, to detect differences in death or chronic lung disease and should compare different categories of devices, establish the impact of synchronisation of NIPPV on safety and efficacy of the technique as well as the best combination of settings for NIPPV (rate, peak pressure and positive end-expiratory). Trials should strive to match the mean airway pressure between the intervention groups to allow a better comparison. Neurally adjusted ventilatory assist needs further assessment with properly powered randomised trials.
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Affiliation(s)
- Brigitte Lemyre
- Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | | | - Paige Benson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | | | - 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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9
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Lemyre B, Deguise MO, Benson P, Kirpalani H, Ekhaguere OA, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev 2023; 7:CD005384. [PMID: 37466143 PMCID: PMC10355255 DOI: 10.1002/14651858.cd005384.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) is a strategy to maintain positive airway pressure throughout the respiratory cycle through the application of a bias flow of respiratory gas to an apparatus attached to the nose. Early treatment with NCPAP is associated with decreased risk of mechanical ventilation exposure and might reduce chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation delivered through the same nasal interface during which patients are exposed to short inflations, along with background end-expiratory pressure. OBJECTIVES To examine the risks and benefits of early (within the first six hours after birth) NIPPV versus early NCPAP for preterm infants at risk of or with respiratory distress syndrome (RDS). Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include the incidence of mortality, chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), pneumothorax, duration of respiratory support, duration of oxygen therapy, and intraventricular hemorrhage (IVH). SEARCH METHODS Searches were conducted in January 2023 in CENTRAL, MEDLINE, Embase, Web of Science, and Dissertation Abstracts. The reference lists of related systematic reviews and of studies selected for inclusion were also searched. SELECTION CRITERIA We considered all randomized and quasi-randomized controlled trials. Eligible studies compared NIPPV versus NCPAP treatment, starting within six hours after birth in preterm infants (< 37 weeks' gestational age (GA)). DATA COLLECTION AND ANALYSIS We collected and analyzed data using the recommendations of the Cochrane Neonatal Review Group. MAIN RESULTS We included 17 trials, enrolling 1958 infants in this review. NIPPV likely reduces the rate of respiratory failure (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.54 to 0.78; risk difference (RD) -0.08, 95% CI -0.12 to -0.05; 17 RCTs, 1958 infants; moderate-certainty evidence) and needing endotracheal tube ventilation (RR 0.67, 95% CI 0.56 to 0.81; RD -0.07, 95% CI -0.11 to -0.04; 16 RCTs; 1848 infants; moderate-certainty evidence) amongst infants treated with early NIPPV compared with early NCPAP. The meta-analysis demonstrated that NIPPV may reduce the risk of developing CLD compared to CPAP (RR 0.70, 95% CI 0.52 to 0.92; 12 RCTs, 1284 infants; low-certainty evidence) slightly. NIPPV may result in little to no difference in mortality (RR 0.82, 95% CI 0.62 to 1.10; 17 RCTs; 1958 infants; I2 of 0%; low-certainty evidence), the incidence of pneumothorax (RR 0.92, 95% CI 0.60 to 1.41; 16 RCTs; 1674 infants; I2 of 0%; low-certainty evidence), and rates of severe IVH (RR 0.98, 95% CI 0.53 to 1.79; 8 RCTs; 977 infants; I2 of 0%; low-certainty evidence). AUTHORS' CONCLUSIONS When applied within six hours after birth, NIPPV likely reduces the risk of respiratory failure and the need for intubation and endotracheal tube ventilation in very preterm infants (GA 28 weeks and above) with respiratory distress syndrome or at risk for RDS. It may also decrease the rate of CLD slightly. However, most trials enrolled infants with a gestational age of approximately 28 to 32 weeks with an overall mean gestational age of around 30 weeks. As such, the results of this review may not apply to extremely preterm infants that are most at risk of needing mechanical ventilation or developing CLD. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.
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Affiliation(s)
- Brigitte Lemyre
- Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Marc-Olivier Deguise
- Dept. of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Paige Benson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Osayame A Ekhaguere
- Division of Neonatal-Perinatal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Australia
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10
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Ishigami AC, Meneses J, Alves JG, Carvalho J, Cavalcanti E, Bhandari V. Nasal intermittent positive pressure ventilation as a rescue therapy after nasal continuous positive airway pressure failure in infants with respiratory distress syndrome. J Perinatol 2023; 43:311-316. [PMID: 36631566 DOI: 10.1038/s41372-023-01600-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/11/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Evaluate whether nasal intermittent positive-pressure ventilation (NIPPV) as rescue therapy after initial nasal continuous positive airway (NCPAP) failure reduces need for invasive mechanical ventilation (IMV) in infants with respiratory distress syndrome (RDS). DESIGN Retrospective cohort involving 156 preterm infants who failed initial NCPAP and were then submitted to NIPPV rescue therapy and classified into NIPPV success or failure, according to need for IMV. RESULT Of all infants included, 85 (54.5%) were successfully rescued with NIPPV while 71 (45.5%) failed. The NIPPV success group had significantly lower rates of bronchopulmonary dysplasia, peri/intraventricular hemorrhage, patent ductus arteriosus and greater survival without morbidities (all p ≤ 0.01). Infants who failed NIPPV had earlier initial NCPAP failure (p = 0.09). In final logistic regression model, birthweight ≤1000 g and need for surfactant remained significant factors for NIPPV failure. CONCLUSION NIPPV rescue therapy reduced the need for IMV in infants that failed NCPAP and was associated with better outcomes.
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Affiliation(s)
- Ana Catarina Ishigami
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Jucille Meneses
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil.
| | - João Guilherme Alves
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Juliana Carvalho
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Emídio Cavalcanti
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper, Camden, NJ, USA.,Cooper Medical School of Rowan University, Camden, NJ, USA
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Ahmad HA, Deekonda V, Patel W, Thabane L, Shah PS, Mukerji A. Comparison of High CPAP versus NIPPV in Preterm Neonates: A Retrospective Cohort Study. Am J Perinatol 2022; 39:1828-1834. [PMID: 33853143 DOI: 10.1055/s-0041-1727159] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The aim of this study was to compare outcomes following receipt of high continuous positive airway pressure (CPAP) versus nasal intermittent positive pressure ventilation (NIPPV) in extremely preterm neonates. STUDY DESIGN We retrospectively compared outcomes of preterm neonates (22-28 weeks' gestation) following their first episode of either high CPAP (≥ 9 cm H2O) or NIPPV. Primary outcome was failure of high CPAP or NIPPV within 7 days, as determined by either need for intubation or use of an alternate noninvasive mode. RESULTS During the 3-year study period, 53 infants received high CPAP, while 119 patients received NIPPV. There were no differences in the primary outcome (adjusted odds ratio 1.21; 95% confidence interval 0.49-3.01). The use of alternate mode of noninvasive support was higher with the use of high CPAP but no other outcome differences were noted. CONCLUSION Based on this cohort, there was no difference in incidence of failure between high CPAP and NIPPV, although infants receiving high CPAP were more likely to require an alternate mode of noninvasive support. KEY POINTS · Use of high CPAP pressures (defined as ≥9 cm H2O) is gradually increasing during care of preterm neonates.. · Limited data exists regarding its efficacy and safety.. · This study compares high CPAP with NIPPV, and demonstrates comparable short-term clinical outcomes..
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Affiliation(s)
| | - Veena Deekonda
- Department of Respiratory Therapy, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Waseemoddin Patel
- Division of Neonatology, Department of Pediatrics, Princess Nourah Bint AbdulRahman University, King Abdullah bin Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Lehana Thabane
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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12
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Mahmoud RA, Schmalisch G, Oswal A, Christoph Roehr C. Non-invasive ventilatory support in neonates: An evidence-based update. Paediatr Respir Rev 2022; 44:11-18. [PMID: 36428196 DOI: 10.1016/j.prrv.2022.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/22/2022] [Indexed: 12/14/2022]
Abstract
Non-invasive ventilatory support (NIV) is considered the gold standard in the care of preterm infants with respiratory distress syndrome (RDS). NIV from birth is superior to mechanical ventilation (MV) for the prevention of death or bronchopulmonary dysplasia (BPD), with a number needed to treat between 25 and 35. Various methods of NIV are available, some of them extensively researched and with well proven efficacy, whilst others are needing further research. Nasal continuous positive airway pressure (nCPAP) has replaced routine invasive mechanical ventilation (MV) for the initial stabilization and the treatment of RDS. Choosing the most suitable form of NIV and the most appropriate patient interface depends on several factors, including gestational age, underlying lung pathophysiology and the local facilities. In this review, we present the currently available evidence on NIV as primary ventilatory support to preventing intubation and for secondary ventilatory support, following extubation. We review nCPAP, nasal high-flow cannula, nasal intermittent positive airway pressure ventilation, bi-level positive airway pressure, nasal high-frequency oscillatory ventilation and nasal neurally adjusted ventilatory assist modes. We also discuss most suitable NIV devices and patient interfaces during resuscitation of the newborn in the delivery room.
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Affiliation(s)
- Ramadan A Mahmoud
- Department of Pediatrics, Sohag Faculty of Medicine, Sohag University, Egypt; Department of Neonatology, Maternity and Child Hospital, Al-kharj, Saudi Arabia
| | - Gerd Schmalisch
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Abhishek Oswal
- Newborn Care, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Charles Christoph Roehr
- Newborn Care, Southmead Hospital, North Bristol Trust, Bristol, UK; University of Bristol, Faculty of Medicine, Bristol, UK.
