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Eicher L, Young AA, Hoover L, Kuo KW, Her J. Retrospective evaluation of the respiratory rate-oxygenation index to predict the outcome of high-flow nasal cannula oxygen therapy in dogs (2018-2021): 81 cases. J Vet Emerg Crit Care (San Antonio) 2024; 34:252-261. [PMID: 38708968 DOI: 10.1111/vec.13373] [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: 04/30/2022] [Revised: 11/27/2022] [Accepted: 12/19/2022] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To evaluate the respiratory rate-oxygenation index (ROX), modified ROX index (ROX-HR), and the ratio of pulse oximetry saturation (Spo2) to Fio2 (SF) to determine if these indices over time are predictive of outcome in dogs treated with high-flow nasal cannula oxygen therapy (HFNC). DESIGN Retrospective study. SETTING Two university teaching hospitals. ANIMALS Eighty-one client-owned dogs treated with HFNC for hypoxemic respiratory failure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The ROX was defined as the SF divided by the respiratory rate (RR), and the ROX-HR was defined as the ROX divided by the heart rate multiplied by 100. The overall success rate of HFNC was 44% (n = 36/81). Dogs weaned from HFNC had a significantly higher ROX (P < 0.0001) at 1-3, 5-10, 12, and 15 hours than dogs that failed HFNC. Both the ROX and SF showed excellent discriminatory power in predicting HFNC failure at 6 hours, with an area under receiver operating curve of 0.85 (95% confidence interval: 0.72-0.99; P < 0.002) and 0.86 (95% confidence interval: 0.73-0.99; P < 0.001), respectively. The optimal cutoff values for predicting HFNC failure at 6 hours were a ROX ≤3.68 (sensitivity 72%, specificity 92%) and an SF ≤143 (sensitivity 79%, specificity 93%). CONCLUSIONS These results suggest that similar to people, the ROX and SF are useful predictors of HFNC failure. These indices are easy to measure at the bedside and may have clinical use. Future prospective studies are warranted to confirm the findings and to optimize cutoff values in a larger population of dogs undergoing HFNC.
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Affiliation(s)
- Logan Eicher
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Anda A Young
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Leanna Hoover
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
| | - Kendon W Kuo
- Department of Clinical Sciences, Auburn University, Auburn, Alabama, USA
| | - Jiwoong Her
- Department of Veterinary Clinical Sciences, The Ohio State University, Columbus, Ohio, USA
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Kaminski DM, Biazus GF, Silveira RC, Procianoy RS. Comparison of the effectiveness of different high-flow devices in neonatal care. J Pediatr (Rio J) 2024; 100:212-217. [PMID: 38036038 PMCID: PMC10943304 DOI: 10.1016/j.jped.2023.10.006] [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: 07/26/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE To evaluate the success rate of high-flow nasal cannula (HFNC) therapy using an adapted obsolete mechanical ventilator (MV), Optiflow™ and Vapotherm™ in newborns (NBs). METHOD This was a retrospective observational study conducted in the neonatal intensive care unit (NICU). The sample comprised NBs who underwent HFNC therapy due to ventilatory dysfunction, for weaning from non-invasive ventilation (NIV), or post-extubation. The three groups, stratified according to gestational age (GA) and birth weight, and corrected GA and weight at the beginning of HFNC use, were as follows: Optiflow ™, Vapotherm ™, and obsolete Mechanical Ventilator (MV) adapted for high flow therapy. Subsequently, the NBs were divided into a success group (SG) and a failure group (FG). HFNC success was defined as a therapy duration exceeding 72 h. RESULTS A total of 209 NBs were evaluated, with 31.1 % using HFNC due to ventilatory dysfunction, 2.4 % after extubation, and 66.5 % after NIV weaning. HFNC success rate was observed in 90.9 % of the NBs, with no difference between equipment types (Vapotherm ™, Optiflow ™, and adapted VM). CONCLUSION Different types of HFNC equipment are equally effective when used in neonatology for respiratory dysfunction, as a method of weaning from NIV and post-extubation. Adapted obsolete MV can be an alternative for HFCN therapy in resource-constrained settings.
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Affiliation(s)
- Diogo Machado Kaminski
- Hospital de Clínicas de Porto Alegre, Department of Physiotherapy, Neonatology Service, Porto Alegre, RS, Brazil.
| | - Graziela Ferreira Biazus
- Hospital de Clínicas de Porto Alegre, Department of Physiotherapy, Neonatology Service, Porto Alegre, RS, Brazil
| | - Rita C Silveira
- Newborn Section at Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Neonatology Service, Porto Alegre, RS, Brazil
| | - Renato Soibelmann Procianoy
- Newborn Section at Universidade Federal do Rio Grande do Sul, Hospital de Clínicas de Porto Alegre, Neonatology Service, Porto Alegre, RS, Brazil
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Manley BJ, Cripps E, Dargaville PA. Non-invasive versus invasive respiratory support in preterm infants. Semin Perinatol 2024; 48:151885. [PMID: 38570268 DOI: 10.1016/j.semperi.2024.151885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Respiratory insufficiency is almost ubiquitous in infants born preterm, with its incidence increasing with lower gestational age. A wide range of respiratory support management strategies are available for these infants, separable into non-invasive and invasive forms of respiratory support. Here we review the history and evolution of respiratory care for the preterm infant and then examine evidence that has emerged to support a non-invasive approach to respiratory management where able. Continuous positive airway pressure (CPAP) is the non-invasive respiratory support mode currently with the most evidence for benefit. CPAP can be delivered safely and effectively and can commence in the delivery room. Particularly in early life, time spent on non-invasive respiratory support, avoiding intubation and mechanical ventilation, affords benefit for the preterm infant by virtue of a lessening of lung injury and hence a reduction in incidence of bronchopulmonary dysplasia. In recent years, enthusiasm for application of non-invasive support has been further bolstered by new techniques for administration of exogenous surfactant. Methods of less invasive surfactant delivery, in particular with a thin catheter, have allowed neonatologists to administer surfactant without resort to endotracheal intubation. The benefits of this approach appear to be sustained, even in those infants subsequently requiring mechanical ventilation. This cements the notion that any reduction in exposure to mechanical ventilation leads to alleviation of injury to the vulnerable preterm lung, with a long-lasting effect. Despite the clear advantages of non-invasive respiratory support, there will continue to be a role for intubation and mechanical ventilation in some preterm infants, particularly for those born <25 weeks' gestation. It is currently unclear what role early non-invasive support has in this special population, with more studies required.
