Patient comfort during treatment with heated humidified high flow nasal cannulae versus nasal continuous positive airway pressure: a randomised cross-over trial

Feasibility of synchronized high flow nasal cannula

BACKGROUND

A high-flow nasal cannula (cHFNC) delivers flow continuously (during inspiration and expiration). Using the diaphragm electrical activity (Edi), synchronizing HFNC could be an alternative (cycling high/low flow on inspiration/expiration, respectively). The objective of this study was to demonstrate the feasibility of synchronized HFNC (sHFNC) and compare it to cHFNC.

METHODS

Different levels of cHFNC and sHFNC (4, 6, 8, and 10 liters per minute [LPM], with 2 LPM on expiration for sHFNC) were compared in eight rabbits (mean weight 3.16 kg), before and after acute lung injury (pre-ALI and post-ALI). Edi, tracheal pressure (Ptr), esophageal pressure (Pes), flow, and arterial CO2 were measured. In addition to the animal study, one 3.52 kg infant received sHFNC and cHFNC using a Servo-U ventilator.

RESULTS

In the animal study, there were more pronounced decreases in Edi, reduced Pes swings and reduced PaCO2 at comparable flows during sHFNC compared to cHFNC both pre and post-ALI (p < .05). Baseline (pre-inspiratory) Ptr was 2-7 cmH2O greater during cHFNC (p < .05) indicating more dynamic hyperinflation. In one infant, the ventilator performed as expected, delivering Edi-synchronized high/low flow.

CONCLUSION

Synchronizing high flow unloaded breathing, decreased Edi, and reduced PaCO2 in an animal model and is feasible in infants.

Non-Invasive Ventilatory Support in Preterm Neonates in the Delivery Room and the Neonatal Intensive Care Unit: A Short Narrative Review of What We Know in 2024

BACKGROUND

Guidelines recommend non-invasive ventilatory (NIV) support as first-line respiratory support mode in preterm infants as NIV is superior to intubation and mechanical ventilation in preventing death or bronchopulmonary dysplasia. However, with an ever-expanding variety of NIV modes available, there is much debate about which NIV modality should ideally be used, how, and when. The aims of this work were to summarise the evidence on different NIV modalities for both primary and secondary respiratory support: nCPAP, nasal high-flow therapy (nHFT), and nasal intermittent positive airway pressure ventilation (nIPPV), bi-level positive airway pressure (BiPAP), nasal high-frequency oscillatory ventilation (nHFOV), and nasally applied, non-invasive neurally adjusted ventilatory assist (NIV-NAVA) modes, with particular focus on their use in preterm infants.

SUMMARY

This is a narrative review with reference to published guidelines by European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. nCPAP is currently the most commonly used primary and secondary NIV modality for premature infants. However, there is increasing evidence on the superiority of nIPPV over nCPAP. No beneficial effect was found for BiPAP over nCPAP. For the use of nHFT, nHFOV, and NIV-NAVA, more studies are needed to establish their place in neonatal respiratory care.

KEY MESSAGES

The superiority of nIPPV over nCPAP needs to be confirmed by contemporaneous trials comparing nCPAP to nIPPV at comparable mean airway pressures. Future trials should study NIV modalities in preterm infants with comparable respiratory pathology and indications, at comparable pressure settings and with different modes of synchronisation. Importantly, future trials should not exclude infants of the smallest gestational ages.

Tools used to assess comfort among patients undergoing high flow nasal cannula: A scoping review

OBJECTIVE

The aims were twofold: (a) to map tools documented in the literature to evaluate comfort among patients undergoing high flow nasal cannula (HFNC) treatment; and (b) to assess if the retrieved tools have been validated for this purpose.

METHODS

A scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). In July 2023, PubMed, Scopus, CINAHL and Cochrane Library were consulted. Studies assessing comfort in adult, paediatric, and neonatal patients undergoing HFNC were included.

RESULTS

Seventy-four articles were included, among which nine (12.2 %) investigated comfort as the primary aim. Twenty-five different tools were found, classifiable into 14 types, mostly unidimensional and originating from those measuring pain. The most widely used was the Visual Analogic Scale (n = 27, 35.6 %) followed by the Numerical Rating Scale (n = 11, 14.5 %) and less defined generic tools (n = 10, 13.2 %) with different metrics (e.g. 0-5, 0-10, 0-100). Only the General Comfort Questionnaire and the Comfort Scale were specifically validated for the assessment of comfort among adults and children, respectively.

CONCLUSION

Although the comfort of patients undergoing HFNC is widely investigated in the literature, there is a scarcity of tools specifically validated in this field. Those used have been validated mainly to assess pain, suggesting the need to inform patients to prevent confusion while measuring comfort during HFNC and to develop more research in the field.

IMPLICATIONS FOR CLINICAL PRACTICE

Comfort assessment is an important aspect of nursing care. Given the lack of validation studies in the field, efforts in research are recommended.

Invasive and non-invasive ventilatory strategies for early and evolving bronchopulmonary dysplasia

In the age of surfactant and antenatal steroids, neonatal care has improved outcomes of preterm infants dramatically. Since the early 2000's neonatologists have strived to decrease bronchopulmonary dysplasia (BPD) by decreasing ventilator-associated lung injury and utilizing many novel modes of non-invasive respiratory support. After the initial success with nasal continuous positive airway pressure, it was established that discontinuing invasive ventilation early in favor of non-invasive respiratory support is the most effective way to reduce the incidence of BPD. In this review, we discuss the management of the preterm lung from the time of delivery, through the phases of respiratory distress syndrome (early BPD) and then evolving BPD. The goal remains to optimize respiratory support of the preterm lung while minimizing ventilator-associated lung injury and oxygen toxicity. A multidisciplinary approach involving the medical team and family is quintessential in reaching this goal and involves adequate respiratory support, optimizing nutrition and fluid balance as well as preventing infections.

Guidelines for high-flow nasal cannula oxygen therapy in neonates (2022)

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.

State of the art on neonatal noninvasive respiratory support: How physiological and technological principles explain the clinical outcomes

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.

Nasal high flow therapy for primary respiratory support in preterm infants

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.

Heated humidified high flow nasal cannula therapy in children with obstructive sleep apnea: A randomized cross-over trial

OBJECTIVE/BACKGROUND

Moderate-to-severe obstructive sleep apnea (OSA) is highly prevalent in children with obesity and/or underlying medical complexity. The first line of therapy, adenotonsillectomy (AT), does not cure OSA in more than 50% of these children. Consequently, continuous positive airway pressure (CPAP) is the main therapeutic option but adherence is often poor. A potential alternative which may be associated with greater adherence is heated high-flow nasal cannula (HFNC) therapy; however, its efficacy in children with OSA has not been systematically investigated. The study aimed to compare the efficacy of HFNC with CPAP to treat moderate-to-severe OSA with the primary outcome measuring the change from baseline in the mean obstructive apnea/hypopnea index (OAHI).

PARTICIPANTS/METHODS

This was a single-blinded randomized, two period crossover trial conducted from March 2019 to December 2021 at a Canadian pediatric quaternary care hospital. Children aged 2-18 years with obesity and medical complexity diagnosed with moderate-to-severe OSA via overnight polysomnography and recommended CPAP therapy were included in the study. Following diagnostic polysomnography, each participant completed two further sleep studies; a HFNC titration study and a CPAP titration study (9 received HFNC first, and 9 received CPAP first) in a random 1:1 allocation order.

RESULTS

Eighteen participants with a mean ± SD age of 11.9 ± 3.8 years and OAHI 23.1 ± 21.7 events/hour completed the study. The mean [95% CI] reductions in OAHI (-19.8[-29.2, -10.5] vs. -18.8 [-28.2, -9.4] events/hour, p = 0.9), nadir oxygen saturation (7.1[2.2, 11.9] vs. 8.4[3.5, 13.2], p = 0.8), oxygen desaturation index (-11.6[-21.0, -2.3] vs. -16.0[-25.3, -6.6], p = 0.5) and sleep efficiency (3.5[-4.8, 11.8] vs. 9.2[0.9, 15.5], p = 0.2) with HFNC and CPAP therapy were comparable between conditions.