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13
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Rodriguez-Fanjul J, Corsini I, Ortí CS, Bobillo-Perez S, Raimondi F. Lung ultrasound to evaluate lung recruitment in neonates with respiratory distress (RELUS study). Pediatr Pulmonol 2022; 57:2502-2510. [PMID: 35792663 DOI: 10.1002/ppul.26066] [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: 06/10/2022] [Accepted: 07/04/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lung ultrasound (LUS) is a bedside tool useful to diagnose neonatal respiratory disease and to guide surfactant therapy. LUS scores have emerged as useful tool for newborn respiratory distress but is unknown if respiratory support settings may influence it. The aim of the study was to evaluate the feasibility of LUS scores evaluating lung recruitment in term newborns with respiratory distress when noninvasive respiratory it is increased. MATERIAL AND METHODS Prospective study in a tertiary neonatal intensive care unit. Inclusion criteria were term neonates with respiratory distress requiring noninvasive respiratory support with nasal continuous positive airway pressure (nCPAP) within first 6 h of life with an LUS score higher than 8 were enrolled. LUS was performed three times. First LUS (LUS-1) was done in patients in nCPAP (Fabian Device) (Acutronic) (pressure of 6 cmH2 O). Afterwards patients were placed in duo positive airway pressure (12/6 cmH2 O), a second LUS (LUS-2) was performed immediately and a third (LUS-3) was done 2 h later on the same respiratory support. The primary outcome was to compare LUS scores in the different timelines. Second outcomes were to evaluate the level of respiratory distress and oxygenation were evaluated with SpO2 /fraction of inspired oxygen (FiO2 ) ratio (S/F ratio), FiO2 ratio, respiratory rate, and blood gas analysis which were analyzed during the LUS-1 and the LUS-3. To evaluate newborn discomfort, patients were evaluated with Crying Requires oxygen Increased vital signs Expression Sleep (CRIES) scale. RESULTS Forty neonates were enrolled. Fifty percent were female (n = 20), median gestational age was 38 + 4 (interquartile range [IQR]: 37 + 5-39 + 4) with a median weight of 3155 g (IQR: 2637-3532). Duration of non invasive ventilation support was 72 h (IQR: 54-96). None of the patients required surfactant therapy or mechanical ventilation. LUS scores were no different between LUS-1 9 (IQR: 8.3-10) and LUS-2 9 (IQR: 8.3-10) (p = 0.675) but there were differences between LUS-1 and LUS-3 7 (IQR: 6.3-8.5) (p = 0.036). There was an improvement in the oxygen parameters, respiratory rate, and CO2 between LUS-1 and LUS-3 (p < 0.001). There were no changes in the CRIES scale. CONCLUSIONS There is an improvement in clinical and laboratory parameters after the increasing of respiratory support in newborns with noninvasive ventilation. We observe a correlation with an improvement in the assessment of lung aeration were evaluated with LUS score.
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Affiliation(s)
- Javier Rodriguez-Fanjul
- Neonatal Intensive Care Unit, Paediatric Department, Hospital Germans Trias i Pujol, Badalona, Spain.,Institut d'Investigació Germans Trias I Pujol, Badalona, Spain
| | - Iuri Corsini
- Neonatology Division, Careggi University Hospital of Florence, Florence, Italy
| | - Clara Sorribes Ortí
- Neonatal Intensive Care Unit, Paediatric Department, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Sara Bobillo-Perez
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Immunological and Respiratory Disorders in the Paediatric Critical Care Patient Research Group, Institut de Recerca Hospital Sant Joan de Déu, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Francesco Raimondi
- Department of Translational Medical Sciences, Neonatology Division, Università "Federico II", Napoli, Italy
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14
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Sabsabi B, Harrison A, Banfield L, Mukerji A. Nasal Intermittent Positive Pressure Ventilation versus Continuous Positive Airway Pressure and Apnea of Prematurity: A Systematic Review and Meta-Analysis. Am J Perinatol 2022; 39:1314-1320. [PMID: 33450781 DOI: 10.1055/s-0040-1722337] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The study aimed to systematically review and analyze the impact of nasal intermittent positive pressure ventilation (NIPPV) versus continuous positive airway pressure (CPAP) on apnea of prematurity (AOP) in preterm neonates. STUDY DESIGN In this systematic review and meta-analysis, experimental studies enrolling preterm infants comparing NIPPV (synchronized, nonsynchronized, and bi-level) and CPAP (all types) were searched in multiple databases and screened for the assessment of AOP. Primary outcome was AOP frequency per hour (as defined by authors of included studies). RESULTS Out of 4,980 articles identified, 18 studies were included with eight studies contributing to the primary outcome. All studies had a high risk of bias, with significant heterogeneity in definition and measurement of AOP. There was no difference in AOPs per hour between NIPPV versus CPAP (weighted mean difference = -0.19; 95% confidence interval [CI]: -0.76 to 0.37; eight studies, 456 patients). However, in a post hoc analysis evaluating the presence of any AOP (over varying time periods), the pooled odds ratio (OR) was lower with NIPPV (OR: 0.46; 95% CI: 0.32-0.67; 10 studies, 872 patients). CONCLUSION NIPPV was not associated with decrease in AOP frequency, although demonstrated lower odds of developing any AOP. However, definite recommendations cannot be made based on the quality of the published evidence. KEY POINTS · AOP is a common clinical complication related to preterm birth.. · NIPPV is often used to mitigate AOP and complications.. · Relative impact of NIPPV and CPAP on AOP remains unclear..
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Affiliation(s)
- Bayane Sabsabi
- Department of Pediatrics, Division of Neonatology, McMaster University, Hamilton, Ontario, Canada
| | - Ava Harrison
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Amit Mukerji
- Department of Pediatrics, Division of Neonatology, McMaster University, Hamilton, Ontario, Canada
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15
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Evaluation of three non-invasive ventilation modes after extubation in the treatment of preterm infants with severe respiratory distress syndrome. J Perinatol 2022; 42:1238-1243. [PMID: 35953535 DOI: 10.1038/s41372-022-01461-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of three different modes of non-invasive post-extubation ventilation support in preterm infants with severe respiratory distress syndrome (RDS). METHODS Infants diagnosed with severe RDS after extubation were randomized to receive nasal continuous positive airway pressure ventilation (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), and non-invasive high-frequency oscillatory ventilation (NHFO). The clinical outcomes and complications of infants in different groups were recorded. RESULTS In infants less than 32 weeks, NCPAP had a significant increase in extubation failure when compared with NIPPV and NHFO, and the gastrointestinal feeding time, the numbers of apnea, and hospitalization costs in the NCPAP group were significantly higher. The incidence of complications was also higher in the NCPAP group. There was no difference in clinical outcomes and complications in infants greater than 32 weeks. CONCLUSION For infants with severe RDS less than 32 weeks after extubation, NIPPV and NHFO are more cost-effective in comparison to NCPAP.
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16
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Fernández García C, Comuñas Gómez JJ, Montaner Ramón A, Camba Longueira F, Castillo Salinas F. Non-invasive mechanical ventilation in Spanish neonatal units. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 97:138-140. [PMID: 35786540 DOI: 10.1016/j.anpede.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/25/2021] [Indexed: 10/17/2022] Open
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17
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Zhu X, Qi H, Feng Z, Shi Y, De Luca D. Noninvasive High-Frequency Oscillatory Ventilation vs Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation as Postextubation Support for Preterm Neonates in China: A Randomized Clinical Trial. JAMA Pediatr 2022; 176:551-559. [PMID: 35467744 PMCID: PMC9039831 DOI: 10.1001/jamapediatrics.2022.0710] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Several respiratory support techniques are available to minimize the use of invasive mechanical ventilation (IMV) in preterm neonates. It is unknown whether noninvasive high-frequency oscillatory ventilation (NHFOV) is more efficacious than nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) in preterm neonates after their first extubation. OBJECTIVE To test the hypothesis that NHFOV is more efficacious than NCPAP or NIPPV in reducing IMV after extubation and until neonatal intensive care unit discharge among preterm neonates. DESIGN, SETTING, AND PARTICIPANTS This multicenter, pathophysiology-based, assessor-blinded, 3-group, randomized clinical trial was conducted in 69 tertiary referral neonatal intensive care units in China, recruiting participants from December 1, 2017, to May 31, 2021. Preterm neonates who were between the gestational age of 25 weeks plus 0 days and 32 weeks plus 6 days and were ready to be extubated were randomized to receive NCPAP, NIPPV or NHFOV. Data were analyzed on an intention-to-treat basis. INTERVENTIONS The NCPAP, NIPPV, or NHFOV treatment was initiated after the first extubation and lasted until discharge. MAIN OUTCOMES AND MEASURES Primary outcomes were total duration of IMV, need for reintubation, and ventilator-free days. These outcomes were chosen to describe the effect of noninvasive ventilation strategy on the general need for IMV. RESULTS A total of 1440 neonates (mean [SD] age at birth, 29.4 [1.8] weeks; 860 boys [59.7%]) were included in the trial. Duration of IMV was longer in NIPPV (mean difference, 1.2; 95% CI, 0.01-2.3 days; P = .04) and NCPAP (mean difference, 1.5 days; 95% CI, 0.3-2.7 days; P = .01) compared with NHFOV. Neonates who were treated with NCPAP needed reintubations more often than those who were treated with NIPPV (risk difference: 8.1%; 95% CI, 2.9%-13.3%; P = .003) and NHFOV (risk difference, 12.5%; 95% CI, 7.5%-17.4%; P < .001). There were fewer ventilator-free days in neonates treated with NCPAP than in those treated with NIPPV (median [25th-75th percentile] difference, -3 [-6 to -1] days; P = .01). There were no differences between secondary efficacy or safety outcomes, except for the use of postnatal corticosteroids (lower in NHFOV than in NCPAP group; risk difference, 7.3%; 95% CI, 2.6%-12%; P = .002), weekly weight gain (higher in NHFOV than in NCPAP group; mean difference, -0.9 g/d; 95% CI, -1.8 to 0 g/d; P = .04), and duration of study intervention (shorter in NHFOV than in NIPPV group; median [25th-75th percentile] difference, -1 [-3 to 0] days; P = .01). CONCLUSIONS AND RELEVANCE Results of this trial indicated that NHFOV, if used after extubation and until discharge, slightly reduced the duration of IMV in preterm neonates, and both NHFOV and NIPPV resulted in a lower risk of reintubation than NCPAP. All 3 respiratory support techniques were equally safe for this patient population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03181958.