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Affiliation(s)
- Brett J Manley
- Neonatal Services and Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics, Gynecology and Newborn Health, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Emily Cripps
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia
| | - Peter A Dargaville
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
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Gaertner VD, Rüegger CM. Optimising success of neonatal extubation: Respiratory support. Semin Fetal Neonatal Med 2023; 28:101491. [PMID: 37993322 DOI: 10.1016/j.siny.2023.101491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
In this review, we examine lung physiology before, during and after neonatal extubation and propose a three-phase model for the extubation procedure. We perform meta-analyses to compare different modes of non-invasive respiratory support after neonatal extubation and based on the findings, the following clinical recommendations are made.
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland; Department of Neonatology, Dr von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany.
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland.
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Huang Y, Zhao J, Hua X, Luo K, Shi Y, Lin Z, Tang J, Feng Z, Mu D. Guidelines for high-flow nasal cannula oxygen therapy in neonates (2022). J Evid Based Med 2023; 16:394-413. [PMID: 37674304 DOI: 10.1111/jebm.12546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
High-flow nasal cannula (HFNC) oxygen therapy, which is important in noninvasive respiratory support, is increasingly being used in critically ill neonates with respiratory failure because it is comfortable, easy to setup, and has a low incidence of nasal trauma. The advantages, indications, and risks of HFNC have been the focus of research in recent years, resulting in the development of the application. Based on current evidence, we developed guidelines for HFNC in neonates using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The guidelines were formulated after extensive consultations with neonatologists, respiratory therapists, nurse specialists, and evidence-based medicine experts. We have proposed 24 recommendations for 9 key questions. The guidelines aim to be a source of evidence and reference of HFNC oxygen therapy in clinical practice, and so that more neonates and their families will benefit from HFNC.
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Affiliation(s)
- Yi Huang
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
| | - Jing Zhao
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Xintian Hua
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Keren Luo
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Zhenlang Lin
- Department of Neonatology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, P.R. China
| | - Jun Tang
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
| | - Zhichun Feng
- Department of Neonatology, Faculty of Pediatrics, Chinese PLA General Hospital, Beijing, P.R. China
| | - Dezhi Mu
- Department of Neonatology, West China Second University Hospital, Sichuan University, Chengdu, P.R. China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Chengdu, P.R. China
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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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Whitney J, Keir I. Clinical review of high-flow nasal oxygen therapy in human and veterinary patients. Front Vet Sci 2023; 10:1070881. [PMID: 36950541 PMCID: PMC10027015 DOI: 10.3389/fvets.2023.1070881] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 02/02/2023] [Indexed: 03/08/2023] Open
Abstract
Oxygen therapy is the first-line treatment for hypoxemic acute respiratory failure. In veterinary medicine this has traditionally been provided via mask, low-flow nasal oxygen cannulas, oxygen cages and invasive positive pressure ventilation. Traditional non-invasive modalities are limited by the maximum flow rate and fraction of inspired oxygen (FiO2) that can be delivered, variability in oxygen delivery and patient compliance. The invasive techniques are able to provide higher FiO2 in a more predictable manner but are limited by sedation/anesthesia requirements, potential complications and cost. High-flow nasal oxygen therapy (HFNOT) represents an alternative to conventional oxygen therapy. This modality delivers heated and humidified medical gas at adjustable flow rates, up to 60 L/min, and FiO2, up to 100%, via nasal cannulas. It has been proposed that HFNOT improves pulmonary mechanics and reduces respiratory fatigue via reduction of anatomical dead space, provision of low-level positive end-expiratory pressure (PEEP), provision of constant FiO2 at rates corresponding to patient requirements and through improved patient tolerance. Investigations into the use of HFNOT in veterinary patients have increased in frequency since its clinical use was first reported in dogs with acute respiratory failure in 2016. Current indications in dogs include acute respiratory failure associated with pulmonary parenchymal disease, upper airway obstruction and carbon monoxide intoxication. The use of HFNOT has also been advocated in certain conditions in cats and foals. HFNOT is also being used with increasing frequency in the treatment of a widening range of conditions in humans. Although there remains conflict regarding its use and efficacy in some patient groups, overall these reports indicate that HFNOT decreases breathing frequency and work of breathing and reduces the need for escalation of respiratory support. In addition, they provide insight into potential future veterinary applications. Complications of HFNOT have been rarely reported in humans and animals. These are usually self-limiting and typically result in lower morbidity and mortality than those associated with invasive ventilation techniques.
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Balasubramanian H, Sakharkar S, Majarikar S, Srinivasan L, Kabra NS, Garg B, Ahmed J. Efficacy and Safety of Two Different Flow Rates of Nasal High-Flow Therapy in Preterm Neonates ≥28 Weeks of Gestation: A Randomized Controlled Trial. Am J Perinatol 2022; 39:1693-1701. [PMID: 33757137 DOI: 10.1055/s-0041-1726122] [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: 10/21/2022]
Abstract
OBJECTIVE The study aimed to compare the efficacy and safety of two different nasal high-flow rates for primary respiratory support in preterm neonates STUDY DESIGN: In this single-center, double-blinded randomized controlled trial, preterm neonates ≥28 weeks of gestation with respiratory distress from birth were randomized to treatment with either increased nasal flow therapy (8-10 L/min) or standard nasal flow therapy (5-7 L/min). The primary outcome of nasal high-flow therapy failure was a composite outcome defined as the need for higher respiratory support (continuous positive airway pressure [CPAP] or mechanical ventilation) or surfactant therapy. RESULTS A total of 212 neonates were enrolled. Nasal high-flow failure rate in the increased flow group was similar to the standard flow group (22 vs. 29%, relative risk = 0.81 [95% confidence interval: 0.57-1.15]). However, nasal flow rate escalation was significantly more common in the standard flow group (64 vs. 43%, p = 0.004). None of the infants in the increased flow group developed air leak syndromes. CONCLUSION Higher nasal flow rate (8-10 L/min) when compared with lower nasal flow rate of 5 to 7 L/min did not reduce the need for higher respiratory support (CPAP/mechanical ventilation) or surfactant therapy in moderately and late preterm neonates. However, initial flow rates of 5 L/min were not optimal for most preterm infants receiving primary nasal flow therapy. KEY POINTS · Use of high nasal flows (8-10 L/min) did not reduce the need for higher respiratory support in moderately and late preterm infants.. · Nasal flow rate of 5 L/min was not optimal for most preterms with respiratory distress from birth.. · Careful patient selection and optimized flow settings could enhance nasal flow success in neonates..