CONCLUSION

HFNC and CPAP therapy yield similar reductions in polysomnography quantified measures of OSA severity among children with obesity and medical complexities.

TRIAL REGISTRATION

NCT05354401 ClinicalTrials.gov.

Non-invasive ventilatory support in neonates: An evidence-based update

Non-invasive ventilatory support (NIV) is considered the gold standard in the care of preterm infants with respiratory distress syndrome (RDS). NIV from birth is superior to mechanical ventilation (MV) for the prevention of death or bronchopulmonary dysplasia (BPD), with a number needed to treat between 25 and 35. Various methods of NIV are available, some of them extensively researched and with well proven efficacy, whilst others are needing further research. Nasal continuous positive airway pressure (nCPAP) has replaced routine invasive mechanical ventilation (MV) for the initial stabilization and the treatment of RDS. Choosing the most suitable form of NIV and the most appropriate patient interface depends on several factors, including gestational age, underlying lung pathophysiology and the local facilities. In this review, we present the currently available evidence on NIV as primary ventilatory support to preventing intubation and for secondary ventilatory support, following extubation. We review nCPAP, nasal high-flow cannula, nasal intermittent positive airway pressure ventilation, bi-level positive airway pressure, nasal high-frequency oscillatory ventilation and nasal neurally adjusted ventilatory assist modes. We also discuss most suitable NIV devices and patient interfaces during resuscitation of the newborn in the delivery room.

Efficacy and Safety of Two Different Flow Rates of Nasal High-Flow Therapy in Preterm Neonates ≥28 Weeks of Gestation: A Randomized Controlled Trial

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..

Characteristics and outcome of infants with bronchopulmonary dysplasia established on long-term ventilation from neonatal intensive care

INTRODUCTION

Ex-preterm infants with severe bronchopulmonary dysplasia (BPD) sometimes require long-term ventilation (LTV) to facilitate weaning from respiratory support. There are however limited data characterizing this cohort. We aim to describe the background characteristics, neonatal comorbidities, characteristics at the initiation of ventilation, and outcomes of neonatal unit graduates with BPD established on LTV.

METHODS

A retrospective cohort study of infants born <32 weeks gestation with BPD referred to a regional LTV service between January 2015 and December 2020.

RESULTS

Twenty-five infants were referred during the study period. Median birth gestation was 26 + 1 weeks (24 + 0-30 + 4) and birth weight 645 g (430-1485). At 36 weeks postmenstrual age (PMA), median FiO₂ was 0.45 (0.24-0.80) and one-quarter of infants remained on invasive ventilation. Twenty (80%) infants were established on noninvasive ventilation (NIV), with the smallest weighing 2085 g, and five (20%) required tracheostomy invasive ventilation (TIV). At initiation of NIV/TIV, median PMA was 41 + 1 weeks and median FiO₂ 0.40 (0.29-0.80). Infants established on TIV spent almost five times longer in hospital before discharge compared to those on NIV (p = 0.003). By March 2022, 18 (72%) infants had discontinued ventilation, spending a median total time of 113 days (18-1792) on ventilation.

CONCLUSION

Due to advances in interfaces, headgear, and ventilator technology, NIV is an attractive and practically achievable option for infants with severe BPD as small as 2 kg. Initiation and weaning should take place in a facility with the required multidisciplinary expertize.

A randomised trial comparing weaning from CPAP alone with weaning using heated humidified high flow nasal cannula in very preterm infants: the CHiPS study

OBJECTIVE

To determine whether weaning from nasal continuous positive airway pressure (nCPAP) using heated humidified high flow nasal cannula (nHF) was non-inferior to weaning using nCPAP alone in relation to time on respiratory support.

STUDY DESIGN

Single-centre, non-inferiority, randomised controlled trial.

SETTING

Neonatal Intensive Care Unit, Middlemore Hospital, Auckland, New Zealand.

PATIENTS

120 preterm infants, <30 weeks' gestation at birth, stable on nCPAP for at least 48 hours.

INTERVENTIONS

Infants underwent stratified randomisation to nHF 6 L/min or bubble CPAP 6 cm water. In both groups, stepwise weaning of their respiratory support over 96 hours according to a strict weaning protocol was carried out.

MAIN OUTCOME MEASURES

Time on respiratory support from randomisation to 72 hours off respiratory support or 36 weeks' postmenstrual age. The non-inferiority threshold was set at 15%.

RESULTS

59 infants were randomised to weaning using nHF and 61 using nCPAP. The groups were well balanced in regards to baseline demographics. The restricted mean duration of respiratory support following randomisation for the nCPAP group, using per-protocol analysis was 401 hours (upper boundary, mean plus 0.15, was 461 hours) and 375 hours in the nHF group (upper 95% CI 413 hours). nHF weaning was, therefore, non-inferior to nCPAP weaning at the non-inferiority threshold. There was no significant difference in time to discharge.

CONCLUSION

For infants ready to wean from nCPAP, the CHiPS study found that nHF was non-inferior to discontinuing nCPAP at 5 cm water.

TRIAL REGISTRATION NUMBER

Australia and New Zealand Clinical Trials Registry (ACTRN12615000077561).

Use of high flow nasal cannula in Spanish neonatal units

INTRODUCTION

The use of high-flow cannula therapy (HFNC) in neonatal units has increased in recent years, but there are no consensus guidelines on its indications and application strategies. Our aim was to know the rate of use of HFNC, their indications and the management variability among Spanish neonatal units.

MATERIAL AND METHODS

Twenty-five-question survey for medical and nursing staff. Level II and III units were contacted by phone and sent in Google forms between September 2016 and December 2018.

RESULTS

Ninety-seven responses (63.9% medical, 36.1% nursing), from 69 neonatal units representing 15 autonomous communities (87% level of care III; 13% level II). All units except one have HFNC with a humidified and heated system. Their most frequent indications are: non-invasive ventilation weaning (79.4%), bronchiolitis (69.1%), respiratory distress of the term newborn (58.8%), after extubation (50.5%). Minimum flow (1-5 L/min) and maximum flow (5-15 L/min) are variable between units. 22.7% have experienced some adverse effect from its use (9 air leak, 12 nasal trauma). Less than half have an employment protocol, but all the answers agree on the usefulness of national recommendations.

CONCLUSIONS

HFNC therapy is widely used in Spanish units, but there is great variability in its indications and strategies of use. National recommendations would be applicable in most units and would allow unifying its use.

Implementation of neurally adjusted ventilatory assist and high flow nasal cannula in very preterm infants in a tertiary level NICU

Preterm infants treated with invasive ventilation are often affected by bronchopulmonary dysplasia, brain structure alterations, and later neurodevelopmental impairment. We studied the implementation of neurally adjusted ventilatory assist (NAVA) and high flow nasal cannula (HFNC) in a level III neonatal unit, and its effects on pulmonary and central nervous system outcomes. This retrospective cohort study included 193 surviving infants born below 32 weeks of gestation in preimplementation (2007-2008) and postimplementation (2016-2017) periods in a single study center in Finland. The proportion of infants requiring invasive ventilation decreased from 67% in the pre- to 48% in the postimplementation period (p = 0.009). Among infants treated with invasive ventilation, 68% were treated with NAVA after its implementation. At the same time, the duration of invasive ventilation of infants born at or below 28 weeks increased threefold compared with the preimplementation period (p = 0.042). The postimplementation period was characterized by a gradual replacement of nasal continuous positive airway pressure (nCPAP) with HFNC, earlier discontinuation of nCPAP, but a longer duration of positive pressure support. The proportion of normal magnetic resonance imaging (MRI) findings at term corrected age increased from 62% to 84% (p = 0.018). Cognitive outcome improved by one standard score between the study periods (p = 0.019). NAVA was used as the primary mode of ventilation in the postimplementation period. During this period, invasive ventilation time was significantly prolonged. HFNC led to a decrease in the use of nCPAP. The change in the respiratory support might have contributed to the improvement in brain MRI findings and cognitive outcomes.