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Affiliation(s)
- Xingwang Zhu
- Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics, Chongqing, China
| | - HongBo Qi
- First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhichun Feng
- Affiliated BaYi Children’s Hospital, People's Liberation Army General Hospital, Beijing, China
| | - Yuan Shi
- Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics, Chongqing, China
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Assistance Publique–Hôpitaux de Paris, Paris-Saclay University Hospitals, Medical Centre A. Béclère, Paris, France,Physiopathology and Therapeutic Innovation, Institut National de la Santé et de la Recherche Médicale U999 Unit, Paris Saclay University, Paris, France
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18
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Usuda H, Carter S, Takahashi T, Newnham JP, Fee EL, Jobe AH, Kemp MW. Perinatal care for the extremely preterm infant. Semin Fetal Neonatal Med 2022; 27:101334. [PMID: 35577715 DOI: 10.1016/j.siny.2022.101334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.
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Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
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19
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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.
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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
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20
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Avila-Alvarez A, García-Muñoz Rodrigo F, Solís-García G, Pertega-Diaz S, Sánchez Luna M, Iriondo-Sanz M, Elorza Fernandez D, Zozaya C. Nasal Intermittent Positive Pressure Ventilation and Bronchopulmonary Dysplasia Among Very Preterm Infants Never Intubated During the First Neonatal Admission: A Multicenter Cohort Study. Front Pediatr 2022; 10:896331. [PMID: 35573942 PMCID: PMC9091508 DOI: 10.3389/fped.2022.896331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/08/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION While non-invasive positive-pressure ventilation (NIPPV) is increasingly used as a mode of respiratory support for preterm infants, it remains unclear whether this technique translates into improved respiratory outcomes. We assessed the association between NIPPV use and bronchopulmonary dysplasia (BPD)-free survival in never intubated very preterm infants. METHODS This multicenter cohort study analyzed data from the Spanish Neonatal Network SEN1500 corresponding to preterm infants born at <32 weeks gestational age and <1,500 g and not intubated during first admission. The exposure of interest was use of NIPPV at any time and the main study outcome was survival without moderate-to-severe BPD. Analyses were performed both by patients and by units. Primary and secondary outcomes were compared using multilevel logistic-regression models. The standardized observed-to-expected (O/E) ratio was calculated to classify units by NIPPV utilization and outcome rates were compared among groups. RESULTS Of the 6,735 infants included, 1,776 (26.4%) received NIPPV during admission and 6,441 (95.6%) survived without moderate-to-severe BPD. After adjusting for confounding variables, NIPPV was not associated with survival without moderate-to-severe BPD (OR 0.84; 95%CI 0.62-1.14). A higher incidence of moderate-to-severe BPD-free survival was observed in high- vs. very low-utilization units, but no consistent association was observed between O/E ratio and either primary or secondary outcomes. CONCLUSION NIPPV use did not appear to decisively influence the incidence of survival without moderate-to-severe BPD in patients managed exclusively with non-invasive ventilation.
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Affiliation(s)
- Alejandro Avila-Alvarez
- Neonatal Unit, Department of Pediatrics, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain.,A Coruña Biomedical Research Institute (INIBIC), A Coruña, Spain
| | - Fermín García-Muñoz Rodrigo
- Division of Neonatology, Complejo Hospitalario Universitario Insular - Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Gonzalo Solís-García
- Division of Neonatology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Sonia Pertega-Diaz
- A Coruña Biomedical Research Institute (INIBIC), A Coruña, Spain.,Research Support Unit, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - Manuel Sánchez Luna
- Division of Neonatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Martin Iriondo-Sanz
- Division of Neonatology, Hospital Sant Joan de Déu, BCNatal, Barcelona University, Barcelona, Spain
| | | | - Carlos Zozaya
- Division of Neonatology, Hospital Universitario La Paz, Madrid, Spain
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21
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Treussart C, Decobert F, Tauzin M, Bourgoin L, Danan C, Dassieu G, Carteaux G, Mekontso-Dessap A, Louis B, Durrmeyer X. Patient-Ventilator Synchrony in Extremely Premature Neonates during Non-Invasive Neurally Adjusted Ventilatory Assist or Synchronized Intermittent Positive Airway Pressure: A Randomized Crossover Pilot Trial. Neonatology 2022; 119:386-393. [PMID: 35504256 DOI: 10.1159/000524327] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/22/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Synchronization of non-invasive ventilation is challenging in extremely premature infants. We compared patient-ventilator synchrony between non-invasive neurally adjusted ventilatory assist (NIV-NAVA) using transdiaphragmatic (Edi) catheter and synchronized intermittent positive airway pressure (SiPAP) using an abdominal trigger. METHODS This study was a monocentric, randomized, crossover trial in premature infants born before 28 weeks of gestation, aged 3 days or more, and below 32 weeks postmenstrual age. NIV-NAVA and SiPAP were applied in a random order for 2 h with analysis of data from the second hour. The primary outcome was the asynchrony index. RESULTS Fourteen patients were included (median [IQR] gestational age at birth 25.6 (25.3-26.4) weeks, median [IQR] birth weight 755 [680-824] g, median [IQR] postnatal age 26.5 [19.8-33.8] days). The median (IQR) asynchrony index was significantly lower in NIV-NAVA versus SiPAP (49.9% [44.1-52.6] vs. 85.8% [74.2-90.9], p < 0.001). Ineffective efforts and auto-triggering were significantly less frequent in NIV-NAVA versus SiPAP (3.0% vs. 32.0% p < 0.001 and 10.0% vs. 26.6%, p = 0.004, respectively). Double triggering was significantly less frequent in SiPAP versus NIV-NAVA (0.0% vs. 9.0%, p < 0.001). No significant difference was observed for premature cycling and late cycling. Peak Edi and swing Edi were significantly lower in NIV-NAVA as compared to SiPAP (7.7 [6.1-9.9] vs. 11.0 [6.7-14.5] μV, p = 0.006; 5.4 [4.2-7.6] vs. 7.6 [4.3-10.8] μV, p = 0.007, respectively). No significant difference was observed between NIV-NAVA and SiPAP for heart rate, respiratory rate, COMFORTneo scores, apnoea, desaturations, or bradycardias. DISCUSSION/CONCLUSION NIV-NAVA markedly improves patient-ventilator synchrony as compared to SiPAP in extremely premature infants.
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Affiliation(s)
| | - Fabrice Decobert
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Manon Tauzin
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France
| | - Laura Bourgoin
- Neonatal Intensive Care Unit, Assistance Publique, Hôpitaux de Marseille, Hôpital de La Conception, Marseille, France
| | - Claude Danan
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Gilles Dassieu
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Guillaume Carteaux
- INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France.,Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.,GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France
| | - Armand Mekontso-Dessap
- Medical Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Henri Mondor, Créteil, France.,GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France
| | - Bruno Louis
- INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France
| | - Xavier Durrmeyer
- Neonatal Intensive Care Unit, CHI Créteil, Créteil, France.,INSERM, CNRS ERL 7000, IMRB, Université Paris Est Creteil, Créteil, France.,GRC CARMAS, IMRB, Université Paris Est Créteil, Faculté de Santé de Créteil, Créteil, France
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22
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Rüegger CM, Owen LS, Davis PG. Nasal Intermittent Positive Pressure Ventilation for Neonatal Respiratory Distress Syndrome. Clin Perinatol 2021; 48:725-744. [PMID: 34774206 DOI: 10.1016/j.clp.2021.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nasal or noninvaisve intermittent positive pressure ventilation (NIPPV) refers to well-established noninvasive respiratory support strategies combining a continuous distending pressure with intermittent pressure increases. Uncertainty remains regarding the benefits provided by the various devices and techniques used to generate NIPPV. Our included meta-analyses of trials comparing NIPPV with continuous positive airway pressure (CPAP) in preterm infants demonstrate that both primary and postextubation NIPPV are superior to CPAP to prevent respiratory failure leading to additional ventilatory support. This short-term benefit is associated with a reduction in bronchopulmonary dysplasia, but not with mortality. Benefits are greatest when ventilator-generated, synchronized NIPPV is used.
