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Matlock DN, Ratcliffe SJ, Courtney SE, Kirpalani H, Firestone K, Stein H, Dysart K, Warren K, Goldstein MR, Lund KC, Natarajan A, Demissie E, Foglia EE. The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation. Trials 2024; 25:201. [PMID: 38509583 PMCID: PMC10953115 DOI: 10.1186/s13063-024-08038-4] [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: 11/07/2023] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation. METHODS This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer. DISCUSSION The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites. TRIAL REGISTRATION www. CLINICALTRIALS gov , trial identifier NCT05446272 , registered July 6, 2022.
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Affiliation(s)
- David N Matlock
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 512-5B, Little Rock, AR, 72205, USA.
- University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | | | | | - Haresh Kirpalani
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- McMaster University, Hamilton, ON, Canada
| | | | | | - Kevin Dysart
- Nemours Children's Health Wilmington, Philadelphia, PA, USA
| | - Karen Warren
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Aruna Natarajan
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ejigayehu Demissie
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth E Foglia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Ramanathan R, Biniwale M. Noninvasive Ventilation. Crit Care Nurs Clin North Am 2024; 36:51-67. [PMID: 38296376 DOI: 10.1016/j.cnc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk of bronchopulmonary dysplasia and or mortality. Most commonly used NIV modes include nasal continuous positive airway pressure, bi-phasic modes, such as, bi-level positive airway pressure, nasal intermittent positive pressure ventilation, high flow nasal cannula, noninvasive neurally adjusted ventilatory assist, and nasal high frequency ventilation are discussed in this review.
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Affiliation(s)
- Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Keck School of Medicine of USC, Los Angeles General Medical Center, 1200 North State Street, IRD-820, Los Angeles, CA 90033, USA.
| | - Manoj Biniwale
- Division of Neonatology, Department of Pediatrics, Keck School of Medicine of USC, Los Angeles General Medical Center, 1200 North State Street, IRD-820, Los Angeles, CA 90033, USA
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Balhareth Y, Razak A. High Flow Nasal Cannula for Weaning Nasal Continuous Positive Airway Pressure in Preterm Infants: A Systematic Review and Meta-Analysis. Neonatology 2024; 121:359-369. [PMID: 38412846 DOI: 10.1159/000536464] [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: 10/09/2023] [Accepted: 01/19/2024] [Indexed: 02/29/2024]
Abstract
INTRODUCTION The aim of this study was to systematically review the benefits and harms of using a high-flow nasal cannula (HFNC) for weaning continuous positive airway pressure (CPAP) support in preterm infants. METHODS Cochrane Central, EMBASE, Medline, and Web of Science were searched from inception to July 15, 2023. Randomised clinical trials (RCTs) comparing weaning CPAP using HFNC versus weaning CPAP alone and evaluating predefined outcomes were included. Two authors independently performed data extraction and methodological quality assessment. Meta-analysis was conducted using a random-effects model, and the certainty of evidence was assessed using Cochrane GRADE. RESULTS Among 843 identified records, seven RCTs involving 781 preterm infants were eligible for analysis. The meta-analysis found no statistically significant difference in duration of respiratory support when using HFNC for weaning compared to weaning CPAP alone (mean difference (95% confidence interval) 3.52 (-0.02, 7.05); 5 RCTs; participants = 488; I2 = 29%). The evidence certainty was downgraded to low due to study limitations and imprecision. There were no significant differences in secondary outcomes, except for a lower occurrence of nasal trauma with HFNC for weaning CPAP compared to weaning CPAP alone (relative risk (95% confidence interval) 0.61 (0.38, 0.99); 4 RCTs; participants = 335; I2 = 0%). The evidence certainty for the secondary outcomes was low to very low. CONCLUSION Low certainty of evidence suggests using HFNC for weaning CPAP in preterm infants may not impact the duration of respiratory support. Caution is advised when considering HFNC for weaning CPAP, especially in extremely preterm infants, until additional supportive evidence on its safety becomes available.
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Affiliation(s)
- Yasser Balhareth
- Department of Pediatrics, King Abdullah bin Abdulaziz University Hospital, Princess Norah Bint Abdulrahman University, Riyadh, Saudi Arabia
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Abdul Razak
- Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
- Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
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Ford VJ, Klein HG, Danner RL, Applefeld WN, Wang J, Cortes-Puch I, Eichacker PQ, Natanson C. Controls, comparator arms, and designs for critical care comparative effectiveness research: It's complicated. Clin Trials 2024; 21:124-135. [PMID: 37615179 PMCID: PMC10891304 DOI: 10.1177/17407745231195094] [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] [Indexed: 08/25/2023]
Abstract
BACKGROUND Comparative effectiveness research is meant to determine which commonly employed medical interventions are most beneficial, least harmful, and/or most costly in a real-world setting. While the objectives for comparative effectiveness research are clear, the field has failed to develop either a uniform definition of comparative effectiveness research or an appropriate set of recommendations to provide standards for the design of critical care comparative effectiveness research trials, spurring controversy in recent years. The insertion of non-representative control and/or comparator arm subjects into critical care comparative effectiveness research trials can threaten trial subjects' safety. Nonetheless, the broader scientific community does not always appreciate the importance of defining and maintaining critical care practices during a trial, especially when vulnerable, critically ill populations are studied. Consequently, critical care comparative effectiveness research trials sometimes lack properly constructed control or active comparator arms altogether and/or suffer from the inclusion of "unusual critical care" that may adversely affect groups enrolled in one or more arms. This oversight has led to critical care comparative effectiveness research trial designs that impair informed consent, confound interpretation of trial results, and increase the risk of harm for trial participants. METHODS/EXAMPLES We propose a novel approach to performing critical care comparative effectiveness research trials that mandates the documentation of critical care practices prior to trial initiation. We also classify the most common types of critical care comparative effectiveness research trials, as well as the most frequent errors in trial design. We present examples of these design flaws drawn from past and recently published trials as well as examples of trials that avoided those errors. Finally, we summarize strategies employed successfully in well-designed trials, in hopes of suggesting a comprehensive standard for the field. CONCLUSION Flawed critical care comparative effectiveness research trial designs can lead to unsound trial conclusions, compromise informed consent, and increase risks to research subjects, undermining the major goal of comparative effectiveness research: to inform current practice. Well-constructed control and comparator arms comprise indispensable elements of critical care comparative effectiveness research trials, key to improving the trials' safety and to generating trial results likely to improve patient outcomes in clinical practice.
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortes-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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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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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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Dopper A, Steele M, Bogossian F, Hough J. High flow nasal cannula for respiratory support in term infants. Cochrane Database Syst Rev 2023; 8:CD011010. [PMID: 37542728 PMCID: PMC10401649 DOI: 10.1002/14651858.cd011010.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
BACKGROUND Respiratory failure or respiratory distress in infants is the most common reason for non-elective admission to hospitals and neonatal intensive care units. Non-invasive methods of respiratory support have become the preferred mode of treating respiratory problems as they avoid some of the complications associated with intubation and mechanical ventilation. High flow nasal cannula (HFNC) therapy is increasingly being used as a method of non-invasive respiratory support. However, the evidence pertaining to its use in term infants (defined as infants ≥ 37 weeks gestational age to the end of the neonatal period (up to one month postnatal age)) is limited and there is no consensus of opinion regarding the safety and efficacy HFNC in this population. OBJECTIVES To assess the safety and efficacy of high flow nasal cannula oxygen therapy for respiratory support in term infants when compared with other forms of non-invasive respiratory support. SEARCH METHODS We searched the following databases in December 2022: Cochrane CENTRAL; PubMed; Embase; CINAHL; LILACS; Web of Science; Scopus. We also searched the reference lists of retrieved studies and performed a supplementary search of Google Scholar. SELECTION CRITERIA We included randomised controlled trials (RCTs) that investigated the use of high flow nasal cannula oxygen therapy in infants ≥ 37 weeks gestational age up to one month postnatal age (the end of the neonatal period). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, performed data extraction, and assessed risk of bias in the included studies. Where studies were sufficiently similar, we performed a meta-analysis using mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). For statistically significant RRs, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to evaluate the certainty of the evidence for clinically important outcomes. MAIN RESULTS We included eight studies (654 participants) in this review. Six of these studies (625 participants) contributed data to our primary analyses. Four studies contributed to our comparison of high flow nasal cannula (HFNC) oxygen therapy versus continuous positive airway pressure (CPAP) for respiratory support in term infants. The outcome of death was reported in two studies (439 infants) but there were no events in either group. HFNC may have little to no effect on treatment failure, but the evidence is very uncertain (RR 0.98, 95% CI 0.47 to 2.04; 3 trials, 452 infants; very low-certainty evidence). The outcome of chronic lung disease (need for supplemental oxygen at 28 days of life) was reported in one study (375 participants) but there were no events in either group. HFNC may have little to no effect on the duration of respiratory support (any form of non-invasive respiratory support with or without supplemental oxygen), but the evidence is very uncertain (MD 0.17 days, 95% CI -0.28 to 0.61; 4 trials, 530 infants; very low-certainty evidence). HFNC likely results in little to no difference in the length of stay at the intensive care unit (ICU) (MD 0.90 days, 95% CI -0.31 to 2.12; 3 trials, 452 infants; moderate-certainty evidence). HFNC may reduce the incidence of nasal trauma (RR 0.16, 95% CI 0.04 to 0.66; 1 trial, 78 infants; very low-certainty evidence) and abdominal overdistension (RR 0.22, 95% CI 0.07 to 0.71; 1 trial, 78 infants; very low-certainty evidence), but the evidence is very uncertain. Two studies contributed to our analysis of HFNC versus low flow nasal cannula oxygen therapy (LFNC) (supplemental oxygen up to a maximum flow rate of 2 L/min). The outcome of death was reported in both studies (95 infants) but there were no events in either group. The evidence suggests that HFNC may reduce treatment failure slightly (RR 0.44, 95% CI 0.21 to 0.92; 2 trials, 95 infants; low-certainty evidence). Neither study reported results for the outcome of chronic lung disease (need for supplemental oxygen at 28 days of life). HFNC may have little to no effect on the duration of respiratory support (MD -0.07 days, 95% CI -0.83 to 0.69; 1 trial, 74 infants; very low-certainty evidence), length of stay at the ICU (MD 0.49 days, 95% CI -0.83 to 1.81; 1 trial, 74 infants; very low-certainty evidence), or hospital length of stay (MD -0.60 days, 95% CI -2.07 to 0.86; 2 trials, 95 infants; very low-certainty evidence), but the evidence is very uncertain. Adverse events was an outcome reported in both studies (95 infants) but there were no events in either group. The risk of bias across outcomes was generally low, although there were some concerns of bias. The certainty of evidence across outcomes ranged from moderate to very low, downgraded due to risk of bias, imprecision, indirectness, and inconsistency. AUTHORS' CONCLUSIONS When compared with CPAP, HFNC may result in little to no difference in treatment failure. HFNC may have little to no effect on the duration of respiratory support, but the evidence is very uncertain. HFNC likely results in little to no difference in the length of stay at the intensive care unit. HFNC may reduce the incidence of nasal trauma and abdominal overdistension, but the evidence is very uncertain. When compared with LFNC, HFNC may reduce treatment failure slightly. HFNC may have little to no effect on the duration of respiratory support, length of stay at the ICU, or hospital length of stay, but the evidence is very uncertain. There is insufficient evidence to enable the formulation of evidence-based guidelines on the use of HFNC for respiratory support in term infants. Larger, methodologically robust trials are required to further evaluate the possible health benefits or harms of HFNC in this patient population.