Impact of early respiratory care for extremely preterm infants

Despite advances in neonatal intensive care, more than half of surviving infants born extremely preterm (EP; < 28 weeks' gestation) develop bronchopulmonary dysplasia (BPD). Prevention of BPD is critical because of its associated mortality and morbidity, including adverse neurodevelopmental outcomes and respiratory health in later childhood and beyond. The respiratory care of EP infants begins before birth, then continues in the delivery room and throughout the primary hospitalization. This chapter will review the evidence for interventions after birth that might improve outcomes for infants born EP, including the timing of umbilical cord clamping, strategies to avoid or minimize exposure to mechanical ventilation, modes of mechanical ventilation and non-invasive respiratory support, oxygen saturation targets, postnatal corticosteroids and other adjunct therapies.

Cost-Effectiveness of Nasal High Flow Versus CPAP for Newborn Infants in Special-Care Nurseries

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.

Nasal High-Flow for Weaning Preterm Newborns with Risk of Chronic Lung Disease from nCPAP

OBJECTIVE

 The aim of the study is to compare the duration of oxygen therapy by using two methods of weaning from nasal continuous positive airway pressure (nCPAP) in very preterm babies.

STUDY DESIGN

 Between April 2014 and December 2016, 90 preterm <32 weeks and birthweight >1,000 g who, after at least 7 days on nCPAP, were clinically stable on <6 cm H₂O and FiO₂ <30% were randomly assigned to weaning directly from nCPAP or with nasal high flow therapy (nHFT). In the nCPAP group, pressure was gradually reduced until the infant was stable on 4 cm H₂O and then discontinued. In the nHFT group, flow rate was reduced until the infant was stable at 3.l pm and then discontinued.

RESULTS

 Eighty-four infants completed the study. There were no differences between the groups for the primary outcome, duration of oxygen therapy (median 33 [14-48] versus 28 [15-37] days; p = 0.17). The incidence of moderate-to-severe bronchopulmonary dysplasia was similar. Weaning time was shorter in the nCPAP group (p = 0.02), but the failure rate was slightly higher although non-significant. In the nHFT group, we observed better perception of patient comfort and a lower incidence of severe nasal injury.

CONCLUSION

 Weaning by nHFT compared with weaning directly off nCPAP does not prolong duration of oxygen therapy. Rather, it is associated with better perceptions of infant comfort among parents and lower rates of severe nasal injury.

KEY POINTS

· Nasal high-flow therapy is commonly used in most neonatal intensive care unit for nCPAP weaning.. · Weaning by nHFT does not increase the duration of oxygen therapy.. · nHFT use improves the perception of infant comfort among parents..

Cerebral oxygenation is stable in preterm infants transitioning to heated humidified high-flow nasal cannula therapy

AIM

To assess cerebral oxygenation in premature infants who are transitioning from nasal continuous positive airway pressure (nCPAP) to heated humidified high-flow nasal cannula therapy (HFNC).

METHODS

A prospective observational study done in a single-centre neonatal intensive care unit (NICU). Regional cerebral oxygen saturations (RcSO₂ ) were measured using frequency-domain near-infrared spectroscopy (FD-NIRS) in very low birthweight (VLBW) premature infants born at <32 weeks transitioning from nCPAP to HFNC.

RESULTS

Median gestational age was 27 weeks and median birthweight was 924 g. Recordings were performed at a median gestational age of 30 weeks and a median postnatal age of 10 days. Median weight at study entry was 1111 g. Cerebral oxygenation was not significantly different in infants transitioning from nCPAP to HFNC (66% vs 66%).

CONCLUSION

No difference in cerebral oxygenation in premature infants transitioning from nCPAP to HFNC was observed. This finding is reassuring and further supports the use of HFNC in preterm infants.

[Use of high flow nasal cannula in Spanish neonatal units]

INTRODUCTION

The use of high-flow cannula therapy (HFNC) in neonatal units has increased in recent years, but there are no consensus guidelines on its indications and application strategies. Our aim was to know the rate of use of HFNC, their indications and the management variability among Spanish neonatal units.

MATERIAL AND METHODS

Twenty-five-question survey for medical and nursing staff. Level II and III units were contacted by phone and sent in Google forms between September 2016 and December 2018.

RESULTS

Ninety-seven responses (63.9% medical, 36.1% nursing), from 69 neonatal units representing 15 autonomous communities (87% level of care III; 13% level II). All units except one have HFNC with a humidified and heated system. Their most frequent indications are: non-invasive ventilation weaning (79.4%), bronchiolitis (69.1%), respiratory distress of the term newborn (58.8%), after extubation (50.5%). Minimum flow (1-5 L/min) and maximum flow (5-15 L/min) are variable between units. 22.7% have experienced some adverse effect from its use (9 air leak, 12 nasal trauma). Less than half have an employment protocol, but all the answers agree on the usefulness of national recommendations.

CONCLUSIONS

HFNC therapy is widely used in Spanish units, but there is great variability in its indications and strategies of use. National recommendations would be applicable in most units and would allow unifying its use.

Gas flow in preterm infants treated with bubble CPAP: an observational study

OBJECTIVE

To measure the nasal gas flow in infants treated with bubble continuous positive airway pressure (CPAP) and compare it with commonly used flows during nasal high flow (nHF) treatment.

DESIGN

This is a prospective, single-centre study. Bubble CPAP pressure was measured at the nasal prongs. Set gas flow was reduced until bubbling in the water chamber just ceased. Set gas flow without bubbling then approximated flow entering the infant's nose ('delivered flow').

SETTING

Neonatal intensive care at The Royal Women's Hospital, Melbourne, Australia.

PATIENTS

Clinically stable preterm infants receiving bubble CPAP therapy.

MAIN OUTCOME MEASURE

Delivered flow (L/min) when bubbling stopped at a range of clinically set CPAP pressures (cm H₂O).

RESULTS

Forty-four infants were studied, with a mean (SD) gestational age at birth of 28.4 (2.2) weeks and birth weight of 1154 (419) g. At the time of the study, infants had a median (IQR) age of 4.5 (2-12) days and a mean (SD) weight of 1205 (407) g. Delivered flow ranged from 0.5 to 9.0 L/min, and increased with higher set CPAP pressures (median 3.5 L/min at CPAP 5 cm H₂O vs 6.3 L/min at CPAP 8 cm H₂O) and heavier weights (median 3.5 L/min in infants <1000 g vs 6.5 L/min for infants >1500 g).

CONCLUSIONS

Nasal gas flows during bubble CPAP in preterm infants are similar to flows used during nHF and increase with higher set bubble CPAP pressures and in larger infants. Trial registration number ACTRN12619000197134.

Discontinuing Nasal Continuous Positive Airway Pressure in Infants ≤32 Weeks of Gestational Age: A Randomized Control Trial

OBJECTIVES

To compare immediate cessation of nasal continuous positive airway pressure (NCPAP) vs a stepwise decrease in pressure on the duration of NCPAP therapy in infants born prematurely.

STUDY DESIGN

A single center study in infants 23⁰-32⁶ weeks of gestational age. NCPAP was stopped either at 5 cm H₂O (control) or 3 cm H₂O after a stepwise pressure wean (wean) using defined stability and failure criteria. Primary outcome is total NCPAP days.

RESULTS

We enrolled 226 infants; 116 were randomly assigned to control and 110 to the wean group. There was no difference in the total NCPAP days between groups (median [25th, 75th percentiles] 16 [5, 36] vs 14 [7, 33] respectively). There were no differences between groups in secondary outcomes, including duration of hospital stay, critical care days, and oxygen supplementation. A higher proportion of control infants failed the initial attempt to discontinue NCPAP (43% vs 27%, respectively; P < .01) and required ≥2 attempts (20% vs 5%, respectively; P < .01). In addition, infants 23-27 weeks of gestational age in the wean group were 2.4-times more likely to successfully stop NCPAP at the first attempt (P = .02) vs controls.