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Affiliation(s)
- Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland.
| | - Louise S Owen
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
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23
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Fernández García C, Comuñas Gómez JJ, Montaner Ramón A, Camba Longueira F, Castillo Salinas F. [Non-invasive mechanical ventilation in Spanish neonatal units<]. An Pediatr (Barc) 2021; 97:S1695-4033(21)00256-3. [PMID: 34556440 DOI: 10.1016/j.anpedi.2021.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/03/2021] [Accepted: 08/25/2021] [Indexed: 11/28/2022] Open
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24
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Wu HL, Lei YQ, Lin WH, Huang ST, Chen Q, Zheng YR. Comparison of Two Noninvasive Ventilation Strategies (NHFOV Versus NIPPV) as Initial Postextubation Respiratory Support in High-Risk Infants After Congenital Heart Surgery. J Cardiothorac Vasc Anesth 2021; 36:1962-1966. [PMID: 34593311 DOI: 10.1053/j.jvca.2021.09.003] [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: 04/19/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aimed to compare the effects of nasal high-frequency oscillatory ventilation (NHFOV) and noninvasive positive-pressure ventilation (NIPPV) as the initial postextubation therapies on preventing extubation failure (EF) in high-risk infants younger than three months after congenital heart surgery (CHS). DESIGN This was a single-center, randomized, unblinded clinical trial. SETTING The study was performed in a teaching hospital. PARTICIPANTS Between January 2020 and January 2021, a total of 150 infants underwent CHS in the authors' hospital. INTERVENTIONS Infants younger than three months with a high risk for extubation failure who were ready for extubation were randomized to either an NHFOV therapy group or an NIPPV therapy group, and received the corresponding noninvasive mechanical ventilation to prevent EF. MEASUREMENTS Primary outcomes were reintubation, long-term noninvasive ventilation (NIV) support (more than 72 hours), and the time in NIV therapy. The secondary outcomes were adverse events, including mild-moderate hypercapnia, severe hypercapnia, severe hypoxemia, treatment intolerance, signs of discomfort, unbearable dyspnea, inability to clear secretions, emesis, and aspiration. MAIN RESULTS Of 92 infants, 45 received NHFOV therapy, and 47 received NIPPV therapy after extubation. There were no significant differences between the NHFOV and the NIPPV therapy groups in the incidences of reintubation, long-term NIV support, and total time under NIV therapy. No significant difference was found of the severe hypercapnia between the two groups, but NHFOV treatment significantly decreased the rate of mild-moderate hypercapnia (p < 0.05). Other outcomes were similar in the two groups. CONCLUSIONS Among infants younger than three months after CHS who had undergone extubation, NIPPV therapy and NHFOV therapy were the equivalent NIV strategies for preventing extubation failure, and NHFOV therapy was more effective in avoiding mild-moderate hypercapnia.
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Affiliation(s)
- Hong-Lin Wu
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yu-Qing Lei
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Wen-Hao Lin
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Shu-Ting Huang
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China; Fujian Children's Hospital, Fuzhou, China; Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
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25
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Mukerji A, Abdul Wahab MG, Razak A, Rempel E, Patel W, Mondal T, Beck J. High CPAP vs. NIPPV in preterm neonates - A physiological cross-over study. J Perinatol 2021; 41:1690-1696. [PMID: 34091605 PMCID: PMC8179075 DOI: 10.1038/s41372-021-01122-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the physiological impact of high CPAP (≥9 cmH2O) vs. NIPPV at equivalent mean airway pressures. STUDY DESIGN In this cross-over study, preterm neonates on high CPAP or NIPPV were placed on the alternate mode. After 30 min, left and right ventricular cardiac output and work of breathing indices were assessed, following which patients were placed back on the original mode and a similar procedure ensued. RESULTS Fifteen infants with mean (SD) postmenstrual age 32.7 (3.0) weeks, and weight 1569 (564) grams were included. No differences in LVO [320 (63) vs. 331 (86) mL/kg/min, P = 0.46] or RVO [420 (135) vs. 437 (141) mL/kg/min, P = 0.19] were noted during high CPAP vs. NIPPV, along with no differences in work of breathing indices. CONCLUSION High CPAP pressures did not adversely impact cardiac output or work of breathing compared to NIPPV at equivalent mean airway pressure.
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Affiliation(s)
- Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada.
| | | | - Abdul Razak
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Emily Rempel
- Department of Respiratory Therapy, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Waseemoddin Patel
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- King Abdullah bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Tapas Mondal
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Member, Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, ON, Canada
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26
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Cresi F, Chiale F, Maggiora E, Borgione SM, Ferroglio M, Runfola F, Maiocco G, Peila C, Bertino E, Coscia A. Short-term effects of synchronized vs. non-synchronized NIPPV in preterm infants: study protocol for an unmasked randomized crossover trial. Trials 2021; 22:392. [PMID: 34127040 PMCID: PMC8200781 DOI: 10.1186/s13063-021-05351-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-invasive ventilation (NIV) has been recommended as the best respiratory support for preterm infants with respiratory distress syndrome (RDS). However, the best NIV technique to be used as first intention in RDS management has not yet been established. Nasal intermittent positive pressure ventilation (NIPPV) may be synchronized (SNIPPV) or non-synchronized to the infant's breathing efforts. The aim of the study is to evaluate the short-term effects of SNIPPV vs. NIPPV on the cardiorespiratory events, trying to identify the best ventilation modality for preterm infants at their first approach to NIV ventilation support. METHODS An unmasked randomized crossover study with three treatment phases was designed. All newborn infants < 32 weeks of gestational age with RDS needing NIV ventilation as first intention or after extubation will be consecutively enrolled in the study and randomized to the NIPPV or SNIPPV arm. After stabilization, enrolled patients will be alternatively ventilated with two different techniques for two time frames of 4 h each. NIPPV and SNIPPV will be administered with the same ventilator and the same interface, maintaining continuous assisted ventilation without patient discomfort. During the whole duration of the study, the patient's cardiorespiratory data and data from the ventilator will be simultaneously recorded using a polygraph connected to a computer. The primary outcome is the frequency of episodes of oxygen desaturation. Secondary outcomes are the number of the cardiorespiratory events, FiO2 necessity, newborn pain score evaluation, synchronization index, and thoracoabdominal asynchrony. The calculated sample size was of 30 patients. DISCUSSION It is known that NIPPV produces a percentage of ineffective acts due to asynchronies between the ventilator and the infant's breaths. On the other hand, an ineffective synchronization could increase work of breathing. Our hypothesis is that an efficient synchronization could reduce the respiratory work and increase the volume per minute exchanged without interfering with the natural respiratory rhythm of the patient with RDS. The results of this study will allow us to evaluate the effectiveness of the synchronization, demonstrating whether SNIPPV is the most effective non-invasive ventilation mode in preterm infants with RDS at their first approach to NIV ventilation. TRIAL REGISTRATION ClinicalTrials.gov NCT03289936 . Registered on September 21, 2017.
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Affiliation(s)
- Francesco Cresi
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Federica Chiale
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy. .,Department of Public Health and Pediatric Sciences, Postgraduate School of Pediatrics, University of Turin, Turin, Italy.
| | - Elena Maggiora
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Silvia Maria Borgione
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Mattia Ferroglio
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Federica Runfola
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy.,Department of Public Health and Pediatric Sciences, Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Giulia Maiocco
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Chiara Peila
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Enrico Bertino
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Alessandra Coscia
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
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27
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Wiegandt FC, Froriep UP, Müller F, Doll T, Dietzel A, Pohlmann G. Breath-Triggered Drug Release System for Preterm Neonates. Pharmaceutics 2021; 13:pharmaceutics13050657. [PMID: 34064425 PMCID: PMC8147847 DOI: 10.3390/pharmaceutics13050657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Abstract
A major disadvantage of inhalation therapy with continuous drug delivery is the loss of medication during expiration. Developing a breath-triggered drug release system can highly decrease this loss. However, there is currently no breath-triggered drug release directly inside the patient interface (nasal prong) for preterm neonates available due to their high breathing frequency, short inspiration time and low tidal volume. Therefore, a nasal prong with an integrated valve releasing aerosol directly inside the patient interface increasing inhaled aerosol efficiency is desirable. We integrated a miniaturized aerosol valve into a nasal prong, controlled by a double-stroke cylinder. Breathing was simulated using a test lung for preterm neonates on CPAP respiratory support. The inhalation flow served as a trigger signal for the valve, releasing humidified surfactant. Particle detection was performed gravimetrically (filter) and optically (light extinction). The integrated miniaturized aerosol valve enabled breath-triggered drug release inside the patient interface with an aerosol valve response time of <25 ms. By breath-triggered release of the pharmaceutical aerosol as a bolus during inhalation, the inhaled aerosol efficiency was increased by a factor of >4 compared to non-triggered release. This novel nasal prong with integrated valve allows breath-triggered drug release directly inside the nasal prong with short response time.
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Affiliation(s)
- Felix C. Wiegandt
- Division of Translational Biomedical Engineering, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, 30625 Hannover, Germany; (U.P.F.); (F.M.); (T.D.)
- Correspondence: (F.C.W.); (G.P.); Tel.: +49-511-5350-287 (F.C.W.); +49-511-5350-116 (G.P.)
| | - Ulrich P. Froriep
- Division of Translational Biomedical Engineering, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, 30625 Hannover, Germany; (U.P.F.); (F.M.); (T.D.)
| | - Fabian Müller
- Division of Translational Biomedical Engineering, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, 30625 Hannover, Germany; (U.P.F.); (F.M.); (T.D.)
| | - Theodor Doll
- Division of Translational Biomedical Engineering, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, 30625 Hannover, Germany; (U.P.F.); (F.M.); (T.D.)
- Department of Otorhinolaryngology, Hannover Medical School, 30625 Hannover, Germany
| | - Andreas Dietzel
- Institute of Microtechnology, Technische Universität Braunschweig, 38124 Braunschweig, Germany;
| | - Gerhard Pohlmann
- Division of Translational Biomedical Engineering, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, 30625 Hannover, Germany; (U.P.F.); (F.M.); (T.D.)
- Correspondence: (F.C.W.); (G.P.); Tel.: +49-511-5350-287 (F.C.W.); +49-511-5350-116 (G.P.)