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Affiliation(s)
| | - Sachin Sakharkar
- Department of Neonatology, Surya Hospital, Mumbai, Maharashtra, India
| | - Swati Majarikar
- Department of Neonatology, Surya Hospital, Mumbai, Maharashtra, India
| | - Lakshmi Srinivasan
- Division of Neonatology, The Children's Hospital of Philadelphia and The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Bhawandeep Garg
- Department of Neonatology, Surya Hospital, Mumbai, Maharashtra, India
| | - Javed Ahmed
- Department of Neonatology, Surya Hospital, Mumbai, Maharashtra, India
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Naples R, Fenton AC, Brodlie M, Harigopal S, O'Brien C. Diaphragm electrical activity during weaning of nasal high-flow therapy in preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 108:237-243. [PMID: 36223982 DOI: 10.1136/archdischild-2022-324112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether electrical activity of the diaphragm (Edi) changes with weaning nasal high-flow (HF) therapy in preterm infants according to a standardised protocol. DESIGN Prospective observational cohort study. SETTING Neonatal intensive care unit. PATIENTS Preterm infants born at <32 weeks gestation, receiving nasal HF as part of routine clinical care. INTERVENTIONS Infants recruited to the study had their HF weaned according to set clinical criteria. Edi was measured using a modified gastric feeding tube serially from baseline (pre-wean) to 24-hours post-wean. MAIN OUTCOME MEASURES Change in Edi from baseline was measured at four time points up to 24 hours after weaning. Minimum Edi during expiration, maximum Edi during inspiration and amplitude of the Edi signal (Edidelta) were measured. Clinical parameters (heart rate, respiratory rate and fraction of inspired oxygen) were also recorded. RESULTS Forty preterm infants were recruited at a mean corrected gestational age of 31.6 (±2.7) weeks. Data from 156 weaning steps were analysed, 91% of which were successful. Edi did not change significantly from baseline during flow reduction steps, but a significant increase in diaphragm activity was observed when discontinuing HF (median increase in Edidelta immediately post-discontinuation 1.7 µV (95% CI: 0.6 to 3.0)) and at 24 hours 1.9 µV (95% CI: 0.7 to 3.8)). No significant difference in diaphragm activity was observed between successful and unsuccessful weaning steps. CONCLUSIONS A protocolised approach to weaning has a high probability of success. Edi does not change with reducing HF rate, but significantly increases with discontinuation of HF from 2 L/min.
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Affiliation(s)
- Rebecca Naples
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan C Fenton
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Sundeep Harigopal
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris O'Brien
- Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
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Losada OR, Ramón AM, Fernández AG, España VF, Turpin AG, Gómez JJC, Salinas FC. Use of high flow nasal cannula in Spanish neonatal units. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:319-325. [PMID: 35523688 DOI: 10.1016/j.anpede.2021.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/18/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The use of high-flow cannula therapy (HFNC) in neonatal units has increased in recent years, but there are no consensus guidelines on its indications and application strategies. Our aim was to know the rate of use of HFNC, their indications and the management variability among Spanish neonatal units. MATERIAL AND METHODS Twenty-five-question survey for medical and nursing staff. Level II and III units were contacted by phone and sent in Google forms between September 2016 and December 2018. RESULTS Ninety-seven responses (63.9% medical, 36.1% nursing), from 69 neonatal units representing 15 autonomous communities (87% level of care III; 13% level II). All units except one have HFNC with a humidified and heated system. Their most frequent indications are: non-invasive ventilation weaning (79.4%), bronchiolitis (69.1%), respiratory distress of the term newborn (58.8%), after extubation (50.5%). Minimum flow (1-5 L/min) and maximum flow (5-15 L/min) are variable between units. 22.7% have experienced some adverse effect from its use (9 air leak, 12 nasal trauma). Less than half have an employment protocol, but all the answers agree on the usefulness of national recommendations. CONCLUSIONS HFNC therapy is widely used in Spanish units, but there is great variability in its indications and strategies of use. National recommendations would be applicable in most units and would allow unifying its use.
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Wang JJ, Zhang L, Cai N. A comparative study of the efficacy and safety of high-flow nasal cannula and nasal continuous positive airway pressure in neonatal respiratory distress syndrome: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e29109. [PMID: 35475798 PMCID: PMC9276122 DOI: 10.1097/md.0000000000029109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND When it comes to preterm newborns, respiratory distress syndrome (RDS) is the most frequent respiratory condition. Despite the fact that it is well acknowledged that preterm delivery plays a significant role, the causes of lung damage are still not completely understood. In newborns with extremely low birth weight and neonatal RDS, nasal continuous positive airway pressure has been suggested as the first respiratory assistance for spontaneous breathing. In the current research, we aim to carry out a meta-analysis to assess the effectiveness and safety of high-flow nasal cannula (HFNC) and non-invasive continuous positive airway pressure (nCPAP) in patients with neonatal respiratory distress syndrome (NRDS). METHODS We intend to search the following databases: PubMed, EMBASE, Cochrane Library, Wanfang database, China National Knowledge Infrastructure (CNKI), and Google Scholar, starting from their initial publication until February 2022, to identify randomized controlled trials comparing HFNC to nCPAP in patients with NRDS. The suitable papers will be chosen by 2 writers who will work independently of one another. Using the Cochrane updated technique for risk of bias, each included article will be subjected to an independent data extraction process by the 2 writers who will then independently evaluate the risk of bias. Consequently, a third author will be asked to address any discrepancies that may arise between the writers. It will be necessary to pool the data and do a meta-analysis with the help of the RevMan 5.3 software. RESULTS In this study, the effectiveness and safety of HFNC will be compared with those of nCPAP in patients with NRDS. CONCLUSION If the results of this research are confirmed, they may serve as a summary of the most recent data for non-invasive respiratory assistance in NRDS. ETHICS AND DISSEMINATION The study will require ethical approval. REGISTRATION NUMBER DOI 10.17605/OSF.IO/BKSQ5.
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Rice JL, Lefton-Greif MA. Treatment of Pediatric Patients With High-Flow Nasal Cannula and Considerations for Oral Feeding: A Review of the Literature. PERSPECTIVES OF THE ASHA SPECIAL INTEREST GROUPS 2022; 7:543-552. [PMID: 36276931 PMCID: PMC9585535 DOI: 10.1044/2021_persp-21-00152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
PURPOSE High-Flow Nasal Cannula (HFNC) has become an increasingly common means of noninvasive respiratory support in pediatrics and is being used in infants and children with respiratory distress both inside and outside of the intensive care units. Despite the widespread use of HFNC, there remains a paucity of data on optimal flow rates and its impact on morbidity, mortality, and desired outcomes. Given the scarcity of information in these critical areas, it is not surprising that guidelines for initiation of oral feeding do not exist. This review article will review HFNC mechanisms of action, its use in specific populations and settings, and finally what is known about initiation of feeding during this therapy. CONCLUSIONS The practice of withholding oral feeding solely, because of HFNC, is not supported in the literature at the time of this writing, but in the absence of safety data from clinical trials, clinicians should proceed with caution and consider patient-specific factors while making decisions about oral feeding. Well-controlled prospective clinical trials are needed for development of best practice clinical guidelines and attainment of optimal outcomes.