CONCLUSIONS

Discontinuation of NCPAP after a gradual pressure wean to 3 cm H₂O did not decrease the duration of NCPAP therapy compared with stopping from 5 cm H₂O in infants ≤32 weeks of gestational age. However, weaning decreased failed initial attempts to stop NCPAP, particularly among infants <28 weeks of gestational age.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02064712.

Flow-synchronized NIPPV with double-inspiratory loop cannula: An in vitro study

BACKGROUND

Although short binasal prongs (SBP) are the most common interface for noninvasive ventilation, the "double-inspiratory loop cannulas" (DILC) have recently been introduced into many neonatal intensive care units. DILC show advantages over SBP, including reduced nasal trauma and increased comfort. However, their higher intrinsic resistance may compromise ventilation. Our aim was to test a new, low resistance DILC interface.

METHODS

A test lung was programmed to simulate preterm neonates (500-2000 g BW) with moderate-to-severe respiratory distress syndrome. The artificial nose was designed to keep prongs-to-nares leaks to around 30%. Giulia® ventilator (GINEVRI srl) was used to provide nasal continuous positive airway pressure (NCPAP) and flow synchronized nasal intermittent positive pressure ventilation (NIPPV). NCPAP was set at 4-10 cmH₂ O and synchronized-NIPPV (SNIPPV) at peak inspiratory pressure, 15-20-25 cmH₂ O; inspiratory time, 0.3-0.5 s; and positive end-expiratory pressure, 5-8 cmH₂ O. Four sizes of Sync-flow Cannula® (GINEVRI srl) were tested. The Sync-flow Cannula® was compared with Neotech RAM® cannula and Ginevri SBP®. The outcome measures were the flow/pressure relationship through the four Sync-flow Cannula® sizes, the difference in resistance, the drop in ventilator-alveoli pressure measured by the test lung and the system response time during flow-SNIPPV.

RESULTS

The smaller DILC sizes had the lowest flow-pressure ratio. The resistance of the RAM® cannula was significantly higher compared to the other interfaces (p < .001). With 30% leaks, there was a 4-38% ventilator-alveoli drop in pressure, depending on interface size. The system response time was excellent (~65-70 ms).

CONCLUSIONS

With about 30% leaks, the Sync-flow Cannula® interfaces result in good pressure transmission and give optimal performance for flow-SNIPPV. Clinical studies are needed to confirm the clinical relevance of these data.

Heated Humidified High-Flow Nasal Cannula vs. Nasal Continuous Positive Airway Pressure for Post-extubation Respiratory Support in Preterm Infants: A Randomized Controlled Trial

OBJECTIVE

The objective of this study was to compare the efficacy and safety of heated humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (nCPAP) for prevention of extubation failure in preterm infants.

METHODS

Preterm infants (gestation ≥28 weeks) were randomized to HHHFNC or nCPAP after extubation. Primary outcome was extubation failure within 72 h of extubation.

RESULTS

A total of 128 preterm infants were randomized to receive either HHHFNC (n = 63) or nCPAP (n = 65) after extubation. The primary outcome of extubation failure within 72 h after extubation was not different between the two groups (HHHFNC, 22.2% vs. nCPAP, 18.5%, risk difference of 3.7% and 95% CI -10.3 to 17.6, p = 0.604). The incidence of nasal trauma was significantly lower in the HHHFNC group than in the nCPAP group 6.3% vs. 21.5%, p = 0.020.

CONCLUSIONS

In our study, HHHFNC was as effective as nCPAP for prevention of extubation failure in preterm infants. Also, HHHFNC was associated with significantly less nasal trauma compared with nCPAP.

Predicting Nasal High-Flow Treatment Success in Newborn Infants with Respiratory Distress Cared for in Nontertiary Hospitals

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.

Risk factors for treatment failure of heated humidified high-flow nasal cannula as an initial respiratory support in newborn infants with respiratory distress

BACKGROUND

Humidified high-flow nasal cannula (HHFNC) has gained popularity because it is easier to use, more comfortable for babies, and advantageous for mother-infant bonding. HHFNC is not inferior to other non-invasive ventilators for preventing adverse outcomes, but more studies are needed to ensure the safe use of HHFNC as an initial respiratory support for newborns. The aim of this study was to investigate risk factors for treatment failure of HHFNC as an initial respiratory support in newborns with respiratory distress after birth.

METHODS

We included 97 newborns who required non-invasive respiratory support within 24 h after birth. The success group included 68 infants who were successfully managed only on HHFNC, and 29 infants were the failure group who required other respiratory support because of respiratory acidosis, hypoxia, or apnea.

RESULTS

Compared with the success group, the failure group had lower GA, a higher rate of antenatal steroid use, prolonged rupture of membrane, lower pH, higher pCO₂ on blood-gas analysis after HHFNC application and higher incidence of respiratory distress syndrome of newborn (RDS). After adjusting for GA, higher FiO₂ settings during acidosis, hypercarbia after the application of HHFNC shown on blood-gas analysis and the presence of RDS remained significant. The rate of treatment failure was 16.2% for ≥36 weeks, 19.3% for ≥34 weeks, and 22.1% for ≥33 weeks.

CONCLUSION

Treatment failure of HHFNC should be considered a risk for newborns of less than 34 weeks and infants with respiratory distress from RDS. Higher FiO₂ settings during HHFNC, and acidosis and hypercarbia after the application of HHFNC shown on blood-gas analysis may help identify high-risk newborns for other non-invasive ventilators or intubation.

Predicting Lung Health Trajectories for Survivors of Preterm Birth

Rates of preterm birth (<37 weeks of gestation) are increasing worldwide. Improved perinatal care has markedly increased survival of very (<32 weeks gestation) and extremely (<28 weeks gestation) preterm infants, however, long term respiratory sequalae are common among survivors. Importantly, individual's lung function trajectories are determined early in life and tend to track over the life course. Preterm infants are impacted by antenatal, postnatal and early life perturbations to normal lung growth and development, potentially resulting in significant shifts from the "normal" lung function trajectory. This review summarizes what is currently known about the long-term lung function trajectories in survivors of preterm birth. Further, this review highlights how antenatal, perinatal and early life factors are likely to contribute to individual lung health trajectories across the life course.

Predictors and Outcomes of Early Intubation in Infants Born at 28-36 Weeks of Gestation Receiving Noninvasive Respiratory Support

OBJECTIVE

To identify predictors and outcomes of early intubation in preterm infants with respiratory distress, and predictors of need for brief respiratory support (≤1 day).

STUDY DESIGN

Secondary analysis of data from a randomized trial comparing nasal high-flow with continuous positive airway pressure as primary respiratory support in preterm infants born at 28-36 weeks of gestation. Intubation was assessed within 72 hours of randomization.

RESULTS

There were 564 included infants with a mean (SD) gestational age of 32.0 (2.2) weeks and birth weight 1744 (589) g; 76 infants (13.5%) received early intubation. On multivariable analysis, lower gestational age and higher pre-randomization fraction of inspired oxygen (FiO₂) predicted intubation. A test based on gestational age of <30 weeks and an FiO₂ of ≥0.30 produced a likelihood ratio of 9.1. Intubation was associated with prolonged duration of respiratory support and supplemental oxygen, with pneumothorax and nasal trauma, and in infants born at <32 weeks of gestational, with bronchopulmonary dysplasia and patent ductus arteriosus requiring treatment. Greater gestational age and lower FiO₂ predicted the need for ≤1 day of respiratory support. A test based on a gestational age of ≥34 weeks and an FiO₂ of 0.21 produced a likelihood ratio of 4.7.