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Affiliation(s)
- Alex Dopper
- School of Allied Health, Australian Catholic University, Brisbane, Australia
| | - Michael Steele
- School of Allied Health, Australian Catholic University, Brisbane, Australia
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Fiona Bogossian
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Australia
- Sunshine Coast Health Institute, Birtinya, Australia
- School of Health, University of the Sunshine Coast, Petrie, Australia
| | - Judith Hough
- School of Allied Health, Australian Catholic University, Brisbane, Australia
- Department of Physiotherapy, Mater Health, South Brisbane, Australia
- Centre for Children's Health Research, The University of Queensland, South Brisbane, Australia
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Hodgson KA, Wilkinson D, De Paoli AG, Manley BJ. Nasal high flow therapy for primary respiratory support in preterm infants. Cochrane Database Syst Rev 2023; 5:CD006405. [PMID: 37144837 PMCID: PMC10161968 DOI: 10.1002/14651858.cd006405.pub4] [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: 05/06/2023]
Abstract
BACKGROUND Nasal high flow (nHF) therapy provides heated, humidified air and oxygen via two small nasal prongs, at gas flows of more than 1 litre/minute (L/min), typically 2 L/min to 8 L/min. nHF is commonly used for non-invasive respiratory support in preterm neonates. It may be used in this population for primary respiratory support (avoiding, or prior to the use of mechanical ventilation via an endotracheal tube) for prophylaxis or treatment of respiratory distress syndrome (RDS). This is an update of a review first published in 2011 and updated in 2016. OBJECTIVES To evaluate the benefits and harms of nHF for primary respiratory support in preterm infants compared to other forms of non-invasive respiratory support. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date March 2022. SELECTION CRITERIA We included randomised or quasi-randomised trials comparing nHF with other forms of non-invasive respiratory support for preterm infants born less than 37 weeks' gestation with respiratory distress soon after birth. DATA COLLECTION AND ANALYSIS We used standard Cochrane Neonatal methods. Our primary outcomes were 1. death (before hospital discharge) or bronchopulmonary dysplasia (BPD), 2. death (before hospital discharge), 3. BPD, 4. treatment failure within 72 hours of trial entry and 5. mechanical ventilation via an endotracheal tube within 72 hours of trial entry. Our secondary outcomes were 6. respiratory support, 7. complications and 8. neurosensory outcomes. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 13 studies (2540 infants) in this updated review. There are nine studies awaiting classification and 13 ongoing studies. The included studies differed in the comparator treatment (continuous positive airway pressure (CPAP) or nasal intermittent positive pressure ventilation (NIPPV)), the devices for delivering nHF and the gas flows used. Some studies allowed the use of 'rescue' CPAP in the event of nHF treatment failure, prior to any mechanical ventilation, and some allowed surfactant administration via the INSURE (INtubation, SURfactant, Extubation) technique without this being deemed treatment failure. The studies included very few extremely preterm infants less than 28 weeks' gestation. Several studies had unclear or high risk of bias in one or more domains. Nasal high flow compared with continuous positive airway pressure for primary respiratory support in preterm infants Eleven studies compared nHF with CPAP for primary respiratory support in preterm infants. When compared with CPAP, nHF may result in little to no difference in the combined outcome of death or BPD (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.74 to 1.60; risk difference (RD) 0, 95% CI -0.02 to 0.02; 7 studies, 1830 infants; low-certainty evidence). Compared with CPAP, nHF may result in little to no difference in the risk of death (RR 0.78, 95% CI 0.44 to 1.39; 9 studies, 2009 infants; low-certainty evidence), or BPD (RR 1.14, 95% CI 0.74 to 1.76; 8 studies, 1917 infants; low-certainty evidence). nHF likely results in an increase in treatment failure within 72 hours of trial entry (RR 1.70, 95% CI 1.41 to 2.06; RD 0.09, 95% CI 0.06 to 0.12; number needed to treat for an additional harmful outcome (NNTH) 11, 95% CI 8 to 17; 9 studies, 2042 infants; moderate-certainty evidence). However, nHF likely does not increase the rate of mechanical ventilation (RR 1.04, 95% CI 0.82 to 1.31; 9 studies, 2042 infants; moderate-certainty evidence). nHF likely results in a reduction in pneumothorax (RR 0.66, 95% CI 0.40 to 1.08; 10 studies, 2094 infants; moderate-certainty evidence) and nasal trauma (RR 0.49, 95% CI 0.36 to 0.68; RD -0.06, 95% CI -0.09 to -0.04; 7 studies, 1595 infants; moderate-certainty evidence). Nasal high flow compared with nasal intermittent positive pressure ventilation for primary respiratory support in preterm infants Four studies compared nHF with NIPPV for primary respiratory support in preterm infants. When compared with NIPPV, nHF may result in little to no difference in the combined outcome of death or BPD, but the evidence is very uncertain (RR 0.64, 95% CI 0.30 to 1.37; RD -0.05, 95% CI -0.14 to 0.04; 2 studies, 182 infants; very low-certainty evidence). nHF may result in little to no difference in the risk of death (RR 0.78, 95% CI 0.36 to 1.69; RD -0.02, 95% CI -0.10 to 0.05; 3 studies, 254 infants; low-certainty evidence). nHF likely results in little to no difference in the incidence of treatment failure within 72 hours of trial entry compared with NIPPV (RR 1.27, 95% CI 0.90 to 1.79; 4 studies, 343 infants; moderate-certainty evidence), or mechanical ventilation within 72 hours of trial entry (RR 0.91, 95% CI 0.62 to 1.33; 4 studies, 343 infants; moderate-certainty evidence). nHF likely results in a reduction in nasal trauma, compared with NIPPV (RR 0.21, 95% CI 0.09 to 0.47; RD -0.17, 95% CI -0.24 to -0.10; 3 studies, 272 infants; moderate-certainty evidence). nHF likely results in little to no difference in the rate of pneumothorax (RR 0.78, 95% CI 0.40 to 1.53; 4 studies, 344 infants; moderate-certainty evidence). Nasal high flow compared with ambient oxygen We found no studies examining this comparison. Nasal high flow compared with low flow nasal cannulae We found no studies examining this comparison. AUTHORS' CONCLUSIONS The use of nHF for primary respiratory support in preterm infants of 28 weeks' gestation or greater may result in little to no difference in death or BPD, compared with CPAP or NIPPV. nHF likely results in an increase in treatment failure within 72 hours of trial entry compared with CPAP; however, it likely does not increase the rate of mechanical ventilation. Compared with CPAP, nHF use likely results in less nasal trauma and likely a reduction in pneumothorax. As few extremely preterm infants less than 28 weeks' gestation were enrolled in the included trials, evidence is lacking for the use of nHF for primary respiratory support in this population.
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Affiliation(s)
- Kate A Hodgson
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Robinson Research Institute, University of Adelaide, Adelaide, Australia
| | | | - Brett J Manley
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
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10
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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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11
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Bronicki RA, Benitz WE, Buckley JR, Yarlagadda VV, Porta NFM, Agana DO, Kim M, Costello JM. Respiratory Care for Neonates With Congenital Heart Disease. Pediatrics 2022; 150:189881. [PMID: 36317970 DOI: 10.1542/peds.2022-056415h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ronald A Bronicki
- Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Jason R Buckley
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Vamsi V Yarlagadda
- Stanford School of Medicine, Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | - Nicolas F M Porta
- Northwestern University Feinberg School of Medicine, Division of Neonatology, Pediatric Pulmonary Hypertension Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Devon O Agana
- Mayo Clinic College of Medicine and Science, Department of Anesthesiology and Pediatric Critical Care Medicine, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Minso Kim
- University of California San Francisco School of Medicine, Division of Critical Care, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - John M Costello
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
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12
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Manley BJ, Buckmaster AG, Travadi J, Owen LS, Roberts CT, Wright IMR, Davis PG, Arnolda G. Trends in the use of non-invasive respiratory support for term infants in tertiary neonatal units in Australia and New Zealand. Arch Dis Child Fetal Neonatal Ed 2022; 107:572-576. [PMID: 35410897 DOI: 10.1136/archdischild-2021-323581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 03/17/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine whether the use of non-invasive respiratory support, such as continuous positive airway pressure and nasal high flow, to treat term infants in Australian and New Zealand tertiary neonatal intensive care units (NICUs) has changed over time, and if so, whether there are parallel changes in short-term respiratory morbidities. DESIGN Retrospective database review of patient-level data from the Australian and New Zealand Neonatal Network (ANZNN) from 2010 to 2018. Denominator data on the number of term inborn livebirths in each facility was only available as annual totals. PATIENTS AND SETTING Term, inborn infants cared for in NICUs within the ANZNN. MAIN OUTCOME MEASURES The primary outcome was the annual change in hospital-specific rates of non-invasive respiratory support per 1000 inborn livebirths, expressed as a percentage change. Secondary outcomes were the change in rates of mechanical ventilation, pneumothorax requiring drainage, exogenous surfactant treatment and death before hospital discharge. RESULTS A total of 14 656 term infants from 21 NICUs were included from 2010 to 2018, of whom 12 719 received non-invasive respiratory support. Non-invasive respiratory support use increased on average by 8.7% per year (95% CI: 7.9% to 9.4% per year); the number of term infants receiving non-invasive respiratory support almost doubled from 980 in 2010 (10.8/1000 livebirths) to 1913 in 2018 (20.8/1000). There was no change over time in rate of mechanical ventilation or death. The rate of pneumothorax requiring drainage increased over time, as did surfactant treatment. CONCLUSIONS Non-invasive respiratory support use to treat term infants cared for in NICUs within the ANZNN is increasing over time. Clinicians should be diligent in selecting infants most likely to benefit from treatment with non-invasive respiratory support in this relatively low-risk population of term newborn infants. Analysis of patient-level data by individual NICUs is recommended to control for potential confounding due to changes in population over time.