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28
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Bianco F, Salomone F, Milesi I, Murgia X, Bonelli S, Pasini E, Dellacà R, Ventura ML, Pillow J. Aerosol drug delivery to spontaneously-breathing preterm neonates: lessons learned. Respir Res 2021; 22:71. [PMID: 33637075 PMCID: PMC7908012 DOI: 10.1186/s12931-020-01585-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/23/2020] [Indexed: 02/07/2023] Open
Abstract
Delivery of medications to preterm neonates receiving non-invasive ventilation (NIV) represents one of the most challenging scenarios for aerosol medicine. This challenge is highlighted by the undersized anatomy and the complex (patho)physiological characteristics of the lungs in such infants. Key physiological restraints include low lung volumes, low compliance, and irregular respiratory rates, which significantly reduce lung deposition. Such factors are inherent to premature birth and thus can be regarded to as the intrinsic factors that affect lung deposition. However, there are a number of extrinsic factors that also impact lung deposition: such factors include the choice of aerosol generator and its configuration within the ventilation circuit, the drug formulation, the aerosol particle size distribution, the choice of NIV type, and the patient interface between the delivery system and the patient. Together, these extrinsic factors provide an opportunity to optimize the lung deposition of therapeutic aerosols and, ultimately, the efficacy of the therapy.In this review, we first provide a comprehensive characterization of both the intrinsic and extrinsic factors affecting lung deposition in premature infants, followed by a revision of the clinical attempts to deliver therapeutic aerosols to premature neonates during NIV, which are almost exclusively related to the non-invasive delivery of surfactant aerosols. In this review, we provide clues to the interpretation of existing experimental and clinical data on neonatal aerosol delivery and we also describe a frame of measurable variables and available tools, including in vitro and in vivo models, that should be considered when developing a drug for inhalation in this important but under-served patient population.
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Affiliation(s)
- Federico Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122 Parma, Italy
| | - Fabrizio Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122 Parma, Italy
| | - Ilaria Milesi
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122 Parma, Italy
| | | | - Sauro Bonelli
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122 Parma, Italy
| | - Elena Pasini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.P.A., 43122 Parma, Italy
| | - Raffaele Dellacà
- TechRes Lab, Dipartimento Di Elettronica, Informazione E Bioingegneria (DEIB), Politecnico Di Milano University, Milano, Italy
| | | | - Jane Pillow
- School of Human Sciences, University of Western Australia, Perth, Australia
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Solevåg AL, Cheung PY, Schmölzer GM. Bi-Level Noninvasive Ventilation in Neonatal Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Neonatology 2021; 118:264-273. [PMID: 33756488 DOI: 10.1159/000514637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 01/08/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bi-level noninvasive ventilation (NIV) has been used in respiratory distress syndrome (RDS) as primary treatment, post-extubation, and to treat apnea. This review summarizes studies on bi-level NIV in premature infants with RDS. Nonsynchronized nasal intermittent positive pressure ventilation (nsNIPPV) and synchronized NIPPV (SNIPPV) use pressure settings ≥ those used during mechanical ventilation (MV), and biphasic continuous positive airway pressure (BiPAP) use two nasal continuous positive airway pressure (NCPAP) levels ≤4 cm H2O apart. METHODS A systematic review (Medline OVID and Pubmed) and meta-analysis of randomized controlled trials. Primary outcomes were bronchopulmonary dysplasia (BPD) and mortality. Secondary outcomes included NIV failure (intubation) and extubation failure (re-intubation). Data were pooled using a fixed-effects model to calculate the relative risk (RR) with 95% confidence interval (CI) between NIV modes (RevMan v 5.3, Copenhagen, Denmark). RESULTS Twenty-four randomized controlled trials that largely did not correct for mean airway pressure (MAP) and used outdated ventilators were included. Compared with NCPAP, both nsNIPPV and SNIPPV resulted in less re-intubation (RR 0.88 with 95% CI (0.80, 0.97) and RR 0.20 (0.10, 0.38), respectively) and BPD (RR 0.69 (0.49, 0.97) and RR 0.51 (0.29, 0.88), respectively). nsNIPPV also resulted in less intubation (RR 0.57 (0.45, 0.73) versus NCPAP, with no difference in mortality. One study showed less intubation in BiPAP versus NCPAP. CONCLUSIONS Bi-level NIV versus NCPAP may reduce MV and BPD in premature infants with RDS. Studies comparing equivalent MAP utilizing currently available machines are needed.
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Affiliation(s)
- Anne Lee Solevåg
- Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway,
| | - Po-Yin Cheung
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Department of Pharmacology, University of Alberta, Edmonton, Alberta, Canada
| | - Georg M Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, Alberta, Canada
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Uchiyama A, Okazaki K, Kondo M, Oka S, Motojima Y, Namba F, Nagano N, Yoshikawa K, Kayama K, Kobayashi A, Soeno Y, Numata O, Suenaga H, Imai K, Maruyama H, Fujinaga H, Furuya H, Ito Y. Randomized Controlled Trial of High-Flow Nasal Cannula in Preterm Infants After Extubation. Pediatrics 2020; 146:peds.2020-1101. [PMID: 33214331 DOI: 10.1542/peds.2020-1101] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Our aim is to compare the efficacy and safety of high-flow nasal cannula (HFNC) against those of nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive-pressure ventilation (NIPPV) after extubation in preterm infants. METHODS This prospective, randomized, noninferiority trial was conducted in 6 tertiary NICUs. Infants born at <34 weeks who needed noninvasive ventilation after extubation were enrolled. We randomly assigned infants to an HFNC group when HFNC was used or to an NCPAP/NIPPV group when NCPAP or NIPPV was used. The primary outcome was treatment failure within 7 days after extubation. We then examined clinical aspects of treatment failure with HFNC use. RESULTS In total, 176 and 196 infants were assigned to the HFNC and NCPAP/NIPPV groups, respectively. The HFNC group showed a significantly higher rate of treatment failure than that of the NCPAP/NIPPV group, with treatment failure occurring in 54 infants (31%) compared with 31 infants (16%) in the NCPAP/NIPPV group (risk difference, 14.9 percentage points; 95% confidence interval, 6.2-23.2). Histologic chorioamnionitis (P = .02), treated patent ductus arteriosus (P = .001), and corrected gestational age at the start of treatment (P = .007) were factors independently related to treatment failure with HFNC use. CONCLUSIONS We found HFNC revealed a significantly higher rate of treatment failure than NCPAP or NIPPV after extubation in preterm infants. The independent factors associated with treatment failure with HFNC use were histologic chorioamnionitis, treated patent ductus arteriosus, and a younger corrected gestational age at the start of treatment.
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Affiliation(s)
- Atsushi Uchiyama
- Department of Pediatrics and .,Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kaoru Okazaki
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masatoshi Kondo
- Department of Neonatology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Shuntaro Oka
- Department of Pediatrics, Saitama Medical Center and Saitama Medical University, Saitama, Japan;
| | - Yukiko Motojima
- Department of Pediatrics, Saitama Medical Center and Saitama Medical University, Saitama, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center and Saitama Medical University, Saitama, Japan
| | - Nobuhiko Nagano
- Department of Pediatrics and Child Health, School of Medicine, Nihon University, Tokyo, Japan
| | - Kayo Yoshikawa
- Department of Pediatrics and Child Health, School of Medicine, Nihon University, Tokyo, Japan.,Department of Pediatrics, Iino Women's and Children's Hospital, Tokyo, Japan
| | - Kazunori Kayama
- Department of Pediatrics and Child Health, School of Medicine, Nihon University, Tokyo, Japan
| | - Akira Kobayashi
- Department of Neonatology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Yoshiki Soeno
- Department of Neonatology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Osamu Numata
- Department of Neonatology, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Hideyo Suenaga
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan.,Department of Pediatrics, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan; and
| | - Ken Imai
- Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Hidehiko Maruyama
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hideshi Fujinaga
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroyuki Furuya
- Basic Clinical Science and Public Health, School of Medicine, Tokai University, Kanagawa, Japan
| | - Yushi Ito
- Division of Neonatology, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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31
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Miyake F, Ito M, Minami H, Tamura M, Namba F. Management of bronchopulmonary dysplasia in Japan: A 10-year nationwide survey. Pediatr Neonatol 2020; 61:272-278. [PMID: 31843363 DOI: 10.1016/j.pedneo.2019.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/19/2019] [Accepted: 11/15/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Bronchopulmonary dysplasia (BPD) is a common complication in very preterm infants. Despite advances in perinatal medicine, the number of BPD patients is increasing in Japan. The aim of this study was to conduct a nationwide survey of the strategies used for the prevention or treatment of BPD. METHODS Questionnaires assessing the current strategies used to prevent or treat BPD, including neonatal resuscitation, drug therapy, and respiratory supportive care, were sent to secondary or tertiary perinatal units in 2015; responses were compared with those obtained from similar surveys in 2005 and 2010. The annual trend in incidence of BPD among the very low birth weight infants (VLBWIs) was determined using the Neonatal Research Network of Japan database. RESULTS The response rates in 2005, 2010, and 2015 were 86.8% (230/265), 64.5% (185/287), and 82.8% (236/285) of units, respectively. The use of patient-triggered ventilation for initial management significantly increased from 50% of units in 2005 to 91% in 2015. By contrast, decreased use of high-frequency oscillatory ventilation (HFOV) from 72% to 65% and that of nasal continuous positive airway pressure from 79% to 68% were reported. The proportion of units where the upper limit of targeted blood oxygen saturation before a diagnosis of BPD was set to ≥95% decreased substantially from 92% to 56% over the 10-year period. Despite these changes in management of BPD, the incidence of BPD among VLBWIs in Japan was increasing over a decade. CONCLUSION This survey demonstrated that there were various changes in practice regarding the prevention or treatment of BPD in Japan. Continuous surveys are required to understand the current clinical situation, and research is needed to develop and evaluate a novel treatment for BPD in premature infants.
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Affiliation(s)
- Fuyu Miyake
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Masato Ito
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Hirotaka Minami
- Department of Pediatrics and Neonatology, Takatsuki General Hospital, Takatsuki, Osaka, Japan
| | - Masanori Tamura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Fumihiko Namba
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.