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Affiliation(s)
- Jessica L. Rice
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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Krawec P, Marshall K, Odunayo A. A Review of High Flow Nasal Cannula Oxygen Therapy in Human and Veterinary Medicine. Top Companion Anim Med 2021; 46:100596. [PMID: 34757156 DOI: 10.1016/j.tcam.2021.100596] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
Respiratory distress is a common ailment in small animal medicine. Oxygen supplementation is a mainstay of initial therapy. High Flow Nasal Cannula Oxygen Therapy (HFNCOT) has become increasingly popular as a treatment modality in human medicine, and more recently in canine patients. These devices deliver high flow rates of heated and humidified oxygen at an adjustable fraction of inspired oxygen (FiO2). This article reviews current literature in human patients on HFNCOT as well as studies that have evaluated its use in veterinary patients. A discussion of the respiratory physiology that is associated with respiratory distress, in addition to an overview of currently available oxygen supplementation modalities is provided. The physiologic benefits of HFNCOT are explained, as are technical aspects associated with its use. Recommendations on initial settings, maintenance therapy, and weaning are also described.
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Affiliation(s)
- Philip Krawec
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville.
| | - Kristen Marshall
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville
| | - Adesola Odunayo
- Department of Small Animal Clinical Sciences, University of Florida, Gainesville, Florida
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Rodriguez Losada O, Montaner Ramón A, Gregoraci Fernández A, Flores España V, Gros Turpin A, Comuñas Gómez JJ, Castillo Salinas F. [Use of high flow nasal cannula in Spanish neonatal units]. An Pediatr (Barc) 2021; 96:S1695-4033(21)00145-4. [PMID: 33771459 DOI: 10.1016/j.anpedi.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION The use of high-flow cannula therapy (HFNC) in neonatal units has increased in recent years, but there are no consensus guidelines on its indications and application strategies. Our aim was to know the rate of use of HFNC, their indications and the management variability among Spanish neonatal units. MATERIAL AND METHODS Twenty-five-question survey for medical and nursing staff. Level II and III units were contacted by phone and sent in Google forms between September 2016 and December 2018. RESULTS Ninety-seven responses (63.9% medical, 36.1% nursing), from 69 neonatal units representing 15 autonomous communities (87% level of care III; 13% level II). All units except one have HFNC with a humidified and heated system. Their most frequent indications are: non-invasive ventilation weaning (79.4%), bronchiolitis (69.1%), respiratory distress of the term newborn (58.8%), after extubation (50.5%). Minimum flow (1-5 L/min) and maximum flow (5-15 L/min) are variable between units. 22.7% have experienced some adverse effect from its use (9 air leak, 12 nasal trauma). Less than half have an employment protocol, but all the answers agree on the usefulness of national recommendations. CONCLUSIONS HFNC therapy is widely used in Spanish units, but there is great variability in its indications and strategies of use. National recommendations would be applicable in most units and would allow unifying its use.
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15
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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: 27] [Impact Index Per Article: 9.0] [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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16
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Arora S, Yadav P, Bajaj H, Thakur AS, Mittal M, Gupta MR, Jose A, Arora R. Improving clinical outcomes of very low birth weight infants: Implementation of standardized management guidelines in tertiary care hospital in Haryana. Int J Pediatr Adolesc Med 2020; 7:174-180. [PMID: 33319015 PMCID: PMC7729219 DOI: 10.1016/j.ijpam.2019.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/02/2019] [Accepted: 08/19/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Standardized written guidelines and protocols in NICU are known to impact neonatal outcomes and improve survival. OBJECTIVE To study and compare the morbidity and mortality outcomes of very low birth weight (VLBW) neonates before and after introduction of structured approach to standardized management guidelines on four interventions in a tertiary care hospital in North India. METHODOLOGY Structured approach to standardized management guidelines on four interventions were implemented for VLBW infants in NICU. a) Humidified and Heated High Flow Nasal Cannula (HHHFNC) as the initial mode of ventilator support in preterm VLBW babies. b) Expressed breast milk for feeding preterm VLBW babies and absolutely no formula milk. c) Hand washing and following "Bundle Care Approach" for Central lines as the cardinal cornerstones for maintaining strict asepsis. d) Development and supportive care to be regularly followed. Data was collected prospectively from July 2015 to December 2016 (Intervention Group) and compared with retrospective matched controls from the previous year (July 2014-June 2015) (Control Group). RESULTS There was a significant decrease in culture positive sepsis in the intervention group compared to control group (3 (2.97%) CI:0.006-0.08 vs 11 (19.64%) CI:0.10-0.32; P = .0004). There was no significant difference in the mortality (5.35% vs3.96% P = .74) amongst the two groups. CONCLUSION Implementing structured approach to above mentioned interventions in the form of standardized management guidelines for preterm VLBW neonates was associated with significant reduction in culture proven sepsis and mechanical ventilation days without affecting mortality or other co-morbidities.
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Affiliation(s)
- Sunaina Arora
- DCH, DNB Pediatrics, Apollo Cradle Hospital, Gurgaon, SCO-1,2 and 3. Apollo Cradle Hospital, Gurgaon Haryana, 122001, India
| | - Pankaj Yadav
- DNB Paediatrics, IAP Neonatology Fellow, Apollo Cradle, Gurgaon, India
| | | | | | | | | | - Abhilash Jose
- GNM Nursing, Nursing Head NICU, Apollo Cradle, Gurgaon, India
| | - Rohit Arora
- Neonatology, Apollo Cradle, Gurgaon, Clinical/ Research Fellow NPM Program, University of Western Ontario, Canada
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17
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Abobakr M, Abdalla A, Barakat T, Abdel-Hady H. Implementation of a protocol-based strategy for weaning nasal high flow therapy in preterm infants. Pediatr Pulmonol 2020; 55:3319-3327. [PMID: 33034941 DOI: 10.1002/ppul.25108] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/17/2020] [Accepted: 10/03/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We compared protocolized weaning versus nonprotocolized weaning practice from nasal high flow therapy (nHFT) in preterm infants. STUDY DESIGN A before-and- after observational study. METHODS The study was conducted in three phases; Phase 1: infants were weaned according to usual practice for 6 months (nonprotocolized), Phase 2: education and training physicians and nursing staff for the protocol for 1 month, and Phase 3: protocol of weaning from nHFT was applied for the following 6 months with specified criteria for readiness to wean, weaning failure and weaning technique. The primary outcome was failure to wean off nHFT. RESULTS One hundred and four preterm infants were enrolled, 51 preterm infants in the protocol group and 53 in the nonprotocol group. The groups were similar in demographic and clinical characteristics at baseline. There were significantly lower number of patients who failed weaning from nHFT in the protocol group compared to nonprotocol group (4 [7.8%] versus 15 [28.3%], p = .007]. There was shorter time to reach full enteral feeding in the protocol group compared with nonprotocol group (p = .03). There were no significant differences between groups regarding other outcomes including total durations of respiratory support, nHFT and oxygen therapy, duration of nHFT after decision of weaning, and neonatal mortality and morbidity. CONCLUSION Implementation of a standardized protocol for weaning from nHFT in preterm infants reduced weaning failure and reduced the time to full feeds. Larger trials are recommended to detect the impact of weaning protocols on other outcomes.