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Affiliation(s)
- Brett J Manley
- Department of Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia .,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Adam G Buckmaster
- Women, Children and Families, Central Coast Local Health District, Gosford, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Javeed Travadi
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Louise S Owen
- Department of Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Ian M R Wright
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia.,School of Medicine and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.,College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Peter G Davis
- Department of Newborn Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia.,Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Gaston Arnolda
- Australian Institute of Health Innovation, Macquarie University Faculty of Medicine and Health Sciences, Sydney, New South Wales, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
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13
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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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14
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Boel L, Hixson T, Brown L, Sage J, Kotecha S, Chakraborty M. Non-invasive respiratory support in preterm infants. Paediatr Respir Rev 2022; 43:53-59. [PMID: 35562288 DOI: 10.1016/j.prrv.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 12/25/2022]
Abstract
Survival of preterm infants has increased steadily over recent decades, primarily due to improved outcomes for those born before 28 weeks of gestation. However, this has not been matched by similar improvements in longer-term morbidity. One of the key long-term sequelae of preterm birth remains bronchopulmonary dysplasia (also called chronic lung disease of prematurity), contributed primarily by the effect of early pulmonary inflammation superimposed on immature lungs. Non-invasive modes of respiratory support have been rapidly introduced providing modest success in reducing the incidence of bronchopulmonary dysplasia when compared with invasive mechanical ventilation, and improved clinical practice has been reported from population-based studies. We present a comprehensive review of the key modes of non-invasive respiratory support currently used in preterm infants, including their mechanisms of action and evidence of benefit from clinical trials.
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Affiliation(s)
- Lieve Boel
- Neonatal Intensive Care Unit, Queen Alexandra Hospital, Portsmouth, UK
| | - Thomas Hixson
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Lisa Brown
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Jayne Sage
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Mallinath Chakraborty
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK; Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, UK.
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15
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Applefeld WN, Wang J, Cortés-Puch I, Klein HG, Eichacker PQ, Cooper D, Danner RL, Natanson C. Modeling current practices in critical care comparative effectiveness research. CRIT CARE RESUSC 2022; 24:150-162. [PMID: 38045594 PMCID: PMC10692606 DOI: 10.51893/2022.2.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To determine whether contemporaneous practices are adequately represented in recent critical care comparative effectiveness research studies. Design: All critical care comparative effectiveness research trials published in the New England Journal of Medicine from April 2019 to March 2020 were identified. To examine studies published in other high impact medical journals during the same period, such trials were subsequently also identified in the Journal of the American Medical Association and The Lancet. All cited sources were reviewed, and the medical literature was searched to find studies describing contemporary practices. Then, the designated control group or the comparable therapies studied were examined to determine if they represented contemporaneous critical care practices as described in the medical literature. Results: Twenty-five of 332 randomised clinical trials published in these three journals during this 1-year period described critical care comparative effectiveness research that met our inclusion criteria. Seventeen characterised current practices before enrolment (using surveys, observational studies and guidelines) and then incorporated current practices into one or more study arm. In the other eight, usual care arms appeared insufficient. Four of these trials randomly assigned patients to one of two fixed approaches at either end of a range of usually titrated care. However, due to randomisation, different subgroups within each arm received care that was inappropriate for their specific clinical conditions. In the other four of these trials, common practices influencing treatment choice were not reflected in the trial design, despite a prior effort to characterise usual care. Conclusion: One-third of critical care comparative effectiveness research trials published in widely read medical journals during a recent year did not include a designated control arm or comparable therapies representative of contemporary practices. Failure to incorporate contemporary practices into critical care comparative effectiveness trials appears to be a widespread design weakness.
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Affiliation(s)
- Willard N. Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortés-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Harvey G. Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Peter Q. Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Diane Cooper
- National Institutes of Health Library, Office of Research Services, National Institutes of Health, Bethesda, MD, USA
| | - Robert L. Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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16
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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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17
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Impact of a Care Bundle on Cost Saving for Noninvasive Respiratory Support for Neonates. Adv Neonatal Care 2022; 22:22-27. [PMID: 33783385 DOI: 10.1097/anc.0000000000000856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neonates often receive noninvasive respiratory support via continuous positive airway pressure (CPAP) or high-flow nasal cannula oxygen (HHFNC). The decision to change from one mode to the other, however, is not evidence based, hence not standardized and does not consider cost implications. PURPOSE To assess the introduction of a care bundle for the medical and nursing staff in a tertiary medical and surgical neonatal center with regard to any financial savings or adverse outcomes. METHODS An education package and written guidelines were used to increase the awareness of the durations for which CPAP and HHFNC Vapotherm (VT) circuits could be used and the costs of the circuits. RESULTS This resulted in a cost saving of £17,000 ($22,254) for the year without adverse outcomes. IMPLICATIONS FOR PRACTICE Introduction of a care bundle involving an education package and written guidelines to increase the awareness of the durations that circuits could be used and the costs of CPAP and HHFNC circuits among the medical and nursing staff can lead to cost savings when incorporated into clinical practice. IMPLICATIONS FOR RESEARCH Strategies, particularly during weaning, which involve changing from one form of noninvasive respiratory support to another, need a greater evidence base. Future research should include awareness of the duration different circuits could be used and the cost implications of changes between modes and hence circuits.
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18
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Stocks EF, Jaleel M, Smithhart W, Burchfield PJ, Thomas A, Mangona KLM, Kapadia V, Wyckoff M, Kakkilaya V, Brenan S, Brown LS, Clark C, Nelson DB, Brion LP. Decreasing delivery room CPAP-associated pneumothorax at ≥35-week gestational age. J Perinatol 2022; 42:761-768. [PMID: 35173286 PMCID: PMC8853308 DOI: 10.1038/s41372-022-01334-4] [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: 11/04/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We previously reported an increase in pneumothorax after implementing delivery room (DR) continuous positive airway pressure (CPAP) for labored breathing or persistent cyanosis in ≥35-week gestational age (GA) neonates unexposed to DR-positive pressure ventilation (DR-PPV). We hypothesized that pneumothorax would decrease after de-implementing DR-CPAP in those unexposed to DR-PPV or DR-O2 supplementation (DR-PPV/O2). STUDY DESIGN In a retrospective cohort excluding DR-PPV the primary outcome was DR-CPAP-related pneumothorax (1st chest radiogram, 1st day of life). In a subgroup treated by the resuscitation team and admitted to the NICU, the primary outcome was DR-CPAP-associated pneumothorax (1st radiogram, no prior PPV) without DR-PPV/O2. RESULTS In the full cohort, occurrence of DR-CPAP-related pneumothorax decreased after the intervention (11.0% vs 6.0%, P < 0.001). In the subgroup, occurrence of DR-CPAP-associated pneumothorax decreased after the intervention (1.4% vs. 0.06%, P < 0.001). CONCLUSION The occurrence of CPAP-associated pneumothorax decreased after avoiding DR-CPAP in ≥35-week GA neonates without DR-PPV/O2.
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Affiliation(s)
- Edward F. Stocks
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA ,grid.266900.b0000 0004 0447 0018Present Address: Oklahoma University, Norman, OK USA
| | - Mambarambath Jaleel
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA
| | - William Smithhart
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA ,Present Address: Newborn Associates, Jackson, MO USA
| | - Patti J. Burchfield
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Anita Thomas
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Kate Louise M. Mangona
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Vishal Kapadia
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Myra Wyckoff
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA
| | | | - Shelby Brenan
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA ,Present Address: Pediatrix, Colorado Springs, CO USA
| | - L. Steven Brown
- grid.417169.c0000 0000 9359 6077Parkland Health & Hospital System, Dallas, TX USA
| | - Christopher Clark
- grid.417169.c0000 0000 9359 6077Parkland Health & Hospital System, Dallas, TX USA
| | - David B. Nelson
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA ,grid.417169.c0000 0000 9359 6077Parkland Health & Hospital System, Dallas, TX USA
| | - Luc P. Brion
- grid.267313.20000 0000 9482 7121University of Texas Southwestern Medical Center, Dallas, TX USA
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19
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Bruet S, Butin M, Dutheil F. Systematic review of high-flow nasal cannula versus continuous positive airway pressure for primary support in preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 107:56-59. [PMID: 34016651 DOI: 10.1136/archdischild-2020-321094] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/13/2021] [Accepted: 05/01/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION We conducted a meta-analysis of trials that compared efficacy and safety of high-flow nasal cannula (HFNC) with continuous positive airway pressure (CPAP) as primary respiratory support in preterm infants and a study of the impact of clinical relevant parameters. METHODS Databases were searched for randomised controlled trials comparing HFNC with CPAP as primary respiratory support in preterm infants. Treatment failure was considered as primary outcome and adverse events as secondary outcomes. We calculated risk ratios (RRs) in intention-to-treat analysis and random-effects meta-analyses of risks were conducted. RESULTS We included 10 studies for a total of 1830 patients. Meta-analysis demonstrated an RR of treatment failure multiplied by 1.34 using HFNC compared with CPAP (RR=1.34, 95% CI 1.01 to 1.68, I2=16.2%). Secondary outcome meta-analysis showed no difference in intubation rates (RR=0.90, 95% CI 0.66 to 1.15) and a lower rate of nasal trauma using HFNC compared with CPAP (RR=0.48, 95% CI 0.31 to 0.65, I²=0.0%). Meta-regressions did not show any influence of gestational age and weight at birth, HFNC flow rate, type of CPAP generator or use of surfactant. CONCLUSIONS Despite a higher risk of treatment failure, considering no difference in intubation rates and a lower rate of nasal trauma using HFNC compared with CPAP, we suggest that HFNC should be used as primary respiratory support in preterm infants.