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Behnke J, Lemyre B, Czernik C, Zimmer KP, Ehrhardt H, Waitz M. Non-Invasive Ventilation in Neonatology. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:177-183. [PMID: 31014448 DOI: 10.3238/arztebl.2019.0177] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 05/29/2018] [Accepted: 01/21/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) has been replaced by early continuous positive airway pressure (CPAP) in the treatment of respiratory distress syndrome (RDS) in preterm infants aiming to reduce the rate of bronchopulmonary dysplasia (BPD). Subsequently, modern non-invasive ventilation strategies (NIV) were introduced into clinical practice with limited evidence of effects on pulmonary and neurodevelopmental outcomes. METHODS We performed a selective literature search in PubMed including randomized controlled trials (RCT) (n ≥ 200) and meta-analyses published in the field of NIV in neonatology and follow-up studies focusing on long term pulmonary and neurodevelopmental outcomes. RESULTS Individual studies do not show a significant risk reduction for the combined endpoint death or BPD in preterm infants caused by early CPAP in RDS when compared to primary intubation. One meta-analysis comparing four studies found CPAP significantly reduces the risk of BPD or death (relative risk: 0.91; 95% confidence interval [0.84;0.99]). Nasal intermittent positive pressure ventilation (NIPPV) as a primary ventilation strategy reduces the rate of intubations in infants with RDS (RR: 0.78 [0.64;0.94]) when compared to CPAP but does not affect the rate of BPD (RR: 0.78 [0.58;1.06]). CONCLUSION Early CPAP reduces the need for IMV and the risk of BPD or death in preterm infants with RDS. NIPPV may offer advantages over CPAP regarding intubation rates. Networking-based follow-up programs are required to assess the effect of NIV on long term pulmonary and neurodevelopmental outcomes.
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Affiliation(s)
- Judith Behnke
- Department of General Pediatrics & Neonatology, Center for Pediatrics and Youth Medicine, Justus Liebig University of Giessen; Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada; Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin; Member of the German Lung Research Center (DZL), Giessen
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33
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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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34
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Son H, Choi EK, Park KH, Shin JH, Choi BM. Risk factors for BiPAP failure as an initial management approach in moderate to late preterm infants with respiratory distress. Clin Exp Pediatr 2020; 63:63-65. [PMID: 32066228 PMCID: PMC7029663 DOI: 10.3345/kjp.2019.01361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 12/18/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Heekwon Son
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Eui Kyung Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Kyu Hee Park
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jeong Hee Shin
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
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35
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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.
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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
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36
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Lee MJ, Choi EK, Park KH, Shin J, Choi BM. Effectiveness of nCPAP for moderate preterm infants compared to BiPAP: A Randomized, Controlled Non-Inferiority Trial. Pediatr Int 2020; 62:59-64. [PMID: 31765030 DOI: 10.1111/ped.14061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/03/2019] [Accepted: 11/14/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bilevel positive airway pressure (BiPAP) has recently been used in preterm infants with respiratory distress as an alternative to nasal continuous positive airway pressure (nCPAP) because, theoretically, BiPAP is thought to be more effective than nCPAP. However, the results of some studies comparing nCPAP with BiPAP as the initial respiratory support were controversial. The aim of this study is to compare the clinical effectiveness and safety of nCPAP with BiPAP at gestational ages of 30+0 to 34+6 weeks. METHODS A total of 93 infants with gestational ages of 30+0 to 34+6 weeks, who presented with respiratory distress within 24 h after birth, were randomized to the nCPAP group or the BiPAP group. The primary outcome was the incidence of treatment failure with these two non-invasive respiratory support devices. Criteria for treatment failure included any of the following: respiratory acidosis (PaCO2 >65 mmHg with pH <7.2), hypoxia (FiO2 >0.4), or apnea (>2-3 episodes of apnea/h). RESULTS There was no statistically significant difference in treatment failure between the two groups (P = 0.576). The risk difference comparing treatment failure rate between nCPAP and BiPAP groups was -4.7% (95% CI: -21.5-11.9). CONCLUSIONS Nasal continuous positive airway pressure is not inferior to BiPAP as an initial management of respiratory distress in these premature infants. We therefore conclude that nCPAP can be used as an initial management for preterm infants at gestational age of between 30 and 35 weeks as a substitute for BiPAP.
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Affiliation(s)
- Mi-Ji Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Eui Kyung Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Kyu Hee Park
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Jeonghee Shin
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
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Yagui ACZ, Gonçalves PA, Murakami SH, Santos AZ, Zacharias RSB, Rebello CM. Is noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) an alternative to NCPAP in preventing extubation failure in preterm infants? J Matern Fetal Neonatal Med 2019; 34:3756-3760. [PMID: 31762348 DOI: 10.1080/14767058.2019.1697669] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Prolonged use of mechanical ventilation is associated with some complications as high mortality and high morbidities as bronchopulmonary dysplasia, ventilator-associated pneumonia, and pneumothorax. However, extubation failure in preterm infants is still high (40-60%) in very low birth weight infants (VLBW). Noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) is triggered by the diaphragmatic electrical activity through a nasogastric tube that synchronizes patient/ventilator respiration, cycle by cycle effectively shortening the assisted cycle trigger and the degree of ventilatory assistance, optimizing the effects of intermittent inspiratory pressure on nasal continuous positive airway pressure (NCPAP). This study aims to compare reintubation rates until 72 h after extubation in preterm infants of high risk for reintubation using NIV-NAVA or NCPAP. Methods: A retrospective study of chart review data collection was performed in a private tertiary hospital. The study was approved by the local institutional Ethics Committee. We included infants considered at high risk of reintubation (BW < 1000 grams; use of invasive mechanical ventilation (IMV) for at least 7 days; or previous extubation failure episode) and compared the two groups according to the type of respiratory support after extubation: 1) NCPAP (n = 32); or 2) NIV-NAVA (n = 17). Demographics data were collected, the primary outcome was reintubation rate until 72 h after extubation. Secondary outcome was time to reintubation, BPD rate, IVH grade ≥ III, pneumothorax and death. Results: There was no difference between both groups in demographic data. The reintubation rate decreased significantly in the NIV-NAVA group compared to NCPAP (50.0-11.7, p < 0.02) despite the significantly higher length of invasive mechanical ventilation (IMV) before extubation attempt in NIV-NAVA group (12.4 versus 5.5 days, p < 0.04). There was no difference between both groups in secondary outcomes. Conclusions: In this small retrospective cohort study, the use of NIV-NAVA as postextubation strategy was effective in reducing extubation failure within 72 hours in preterm infants when compared to traditional NCPAP.
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Affiliation(s)
- Ana C Z Yagui
- Hospital Israelita Albert Einstein , São Paulo, Brazil
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38
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Ventilation strategies in transition from neonatal respiratory distress to chronic lung disease. Semin Fetal Neonatal Med 2019; 24:101035. [PMID: 31759915 DOI: 10.1016/j.siny.2019.101035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the advance in neonatal care over the past few decades, preventing preterm infants with respiratory distress syndrome progress to bronchopulmonary dysplasia remained challenging. In this review, we will discuss the respiratory support strategies in preterm infants with RDS evolving into BPD based on the changes in pulmonary mechanics and pathophysiology as well as currently available evidence.
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39
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Ekhaguere O, Patel S, Kirpalani H. Nasal Intermittent Mandatory Ventilation Versus Nasal Continuous Positive Airway Pressure Before and After Invasive Ventilatory Support. Clin Perinatol 2019; 46:517-536. [PMID: 31345544 DOI: 10.1016/j.clp.2019.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Continuous positive airway pressure (CPAP), noninvasive intermittent positive pressure ventilation (NIPPV), and heated humidified high-flow nasal cannula (HHFNC) are modes of noninvasive respiratory support used in neonatal practice. These modes of noninvasive respiratory support may obviate mechanical ventilation, prevent extubation failure, and reduce the risk of developing bronchopulmonary dysplasia. Although the physiologic bases of CPAP and HHFNC are well delineated, and their modes and practical application consistent, those of NIPPV are unproven and varied. Available evidence suggests that NIPPV is superior to CPAP as a primary and postextubation respiratory support in preterm infants.
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Affiliation(s)
- Osayame Ekhaguere
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University, Riley Hospital for Children at Indiana University Health, 1030 West Michigan Street, C4600, Indianapolis, IN 46202, USA.
| | - Shama Patel
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University, Riley Hospital for Children at Indiana University Health, 1030 West Michigan Street, C4600, Indianapolis, IN 46202, USA
| | - Haresh Kirpalani
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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40
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Current insights in non-invasive ventilation for the treatment of neonatal respiratory disease. Ital J Pediatr 2019; 45:105. [PMID: 31426828 PMCID: PMC6700989 DOI: 10.1186/s13052-019-0707-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 08/13/2019] [Indexed: 11/10/2022] Open
Abstract
Deleterious consequences of the management of respiratory distress syndrome (RDS) with invasive ventilation have led to more in-depth investigation of non-invasive ventilation (NIV) modalities. NIV has significantly and positively altered the treatment outcomes and improved mortality rates of preterm infants with RDS. Among the different NIV modes, nasal intermittent positive pressure ventilation (NIPPV) has shown considerable benefits compared to nasal continuous positive airway pressure (NCPAP). Despite reports of heated humidified high-flow nasal cannula’s (HHHFNC) non-inferiority compared to NCPAP, some trials have been terminated due to high treatment failure rates with HHHFNC use. Moreover, RDS management with the combination of INSURE (INtubation SURfactant Extubation) technique and NIV ensures higher success rates. This review elaborates on the currently used various modes of NIV and novel techniques are also briefly discussed.