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Affiliation(s)
- Marwa Abobakr
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Ahmed Abdalla
- Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Tarik Barakat
- Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hesham Abdel-Hady
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, Egypt.,Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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18
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Lin X, Jia P, Li XQ, Liu Q. [Efficacy of high-flow nasal cannula versus nasal continuous positive airway pressure in the treatment of respiratory distress syndrome in neonates: a Meta analysis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22:1164-1171. [PMID: 33172549 PMCID: PMC7666385 DOI: 10.7499/j.issn.1008-8830.2005102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/15/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To systematically evaluate the efficacy and safety of high-flow nasal cannula (HFNC) therapy versus nasal continuous positive airway pressure (nCPAP) in the treatment of respiratory distress syndrome (RDS) in neonates. METHODS PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine disc, Wanfang Database, CNKI, and Weipu Database were searched for the randomized controlled trials (RCTs) of HFNC versus nCPAP in the treatment of neonatal RDS published up to April 1, 2020. RevMan5.3 software was used to perform a Meta analysis of the eligible RCTs. RESULTS A total of 12 RCTs were included, with 2 861 neonates in total, among whom 2 698 neonates (94.30%) had a gestational age of ≥28 weeks and 163 (5.70%) had a gestational age of <28 weeks. For primary respiratory support, the HFNC group had a significantly higher rate of treatment failure than the nCPAP group (RR=1.86, 95%CI: 1.53-2.25, P<0.001), but there were no significant differences between the two groups in the rate of invasive mechanical ventilation (P=0.40) and the rate of use of pulmonary surfactant (P=0.77). For post-extubation respiratory support, there were no significant differences between the two groups in the treatment failure rate, reintubation rate, and total oxygen supply time (P>0.05). For primary respiratory support and post-extubation respiratory support, the HFNC group had a significantly lower incidence rate of nasal injury than the nCPAP group (P<0.001), and there were no significant differences between the two groups in the mortality rate and incidence rates of the complications such as air leak syndrome, bronchopulmonary dysplasia, and necrotizing enterocolitis (P>0.05). CONCLUSIONS Based on the current clinical evidence, HFNC has a higher failure rate than nCPAP when used as primary respiratory support for neonates with RDS, and therefore it is not recommended to use HFNC as the primary respiratory support for neonates with RDS. In RDS neonates with a gestational age of ≥28 weeks, HFNC can be used as post-extubation respiratory support in the weaning phase.
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Affiliation(s)
- Xi Lin
- Department of Pediatrics, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China.
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19
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Morris L, Cook N, Ramsey A, Alacapa JV, Smith LE, Gray C, Craft JA, Chin R, Christensen M. Weaning Humidified High Flow Oxygen Therapy among Paediatric Patients: An Integrative Review of Literature. J Pediatr Nurs 2020; 50:37-45. [PMID: 31704558 DOI: 10.1016/j.pedn.2019.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 01/09/2023]
Abstract
PROBLEM The paucity of up-to-date recommendations and evidence-based models, whether it is physician-initiated or initiated by other healthcare professionals, for humidified high flow oxygen therapy among children. ELIGIBILITY CRITERIA The inclusion criteria included the following: 1) use of high flow oxygen therapy (≥15 L/min); 2) published studies from the year 2000 and onwards; 3) research article in a peer-reviewed journal; 4) studies conducted in a hospital setting involving paediatric patients <18 years old; 5) availability of full article online. SAMPLE From March to April 2018, electronic databases such as PubMed, Cumulative Index of Nursing and Allied Health Literature, Excerpta Medica Database, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, SCOPUS, Ovid, Informit, and Google Scholar were accessed. The systematic search initially yielded 41 studies. RESULTS Eventually, three eligible studies were reviewed and appraised. Overarching themes were identified: 1) the lack of weaning standards; 2) the limited focus on young population in intensive care settings; and 3) the paucity of weaning models. CONCLUSION The lack of studies suggested that this is a fertile area for research. In this light, this paper challenged researchers, clinicians, and experts to develop evidence-based standards and models of weaning towards efficient and better quality of care. IMPLICATION This review may lead to the development of nurse-led or nurse-initiated weaning protocols to enable timely weaning intervention for children and thus reduce the need for prolonged oxygen use. Furthermore, this may also instigate an economic evaluation of a nurse-lead weaning against current models of medically lead weaning.
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Affiliation(s)
- Louise Morris
- Campbelltown Hospital, Campbelltown, New South Wales, Australia
| | - Nicole Cook
- Campbelltown Hospital, Campbelltown, New South Wales, Australia
| | - Amanda Ramsey
- Campbelltown Hospital, Campbelltown, New South Wales, Australia
| | - Jason V Alacapa
- Centre for Applied Nursing Research, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia; Western Sydney University, Liverpool, New South Wales, Australia; University of New South Wales, Kensington, New South Wales, Australia.