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Affiliation(s)
- Shaam Bruet
- Neonatology and NICU, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marine Butin
- Neonatology and NICU, Hospices Civils de Lyon, Lyon, France.,Staphylococcal pathogenesis research group, International Center for Infectiology Research, INSERM U1111, Lyon, France
| | - Frederic Dutheil
- Physiological and Psychosocial Stress, LaPSCo, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France.,Preventive and Occupational Medicine, University Hospital of Clermont-Ferrand, Witty Fit, F-63000, CHU Clermont-Ferrand, Clermont-Ferrand, France
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20
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Luo K, Huang Y, Xiong T, Tang J. High-flow nasal cannula versus continuous positive airway pressure in primary respiratory support for preterm infants: A systematic review and meta-analysis. Front Pediatr 2022; 10:980024. [PMID: 36479290 PMCID: PMC9720183 DOI: 10.3389/fped.2022.980024] [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: 06/28/2022] [Accepted: 11/03/2022] [Indexed: 11/22/2022] Open
Abstract
Respiratory support is crucial for the survival of preterm infants, and High-flow Nasal Cannula Oxygen Therapy (HFNC) and Continuous Positive Airway Pressure (CPAP) are commonly used for neonatal respiratory support. This meta-analysis aimed to compare the effects of HFNC and CPAP in primary respiratory support for preterm infants, to provide evidence-based support for clinical practice. PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CNKI, VIP, WANFANG and SinoMed were searched for eligible studies. The primary outcomes included the incidence of treatment failure and the application of mechanical ventilation. A total of 27 eligible studies with 3,351 participants were included. There was no significant difference in the incidence of respiratory support failure [RR = 1.17, 95%CI (0.88-1.56)] and the application of mechanical ventilation [RR = 1.00, 95%CI (0.84-1.19)] between HFNC group and CPAP group. HFNC resulted in lower rate of air leaks [RR = 0.65, 95%CI (0.46-0.92)], nasal trauma [RR = 0.36, 95%CI (0.29-0.45)] and abdominal distension [RR = 0.39, 95%CI (0.27-0.58)], and later time of mechanical ventilation initiating [SMD = 0.60, 95%CI (0.21-0.99)], less duration of oxygen therapy [SMD = -0.35, 95%CI (-0.68 to -0.02)] and earlier enteral feeding [SMD = -0.54, 95%CI (-0.95 to -0.13)]. Alternative non-invasive respiratory support after initial treatment failure resulted in no difference in the application of mechanical ventilation between the two groups [RR = 0.99, 95%CI (0.52-1.88)]. HFNC might be more effective and safer in primary respiratory support for preterm infants. Using CPAP as a remedy for the treatment failure of HFNC could not avoid intubation. For premature infants with the gestational age <28 weeks, HFNC as primary respiratory support still needs to be further elucidated. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022313479, identifier: CRD42022313479.
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Affiliation(s)
- Keren Luo
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
| | - Yi Huang
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
| | - Tao Xiong
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
| | - Jun Tang
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
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21
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Standardized nCPAP Care Bundle to Decrease Days to Wean Off nCPAP: A Quality Improvement Initiative. Adv Neonatal Care 2021; 22:284-290. [PMID: 34743116 DOI: 10.1097/anc.0000000000000960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Effective bubble nasal continuous positive airway pressure (bnCPAP) implementation is a means to maintain functional residual capacity (FRC) and avoid pulmonary morbidities in neonates. PURPOSE A quality improvement project was introduced to establish a standardized bnCPAP care bundle. METHODS A bnCPAP care bundle focusing on shoulder roll use, bnCPAP positioning, assessment for suctioning need, and nasopharynx suctioning was created. The outcome measures collected were percentage of time the infant's pulse saturation was less than 86%, corrected gestational age (CGA) when off bnCPAP, length of time a neonate is on bnCPAP, Downes' score, and compliance to bnCPAP care bundle. RESULTS An independent-samples t test found a statistically significant higher mean prior to the initiative in the percentage of time the oxygen saturation was less than 86%, Downes' score, length of time, and CGA to wean off bnCPAP (M = 11.7% ± 10.1%, M = 1.6 ± 1.1, M = 27.7 days ± 29.0 days, and M = 35.0 weeks ± 3.38 weeks, respectively) than after the initiative (M = 4.0% ± 4.8%, M = 1.1 ± 0.8, M = 11.2 days ± 10.2 days, and M = 32.8 weeks ± 1.00 weeks, respectively). IMPLICATIONS FOR PRACTICE AND RESEARCH Implementing a standardized bnCPAP care bundle showed improvement in oxygen saturation and increased success of weaning off bnCPAP. Future studies to increase the collected data are needed to compare the outcomes on infants born at each gestational age.
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22
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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: 0] [Impact Index Per Article: 0] [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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23
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Patterson HR, Pollock W. A Comparison of Moderate to Late Preterm Neonates Receiving Nasal Continuous Positive Airway Pressure in Australian Tertiary and Nontertiary Centers. Neonatal Netw 2021; 39:189-199. [PMID: 32675314 DOI: 10.1891/0730-0832.39.4.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Transfer of neonates ≥32 weeks' gestation with acute respiratory distress to tertiary (T) centers can be reduced by treatment with nasal continuous positive airway pressure (nCPAP) in nontertiary (NT) centers. This can lead to considerable financial and emotional benefits. The aim of this project was to compare management of nCPAP in T and NT centers. DESIGN Five-year retrospective, observational cohort study (2010-2014). SAMPLE All NT eligible neonates from four sites (n = 484) were compared with a similar randomized cohort of inborn neonates at two T centers (n = 601) in Victoria, Australia. MAIN OUTCOME VARIABLE Any difference in management or short-term outcome. RESULTS Moderately preterm and term neonates born in NT centers had lower Apgar scores at five minutes of age and received more conservative management delivered by different equipment. Despite a higher incidence of air leaks in NT centers, the short-term outcomes were otherwise similar between centers. T centers were more likely to administer nCPAP to term babies for <24 hours.
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24
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Huang L, Manley BJ, Arnolda GRB, Owen LS, Wright IMR, Foster JP, Davis PG, Buckmaster AG, Dalziel KM. Cost-Effectiveness of Nasal High Flow Versus CPAP for Newborn Infants in Special-Care Nurseries. Pediatrics 2021; 148:peds.2020-020438. [PMID: 34272343 DOI: 10.1542/peds.2020-020438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Treating respiratory distress in newborns is expensive. We compared the cost-effectiveness of 2 common noninvasive therapies, nasal continuous positive airway pressure (CPAP) and nasal high-flow (nHF), for newborn infants cared for in nontertiary special care nurseries. METHODS The economic evaluation was planned alongside a randomized control trial conducted in 9 Australian special care nurseries. Costs were considered from a hospital perspective until infants were 12 months of age. A total of 754 infants with respiratory distress, born ≥31 weeks' gestation and with birth weight ≥1200 g, <24 hours old, requiring noninvasive respiratory support and/or supplemental oxygen for >1 hour were recruited during 2015-2017. Inpatient costing records were obtained for 753 infants, of whom 676 were included in the per-protocol analysis. Two scenarios were considered: (1) CPAP versus nHF, with infants in the nHF group having "rescue" CPAP backup available (trial scenario); and (2) CPAP versus nHF, as sole primary support (hypothetical scenario). Effectiveness outcomes were rate of endotracheal intubation and transfer to a tertiary-level NICU. RESULTS As sole primary support, CPAP is more effective and on average cheaper, and thus is superior. However, nHF with back-up CPAP produced equivalent cost and effectiveness results, and there is no reason to make a decision between the 2 treatments on the basis of the cost or effectiveness outcomes. CONCLUSIONS Nontertiary special care nurseries choosing to use only 1 of the modes should choose CPAP. In units with both modes available, using nHF as first-line therapy may be acceptable if there is back-up CPAP.
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Affiliation(s)
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Victoria, Australia.,Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Victoria, Australia
| | - Gaston R B Arnolda
- School of Population Health, University of New South Wales, New South Wales, Australia.,Australian Institute for Healthcare Innovation, Macquarie University, New South Wales, Australia
| | - Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Victoria, Australia.,Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Victoria, Australia
| | - Ian M R Wright
- Illawarra Health and Medical Research Institute, University of Wollongong and Illawarra and Shoalhaven Health District, New South Wales, Australia.,College of Medicine and Dentistry, James Cook University, Queensland, Australia
| | - Jann P Foster
- School of Nursing and Midwifery, Western Sydney University, New South Wales, Australia.,Ingham Institute, New South Wales, Australia.,Sydney Medical School, Sydney Nursing School, University of Sydney, New South Wales, Australia
| | - Peter G Davis
- Department of Obstetrics and Gynaecology, The University of Melbourne, Victoria, Australia.,Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Victoria, Australia
| | - Adam G Buckmaster
- Paediatrics, Central Coast Local Health District, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, New South Wales, Australia
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25
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Yieh L, Dukhovny D. What Helps Us Decide to Adopt an Intervention: Efficacy, Costs, or Both? Pediatrics 2021; 148:peds.2021-051016. [PMID: 34272342 DOI: 10.1542/peds.2021-051016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Leah Yieh
- Fetal and Neonatal Institute, Division of Neonatal Medicine, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California .,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, California
| | - Dmitry Dukhovny
- Division of Neonatology, Department of Pediatrics, School of Medicine, Oregon Health Sciences University, Portland, Oregon
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26
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Siva NV, Reynolds PR. Stabilisation of the preterm infant in the delivery room using nasal high flow: A 5-year retrospective analysis. Acta Paediatr 2021; 110:2065-2071. [PMID: 33638878 DOI: 10.1111/apa.15824] [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: 11/09/2020] [Revised: 02/18/2021] [Accepted: 02/25/2021] [Indexed: 11/28/2022]
Abstract
AIM This study reviews clinical outcomes after initiating a routine policy of preterm respiratory stabilisation using nasal high flow (HF) in the delivery room (DR). METHOD This was a retrospective observational cohort study in a single-centre neonatal intensive care unit and included all neonates born before 32 weeks of gestation between 1 April 2015 and 31 March 2020. Stabilisation measures and outcomes were recorded including oxygen requirements, admission temperature, surfactant administration, invasive ventilation within 72 h of birth, bronchopulmonary dysplasia (BPD) and death. RESULTS There were 491 eligible babies during the 5-year epoch. 292 were stabilised using HF in the DR. The median admission temperature in babies transferred on HF was 36.8°C, and the median FiO2 at admission was 25%. 45% of these infants received surfactant. At 72 postnatal hours, 78% were either sustained on HF or were either self-ventilating in air (SVIA) or receiving low-flow nasal cannula (LFNC) respiratory support. 27% were intubated within 7 days. At 36 weeks postmenstrual age, 36% of survivors had BPD. CONCLUSION We have demonstrated that preterm babies <32 weeks can be effectively stabilised on HF in the DR.