CONCLUSIONS

In preterm infants 28-36 week of gestation receiving primary noninvasive respiratory support, lower gestational age, and higher FiO₂ predicted need for intubation within 72 hours. Intubation was associated with adverse respiratory outcomes. Greater gestational age and lower FiO₂ predicted need for ≤1 day of respiratory support. It may be reasonable to defer the use of respiratory support in more mature infants with low FiO₂ requirements. TRIAL REGISTRATION AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY: ACTRN12613000303741.

Weaning Humidified High Flow Oxygen Therapy among Paediatric Patients: An Integrative Review of Literature

PROBLEM

The paucity of up-to-date recommendations and evidence-based models, whether it is physician-initiated or initiated by other healthcare professionals, for humidified high flow oxygen therapy among children.

ELIGIBILITY CRITERIA

The inclusion criteria included the following: 1) use of high flow oxygen therapy (≥15 L/min); 2) published studies from the year 2000 and onwards; 3) research article in a peer-reviewed journal; 4) studies conducted in a hospital setting involving paediatric patients <18 years old; 5) availability of full article online.

SAMPLE

From March to April 2018, electronic databases such as PubMed, Cumulative Index of Nursing and Allied Health Literature, Excerpta Medica Database, Cochrane Library, Joanna Briggs Institute Library of Systematic Reviews, SCOPUS, Ovid, Informit, and Google Scholar were accessed. The systematic search initially yielded 41 studies.

RESULTS

Eventually, three eligible studies were reviewed and appraised. Overarching themes were identified: 1) the lack of weaning standards; 2) the limited focus on young population in intensive care settings; and 3) the paucity of weaning models.

CONCLUSION

The lack of studies suggested that this is a fertile area for research. In this light, this paper challenged researchers, clinicians, and experts to develop evidence-based standards and models of weaning towards efficient and better quality of care.

IMPLICATION

This review may lead to the development of nurse-led or nurse-initiated weaning protocols to enable timely weaning intervention for children and thus reduce the need for prolonged oxygen use. Furthermore, this may also instigate an economic evaluation of a nurse-lead weaning against current models of medically lead weaning.

Is Nasal High Flow Inferior to Continuous Positive Airway Pressure for Neonates?

Nasal high-flow therapy (nHF) is increasingly used for neonates, with perceived benefits including reduced rates of nasal trauma and parent and nursing staff preference. Current evidence suggests that although nHF is a reasonable alternative for postextubation support of preterm infants, continuous positive airway pressure is a superior modality for primary support of respiratory distress syndrome. Minimal evidence exists for use of nHF in extremely preterm infants less than 28 weeks' gestation. Depending on clinician preference, units may still choose nHF in some settings, although careful choice of appropriate patients, and availability of rescue continuous positive airway pressure, is essential.

Nasal Intermittent Mandatory Ventilation Versus Nasal Continuous Positive Airway Pressure Before and After Invasive Ventilatory Support

Continuous positive airway pressure (CPAP), noninvasive intermittent positive pressure ventilation (NIPPV), and heated humidified high-flow nasal cannula (HHFNC) are modes of noninvasive respiratory support used in neonatal practice. These modes of noninvasive respiratory support may obviate mechanical ventilation, prevent extubation failure, and reduce the risk of developing bronchopulmonary dysplasia. Although the physiologic bases of CPAP and HHFNC are well delineated, and their modes and practical application consistent, those of NIPPV are unproven and varied. Available evidence suggests that NIPPV is superior to CPAP as a primary and postextubation respiratory support in preterm infants.

Managing neonatal pain in the era of non-invasive respiratory support

Non-invasive ventilation is currently the preferred respiratory support for premature infants with respiratory distress. The lung-protective effects of non-invasive ventilation should however not prompt disregard for the possible pain and discomfort it can generate. Non-pharmacological interventions should be used in all premature infants, regardless of their respiratory support, and are not detailed in this review. This review includes currently available evidence and gaps in knowledge regarding three aspects of pain management in premature infants receiving non-invasive ventilation: optimisation of non-invasive ventilation especially through the choice of positive pressure source, appropriate interface and synchronisation; sedative or analgesic drug use for strategies aiming at administering surfactant with reduction or avoidance of tracheal ventilation; risks and benefits of some analgesic and/or sedative drugs used to treat or prevent prolonged pain and discomfort during non-invasive ventilation. In spite of limited robust evidence, this overview should trigger caregivers' reflections on their daily practice.

Heated Humidified High-Flow Nasal Cannula for Preterm Infants: An Updated Systematic Review and Meta-analysis

Background

Heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity as a mode of respiratory support. We updated a systematic review and meta-analyses examining the efficacy and safety of HHHFNC compared with standard treatments for preterm infants. The primary outcome was the need for reintubation for preterm infants following mechanical ventilation (post-extubation analysis) or need for intubation for preterm infants not previously intubated (analysis of primary respiratory support)

Methods

We searched PubMed, MEDLINE, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of HHHFNC versus standard treatments. Meta-analysis was conducted using Review Manager 5.3.

Results

The post-extubation analysis included ten RCTs (n = 1,201), and the analysis of primary respiratory support included ten RCTs (n = 1,676). There were no statistically significant differences for outcomes measuring efficacy, including the primary outcome. There were statistically significant differences favoring HHHFNC versus nasal cannula positive airway pressure (NCPAP) for air leak (post-extubation, risk ratio [RR] 0.29, 95 percent confidence interval [CI] 0.11 to 0.76, I2 = 0) and nasal trauma (post-extubation: 0.35, 95 percent CI 0.27 to 0.46, I2 = 5 percent; primary respiratory support: RR 0.52, 95 percent CI 0.37 to 0.74; I2 = 27 percent). Studies, particularly those of primary respiratory support, included very few preterm infants with gestational age (GA) <28 weeks.

Conclusions

HHHFNC may offer an efficacious and safe alternative to NCPAP for some infants but evidence is lacking for preterm infants with GA ≤28 weeks.

Approaches to Noninvasive Respiratory Support in Preterm Infants: From CPAP to NAVA

Endotracheal intubation and invasive mechanical ventilation have been mainstays in respiratory care of neonates with respiratory distress syndrome. Together with antenatal steroids and surfactant, this approach has accounted for significant reductions in neonatal mortality. However, with the increased survival of very low birthweight infants, the incidence of bronchopulmonary dysplasia (BPD), the primary respiratory morbidity of prematurity, has also increased. Arrest of alveolar growth and development and the abnormal development of the pulmonary vasculature after birth are the primary causes of BPD. However, invasive ventilation-associated lung inflammation and airway injury have long been believed to be important contributors. In fact, discontinuing invasive ventilation in favor of noninvasive respiratory support has been considered the single best approach that neonatologists can implement to reduce BPD. In this review, we present and discuss the mechanisms, efficacy, and long-term outcomes of the four main approaches to noninvasive respiratory support of the preterm infant currently in use: nasal continuous positive airway pressure, high-flow nasal cannula, nasal intermittent mandatory ventilation, and neurally adjusted ventilatory assist. We show that noninvasive ventilation can decrease rates of intubation and the need for invasive ventilation in preterm infants with respiratory distress syndrome. However, none of these noninvasive approaches decrease rates of BPD. Accordingly, noninvasive respiratory support should be considered for clinical goals other than the reduction of BPD.

Nasal High-Flow Therapy for Newborn Infants in Special Care Nurseries

BACKGROUND

Nasal high-flow therapy is an alternative to nasal continuous positive airway pressure (CPAP) as a means of respiratory support for newborn infants. The efficacy of high-flow therapy in nontertiary special care nurseries is unknown.

METHODS

We performed a multicenter, randomized, noninferiority trial involving newborn infants (<24 hours of age; gestational age, ≥31 weeks) in special care nurseries in Australia. Newborn infants with respiratory distress and a birth weight of at least 1200 g were assigned to treatment with either high-flow therapy or CPAP. The primary outcome was treatment failure within 72 hours after randomization. Infants in whom high-flow therapy failed could receive CPAP. Noninferiority was determined by calculating the absolute difference in the risk of the primary outcome, with a noninferiority margin of 10 percentage points.