| | - Louise E Smith
- Centre for Applied Nursing Research, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia; Western Sydney University, Liverpool, New South Wales, Australia; University of New South Wales, Kensington, New South Wales, Australia
| | | | - Judy A Craft
- Centre for Applied Nursing Research, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia; Western Sydney University, Liverpool, New South Wales, Australia; University of Sunshine Coast, Sippy Downs, Queensland, Australia
| | - Raymond Chin
- Campbelltown Hospital, Campbelltown, New South Wales, Australia; Western Sydney University, Liverpool, New South Wales, Australia
| | - Martin Christensen
- Centre for Applied Nursing Research, Ingham Institute of Applied Medical Research, Liverpool, New South Wales, Australia; Western Sydney University, Liverpool, New South Wales, Australia; University of Sunshine Coast, Sippy Downs, Queensland, Australia
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20
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Rub DM, Sivieri EM, Abbasi S, Eichenwald E. Effect of high-frequency oscillation on pressure delivered by high flow nasal cannula in a premature infant lung model. Pediatr Pulmonol 2019; 54:1860-1865. [PMID: 31339005 DOI: 10.1002/ppul.24459] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 06/25/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE This study describes the effect of high-frequency oscillation on airway pressure generated by high flow nasal cannula (HFNC) in a premature infant lung model. DESIGN/METHODS A premature in 0.5 or 1.0 mL/cmH 2 O, respiratory rate (RR) of 40 or 60 breaths per min, and tidal volume of 6 mL. Oscillation was achieved by passing the HFNC supply flow through a 3-way solenoid valve operating at 4, 6, 8, or 10 Hz. Airway pressure at the simulated trachea was recorded following equilibration of end-tidal CO 2 both with and without oscillation. RESULTS Superimposing high-frequency oscillations onto HFNC resulted in an average decrease in mean airway pressure of 17.9% (P = .011). The difference between the maximum and minimum airway pressures, ∆ P min-max, significantly increased as oscillation frequency decreased ( P < .001). Airway pressure during oscillation was 12.8% greater with the 1.0 vs the 0.5 mL/cmH 2 O compliance at flows > 4 L/min ( P = .031). CO 2 clearance was 13.1% greater with the 1.0 vs 0.5 mL/cmH 2 O compliance at oscillation frequencies less than 8 Hz ( P = .015). CONCLUSION In this in-vitro study we demonstrate that delivered mean airway pressure decreases when applying high-frequency oscillation to HFNC, while still improving CO2 clearance. The combination of improved CO 2 clearance and reduced pressure delivery of this novel noninvasive modality may prove to be a useful improvement in the respiratory care of infants in respiratory distress.
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Affiliation(s)
- David M Rub
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emidio M Sivieri
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Soraya Abbasi
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Eric Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania
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21
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Hodgson KA, Manley BJ, Davis PG. Is Nasal High Flow Inferior to Continuous Positive Airway Pressure for Neonates? Clin Perinatol 2019; 46:537-551. [PMID: 31345545 DOI: 10.1016/j.clp.2019.05.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Nasal high-flow therapy (nHF) is increasingly used for neonates, with perceived benefits including reduced rates of nasal trauma and parent and nursing staff preference. Current evidence suggests that although nHF is a reasonable alternative for postextubation support of preterm infants, continuous positive airway pressure is a superior modality for primary support of respiratory distress syndrome. Minimal evidence exists for use of nHF in extremely preterm infants less than 28 weeks' gestation. Depending on clinician preference, units may still choose nHF in some settings, although careful choice of appropriate patients, and availability of rescue continuous positive airway pressure, is essential.
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Affiliation(s)
- Kate A Hodgson
- Neonatal Services, Newborn Research Centre, The Royal Women's Hospital, Level 7, 20 Flemington Road, Parkville, Victoria 3052, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Australia.
| | - Brett J Manley
- Neonatal Services, Newborn Research Centre, The Royal Women's Hospital, Level 7, 20 Flemington Road, Parkville, Victoria 3052, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Australia
| | - Peter G Davis
- Neonatal Services, Newborn Research Centre, The Royal Women's Hospital, Level 7, 20 Flemington Road, Parkville, Victoria 3052, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Murdoch Children's Research Institute, Australia
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22
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Li J, Gong L, Ari A, Fink JB. Decrease the flow setting to improve trans-nasal pulmonary aerosol delivery via "high-flow nasal cannula" to infants and toddlers. Pediatr Pulmonol 2019; 54:914-921. [PMID: 30920155 DOI: 10.1002/ppul.24274] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/16/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Trans-nasal pulmonary aerosol delivery for infants and toddlers has recently gained popularity, however, the reported lung deposition is low. We aimed to investigate the influential factors to improve the delivery. METHODS Anatomic airway manikins simulating infant (5 kg) and toddler (15 kg) with collecting filter connected the trachea and breath simulator, were set to represent quiet and distressed breathing. Nasal cannula flow was set at 0.125, 0.25, 0.5, 1, and 2 L/kg/min. A mesh nebulizer (Aerogen) was placed at the inlet of humidifier (Fisher & Paykel) and proximal to patient. Albuterol (5 mg in 1 mL) was nebulized for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm). RESULTS Inhaled dose was higher with nebulizer placed at the inlet of humidifier than proximal to patient in all settings, except the infant model at low gas flow settings (0.125 and 0.25 L/kg/min). When nebulizer was placed at the inlet of humidifier, inhaled dose was higher when gas flow was below patient's inspiratory flow than when gas flow exceeded patient's inspiratory flow (8.77 ± 3.84 vs 2.16 ± 1.29%, P < 0.001); aerosol deposition increased as gas flow decreased, with greatest deposition at gas flow of 0.25 L/kg/min (11.29 ± 2.15%). A multiple linear regression identified gas flow as the primary predictor of aerosol delivery. CONCLUSIONS Trans-nasal pulmonary aerosol delivery was significantly improved when gas flow was below patient's inspiratory flow, aerosol deposition increased with decreased nasal cannula flow, with greatest deposition at 0.25 L/kg/min.
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Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Lingyue Gong
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Arzu Ari
- Department of Respiratory Care, College of Health Professions, Texas State University, Round Rock, Texas
| | - James B Fink
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
- Aerogen Pharma Corp, San Mateo, California
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23
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Bresesti I, Zivanovic S, Ives KN, Lista G, Roehr CC. National surveys of UK and Italian neonatal units highlighted significant differences in the use of non-invasive respiratory support. Acta Paediatr 2019; 108:865-869. [PMID: 30307647 DOI: 10.1111/apa.14611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/11/2018] [Accepted: 10/08/2018] [Indexed: 11/30/2022]
Abstract
AIM This study compared how non-invasive respiratory support (NRS) was provided in neonatal units in Italy and the UK. METHODS An NRS questionnaire was sent to tertiary neonatal centres, identified by national societies, from November 2015 to May 2016. RESULTS Responses were received from 49/57 (86%) UK units and 103/115 (90%) Italian units. NRS was started in the delivery room by 61% of UK units and 85% of Italian units. In neonatal intensive care units, 33% of UK units used nasal high-flow therapy (HFT) as primary support, compared to 3% in Italy. Nasal continuous positive airway pressure (CPAP) was used in 57% of UK units and 90% of Italian units. The commonest starting flow rate on nasal HFT for term and preterm infants was 6 L/min in the UK, while Italian units mainly used this flow for term infants. In the UK, 67% of units decreased nasal HFT by 1 L/min per day. In Italy, infants on nasal CPAP were weaned by 1 cm H2 O per day in 39% of units. CONCLUSION The way that NRS was managed for very preterm infants differed between the UK and Italy, reflecting a lack of evidence on optimal NRS and the use of local protocols.