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Affiliation(s)
- Naren V. Siva
- Neonatal Intensive Care Unit St. Peter's Hospital Ashford & St. Peter’s Hospitals NHS Foundation Trust Chertsey UK
| | - Peter R. Reynolds
- Neonatal Intensive Care Unit St. Peter's Hospital Ashford & St. Peter’s Hospitals NHS Foundation Trust Chertsey UK
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27
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Villosis MFB, Barseghyan K, Ambat MT, Rezaie KK, Braun D. Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle. JAMA Netw Open 2021; 4:e2114140. [PMID: 34181013 PMCID: PMC8239950 DOI: 10.1001/jamanetworkopen.2021.14140] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade. OBJECTIVE To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019). INTERVENTIONS A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable. MAIN OUTCOMES AND MEASURES The primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge. Balancing measures were adjusted mortality and adjusted mortality or specified morbidities. RESULTS The study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly. CONCLUSIONS AND RELEVANCE A sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.
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Affiliation(s)
- Maria Fe B. Villosis
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Karine Barseghyan
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Ma. Teresa Ambat
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Kambiz K. Rezaie
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - David Braun
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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28
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Sivieri EM, Rub DM, Abbasi S, Eichenwald EC. Preserved pressure delivery during high-frequency oscillation of bubble CPAP in a premature infant lung model with both normal and abnormal lung mechanics. Pediatr Pulmonol 2021; 56:1136-1144. [PMID: 33497536 DOI: 10.1002/ppul.25267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/01/2020] [Accepted: 01/07/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Bubble continuous positive airway pressure (BCPAP) generates pressure oscillations which are suggested to improve gas exchange through mechanisms similar to high frequency (HF) ventilation. In a previous in-vitro lung model with normal lung mechanics, significantly improved CO2 washout was demonstrated using an HF interrupter in the supply flow of a BCPAP system. The effect of HF with BCPAP on delivered airway pressure (Paw) has not been fully investigated in a lung model having abnormal pulmonary mechanics. OBJECTIVE To measure Paw in an infant lung model simulating normal and abnormal pulmonary compliance and resistance while connected to a BCPAP system with superimposed HF oscillations created using an in-line flow interrupter. DESIGN/METHODS A premature infant lung model with either: normal lung mechanics, compliance 1.0 ml/cm H2 O, airway resistance 56 cm H2 O/(L/s); or abnormal mechanics, compliance 0.5 ml/cm H2 O, airway resistance 136 cm H2 O/(L/s), was connected to BCPAP with HF at either 4, 6, 8, 10, or 12 Hz. Paw was measured at BCPAPs of 4, 6, and 8 cm H2 O and respiratory rates (RR) of 40, 60, and 80 breaths/min and 6.0 ml tidal volume. RESULTS Mean Paw averaged over all five frequencies showed no significant change from non-oscillated levels at all BCPAPs and RRs for both lung models. Paw amplitudes (peak-to-trough) during oscillation were significantly greater than the non-oscillated levels by an average of 1.7 ± 0.5 SD and 2.6 ± 0.5 SD cm H2 O (p < .001) for the normal and abnormal models, respectively. CONCLUSIONS HF oscillation of BCPAP using a flow interrupter did not alter mean delivered Paw compared to non-oscillated BCPAP for both normal and abnormal lung mechanics models. This simple modification to BCPAP may be a useful enhancement to this mode of non-invasive respiratory support.
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Affiliation(s)
- Emidio M Sivieri
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David M Rub
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Soraya Abbasi
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric C Eichenwald
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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29
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Drevhammar T, Berg N, Nilsson K, Jonsson B, Prahl Wittberg L. Flows and function of the Infant Flow neonatal continuous positive airway pressure device investigated with computational fluid dynamics. Acta Paediatr 2021; 110:811-817. [PMID: 32726471 DOI: 10.1111/apa.15502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 07/14/2020] [Accepted: 07/22/2020] [Indexed: 11/26/2022]
Abstract
AIM The first dedicated neonatal continuous positive airway pressure (CPAP) device using variable flow was the Infant Flow. The system was pressure stable with a low resistance to breathing. The aim of this study was to describe the flow and function of the Infant Flow geometry using simulated breathing and computational fluid dynamics. METHOD The original Infant Flow geometry was used with simulated term infant breathing at three levels of CPAP. The large eddy simulation methodology was applied in combination with the WALE sub-grid scale model. RESULTS The simulation fully resolved the flow phenomena in the Infant Flow geometry. The main flow feature during inspiration was support by gas entrainment and mixing. During expiration, the jet deflected towards the outlet with unstable impingement of the jet at the opposing edge. CONCLUSION The proposed mechanism has previously been based on theoretical reasoning, and our results present the first detailed description of the Infant Flow. The pressure stability was based on a jet supporting inspiration by gas entrainment and then being deflected during exhalation. This confirmed previously assumed principles of function and flows within the geometry and provided a base for further developments.
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Affiliation(s)
- Thomas Drevhammar
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Niclas Berg
- FLOW & BioMEx Department of Engineering Mechanics Royal Institute of Technology (KTH) Stockholm Sweden
| | - Kjell Nilsson
- Anaesthesiology and Intensive Care Östersund Hospital Östersund Sweden
| | - Baldvin Jonsson
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Lisa Prahl Wittberg
- FLOW & BioMEx Department of Engineering Mechanics Royal Institute of Technology (KTH) Stockholm Sweden
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30
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Maamari M, Nino G, Bost J, Cheng Y, Sochet A, Sharron M. Predicting Failure of Non-Invasive Ventilation With RAM Cannula in Bronchiolitis. J Intensive Care Med 2021; 37:120-127. [PMID: 33412988 DOI: 10.1177/0885066620979642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION In infants hospitalized for bronchiolitis on non-invasive ventilation (NIV) via the RAM cannula nasal interface, variables predicting subsequent intubation, or NIV non-response, are understudied. We sought to identify predictors of NIV non-response. METHODS We performed a retrospective cohort study in infants admitted for respiratory failure from bronchiolitis placed on NIV in a quaternary children's hospital. We excluded children with concurrent sepsis, critical congenital heart disease, or with preexisting tracheostomy. The primary outcome was NIV non-response defined as intubation after a trial of NIV. Secondary outcomes were vital sign values before and after NIV initiation, duration of NIV and intubation, and mortality. Primary analyses included Chi-square, Wilcoxon rank-sum, student's t test, paired analyses, and adjusted and unadjusted logistic regression assessing heart rate (HR) and respiratory rate (RR) before and after NIV initiation. RESULTS Of 138 infants studied, 34% were non-responders. There were no differences in baseline characteristics of responders and non-responders. HR decreased after NIV initiation in responders (156 [143-156] to149 [141-158], p < 0.01) compared to non-responders (158 [149-166] to 158 [145-171], p = 0.73). RR decreased in responders (50 [43-58] vs 47 [41-54]) and non-responders (52 [48-58] vs 51 [40-55], both p < 0.01). Concurrent bacterial pneumonia (OR 6.06, 95% CI: 2.54-14.51) and persistently elevated HR (OR: 1.04, 95% CI: 1.01-1.07) were associated with NIV non-response. CONCLUSION In children with acute bronchiolitis who fail to respond to NIV and require subsequent intubation, we noted associations with persistently elevated HR after NIV initiation and concurrent bacterial pneumonia.
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Affiliation(s)
- Mia Maamari
- Division of Critical Care Medicine, 12334Children's National Health System, Washington, DC, USA
| | - Gustavo Nino
- Division of Pulmonology, 12334Children's National Health System, Washington, DC, USA
| | - James Bost
- Division of Biostatistics and Study Methodology, 12334Children's National Health System, Washington, DC, USA
| | - Yao Cheng
- Division of Biostatistics and Study Methodology, 12334Children's National Health System, Washington, DC, USA
| | - Anthony Sochet
- Division of Anesthesia and Critical Care Medicine, 1500Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Matthew Sharron
- Division of Critical Care Medicine, 12334Children's National Health System, Washington, DC, USA
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Leichsenring F, Steinert C, Beutel ME, Feix L, Gündel H, Hermann A, Karabatsiakis A, Knaevelsrud C, König HH, Kolassa IT, Kruse J, Niemeyer H, Nöske F, Palmer S, Peters E, Reese JP, Reuss A, Salzer S, Schade-Brittinger C, Schuster P, Stark R, Weidner K, von Wietersheim J, Witthöft M, Wöller W, Hoyer J. Trauma-focused psychodynamic therapy and STAIR Narrative Therapy of post-traumatic stress disorder related to childhood maltreatment: trial protocol of a multicentre randomised controlled trial assessing psychological, neurobiological and health economic outcomes (ENHANCE). BMJ Open 2020; 10:e040123. [PMID: 33334832 PMCID: PMC7747578 DOI: 10.1136/bmjopen-2020-040123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 11/05/2020] [Accepted: 11/13/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Success rates of psychotherapy in post-traumatic stress disorder related to childhood maltreatment (PTSD-CM) are limited. METHODS AND ANALYSIS Observer-blind multicentre randomised clinical trial (A-1) of 4-year duration comparing enhanced methods of STAIR Narrative Therapy (SNT) and of trauma-focused psychodynamic therapy (TF-PDT) each of up to 24 sessions with each other and a minimal attention waiting list in PTSD-CM. Primary outcome is severity of PTSD (Clinician-Administered PTSD Scale for DSM-5 total) assessed by masked raters. For SNT and TF-PDT, both superiority and non-inferiority will be tested. Intention-to-treat analysis (primary) and per-protocol analysis (secondary). Assessments at baseline, after 10 sessions, post-therapy/waiting period and at 6 and 12 months of follow-up. Adult patients of all sexes between 18 and 65 years with PTSD-CM will be included. Continuing stable medication is permitted. To be excluded: psychotic disorders, risk of suicide, ongoing abuse, acute substance related disorder, borderline personality disorder, dissociative identity disorder, organic mental disorder, severe medical conditions and concurrent psychotherapy. To be assessed for eligibility: n=600 patients, to be e randomly allocated to the study conditions: n=328. Data management, randomisation and monitoring will be performed by an independent European Clinical Research Infrastructure Network (ECRIN)-certified data coordinating centre for clinical trials (KKS Marburg). Report of AEs to a data monitoring and safety board. Complementing study A-1, four inter-related add-on projects, including subsamples of the treatment study A-1, will examine (1) treatment integrity (adherence and competence) and moderators and mediators of outcome (B-1); (2) biological parameters (B-2, eg, DNA damage, reactive oxygen species and telomere shortening); (3) structural and functional neural changes by neuroimaging (B-3) and (4) cost-effectiveness of the treatments (B-4, costs and utilities). ETHICS AND DISSEMINATION Approval by the institutional review board of the University of Giessen (AZ 168/19). Following the Consolidated Standards of Reporting Trials statement for non-pharmacological trials, results will be reported in peer-reviewed scientific journals and disseminated to patient organisations and media. TRIAL REGISTRATION NUMBER DRKS 00021142.