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Bianco F, Ricci F, Catozzi C, Murgia X, Schlun M, Bucholski A, Hetzer U, Bonelli S, Lombardini M, Pasini E, Nutini M, Pertile M, Minocchieri S, Simonato M, Rosa B, Pieraccini G, Moneti G, Lorenzini L, Catinella S, Villetti G, Civelli M, Pioselli B, Cogo P, Carnielli V, Dani C, Salomone F. From bench to bedside: in vitro and in vivo evaluation of a neonate-focused nebulized surfactant delivery strategy. Respir Res 2019; 20:134. [PMID: 31266508 PMCID: PMC6604359 DOI: 10.1186/s12931-019-1096-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/12/2019] [Indexed: 01/17/2023] Open
Abstract
Background Non-invasive delivery of nebulized surfactant has been a neonatology long-pursued goal. Nevertheless, the clinical efficacy of nebulized surfactant remains inconclusive, in part, due to the great technical challenges of depositing nebulized drugs in the lungs of preterm infants. The aim of this study was to investigate the feasibility of delivering nebulized surfactant (poractant alfa) in vitro and in vivo with an adapted, neonate-tailored aerosol delivery strategy. Methods Particle size distribution of undiluted poractant alfa aerosols generated by a customized eFlow-Neos nebulizer system was determined by laser diffraction. The theoretical nebulized surfactant lung dose was estimated in vitro in a clinical setting replica including a neonatal continuous positive airway pressure (CPAP) circuit, a cast of the upper airways of a preterm neonate, and a breath simulator programmed with the tidal breathing pattern of an infant with mild respiratory distress syndrome (RDS). A dose-response study with nebulized surfactant covering the 100–600 mg/kg nominal dose-range was conducted in RDS-modelling, lung-lavaged spontaneously-breathing rabbits managed with nasal CPAP. The effects of nebulized poractant alfa on arterial gas exchange and lung mechanics were assessed. Exogenous alveolar disaturated-phosphatidylcholine (DSPC) in the lungs was measured as a proxy of surfactant deposition efficacy. Results Laser diffraction studies demonstrated suitable aerosol characteristics for inhalation (mass median diameter, MMD = 3 μm). The mean surfactant lung dose determined in vitro was 13.7% ± 4.0 of the 200 mg/kg nominal dose. Nebulized surfactant delivered to spontaneously-breathing rabbits during nasal CPAP significantly improved arterial oxygenation compared to animals receiving CPAP only. Particularly, the groups of animals treated with 200 mg/kg and 400 mg/kg of nebulized poractant alfa achieved an equivalent pulmonary response in terms of oxygenation and lung mechanics as the group of animals treated with instilled surfactant (200 mg/kg). Conclusions The customized eFlow-Neos vibrating-membrane nebulizer system efficiently generated respirable aerosols of undiluted poractant alfa. Nebulized surfactant delivered at doses of 200 mg/kg and 400 mg/kg elicited a pulmonary response equivalent to that observed after treatment with an intratracheal surfactant bolus of 200 mg/kg. This bench-characterized nebulized surfactant delivery strategy is now under evaluation in Phase II clinical trial (EUDRACT No.:2016–004547-36). Electronic supplementary material The online version of this article (10.1186/s12931-019-1096-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- F Bianco
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - F Ricci
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - C Catozzi
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - X Murgia
- Scientific Consultancy, Saarbrücken, Germany
| | - M Schlun
- PARI Pharma GmbH, Starnberg, Germany
| | | | - U Hetzer
- PARI Pharma GmbH, Starnberg, Germany
| | - S Bonelli
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - M Lombardini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - E Pasini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - M Nutini
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - M Pertile
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - S Minocchieri
- Division of Neonatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - M Simonato
- Pediatric Research Institute "Città della Speranza", Padova, Italy
| | - B Rosa
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - G Pieraccini
- Mass Spectrometry Center (CISM), Polo Biomedico, Careggi University Hospital of Florence, Florence, Italy
| | - G Moneti
- Mass Spectrometry Center (CISM), Polo Biomedico, Careggi University Hospital of Florence, Florence, Italy
| | - L Lorenzini
- Health Science and Technologies Interdepartmental Center for Industrial Research (HST-ICIR), University of Bologna, Bologna, Italy
| | - S Catinella
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - G Villetti
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - M Civelli
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - B Pioselli
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
| | - P Cogo
- Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy
| | - V Carnielli
- Polytechnic University of Marche and Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - C Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence School of Medicine, Careggi University Hospital of Florence, Viale Morgagni, 85, Florence, Italy.
| | - F Salomone
- Department of Preclinical Pharmacology, R&D, Chiesi Farmaceutici S.p.A, Parma, Italy
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Charles E, Hunt KA, Rafferty GF, Peacock JL, Greenough A. Work of breathing during HHHFNC and synchronised NIPPV following extubation. Eur J Pediatr 2019; 178:105-110. [PMID: 30374754 DOI: 10.1007/s00431-018-3254-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 10/28/2022]
Abstract
Our aim was to compare the work of breathing (WOB) during synchronised nasal intermittent positive pressure ventilation (SNIPPV) and heated humidified high flow nasal cannula (HHHFNC) when used as post-extubation support in preterm infants. A randomised crossover study was undertaken of nine infants with a median gestational age of 27 (range 24-31) weeks and post-natal age of 7 (range 2-50) days. Infants were randomised to either SNIPPV or HHHFNC immediately following extubation. They were studied for 2 h on one mode and then switched to the other modality and studied for a further 2-h period. The work of breathing, assessed by measuring the pressure time product of the diaphragm (PTPdi), and thoracoabdominal asynchrony (TAA) were determined at the end of each 2-h period. The infants' inspired oxygen requirement, oxygen saturation, heart rate and respiratory rate were also recorded. The median PTPdi was lower on SNIPPV than on HHHFNC (232 (range 130-352) versus 365 (range 136-449) cmH2O s/min, p = 0.0077), and there was less thoracoabdominal asynchrony (13.4 (range 8.5-41.6) versus 36.1 (range 4.3-50.4) degrees, p = 0.038).Conclusion: In prematurely born infants, SNIPPV compared to HHHFNC post-extubation reduced the work of breathing and thoracoabdominal asynchrony. What is Known: • The work of breathing and extubation failure are not significantly different in prematurely-born infants supported by HHHFNC or nCPAP. • SNIPPV reduces inspiratory effort and increases tidal volume and carbon dioxide exchange compared to nCPAP in prematurely born infants. What is New: • SNIPPV, as compared to HHHFNC, reduced the work of breathing in prematurely-born infants studied post-extubation. • SNIPPV, as compared to HHHFNC, reduced thoracoabdominal asynchrony in prematurely born infants studied post-extubation.
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Affiliation(s)
- Elinor Charles
- MRC & Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, NICU, 4th Floor Golden Jubilee Wing, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. .,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Katie A Hunt
- MRC & Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, NICU, 4th Floor Golden Jubilee Wing, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. .,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Gerrard F Rafferty
- Centre for Human and Aerospace Physiological Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Janet L Peacock
- School of Population Health and Environmental Sciences, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Anne Greenough
- MRC & Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, NICU, 4th Floor Golden Jubilee Wing, King's College Hospital, Denmark Hill, London, SE5 9RS, UK. .,Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK. .,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
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Ricci F, Casiraghi C, Storti M, D’Alò F, Catozzi C, Ciccimarra R, Ravanetti F, Cacchioli A, Villetti G, Civelli M, Murgia X, Carnielli V, Salomone F. Surfactant replacement therapy in combination with different non-invasive ventilation techniques in spontaneously-breathing, surfactant-depleted adult rabbits. PLoS One 2018; 13:e0200542. [PMID: 30001410 PMCID: PMC6042776 DOI: 10.1371/journal.pone.0200542] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 06/28/2018] [Indexed: 12/14/2022] Open
Abstract
Nasal intermittent positive pressure ventilation (NIPPV) holds great potential as a primary ventilation support method for Respiratory Distress Syndrome (RDS). The use of NIPPV may also be of great value combined with minimally invasive surfactant delivery. Our aim was to implement an in vivo model of RDS, which can be managed with different non-invasive ventilation (NIV) strategies, including non-synchronized NIPPV, synchronized NIPPV (SNIPPV), and nasal continuous positive airway pressure (NCPAP). Forty-two surfactant-depleted adult rabbits were allocated in six different groups: three groups of animals were treated with only NIV for three hours (NIPPV, SNIPPV, and NCPAP groups), while three other groups were treated with surfactant (SF) followed by NIV (NIPPV+SF, SNIPPV+SF, and NCPAP+SF groups). Arterial gas exchange, ventilation indices, and dynamic compliance were assessed. Post-mortem the lungs were sampled for histological evaluation. Surfactant depletion was successfully achieved by repeated broncho-alveolar lavages (BALs). After BALs, all animals developed a moderate respiratory distress, which could not be reverted by merely applying NIV. Conversely, surfactant administration followed by NIV induced a rapid improvement of arterial oxygenation in all surfactant-treated groups. Breath synchronization was associated with a significantly better response in terms of gas exchange and dynamic compliance compared to non-synchronized NIPPV, showing also the lowest injury scores after histological assessment. The proposed in vivo model of surfactant deficiency was successfully managed with NCPAP, NIPPV, or SNIPPV; this model resembles a moderate respiratory distress and it is suitable for the preclinical testing of less invasive surfactant administration techniques.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Xabi Murgia
- Department of Drug Delivery, Helmholtz Institute for Pharmaceutical Research Saarland, Saarbrücken, Germany
| | - Virgilio Carnielli
- Division of Neonatology, Polytechnic University of Marche and Salesi Children’s Hospital, Ancona, Italy
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Zhu ZC, Zhou JG, Chen C. [Research advances in neonatal nasal intermittent positive pressure ventilation]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1301-1305. [PMID: 29237534 PMCID: PMC7389797 DOI: 10.7499/j.issn.1008-8830.2017.12.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 10/13/2017] [Indexed: 06/07/2023]
Abstract
Nasal intermittent positive pressure ventilation (NIPPV) can augment nasal continuous positive airway pressure (nCPAP) by delivering intermittent positive pressure ventilation in a noninvasive way and can provide a new option for neonatal noninvasive respiratory support. NIPPV has an advantage over nCPAP in primary and post-extubation respiratory support. Moreover, it can reduce severe apnea of prematurity. Synchronized NIPPV has promising application prospects. This review article summarizes the advances in the application of NIPPV in neonatal respiratory support to promote the understanding and standardization of this technique.