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Affiliation(s)
- Ilia Bresesti
- Division of Neonatology “V. Buzzi” Children's Hospital ASST‐FBF‐Sacco Milan Italy
- Newborn Services John Radcliffe Hospital Oxford UK
| | - Sanja Zivanovic
- Newborn Services John Radcliffe Hospital Oxford UK
- Medical Sciences Division Department of Paediatrics University of Oxford Oxford UK
| | | | - Gianluca Lista
- Division of Neonatology “V. Buzzi” Children's Hospital ASST‐FBF‐Sacco Milan Italy
| | - Charles Christoph Roehr
- Newborn Services John Radcliffe Hospital Oxford UK
- Medical Sciences Division Department of Paediatrics University of Oxford Oxford UK
- Abteilung für Neonatologie Charité Universitätsmedizin Berlin Berlin Germany
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24
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Sivieri EM, Eichenwald E, Bakri SM, Abbasi S. Effect of high frequency oscillatory high flow nasal cannula on carbon dioxide clearance in a premature infant lung model: A bench study. Pediatr Pulmonol 2019; 54:436-443. [PMID: 30549451 DOI: 10.1002/ppul.24216] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/13/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study compared CO2 clearance in a premature infant lung model connected to a high flow nasal cannula (HFNC) system supplied with oscillatory versus non-oscillatory flow. DESIGN/METHODS The lung model was set to compliance 1.0 mL/cmH2 O, RR 60 breaths/min, and 6 mL tidal volume. A 100% CO2 was injected at a constant 15 mL/min. To create oscillation, HFNC flow was interrupted at rates of 4-6-8 and 10 Hz. equilibrated end-tidal CO2 (ETCO2 ) was recorded with and without oscillation at set flows of 2-8 L/min and repeated for each oscillation frequency. RESULTS Overall ETCO2 decreased significantly (P < 0.001) during both non-oscillatory and oscillatory HFNC as set flow increased from 2 to 8 L/min by 26.3% and 60.8%, respectively. Oscillatory ETCO2 levels decreased linearly compared to non-oscillatory HFNC with negligible difference at 2 L/min and a 48.4% difference at 8 L/min (P < 0.001). There were no differences in ETCO2 levels between oscillation frequencies at any flow except at 6 Hz for which ETCO2 was significantly lower (P < 0.01) than at 4, 8, and 10 Hz for 5-8 L/min HFNC flows. Amplitude of volume oscillations increased with increasing flow from 0.5 mL at 2 L/min to 4.0 mL at 8 L/min (P < 0.001), and decreased with increasing oscillation frequency. CONCLUSION Oscillatory HFNC as compared to non-oscillatory was associated with significantly improved CO2 clearance in this premature infant lung model. This simple modification of the HFNC system may prove to be a useful enhancement to this mode of non-invasive respiratory support for preterm infants at high risk for respiratory failure.
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Affiliation(s)
- Emidio M Sivieri
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eric Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Salma M Bakri
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Soraya Abbasi
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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25
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Hodgson KA, Davis PG, Owen LS. Nasal high flow therapy for neonates: Current evidence and future directions. J Paediatr Child Health 2019; 55:285-290. [PMID: 30614098 DOI: 10.1111/jpc.14374] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 10/18/2018] [Accepted: 12/16/2018] [Indexed: 11/28/2022]
Abstract
Nasal high flow (nHF) therapy is a commonly used method of providing non-invasive respiratory support for neonates. It has several potential mechanisms of action: continuous distending pressure, nasopharyngeal dead space washout, provision of heated and humidified gases and reduction of work of breathing. nHF is used in a number of clinical scenarios for preterm and term infants, including primary respiratory and post-extubation support. In recent years, large trials have generated evidence pertinent to these indications. Novel applications for nHF in neonates warrant further research: during endotracheal intubation, for initial delivery room stabilisation of preterm infants and in conjunction with minimally invasive surfactant therapy.
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Affiliation(s)
- Kate A Hodgson
- Newborn Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Louise S Owen
- Newborn Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia
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Cresi F, Maggiora E, Borgione SM, Spada E, Coscia A, Bertino E, Meneghin F, Corvaglia LT, Ventura ML, Lista G. Enteral Nutrition Tolerance And REspiratory Support (ENTARES) Study in preterm infants: study protocol for a randomized controlled trial. Trials 2019; 20:67. [PMID: 30658676 PMCID: PMC6339423 DOI: 10.1186/s13063-018-3119-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/08/2018] [Indexed: 01/05/2023] Open
Abstract
Background Respiratory distress syndrome (RDS) and feeding intolerance are common conditions in preterm infants and among the major causes of neonatal mortality and morbidity. For many years, preterm infants with RDS have been treated with mechanical ventilation, increasing risks of acute lung injury and bronchopulmonary dysplasia. In recent years non-invasive ventilation techniques have been developed. Showing similar efficacy and risk of bronchopulmonary dysplasia, nasal continuous positive airway pressure (NCPAP) and heated humidified high-flow nasal cannula (HHHFNC) have become the most widespread techniques in neonatal intensive care units. However, their impact on nutrition, particularly on feeding tolerance and risk of complications, is still unknown in preterm infants. The aim of the study is to evaluate the impact of NCPAP vs HHHFNC on enteral feeding and to identify the most suitable technique for preterm infants with RDS. Methods A multicenter randomized single-blind controlled trial was designed. All preterm infants with a gestational age of 25–29 weeks treated with NCPAP or HHHFNC for RDS and demonstrating stability for at least 48 h along with the compliance with inclusion criteria (age less than 7 days, need for non-invasive respiratory support, suitability to start enteral feeding) will be enrolled in the study and randomized to the NCPAP or HHHFNC arm. All patients will be monitored until discharge, and data will be analyzed according to an intention-to-treat model. The primary outcome is the time to reach full enteral feeding, while parameters of respiratory support, feeding tolerance, and overall health status will be evaluated as secondary outcomes. The sample size was calculated at 141 patients per arm. Discussion The identification of the most suitable technique (NCPAP vs HHHFNC) for preterm infants with feeding intolerance could reduce gastrointestinal complications, improve growth, and reduce hospital length of stay, thus improving clinical outcomes and reducing health costs. The evaluation of the timing of oral feeding could be useful in understanding the influence that these techniques could have on the development of sucking-swallow coordination. Moreover, the evaluation of the response to NCPAP and HHHFNC could clarify their efficacy as a treatment for RDS in extremely preterm infants. Trial registration ClinicalTrials.gov, NCT03548324. Registered on 7 June 2018. Electronic supplementary material The online version of this article (10.1186/s13063-018-3119-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francesco Cresi
- Neonatal Pathology and Neonatal Intensive Care Unit, Università di Torino, Turin, Italy
| | - Elena Maggiora
- Neonatal Pathology and Neonatal Intensive Care Unit, Università di Torino, Turin, Italy.