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Affiliation(s)
- Falk Leichsenring
- Justus Liebig University Giessen and Philipps University Marburg, Center for Mind, Brain and Behavior (CMBB), Giessen and Marburg, Germany
- Department of Psychotherapy and Psychosomatics, Justus Liebig University Giessen, Giessen, Germany
| | - Christiane Steinert
- Department of Psychotherapy and Psychosomatics, Justus Liebig University Giessen, Giessen, Germany
- International Psychoanalytic University Berlin gGmbH, Berlin, Germany
| | - Manfred E Beutel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Lila Feix
- Department of Psychotherapy and Psychosomatics, Justus Liebig University Giessen, Giessen, Germany
| | - Harald Gündel
- Department of Psychosomatic Medicine and Psychotherapy, University Ulm Medical Centre, Ulm, Germany
| | - Andrea Hermann
- Justus Liebig University Giessen and Philipps University Marburg, Center for Mind, Brain and Behavior (CMBB), Giessen and Marburg, Germany
- Department of Psychotherapy and Systems Neuroscience, Justus Liebig Universitat Giessen, Giessen, Germany
- Justus Liebig University Giessen Bender Institute of Neuroimaging, Giessen, Germany
| | - Alexander Karabatsiakis
- Clinical Psychology II, University of Innsbruck, Innsbruck, Tirol, Austria
- Institute for Psychology and Education, Clinical & Biological Psychology, Ulm University, Ulm, Germany
| | - Christine Knaevelsrud
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - Hans-Helmut König
- Department for Health Economics and Health Services Research, Universitatsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Iris T Kolassa
- Institute for Psychology and Education, Clinical & Biological Psychology, Ulm University, Ulm, Germany
| | - Johannes Kruse
- Department of Psychotherapy and Psychosomatics, Justus Liebig University Giessen, Giessen, Germany
- Department of Psychotherapy and Psychosomatics, Philipps University Marburg, Marburg, Germany
| | - Helen Niemeyer
- Division of Clinical Psychological Intervention, Department of Education and Psychology, Freie Universitat Berlin, Berlin, Germany
| | - Fatima Nöske
- Department of Psychotherapy and Psychosomatics, Justus Liebig University Giessen, Giessen, Germany
| | - Sebastian Palmer
- Department of Psychotherapy and Systems Neuroscience, Justus Liebig Universitat Giessen, Giessen, Germany
| | - Eva Peters
- Psychoneuroimmunology Laboratory, Department of Psychosomatics and Psychotherapy, Justus Liebig Universitat Giessen, Giessen, Germany
- Charité Center 12 Internal Medicine and Dermatology, Division for General Internal Medicine, Psychosomatics and Psychotherapy, Universitätsmedizin Berlin, Berlin, Germany
| | - Jens-Peter Reese
- Institute for Clinical Epidemiology and Biometry, Julius-Maximilians-Universität of Würzburg, Würzburg, Germany
- Coordinating Center for Clinical Trials - KKS, Philipps-Universitat Marburg, Marburg, Germany
| | - Alexander Reuss
- Coordinating Center for Clinical Trials - KKS, Philipps-Universitat Marburg, Marburg, Germany
| | - Simone Salzer
- International Psychoanalytic University Berlin gGmbH, Berlin, Germany
- Clinic of Psychosomatic Medicine and Psychotherapy, Georg-August-University Göttingen, Göttingen, Germany
| | | | - Patrick Schuster
- Department of Psychotherapy and Psychosomatics, Justus Liebig University Giessen, Giessen, Germany
| | - Rudolf Stark
- Justus Liebig University Giessen and Philipps University Marburg, Center for Mind, Brain and Behavior (CMBB), Giessen and Marburg, Germany
- Department of Psychotherapy and Systems Neuroscience, Justus Liebig Universitat Giessen, Giessen, Germany
- Justus Liebig University Giessen Bender Institute of Neuroimaging, Giessen, Germany
| | - Kerstin Weidner
- Department of Psychotherapy and Psychosomatic Medicine, Medizinische Fakultät Carl Gustav Carus, Technische Universitat Dresden, Dresden, Germany
| | - Jörn von Wietersheim
- Department of Psychosomatic Medicine and Psychotherapy, University Ulm Medical Centre, Ulm, Germany
| | - Michael Witthöft
- Department of Clinical Psychology, Psychotherapy and Experimental Psychopathology, Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Jürgen Hoyer
- Institute of Clincal Psychology and Psychotherapy, Technische Universität Dresden, Dresden, Germany
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Extubation Failure and Major Adverse Events Secondary to Extubation Failure Following Neonatal Cardiac Surgery. Pediatr Crit Care Med 2020; 21:e1119-e1125. [PMID: 32804741 DOI: 10.1097/pcc.0000000000002470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the prevalence and consequences of major adverse events secondary to extubation failure after neonatal cardiac surgery. DESIGN A single-center cohort study. SETTING A medical-surgical, 30-bed PICU in Victoria, Australia. PATIENTS One thousand one hundred eighty-eight neonates less than or equal to 28 days old who underwent cardiac surgery from January 2007 to December 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Extubation failure was defined as unplanned reintubation within 72 hours after a planned extubation. Major adverse event was defined as one or more of cardiac arrest, emergency chest reopening, extracorporeal membrane oxygenation, or death within 72 hours after extubation. One hundred fifteen of 1,188 (9.7%) neonates had extubation failure. Hospital mortality was 17.4% and 2.0% in neonates with and without extubation failure. Major adverse event occurred in 12 of 115 reintubated neonates (10.4%). major adverse event included cardiac arrest (n = 10), chest reopening (n = 8), extracorporeal membrane oxygenation (n = 5), and death (n = 0). Cardiovascular compromise accounted for major adverse event in eight: ventricular dysfunction (n = 3), pulmonary overcirculation (n = 2), coronary ischemia (n = 2), cardiac tamponade (n = 1). In a multivariable logistic regression, factors associated with major adverse event were high complexity in cardiac surgery (odds ratio 5.9; 95% CI: 1.1-32.2) and airway anomaly (odds ratio 6.0; 95% CI: 1.1-32.6). Hospital morality was 25% and 17% in reintubated neonates with and without major adverse event. CONCLUSIONS Around 10% of reintubated neonates suffered major adverse event within 72 hours of extubation. Neonates suffering major adverse event had high mortality. Major adverse event should be monitored and reported in future studies of extubation failure. Along with tracking of extubation failure rates, major adverse event secondary to extubation failure may also serve as a key performance indicator for ICUs and registries.
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McKimmie-Doherty M, Arnolda GRB, Buckmaster AG, Owen LS, Hodgson KA, Wright IMR, Roberts CT, Davis PG, Manley BJ. Predicting Nasal High-Flow Treatment Success in Newborn Infants with Respiratory Distress Cared for in Nontertiary Hospitals. J Pediatr 2020; 227:135-141.e1. [PMID: 32679201 DOI: 10.1016/j.jpeds.2020.07.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/28/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate demographic and clinical variables as predictors of nasal high-flow treatment success in newborn infants with respiratory distress cared for in Australian nontertiary special care nurseries. STUDY DESIGN A secondary analysis of the HUNTER trial, a multicenter, randomized controlled trial evaluating nasal high-flow as primary respiratory support for newborn infants with respiratory distress who were born ≥31 weeks of gestation and with birth weight ≥1200 g, and cared for in Australian nontertiary special care nurseries. Treatment success within 72 hours after randomization to nasal high-flow was determined using objective criteria. Univariable screening and multivariable analysis was used to determine predictors of nasal high-flow treatment success. RESULTS Infants (n = 363) randomized to nasal high-flow in HUNTER were included in the analysis; the mean gestational age was 36.9 ± 2.7 weeks and birth weight 2928 ± 782 g. Of these infants, 290 (80%) experienced nasal high-flow treatment success. On multivariable analysis, nasal high-flow treatment success was predicted by higher gestational age and lower fraction of inspired oxygen immediately before randomization, but not strongly. The final model was found to have an area under the curve of 0.65, which after adjustment for optimism was found to be 0.63 (95% CI, 0.57-0.70). CONCLUSIONS Gestational age and supplemental oxygen requirement may be used to guide decisions regarding the most appropriate initial respiratory support for newborn infants in nontertiary special care nurseries. Further prospective research is required to better identify which infants are most likely to be successfully treated with nasal high-flow. TRIAL REGISTRATION ACTRN12614001203640.
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Affiliation(s)
- Megan McKimmie-Doherty
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Newborn Research Center, The Royal Women's Hospital, Melbourne, Australia
| | - Gaston R B Arnolda
- Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia
| | - Adam G Buckmaster
- Pediatrics, Central Coast Local Health District, Gosford, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Louise S Owen
- Newborn Research Center, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Parkville, Victoria, Australia; Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Kate A Hodgson
- Newborn Research Center, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Parkville, Victoria, Australia; Pediatric Infant Perinatal Emergency Retrieval, Royal Children's Hospital, Melbourne, Australia
| | - Ian M R Wright
- Illawarra Health and Medical Research Institute, and Graduate Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Illawarra and Shoalhaven Health District, Wollongong, New South Wales, Australia; The University of Queensland Center for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia; James Cook University, Douglas, Queensland, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Center, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Parkville, Victoria, Australia; Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Brett J Manley
- Newborn Research Center, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynecology, The University of Melbourne, Parkville, Victoria, Australia; Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.