RESULTS

A total of 754 infants (mean gestational age, 36.9 weeks, and mean birth weight, 2909 g) were included in the primary intention-to-treat analysis. Treatment failure occurred in 78 of 381 infants (20.5%) in the high-flow group and in 38 of 373 infants (10.2%) in the CPAP group (risk difference, 10.3 percentage points; 95% confidence interval [CI], 5.2 to 15.4). In a secondary per-protocol analysis, treatment failure occurred in 49 of 339 infants (14.5%) in the high-flow group and in 27 of 338 infants (8.0%) in the CPAP group (risk difference, 6.5 percentage points; 95% CI, 1.7 to 11.2). The incidences of mechanical ventilation, transfer to a tertiary neonatal intensive care unit, and adverse events did not differ significantly between the groups.

CONCLUSIONS

Nasal high-flow therapy was not shown to be noninferior to CPAP and resulted in a significantly higher incidence of treatment failure than CPAP when used in nontertiary special care nurseries as early respiratory support for newborn infants with respiratory distress. (Funded by the Australian National Health and Medical Research Council and Monash University; HUNTER Australian and New Zealand Clinical Trials Registry number, ACTRN12614001203640.).

National surveys of UK and Italian neonatal units highlighted significant differences in the use of non-invasive respiratory support

AIM

This study compared how non-invasive respiratory support (NRS) was provided in neonatal units in Italy and the UK.

METHODS

An NRS questionnaire was sent to tertiary neonatal centres, identified by national societies, from November 2015 to May 2016.

RESULTS

Responses were received from 49/57 (86%) UK units and 103/115 (90%) Italian units. NRS was started in the delivery room by 61% of UK units and 85% of Italian units. In neonatal intensive care units, 33% of UK units used nasal high-flow therapy (HFT) as primary support, compared to 3% in Italy. Nasal continuous positive airway pressure (CPAP) was used in 57% of UK units and 90% of Italian units. The commonest starting flow rate on nasal HFT for term and preterm infants was 6 L/min in the UK, while Italian units mainly used this flow for term infants. In the UK, 67% of units decreased nasal HFT by 1 L/min per day. In Italy, infants on nasal CPAP were weaned by 1 cm H₂ O per day in 39% of units.

CONCLUSION

The way that NRS was managed for very preterm infants differed between the UK and Italy, reflecting a lack of evidence on optimal NRS and the use of local protocols.

Enteral Nutrition Tolerance And REspiratory Support (ENTARES) Study in preterm infants: study protocol for a randomized controlled trial

Background

Respiratory distress syndrome (RDS) and feeding intolerance are common conditions in preterm infants and among the major causes of neonatal mortality and morbidity.

For many years, preterm infants with RDS have been treated with mechanical ventilation, increasing risks of acute lung injury and bronchopulmonary dysplasia.

In recent years non-invasive ventilation techniques have been developed. Showing similar efficacy and risk of bronchopulmonary dysplasia, nasal continuous positive airway pressure (NCPAP) and heated humidified high-flow nasal cannula (HHHFNC) have become the most widespread techniques in neonatal intensive care units. However, their impact on nutrition, particularly on feeding tolerance and risk of complications, is still unknown in preterm infants.

The aim of the study is to evaluate the impact of NCPAP vs HHHFNC on enteral feeding and to identify the most suitable technique for preterm infants with RDS.

Methods

A multicenter randomized single-blind controlled trial was designed. All preterm infants with a gestational age of 25–29 weeks treated with NCPAP or HHHFNC for RDS and demonstrating stability for at least 48 h along with the compliance with inclusion criteria (age less than 7 days, need for non-invasive respiratory support, suitability to start enteral feeding) will be enrolled in the study and randomized to the NCPAP or HHHFNC arm. All patients will be monitored until discharge, and data will be analyzed according to an intention-to-treat model.

The primary outcome is the time to reach full enteral feeding, while parameters of respiratory support, feeding tolerance, and overall health status will be evaluated as secondary outcomes. The sample size was calculated at 141 patients per arm.

Discussion

The identification of the most suitable technique (NCPAP vs HHHFNC) for preterm infants with feeding intolerance could reduce gastrointestinal complications, improve growth, and reduce hospital length of stay, thus improving clinical outcomes and reducing health costs. The evaluation of the timing of oral feeding could be useful in understanding the influence that these techniques could have on the development of sucking-swallow coordination. Moreover, the evaluation of the response to NCPAP and HHHFNC could clarify their efficacy as a treatment for RDS in extremely preterm infants.

Trial registration

ClinicalTrials.gov, NCT03548324. Registered on 7 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3119-0) contains supplementary material, which is available to authorized users.

High flow nasal cannula in the emergency department: indications, safety and effectiveness

INTRODUCTION

Heated humidified high flow nasal cannula therapy (HHHFNCT) is emerging as a popular non-invasive mode of respiratory support in adults and children. In recent years, its use has extended beyond the intensive care unit to other clinical areas. This review aims to explore the mechanism of action, indications, safety, and effectiveness of HHHFNCT use in the Emergency Department (ED).

AREAS COVERED

The mechanism of action of HHHFNCT, as well as its use in adult and pediatric ED will be discussed in this review.

EXPERT COMMENTARY

While there exists increasing enthusiasm in the use of HHHFNCT in the ED, constant monitoring of the patients and an experienced assessment of their response to treatment are critical and may require additional manpower deployment, which may be challenging, in the busy ED environment. Our experience with the use of HHHFNCT in children is still growing. Continual research in this area remains crucial in helping us better understand the patient types and conditions managed in ED that would most benefit from this device.

Rapid systematic review shows that using a high-flow nasal cannula is inferior to nasal continuous positive airway pressure as first-line support in preterm neonates

AIM

We reviewed using a high-flow nasal cannula (HFNC) as first-line support for preterm neonates with, or at risk of, respiratory distress.

METHODS

This rapid systematic review covered biomedical databases up to June 2017. We included randomised controlled trials (RCTs) published in English. The reference lists of the studies and relevant reviews we included were also screened. We performed the study selection, data extraction, study quality assessment, meta-analysis and quality of evidence assessment following the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

Pooled results from six RCTs covering 1227 neonates showed moderate-quality evidence that HFNC was associated with a higher rate of failure than nasal continuous positive airway pressure (NCPAP) in preterm neonates of at least 28 weeks of gestation, with a risk ratio of 1.57. Low-quality evidence showed no significant differences between HFNC and NCPAP in the need for intubation and bronchopulmonary dysplasia rate. HFNC yielded a lower rate of nasal injury (risk ratio 0.50). When HFNC failed, intubation was avoided in some neonates by switching them to NCPAP.

CONCLUSION

HFNC had higher failure rates than NCPAP when used as first-line support. Subsequently switching to NCPAP sometimes avoided intubation. Data on the most immature neonates were lacking.

A randomised cross-over study showed no difference in diaphragm activity during weaning from respiratory support

AIM

We measured electrical activity of the diaphragm (Edi) to compare the breathing effort in preterm infants during weaning from respiratory support with high-flow nasal cannulae (HFNC) or nasal continuous positive airway pressure (nCPAP).

METHODS

This randomised cross-over study was carried out at St Olav's University Hospital, Trondheim, Norway, from December 2013 to June 2015. We gave 21 preterm infants weighing at least 1000 g HFNC 6 L/minute for four hours and nCPAP 3 cmH₂ O for four hours with a one-hour wash-out period. Measurements included diaphragmatic load, Edi, vital signs and a modified Silverman-Andersen Retraction Score.

RESULTS

We found no differences in HFNC and nCPAP in the median Edi peak (8.0 μV versus 7.8 μV, p = 0.095), median Edi min (1.1 μV versus 1.2 μV in, p = 0.958) or mean heart rate (157 versus 159, p = 0.300) in the 21 infants who took part. The mean respiratory rate was significantly lower during HFNC than nCPAP (47 versus 52, p = 0.012). The modified Silverman-Andersen Retraction Score showed no significant differences.