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Affiliation(s)
- Zhi-Cheng Zhu
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai 201102, China.
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Salvo V, Lista G, Lupo E, Ricotti A, Zimmermann LJI, Gavilanes AWD, Gitto E, Colivicchi M, Ferraù V, Gazzolo D. Comparison of three non-invasive ventilation strategies (NSIPPV/BiPAP/NCPAP) for RDS in VLBW infants. J Matern Fetal Neonatal Med 2017; 31:2832-2838. [PMID: 28718356 DOI: 10.1080/14767058.2017.1357693] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Vincenzo Salvo
- Neonatal Intensive Care Unit, “G. Martino” University Hospital of Messina, Messina, Italy
| | - Gianluca Lista
- Neonatal Intensive Care Unit, V. Buzzi Children’s Hospital, ASST-FBF-Sacco, Milan, Italy
| | - Enrica Lupo
- Neonatal Intensive Care Unit, V. Buzzi Children’s Hospital, ASST-FBF-Sacco, Milan, Italy
| | - Alberto Ricotti
- Neonatal Intensive Care Unit, C. Arrigo Children’s Hospital, Alessandria, Italy
| | - Luc J. I. Zimmermann
- Department of Pediatrics and Neonatology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Antonio W. D. Gavilanes
- Department of Pediatrics and Neonatology, School for Oncology and Developmental Biology (GROW), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Eloisa Gitto
- Neonatal Intensive Care Unit, “G. Martino” University Hospital of Messina, Messina, Italy
| | - Micaela Colivicchi
- Neonatal Intensive Care Unit, C. Arrigo Children’s Hospital, Alessandria, Italy
| | - Valeria Ferraù
- Neonatal Intensive Care Unit, “G. Martino” University Hospital of Messina, Messina, Italy
| | - Diego Gazzolo
- Neonatal Intensive Care Unit, C. Arrigo Children’s Hospital, Alessandria, Italy
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Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev 2017; 2:CD003212. [PMID: 28146296 PMCID: PMC6464652 DOI: 10.1002/14651858.cd003212.pub3] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Previous randomised trials and meta-analyses have shown that nasal continuous positive airway pressure (NCPAP) is a useful method for providing respiratory support after extubation. However, this treatment sometimes 'fails' in infants, and they may require endotracheal re-intubation with its attendant risks and expense. Nasal intermittent positive pressure ventilation (NIPPV) can augment NCPAP by delivering ventilator breaths via nasal prongs. Older children and adults with chronic respiratory failure benefit from NIPPV, and the technique has been applied to neonates. However, serious side effects including gastric perforation have been reported with older methods of providing NIPPV. OBJECTIVES Primary objective To compare effects of management with NIPPV versus NCPAP on the need for additional ventilatory support in preterm infants whose endotracheal tube was removed after a period of intermittent positive pressure ventilation. Secondary objectives To compare rates of gastric distension, gastrointestinal perforation, necrotising enterocolitis and chronic lung disease; duration of hospitalisation; and rates of apnoea, air leak and mortality for NIPPV and NCPAP. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9), MEDLINE via PubMed (1966 to 28 September 2015), Embase (1980 to 28 September 2015) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 28 September 2015). We also searched clinical trials databases, conference proceedings and reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included randomised and quasi-randomised trials comparing use of NIPPV versus NCPAP in extubated preterm infants. NIPPV included non-invasive support delivered by a mechanical ventilator or a bilevel device in a synchronised or non-synchronised way. Participants included ventilated preterm infants who were ready to be extubated to non-invasive respiratory support. Interventions compared were NIPPV, delivered by short nasal prongs or nasopharyngeal tube, and NCPAP, delivered by the same methods.Types of outcomes measures included failure of therapy (respiratory failure, rates of endotracheal re-intubation); gastrointestinal complications (i.e. abdominal distension requiring cessation of feeds, gastrointestinal perforation or necrotising enterocolitis); pulmonary air leak; chronic lung disease (oxygen requirement at 36 weeks' postmenstrual age) and mortality. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data regarding clinical outcomes including extubation failure; endotracheal re-intubation; rates of apnoea, gastrointestinal perforation, feeding intolerance, necrotising enterocolitis, chronic lung disease and air leak; and duration of hospital stay. We analysed trials using risk ratio (RR), risk difference (RD) and the number needed to treat for an additional beneficial outcome (NNTB) or an additional harmful outcome (NNTH) for dichotomous outcomes, and mean difference (MD) for continuous outcomes. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence. MAIN RESULTS Through the search, we identified 10 trials enrolling a total of 1431 infants and comparing extubation of infants to NIPPV or NCPAP. Three trials had methodological limitations and possible selection bias.Five trials used the synchronised form of NIPPV, four used the non-synchronised form and one used both methods. Eight studies used NIPPV delivered by a ventilator, one used a bilevel device and one used both methods. When all studies were included, meta-analysis demonstrated a statistically and clinically significant reduction in the risk of meeting extubation failure criteria (typical RR 0.70, 95% CI 0.60 to 0.80; typical RD -0.13, 95% CI -0.17 to -0.08; NNTB 8, 95% CI 6 to 13; 10 trials, 1431 infants) and needing re-intubation (typical RR 0.76, 95% CI 0.65 to 0.88; typical RD -0.10, 95% CI -0.15 to -0.05; NNTB 10, 95% CI 7 to 20; 10 trials, 1431 infants). We graded evidence for these outcomes as moderate, as all trial interventions were unblinded. Although methods of synchronisation varied (Graseby capsule or pneumotachograph/flow-trigger), the five trials that synchronised NIPPV showed a statistically significant benefit for infants extubated to NIPPV in terms of prevention of extubation failure up to one week after extubation.Unsynchronised NIPPV also reduced extubation failure. NIPPV provided via a ventilator is more beneficial than that provided by bilevel devices in reducing extubation failure during the first week. When comparing interventions, investigators found no significant reduction in rates of chronic lung disease (typical RR 0.94, 95% CI 0.80 to 1.10; typical RD -0.02, 95% CI -0.08 to 0.03) or death, and no difference in the incidence of necrotising enterocolitis. Air leaks were reduced in infants randomised to NIPPV (typical RR 0.48, 95% CI 0.28 to 0.82; typical RD -0.03, 95% CI -0.05 to -0.01; NNTB 33, 95% CI 20 to 100). We graded evidence quality as moderate (unblinded studies) or low (imprecision) for secondary outcomes. AUTHORS' CONCLUSIONS Implications for practice NIPPV reduces the incidence of extubation failure and the need for re-intubation within 48 hours to one week more effectively than NCPAP; however, it has no effect on chronic lung disease nor on mortality. Synchronisation may be important in delivering effective NIPPV. The device used to deliver NIPPV may be important; however, data are insufficient to support strong conclusions. NIPPV does not appear to be associated with increased gastrointestinal side effects. Implications for research Large trials should establish the impact of synchronisation of NIPPV on safety and efficacy of the technique and should compare the efficacy of bilevel devices versus a ventilator for providing NIPPV.
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Affiliation(s)
- Brigitte Lemyre
- Children's Hospital of Eastern OntarioDivision of Neonatology401 Smyth RoadOttawaONCanadaKlH 8L1
| | | | | | - Haresh Kirpalani
- University of Pennsylvania School of Medicine and Department of Clinical Epidemiology and Biostatistics, McMaster UniversityDepartment of PediatricsChildren's Hospital of PhiladelphiaSouth 34th Street & Civic Center BlvdPhiladelphiaPennsylvaniaUSA19104
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48
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Dysart KC. Physiologic Basis for Nasal Continuous Positive Airway Pressure, Heated and Humidified High-Flow Nasal Cannula, and Nasal Ventilation. Clin Perinatol 2016; 43:621-631. [PMID: 27837748 DOI: 10.1016/j.clp.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Noninvasive support modalities have become ever more present in the care of newborns with a wide variety of disease processes. As clinicians have continued to avoid intubation and mechanical ventilation in preterm and term infants, the technologies available to support these groups have grown. Despite this rapid growth they can be broken down into 3 large categories of support, all attempting to deliver both flow and pressure to the nasopharynx supporting both phases of spontaneous breathing. The goal of all of the therapies is to stabilize a heterogeneous group of disorders with some common pathologies and avoid invasive support modalities.
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Affiliation(s)
- Kevin C Dysart
- Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Abstract
To minimize ventilator-associated lung injury in neonates, use of noninvasive (NIV) respiratory support has markedly increased over the past decade, especially in neonates younger than 28-weeks gestational age and 1250 g. Previously, neonates with respiratory failure who required anything greater than an oxyhood or low-flow nasal cannula were intubated for transport. This increased use has required transport teams to develop or incorporate a new set of support tools to minimize lung injury. This article reviews the various modes of NIV used during neonatal transport, important patient selection criteria, appropriate assessment, and the associated risks and benefits.
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Affiliation(s)
- Donald Null
- Division of Neonatology, Newborn ICU, Neonatal Transport, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
| | - Kevin Crezee
- Department of Medical Affairs, Mallinckrodt Pharmaceuticals, Perryville III Corporate Park, 53 Frontage Road, 3rd Floor, PO Box 9001, Hampton, NJ 08827-9001, USA
| | - Tamara Bleak
- Intermountain Life Flight Children's Services, 250 North 2370 West, Salt Lake City, UT 84116, USA
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