| | - Silvia Maria Borgione
- Neonatal Pathology and Neonatal Intensive Care Unit, Università di Torino, Turin, Italy
| | - Elena Spada
- Neonatal Pathology and Neonatal Intensive Care Unit, Università di Torino, Turin, Italy
| | - Alessandra Coscia
- Neonatal Pathology and Neonatal Intensive Care Unit, Università di Torino, Turin, Italy
| | - Enrico Bertino
- Neonatal Pathology and Neonatal Intensive Care Unit, Università di Torino, Turin, Italy
| | - Fabio Meneghin
- Neonatal Pathology and Neonatal Intensive Care Unit, Vittore-Buzzi Children Hospital, Milan, Italy
| | - Luigi Tommaso Corvaglia
- Neonatology and Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Maria Luisa Ventura
- Neonatal Intensive Care Unit, Fondazione MBBM, S. Gerardo Hospital, Monza, Italy
| | - Gianluca Lista
- Neonatal Pathology and Neonatal Intensive Care Unit, Vittore-Buzzi Children Hospital, Milan, Italy
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Conte F, Orfeo L, Gizzi C, Massenzi L, Fasola S. Rapid systematic review shows that using a high-flow nasal cannula is inferior to nasal continuous positive airway pressure as first-line support in preterm neonates. Acta Paediatr 2018; 107:1684-1696. [PMID: 29751368 DOI: 10.1111/apa.14396] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/19/2018] [Accepted: 05/04/2018] [Indexed: 12/12/2022]
Abstract
AIM We reviewed using a high-flow nasal cannula (HFNC) as first-line support for preterm neonates with, or at risk of, respiratory distress. METHODS This rapid systematic review covered biomedical databases up to June 2017. We included randomised controlled trials (RCTs) published in English. The reference lists of the studies and relevant reviews we included were also screened. We performed the study selection, data extraction, study quality assessment, meta-analysis and quality of evidence assessment following the Grading of Recommendations Assessment, Development and Evaluation system. RESULTS Pooled results from six RCTs covering 1227 neonates showed moderate-quality evidence that HFNC was associated with a higher rate of failure than nasal continuous positive airway pressure (NCPAP) in preterm neonates of at least 28 weeks of gestation, with a risk ratio of 1.57. Low-quality evidence showed no significant differences between HFNC and NCPAP in the need for intubation and bronchopulmonary dysplasia rate. HFNC yielded a lower rate of nasal injury (risk ratio 0.50). When HFNC failed, intubation was avoided in some neonates by switching them to NCPAP. CONCLUSION HFNC had higher failure rates than NCPAP when used as first-line support. Subsequently switching to NCPAP sometimes avoided intubation. Data on the most immature neonates were lacking.
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Affiliation(s)
- Francesca Conte
- Neonatal Intensive Care Unit; San Giovanni Calibita Fatebenefratelli Hospital; Rome Italy
| | - Luigi Orfeo
- Neonatal Intensive Care Unit; San Giovanni Calibita Fatebenefratelli Hospital; Rome Italy
| | - Camilla Gizzi
- Neonatal Intensive Care Unit; Azienda Ospedaliera Regionale San Carlo; Potenza Italy
| | - Luca Massenzi
- Neonatal Intensive Care Unit; San Giovanni Calibita Fatebenefratelli Hospital; Rome Italy
| | - Salvatore Fasola
- Institute of Biomedicine and Molecular Immunology; National Research Council of Italy; Palermo Italy
- Department of Economic, Business and Statistical Sciences; University of Palermo; Palermo Italy
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High-Flow Nasal Cannula Practice Patterns Reported by Neonatologists and Neonatal Nurse Practitioners in the United States. Adv Neonatal Care 2018; 18:400-412. [PMID: 30063474 DOI: 10.1097/anc.0000000000000536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND High-flow nasal cannula (HFNC) is widely used to treat neonatal respiratory conditions. Significant evidence emerged in recent years to guide practice, yet current practice patterns and their alignment with the evidence remain unknown. PURPOSE To examine current HFNC practice patterns and availability of clinical practice guidelines used in neonatal intensive care units in the United States. METHODS/ANALYSIS A nonexperimental, descriptive study was designed using a web-based survey to elicit a convenience sample of US neonatal providers. Quantitative data were analyzed using descriptive statistics, χ tests were used to test for differences among the categories, and post hoc comparisons among each combination of categories were conducted using a Bonferroni-corrected α of .05 to determine significance as appropriate. RESULTS A total of 947 responses were analyzed (626 neonatologists and 321 neonatal nurse practitioners). Univariate analyses suggested wide variations in practice patterns. One-third of the respondents used clinical guidelines, the majority utilized HFNC devices in conjunction with nasal continuous positive airway pressure, more than two-thirds used HFNC as a primary respiratory support treatment, and among all respondents, significant differences related to HFNC device types were reported. IMPLICATIONS FOR PRACTICE US providers revealed wide practice variations related to HFNC therapy. In addition, type of device used appears to impact practice patterns and approaches. Use of standardized guidelines was reported by one third of the respondents, and as such may be the contributing factor for wide practice variations. IMPLICATIONS FOR RESEARCH Future Research is needed to target aspects of practice where practice variations exist, or practice is not supported by evidence. Significant practice differences related to the device types should be considered in future research design.
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Boyle MA, Dhar A, Broster S. Introducing high-flow nasal cannula to the neonatal transport environment. Acta Paediatr 2017; 106:1363. [PMID: 28489289 DOI: 10.1111/apa.13910] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Michael A. Boyle
- Acute Neonatal Transfer Service; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Arunava Dhar
- Acute Neonatal Transfer Service; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
| | - Susan Broster
- Acute Neonatal Transfer Service; Cambridge University Hospitals NHS Foundation Trust; Cambridge UK
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