CONCLUSION

This study of preterm infants found no difference in the breathing effort measured by Edi between HFNC 6 L/minute and nCPAP 3 cmH₂ O. HFNC could replace nCPAP when preterm infants are ready for weaning.

High-Flow Nasal Cannula Practice Patterns Reported by Neonatologists and Neonatal Nurse Practitioners in the United States

BACKGROUND

High-flow nasal cannula (HFNC) is widely used to treat neonatal respiratory conditions. Significant evidence emerged in recent years to guide practice, yet current practice patterns and their alignment with the evidence remain unknown.

PURPOSE

To examine current HFNC practice patterns and availability of clinical practice guidelines used in neonatal intensive care units in the United States.

METHODS/ANALYSIS

A nonexperimental, descriptive study was designed using a web-based survey to elicit a convenience sample of US neonatal providers. Quantitative data were analyzed using descriptive statistics, χ tests were used to test for differences among the categories, and post hoc comparisons among each combination of categories were conducted using a Bonferroni-corrected α of .05 to determine significance as appropriate.

RESULTS

A total of 947 responses were analyzed (626 neonatologists and 321 neonatal nurse practitioners). Univariate analyses suggested wide variations in practice patterns. One-third of the respondents used clinical guidelines, the majority utilized HFNC devices in conjunction with nasal continuous positive airway pressure, more than two-thirds used HFNC as a primary respiratory support treatment, and among all respondents, significant differences related to HFNC device types were reported.

IMPLICATIONS FOR PRACTICE

US providers revealed wide practice variations related to HFNC therapy. In addition, type of device used appears to impact practice patterns and approaches. Use of standardized guidelines was reported by one third of the respondents, and as such may be the contributing factor for wide practice variations.

IMPLICATIONS FOR RESEARCH

Future Research is needed to target aspects of practice where practice variations exist, or practice is not supported by evidence. Significant practice differences related to the device types should be considered in future research design.

Refining the Use of Nasal High-Flow Therapy as Primary Respiratory Support for Preterm Infants

OBJECTIVE

To identify clinical and demographic variables that predict nasal high-flow (nHF) treatment failure when used as a primary respiratory support for preterm infants.

STUDY DESIGN

This secondary analysis used data from a multicenter, randomized, controlled trial comparing nHF with continuous positive airway pressure as primary respiratory support in preterm infants 28-36 completed weeks of gestation. Treatment success or failure with nHF was determined using treatment failure criteria within the first 72 hours after randomization. Infants in whom nHF treatment failed received continuous positive airway pressure, and were then intubated if failure criteria were again met.

RESULTS

There were 278 preterm infants included, with a mean gestational age (GA) of 32.0 ± 2.1 weeks and a birth weight of 1737 ± 580 g; of these, nHF treatment failed in 71 infants (25.5%). Treatment failure was moderately predicted by a lower GA and higher prerandomization fraction of inspired oxygen (FiO₂): area under a receiver operating characteristic curve of 0.76 (95% CI, 0.70-0.83). Nasal HF treatment success was more likely in infants born at ≥30 weeks GA and with prerandomization FiO₂ <0.30.

CONCLUSIONS

In preterm infants ≥28 weeks' GA enrolled in a randomized, controlled trial, lower GA and higher FiO₂ before randomization predicted early nHF treatment failure. Infants were more likely to be successfully treated with nHF from soon after birth if they were born at ≥30 weeks GA and had a prerandomization FiO₂ <0.30. However, even in this select population, continuous positive airway pressure remains superior to nHF as early respiratory support in preventing treatment failure.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12613000303741.

Cost-Effectiveness Analysis of Nasal Continuous Positive Airway Pressure Versus Nasal High Flow Therapy as Primary Support for Infants Born Preterm

OBJECTIVE

To compare the cost-effectiveness of 2 common "noninvasive" modes of respiratory support for infants born preterm.

STUDY DESIGN

An economic evaluation was conducted as a component of a multicenter, randomized control trial from 2013 to 2015 enrolling infants born preterm at ≥28 weeks of gestation with respiratory distress, <24 hours old, who had not previously received endotracheal intubation and mechanical ventilation or surfactant. The economic evaluation was conducted from a healthcare sector perspective and the time horizon was from birth until death or first discharge. The cost-effectiveness of continuous positive airway pressure (CPAP) vs high-flow with "rescue" CPAP backup and high-flow without rescue CPAP backup (as sole primary support) were analyzed by using the hospital cost of inpatient stay in a tertiary center and the rates of endotracheal intubation and mechanical ventilation during admission.

RESULTS

Hospital inpatient cost records for 435 infants enrolled in all Australian centers were obtained. With "rescue" CPAP backup, an incremental cost-effectiveness ratio was estimated of A$179 000 (US$123 000) per ventilation avoided if CPAP was used compared with high flow. Without rescue CPAP backup, cost per ventilation avoided was A$7000 (US$4800) if CPAP was used compared with high flow.

CONCLUSIONS

As sole primary support, CPAP is highly likely to be cost-effective compared with high flow. Neonatal units choosing to use only one device should apply CPAP as primary respiratory support. Compared with high-flow with rescue CPAP backup, CPAP is unlikely to be cost-effective if willingness to pay per ventilation avoided is less than A$179 000 (US$123 000).

The clinical effectiveness and cost-effectiveness of heated humidified high-flow nasal cannula compared with usual care for preterm infants: systematic review and economic evaluation

BACKGROUND

Respiratory problems are one of the most common causes of morbidity in preterm infants and may be treated with several modalities for respiratory support such as nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive-pressure ventilation. The heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity in clinical practice.

OBJECTIVES

To address the clinical effectiveness of HHHFNC compared with usual care for preterm infants we systematically reviewed the evidence of HHHFNC with usual care following ventilation (the primary analysis) and with no prior ventilation (the secondary analysis). The primary outcome was treatment failure defined as the need for reintubation (primary analysis) or intubation (secondary analysis). We also aimed to assess the cost-effectiveness of HHHFNC compared with usual care if evidence permitted.

DATA SOURCES

The following databases were searched: MEDLINE (2000 to 12 January 2015), EMBASE (2000 to 12 January 2015), The Cochrane Library (issue 1, 2015), ISI Web of Science (2000 to 12 January 2015), PubMed (1 March 2014 to 12 January 2015) and seven trial and research registers. Bibliographies of retrieved citations were also examined.

REVIEW METHODS

Two reviewers independently screened all titles and abstracts to identify potentially relevant studies for inclusion in the review. Full-text copies were assessed independently. Data were extracted and assessed for risk of bias. Summary statistics were extracted for each outcome and, when possible, data were pooled. A meta-analysis was only conducted for the primary analysis, using fixed-effects models. An economic evaluation was planned.

RESULTS

Clinical evidence was derived from seven randomised controlled trials (RCTs): four RCTs for the primary analysis and three RCTs for the secondary analysis. Meta-analysis found that only for nasal trauma leading to a change of treatment was there a statistically significant difference, favouring HHHFNC over NCPAP [risk ratio (RR) 0.21, 95% confidence interval (CI) 0.10 to 0.42]. For the following outcomes, there were no statistically significant differences between arms: treatment failure (reintubation < 7 days; RR 0.76, 95% CI 0.54 to 1.09), bronchopulmonary dysplasia (RR 0.92, 95% CI 0.72 to 1.17), death (RR 0.56, 95% CI 0.22 to 1.44), pneumothorax (RR 0.33, 95% CI 0.03 to 3.12), intraventricular haemorrhage (grade ≥ 3; RR 0.41, 95% CI 0.15 to 1.15), necrotising enterocolitis (RR 0.41, 95% CI 0.15 to 1.14), apnoea (RR 1.08, 95% CI 0.74 to 1.57) and acidosis (RR 1.16, 95% CI 0.38 to 3.58). With no evidence to support the superiority of HHHFNC over NCPAP, a cost-minimisation analysis was undertaken, the results suggesting HHHFNC to be less costly than NCPAP. However, this finding is sensitive to the lifespan of equipment and the cost differential of consumables.