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Nielsen KR, Becerra MR, Mallma G, Ellington LE, Onchiri F, Roberts JS, Zunt J, Tantaleán da Fieno J. Nasal high flow therapy introduction lowers reintubation risk in a Peruvian paediatric intensive care unit. Acta Paediatr 2020; 109:2748-2754. [PMID: 32198789 DOI: 10.1111/apa.15265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/15/2020] [Accepted: 03/17/2020] [Indexed: 11/28/2022]
Abstract
AIM We examined the impact of introducing high-flow nasal oxygen therapy (HFNT) on children under five with post-extubation respiratory failure in a paediatric intensive care unit (PICU) in Peru. METHODS This quasi-experimental study compared clinical outcomes before and after initial HFNT deployment in the PICU at Instituto Nacional de Salud del Niño in Lima in June 2016. We compared three groups: 29 received post-extubation HFNT and 17 received continuous positive airway pressure (CPAP) from 2016-17 and 12 historical controls received CPAP from 2012-16. The primary outcome was the need for mechanical ventilation. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated via survival analysis. RESULTS High-flow nasal oxygen therapy and CPAP did not alter the need for mechanical ventilation after extubation (aHR 0.47, 95% CI 0.15-1.48 and 0.96, 95% CI 0.35-2.62, respectively) but did reduce the risk of reintubation (aHR 0.18, 95% CI 0.06-0.57 and 0.14, 95% CI 0.03-0.72, respectively). PICU length of stay was 11, 18 and 37 days for CPAP, HFNT and historical CPAP and mortality was 12%, 7% and 27%, respectively. There was no effect on the duration of sedative infusions. CONCLUSION High-flow nasal oxygen therapy provided effective support for some children, but larger studies in resource-constrained settings are needed.
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Affiliation(s)
- Katie R. Nielsen
- Department of Pediatrics Critical Care Medicine University of Washington Seattle, Washington
- Department of Global Health University of Washington Seattle, Washington
| | - María R. Becerra
- Departamento de Cuidados Intensivos Instituto Nacional de Salud del Niño Lima Peru
| | - Gabriela Mallma
- Departamento de Cuidados Intensivos Instituto Nacional de Salud del Niño Lima Peru
| | | | - Frankline Onchiri
- Seattle Children's Core for Biomedical Statistics Seattle Children's Research Institute Seattle, Washington
| | - Joan S. Roberts
- Department of Pediatrics Critical Care Medicine University of Washington Seattle, Washington
| | - Joseph Zunt
- Department of Global Health University of Washington Seattle, Washington
- Department of Neurology University of Washington Seattle, Washington
| | - José Tantaleán da Fieno
- Departamento de Cuidados Intensivos Instituto Nacional de Salud del Niño Lima Peru
- Universidad Nacional Federico Villarreal Lima Peru
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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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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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Feng SYS, Rao S, Patole S. A survey on criteria for intubation in moderate to late preterm infants with respiratory distress. Pediatr Pulmonol 2020; 55:2970-2982. [PMID: 32886426 DOI: 10.1002/ppul.25054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/14/2020] [Accepted: 08/26/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Majority of preterm infants do well with continuous positive airway pressure (CPAP) as the sole respiratory management; but some require endotracheal intubation and surfactant administration. While intubation is needed predominantly in extremely preterm infants (<28 weeks); some of the more mature preterm infants also require it. Currently, there are no clear guidelines regarding indications for endotracheal intubation in such infants. AIMS To understand the current practice regarding "criteria for intubation" in moderate to late preterm infants with respiratory distress. METHODS A survey of neonatologists in Australia New Zealand Neonatal Network (ANZNN) was conducted between April and June 2019. RESULTS At least one neonatologist each from 29 of the 30 tertiary ANZNN Neonatal Intensive Care Units (NICUs) responded to the survey. In total, 118/200 (59%) neonatologists responded. The most common criteria for intubation were CPAP = 8 cmH2 O (61%), pH < 7.2 (55%), pCO2 > 70 mmHg (48%), FiO2 > 40% (40%), chest retractions (48%), more than two episodes of apnea requiring intervention (54%), and chest X-ray (CXR) showing moderate-severe hyaline membrane disease (HMD, 49%). CONCLUSION While there were variations in practice, nearly 50% of the neonatologists shared a common threshold with regards to the CPAP level, FiO2 , blood gas parameters, and clinical and radiological findings. The results of this survey will help in designing future randomized controlled trials (RCTs) on this subject.
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Affiliation(s)
- Susan Y S Feng
- Neonatal Directorate, King Edward Memorial Hospital and Perth Children's Hospital, Subiaco, Western Australia, Australia
| | - Shripada Rao
- Neonatal Directorate, King Edward Memorial Hospital and Perth Children's Hospital, Subiaco, Western Australia, Australia
| | - Sanjay Patole
- Neonatal Directorate, King Edward Memorial Hospital and Perth Children's Hospital, Subiaco, Western Australia, Australia
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Hodgson KA, Owen LS, Kamlin CO, Roberts CT, Donath SM, Davis PG, Manley BJ. A multicentre, randomised trial of stabilisation with nasal high flow during neonatal endotracheal intubation (the SHINE trial): a study protocol. BMJ Open 2020; 10:e039230. [PMID: 33020105 PMCID: PMC7537449 DOI: 10.1136/bmjopen-2020-039230] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Neonatal endotracheal intubation is an essential but potentially destabilising procedure. With an increased focus on avoiding mechanical ventilation, particularly in preterm infants, there are fewer opportunities for clinicians to gain proficiency in this important emergency skill. Rates of successful intubation at the first attempt are relatively low, and adverse event rates are high, when compared with intubations in paediatric and adult populations. Interventions to improve operator success and patient stability during neonatal endotracheal intubations are needed. Using nasal high flow therapy extends the safe apnoea time of adults undergoing upper airway surgery and during endotracheal intubation. This technique is untested in neonates. METHODS AND ANALYSIS The Stabilisation with nasal High flow during Intubation of NEonates (SHINE) trial is a multicentre, randomised controlled trial comparing the use of nasal high flow during neonatal intubation with standard care (no nasal high flow). Intubations are randomised individually, and stratified by site, use of premedications, and postmenstrual age (<28 weeks' gestation; ≥28 weeks' gestation). The primary outcome is the incidence of successful intubation on the first attempt without physiological instability of the infant. Physiological instability is defined as an absolute decrease in peripheral oxygen saturation >20% from preintubation baseline and/or bradycardia (<100 beats per minute). ETHICS AND DISSEMINATION The SHINE trial received ethical approval from the Human Research Ethics Committees of The Royal Women's Hospital, Melbourne, Australia and Monash Health, Melbourne, Australia. The trial is currently recruiting in these two sites. The findings of this study will be disseminated via peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12618001498280.
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Affiliation(s)
- Kate A Hodgson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Louise S Owen
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Camille Omar Kamlin
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Susan M Donath
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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39
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Baldursdottir S, Falk M, Donaldsson S, Jonsson B, Drevhammar T. Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design. Arch Dis Child Fetal Neonatal Ed 2020; 105:550-554. [PMID: 32047029 PMCID: PMC7547905 DOI: 10.1136/archdischild-2019-318073] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The original bubble continuous positive airway pressure (bCPAP) design has wide-bore tubing and a low-resistance interface. This creates a stable airway pressure that is reflected by the submersion depth of the expiratory tubing. Several systems with alterations to the original bCPAP design are now available. Most of these are aimed for use in low-income and middle-income countries and have not been compared with the original design. OBJECTIVE We identified three major alterations to the original bCPAP design: (1) resistance of nasal interface, (2) volume of dead space and (3) diameter of expiratory tubing. Our aim was to study the effect of these alterations on CPAP delivery and work of breathing in a mechanical lung model. Dead space should always be avoided and was not further tested. METHODS The effect of nasal interface resistance and expiratory tubing diameter was evaluated with simulated breathing in a mechanical lung model without interface leakage. The main outcome was delivered CPAP and imposed work of breathing. RESULTS High-resistance interfaces and narrow expiratory tubing increased the work of breathing. Additionally, narrow expiratory tubing resulted in higher CPAP levels than indicated by the submersion depth. CONCLUSION Our study shows the significant effect on CPAP delivery and imposed work of breathing when using high-resistance interfaces and narrow expiratory tubing in bCPAP systems. New systems should include low-resistance interfaces and wide-bore tubing and be compared with the original bCPAP. Referring to all systems that bubble as bCPAP is misleading and potentially hazardous.
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Affiliation(s)
- Sonja Baldursdottir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden,Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Markus Falk
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden,Department of Anesthesiology, Östersund Hospital, Östersund, Sweden
| | - Snorri Donaldsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden,Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Baldvin Jonsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden,Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Drevhammar
- Department of Anesthesiology, Östersund Hospital, Östersund, Sweden .,Department of Anesthesiology, Östersund Hospital, Östersund, Sweden
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40
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Haward MF, Moore GP, Lantos J, Janvier A. Paediatric ethical issues during the COVID-19 pandemic are not just about ventilator triage. Acta Paediatr 2020; 109:1519-1521. [PMID: 32364256 PMCID: PMC7267437 DOI: 10.1111/apa.15334] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Marlyse F. Haward
- Division of Neonatology Department of Pediatrics Children’s Hospital at Montefiore Montefiore Medical Center Albert Einstein College of Medicine Bronx NY USA
| | - Gregory P. Moore
- Division of Neonatology Department of Pediatrics, Children’s Hospital of Eastern Ontario University of Ottawa Ottawa ON Canada
- Division of Newborn Care Department of Obstetrics and Gynecology The Ottawa Hospital General Campus University of Ottawa Ottawa ON Canada
| | - John Lantos
- Department of Pediatrics Children’s Mercy Hospital Kansas City MO USA
| | - Annie Janvier
- Department of Pediatrics, Bureau de l’Éthique Clinique Université de Montréal Montréal QC Canada
- Division of Neonatology, Research Center Clinical Ethics Unit Palliative Care Unit Unité de recherche en éthique clinique et partenariat famille CHU Sainte‐Justine Montréal QC Canada
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41
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Haward MF, Janvier A, Moore GP, Laventhal N, Fry JT, Lantos J. Should Extremely Premature Babies Get Ventilators During the COVID-19 Crisis? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:37-43. [PMID: 32400291 DOI: 10.1080/15265161.2020.1764134] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In a crisis, societal needs take precedence over a patient's best interests. Triage guidelines, however, differ on whether limited resources should focus on maximizing lives or life-years. Choosing between these two approaches has implications for neonatology. Neonatal units have ventilators, some adaptable for adults. This raises the question of whether, in crisis conditions, guidelines for treating extremely premature babies should be altered to free-up ventilators. Some adults who need ventilators will have a survival rate higher than some extremely premature babies. But surviving babies will likely live longer, maximizing life-years. Empiric evidence demonstrates that these babies can derive significant survival benefits from ventilation when compared to adults. When "triaging" or choosing between patients, justice demands fair guidelines. Premature babies do not deserve special consideration; they deserve equal consideration. Solidarity is crucial but must consider needs specific to patient populations and avoid biases against people with disabilities and extremely premature babies.