LIMITATIONS

There is a lack of published RCTs of relatively large-sized populations comparing HHHFNC with usual care; this is particularly true for preterm infants who had received no prior ventilation.

CONCLUSIONS

There is a lack of convincing evidence suggesting that HHHFNC is superior or inferior to usual care, in particular NCPAP. There is also uncertainty regarding whether or not HHHFNC can be considered cost-effective. Further evidence comparing HHHFNC with usual care is required.

STUDY REGISTRATION

This review is registered as PROSPERO CRD42015015978.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Successful Deployment of High Flow Nasal Cannula in a Peruvian Pediatric Intensive Care Unit Using Implementation Science-Lessons Learned

Acute lower respiratory infections are the leading cause of death outside the neonatal period for children less than 5 years of age. Widespread availability of invasive and non-invasive mechanical ventilation in resource-rich settings has reduced mortality rates; however, these technologies are not always available in many low- and middle-income countries due to the high cost and trained personnel required to implement and sustain their use. High flow nasal cannula (HFNC) is a form of non-invasive respiratory support with growing evidence for use in pediatric respiratory failure. Its simple interface makes utilization in resource-limited settings appealing, although widespread implementation in these settings lags behind resource-rich settings. Implementation science is an emerging field dedicated to closing the know-do gap by incorporating evidence-based interventions into routine care, and its principles have guided the scaling up of many global health interventions. In 2016, we introduced HFNC use for respiratory failure in a pediatric intensive care unit in Lima, Peru using implementation science methodology. Here, we review our experience in the context of the principles of implementation science to serve as a guide for others considering HFNC implementation in resource-limited settings.

Nasal high flow therapy in very low birth weight infants with mild respiratory distress syndrome: a single center experience

BACKGROUND

Pulmonary disorders and respiratory failure represent one of the most common morbidities of preterm newborns admitted to neonatal intensive care units (NICUs). The use of nasal high-flow therapy (nHFT) has been more recently introduced into the NICUs as a non-invasive respiratory (NIV) support.

METHODS

We performed a retrospective study to evaluate safety and effectiveness of nHFT as primary support for infants born < 29 weeks of gestation and/or VLBW presenting with mild Respiratory Distress Syndrome (RDS). The main outcome was the percentage of patients that did not need mechanical ventilation. Secondary outcomes were rate of bronchopulmonary dysplasia (BDP), air leaks, nasal injury, late onset sepsis (LOS), intraventricular hemorrhage (IVH), retinopathy (ROP), necrotizing enterocolitis (NEC), hemodynamically-significant patent ductus arteriosus (PDA) and death.

RESULTS

Sixty-four preterm newborns were enrolled. Overall, 93% of enrolled patients did not need mechanical ventilation. In a subgroup analysis, 88.5% of infants < 29 weeks and 86.7% of infants ELBW (< 1000 g BW) did not need mechanical ventilation. BPD was diagnosed in 26.6% of preterms enrolled (Mild 20%, Moderate 4.5%, Severe 1.5%). In subgroup analysis, BPD was diagnosed in 53.9% of newborns with GA < 29 weeks, in 53.3% of ELBW newborns and in 11.1% of small for gestational age (SGA) newborns. Neither air leaks nor nasal injury were recorded as well as no exitus occurred. LOS, IVH, ROP, NEC and PDA occurred respectively in 16.1%, 0%, 7.8%, and 1.6% of newborns.

CONCLUSIONS

According to our results, n-HFT seems to be effective as first respiratory support in preterm newborns with mild RDS. Further studies in a larger number of preterm newborns are required to confirm nHFT effectiveness in the acute phase of RDS.

Does Topical Lidocaine Reduce the Pain Associated With the Insertion of Nasal Continuous Positive Airway Pressure Prongs in Preterm Infants?: A Randomized, Controlled Pilot Trial

OBJECTIVE

To evaluate the efficacy of topical lidocaine 2% gel in reducing the pain associated with the insertion of nasal continuous positive airway pressure (nCPAP) prongs in preterm infants.

MATERIALS AND METHODS

A pilot randomized controlled trial. Sixty preterm infants, categorized into lidocaine (n=30) and control groups (n=30). The primary outcome was Premature Infant Pain Profile (PIPP) score, secondary outcomes included salivary cortisol, presence of cry, the duration of first cry, and adverse effects of lidocaine.

RESULTS

There were no statistically significant differences between lidocaine and control groups regarding PIPP scores (mean±SD: 7.2±2.3 vs. 9.3±3.0, respectively, P=0.086). None of the infants in the lidocaine group had severe pain defined as a PIPP score>12, compared with 3 (10%) infants in the control group (P=0.056). Salivary cortisol concentrations were not significantly different between the lidocaine and control groups (mean±SD: 2.57±1.79 vs. 4.82±1.61 μg/dL, respectively, P=0.11). Standardized effect sizes for topical lidocaine were medium to large for reduction in PIPP scores and large for reduction in salivary cortisol (Cohen d=-0.78 and -1.32, respectively). No adverse effects were reported in infants receiving lidocaine.

DISCUSSION

Our data suggest that topical lidocaine did not reduce the pain associated with the insertion of nCPAP prongs in preterm infants. However, the trends for lower PIPP scores in the lidocaine group and the effect sizes for lidocaine on PIPP scores and salivary cortisol were large enough so that a large-scale randomized clinical trial is warranted to confirm or refute our results. Such a study should compare 2 or more active pain interventions during nCPAP application, rather than evaluating a single intervention versus placebo or no treatment.

Nasal high flow treatment in preterm infants

Nasal High Flow (HF) is a mode of ‘non-invasive’ respiratory support for preterm infants, with several potential modes of action, including generation of distending airway pressure, washout of the nasopharyngeal dead space, reduction of work of breathing, and heating and humidification of inspired gas. HF has several potential advantages over continuous positive airway pressure (CPAP), the most commonly applied form of non-invasive support, such as reduced nasal trauma, ease of use, and infant comfort, which has led to its rapid adoption into neonatal care. In recent years, HF has become a well-established and commonly applied treatment in neonatal care.

Recent trials comparing HF and CPAP as primary support have had differing results. Meta-analyses suggest that primary HF results in an increased risk of treatment failure, but that ‘rescue’ CPAP use in those infants with HF failure results in no greater risk of mechanical ventilation. Even in studies with higher rates of HF failure, the majority of infants were successfully treated with HF, and rates of important neonatal morbidities did not differ between treatment groups. Importantly, these studies have included only infants born at ≥28 weeks’ gestational age (GA). The decision whether to apply primary HF will depend on the value placed on its advantages over CPAP by clinicians, the approach to surfactant treatment, and the severity of respiratory disease in the relevant population of preterm infants.

Post-extubation HF use results in similar rates of treatment failure, mechanical ventilation, and adverse events compared to CPAP. Post-extubation HF appears most suited to infants ≥28 weeks; there are few published data for infants below this gestation, and available evidence suggests that these infants are at high risk of HF failure, although rates of intubation and other morbidities are similar to those seen with CPAP. There is no evidence that using HF to ‘wean’ off CPAP allows for respiratory support to be ceased more quickly, but given its advantages it would appear to be a suitable alternative in infants who require ongoing non-invasive support. Safety data from randomised trials are reassuring, although more evidence in extremely preterm infants (<28 weeks’ GA) is required.

The Role of Heated Humidified High-flow Nasal Cannula as Noninvasive Respiratory Support in Neonates

Recently, heated humidified high-flow nasal cannula (HHHFNC) has been introduced and applied as a noninvasive respiratory support in neonates. Although HHHFNC is widely used in neonates presenting with respiratory distress, the efficiency and safety when compared with nasal continuous positive airway pressure or noninvasive positive pressure ventilation are still controversial. This review aims to evaluate the performance and applications of HHHFNC in neonates.