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Affiliation(s)
| | | | | | | | - Jessica T Fry
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Northwestern University Feinberg School of Medicine
| | - John Lantos
- Children's Mercy Bioethics Center
- Children's Mercy Hospital
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42
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Wightman S, O'Shea J. In newborns with respiratory distress, high flow is inferior to CPAP. Arch Dis Child Educ Pract Ed 2020; 105:192. [PMID: 31792038 DOI: 10.1136/archdischild-2019-318276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Joyce O'Shea
- Royal Hospital for Children Glasgow, Glasgow, UK
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43
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Sammour I, Karnati S. Non-invasive Respiratory Support of the Premature Neonate: From Physics to Bench to Practice. Front Pediatr 2020; 8:214. [PMID: 32457860 PMCID: PMC7227410 DOI: 10.3389/fped.2020.00214] [Citation(s) in RCA: 6] [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: 12/03/2019] [Accepted: 04/09/2020] [Indexed: 12/04/2022] Open
Abstract
Premature births continue to rise globally with a corresponding increase in various morbidities among this population. Rates of respiratory distress syndrome and the consequent development of Bronchopulmonary Dysplasia (BPD) are highest among the extremely preterm infants. The majority of extremely low birth weight premature neonates need some form of respiratory support during their early days of life. Invasive modes of respiratory assistance have been popular amongst care providers for many years. However, the practice of prolonged invasive mechanical ventilation is associated with an increased likelihood of developing BPD along with other comorbidities. Due to the improved understanding of the pathophysiology of BPD, and technological advances, non-invasive respiratory support is gaining popularity; whether as an initial mode of support, or for post-extubation of extremely preterm infants with respiratory insufficiency. Due to availability of a wide range of modalities, wide variations in practice exist among care providers. This review article aims to address the physical and biological basis for providing non-invasive respiratory support, the current clinical evidence, and the most recent developments in this field of Neonatology.
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Affiliation(s)
- Ibrahim Sammour
- Department of Neonatology, Lerner College of Medicine, Pediatric Institute, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, OH, United States
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44
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Brown KL, De Luca D. Focus on paediatrics. Intensive Care Med 2020; 46:1254-1257. [PMID: 32232504 PMCID: PMC7223899 DOI: 10.1007/s00134-020-06017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/17/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Katherine L Brown
- Heart and Lung Division and Biomedical Research Centre, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK. .,Institute of Cardiovascular Science University College, Zayed Rare Diseases Research Building, Guildford Street, London, WC1N 1DZ, UK.
| | - Daniele De Luca
- Pédiatrie et Réanimation Néonatale, Hôpital Antoine Béclère, GHU Paris Saclay, APHP, Paris, France.,Physiopathologie et Innovation Thérapeutique Unit, INSERM Unit U999, Université Paris Saclay, Faculté de Médecine Paris Sud, Saint-Aubin, France
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45
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Hough JL, Shearman AD, Jardine L, Schibler A. Nasal high flow in preterm infants: A dose-finding study. Pediatr Pulmonol 2020; 55:616-623. [PMID: 31868983 DOI: 10.1002/ppul.24617] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 12/12/2019] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To investigate the relationship between applied flows of nasal high flow (NHF) and physiological outcomes and work of breathing (WOB), to identify an optimal delivery flow which results in reduced WOB in preterm infants. DESIGN A prospective observational clinical study with randomly applied NHF rates. PATIENTS AND SETTING Preterm infants within 72 hours of commencement of NHF respiratory support. INTERVENTIONS Infants were initially placed on 8 L/min of NHF and flows of 2, 4, and 6 L/min were then applied in random order. MEASUREMENTS AND RESULTS WOB was measured using transcutaneous electromyography and respiratory inductance plethysmography. Physiological variables were also recorded. Measurements taken 10 minutes after each flow change were compared with 8 L/min. Sixteen infants with a median gestational age of 28 (range 24-31) weeks and postnatal age of 14 (2-55) days were included in the study. The median flow rate before the study was 6 (4-8) L/min and a fraction of inspired oxygen (FiO2 ) was 0.21 (0.21-0.26). Changes in flow resulted in changes in activity in the front diaphragm (P = .027) and intercostals (P = .034). The electrical activity of the front diaphragm at 8 L/min was significantly lower than that at 2 L/min (P = .016). Respiratory rate was lowest at 6 L/min (P = .002) and SpO2 /FiO2 was highest at 8 L/min (P < .04). CONCLUSION In preterm infants, changes in WOB resulting from randomly applied levels of NHF can be demonstrated by measuring the electrical activity of the diaphragm and intercostal muscles with transcutaneous electromyography. In combination with physiological measurements, the similarities in electrical activity between 4, 6, and 8 L/min suggest that these three flows may be equally as effective.
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Affiliation(s)
- Judith L Hough
- Program for Optimising Outcomes for Mothers and Babies At-Risk, Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia.,School of Allied Health, Australian Catholic University, Banyo, Queensland, Australia.,Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Andrew D Shearman
- Program for Optimising Outcomes for Mothers and Babies At-Risk, Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Luke Jardine
- Program for Optimising Outcomes for Mothers and Babies At-Risk, Mater Research Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Andreas Schibler
- Pediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
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46
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Mazmanyan P, Darakchyan M, Pinkham MI, Tatkov S. Mechanisms of nasal high flow therapy in newborns. J Appl Physiol (1985) 2020; 128:822-829. [PMID: 32078463 PMCID: PMC7191511 DOI: 10.1152/japplphysiol.00871.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
In newborns, it is unclear how nasal high flow (NHF) generates positive airway pressure. In addition, the reported benefits of NHF such as reduction in work of breathing may be independent of airway pressure. The authors hypothesized that during NHF the area of leak and the flow determine airway pressure and that NHF can reduce the required minute ventilation to maintain gas exchange. In response to NHF, pressure was measured in the upper airways of 9 newborns and ventilation was measured in another group of 17 newborns. In a bench model, airway pressures were measured during NHF with different prong sizes, nare sizes, and flows. The airway pressures during 8 L/min NHF were greater when a larger cannula versus a smaller cannula was used (P < 0.05). NHF reduced minute ventilation in 16 of 17 neonates, with a mean decrease of 24% from a baseline of 0.66 L/min (SD 0.21) (P < 0.001), and was unrelated to changes in airway pressure; arterial oxygen saturation by pulse oximetry (SpO2) and tissue CO2 were unchanged. In the bench model, the airway pressure remained <2 cmH2O when <50% of the “nare” was occluded by the prongs. As the leak area decreased, because of a smaller nare or a larger cannula, the airway pressure increased exponentially and was dependent on flow. In newborns NHF using room air substantially reduced minute ventilation without affecting gas exchange irrespective of a decrease or an increase of respiratory rate. NHF generates low positive airway pressure that exponentially increases with flow and occlusion of the nares. NEW & NOTEWORTHY In healthy newborns, nasal high flow (NHF) with room air reduced minute ventilation by one-fourth without affecting gas exchange but, in contrast to adults, produced variable response in respiratory rate during sleep. During NHF, pressure in the upper airways did not exceed 2 cmH2O at 8 L/min (3.4 L·min−1·kg−1) and was unaffected by opening of the mouth. NHF can generate higher pressure with larger prongs that decrease the leak around the cannula or by increasing the flow rate.
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Affiliation(s)
- Pavel Mazmanyan
- Department of Neonatology, Yerevan State Medical University, Yerevan, Armenia
| | - Mari Darakchyan
- Department of Neonatology, Yerevan State Medical University, Yerevan, Armenia
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47
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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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48
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Buckmaster A, Arnolda G, Owen L, Roberts C, Davis P, Manley B. Lost in Transition: Is Early Respiratory Support in Newborn Infants the Best Option? Neonatology 2020; 117:517-521. [PMID: 32674103 DOI: 10.1159/000508554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Late preterm and term newborns with respiratory distress are increasingly treated with non-invasive ventilation (NIV) including nasal high-flow or continuous positive airway pressure. For infants with mild distress, NIV may be unnecessary. OBJECTIVES We speculated that treatment with supplemental oxygen (SO) prior to NIV could help clinicians select infants for NIV treatment, and examined this hypothesis using data from a recently completed trial. METHOD Post hoc analysis of data from a subset of infants enrolled in the HUNTER trial. Infants born at ≥36 weeks' gestation were categorized by whether they were receiving SO prior to randomization. The 2 groups were compared for illness severity (indicated by treatment failure at 72 h, mechanical ventilation, need for up-transfer, SO requirement post-randomization, and length of time receiving respiratory support), use of selected medical interventions (antibiotics, intravenous fluids), and breastfeeding at discharge. RESULTS Analysis included 380 infants. Infants not receiving SO had less severe illness; lower rates of treatment failure (7.3 vs. 17.2%), mechanical ventilation (0.6 vs. 5.9%), need for transfer (6.8 vs. 13.8%), and more often did not receive any SO post-randomization (75.1 vs. 3.0%). Most infants in both groups received intravenous fluids (93 and 98%) and antibiotics (81 and 93%); the rate of full breastfeeding was low in both groups (51 and 45%). CONCLUSIONS Late preterm and term newborn infants without SO requirement at the time of commencing NIV for respiratory distress are at lower risk of requiring treatment escalation. Close observation of these infants (watch and wait strategy) may avoid unnecessary treatment.
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Affiliation(s)
- Adam Buckmaster
- Women, Children and Families, Central Coast Local Health District, Gosford, New South Wales, Australia, .,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia,
| | - Gaston Arnolda
- Australian Institute for Healthcare Innovation, Macquarie University, North Ryde, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Louise Owen
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Calum Roberts
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia.,Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Peter Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
| | - Brett Manley
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Victoria, Australia
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