Binasal Prong versus Nasal Mask for Applying CPAP to Preterm Infants: A Randomized Controlled Trial

Mask-related pressure injury prevention associated with non-invasive ventilation: A systematic review

Noninvasive ventilation interfaces are one of the main factors contributing to pressure injuries caused by medical devices. Prevention is still the best course of action when discussing noninvasive ventilation-induced pressure injuries. A systematic review was designed to summarize and analyse all published literature on strategies to prevent pressure injuries caused by masks in patients undergoing noninvasive ventilation. The protocol of the systematic review followed the PRISMA guideline. An extensive search from the beginning to May 16, 2023, using current articles in databases such as Web of Science (WOS), Scopus, PubMed, and Cochrane Library was conducted. Medical Subject Headings (MESH) were used as follows: "Pressure Injury," "Noninvasive Ventilation," "Prevention," and "Pressure Sore." Any language-published studies that met the inclusion criteria were included in this review. A risk of bias assessment was conducted using the Joanna Briggs Institute tool, including evaluation methodologies for all studies. Database searches yielded 2546 articles, which were reduced to 23 that met our criteria after reviewing full texts. A narrative synthesis was conducted. As a result, type of interface (14 studies), dressings (4 studies), adjustment of mask leakage (1 study), humidity (1 study), positioning (1 study), and design of personalized masks (2 studies) seem to be a practical approach to prevent pressure injuries caused by masks in patients undergoing noninvasive ventilation. The results of our study show the effectiveness of preventive methods in reducing the incidence of pressure injuries caused by masks. Given the significant occurrence of pressure injury related to noninvasive ventilation and the crucial role of prevention and treatment, it is imperative to conduct more rigorous studies to ascertain the efficacy of each strategy.

Effect of different noninvasive ventilation interfaces on the prevention of facial pressure injury: A network meta-analysis

OBJECTIVE

To assess the effect of different noninvasive ventilation interfaces on preventing the facial pressure injury.

METHODS

This network meta-analysis was conducted following the PRISMA reporting guidelines. Seven electronic databases were systematically searched for randomised controlled trials about the comparative effectiveness of different interfaces in preventing facial pressure injury with noninvasive ventilation in adults and newborns from inception to June 2023. The acronym of PICOS was used and the keywords as well as inclusion/exclusion criteria were determined. Study selection and data extraction were performed by two independent reviewers. The Cochrane risk of bias assessment tool was used to assess the methodological quality.

RESULTS

A total of 78 randomised controlled trials involving 7,291 patients were included. The results of network meta-analysis showed that the effectiveness of the eight noninvasive ventilation interfaces on the prevention of facial pressure injury was in the order of: nasal cannula > full-face mask > rotation of nasal mask with nasal prongs > helmet > nasal mask > oronasal mask > nasal prongs > face mask. The use of full-face mask in adults and nasal cannula in newborns had the best effect on preventing the incidence of facial pressure injury.

CONCLUSIONS

The use of full-face mask in adults and nasal cannula in newborns had the most clinical advantage in preventing the incidence of facial pressure injury and were worthy promoting in clinical practice.

IMPLICATIONS FOR CLINICAL PRACTICE

This study provides a certain theoretical basis for the selection of appropriate interface for patients with noninvasive ventilation. Clinical practitioners should choose the appropriate interfaces based on the patient's specific condition to reduce the incidence of facial pressure injury, enhance patient comfort, and improve the effectiveness of respiratory therapy.

Prongs or Mask for Nasal Continuous Positive Airway Pressure in Neonates: Which One Is More Comfortable?

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) is a common mode of respiratory support in neonatal intensive care units. Our objective was to compare whether NCPAP given with nasal prongs compared with a nasal mask reduces the pain scores in preterm infants with respiratory distress.

METHODS

Preterm infants on NCPAP due to respiratory distress were included in the study. All infants received NCPAP via the Infant Flow SiPAP. The COVERS pain scale was used to score the infants' pain. Each infant was studied alternating between nasal prongs and a nasal mask. Heart rate, respiratory rate, oxygen saturation, and transcutaneous CO2 (tcCO2) were monitored. Blood pressure and the infants' pain scores were determined every 30 minutes and the average of measurements was taken.

RESULTS

The median (interquartile range) values of pain scores, respiratory rates, oxygen saturations, tcCO2 levels, and systolic blood pressures differed significantly and favored the nasal mask.

CONCLUSIONS

This study demonstrates that continuous positive airway pressure via a nasal mask leads to a significant reduction in pain scores without altering the respiratory parameters of babies. On the basis of this study, it is possible to conclude that NCPAP applied via nasal mask may be a good alternative to NCPAP applied via nasal prongs.

French Neonatal Society issues recommendations on preventing nasal injuries in preterm newborn infants during non-invasive respiratory support

AIM

To issue practical recommendations regarding the optimal care of nasal skin when non-invasive ventilation support is used.

METHODS

We performed a systematic search of PubMed to identify relevant papers published in English or French through December 2019. Different grades of evidence were evaluated.

RESULTS

Forty-eight eligible studies. The incidence in preterm infants was high. The lesions were more frequent for preterm infants born under 30 weeks of gestational age and/or below 1500 g. The lesion was most often located on the skin of the nose but could also be found on the intranasal mucous membranes or elsewhere on the face. Nasal injuries appear early after the beginning of non-invasive ventilation at a mean of 2-3 days for cutaneous lesions and eight or nine for intranasal lesions. The most effective strategies to prevent trauma are the use of a hydrocolloid at the beginning of the support ventilation, the preferential use of a mask and the rotation of ventilation interfaces.

CONCLUSION

Nasal injuries with continuous positive airway pressure treatment in preterm newborn infants were frequent and can induce pain, discomfort and sequelae. The immature skin of preterm newborn infants needs specific attention from trained caregivers and awareness by parents.

Incidence of nasal pressure injury in preterm infants on nasal mask noninvasive ventilation

OBJECTIVE

The aim of this study was to evaluate the incidence of nasal injury in preterm newborns (NB) using the Neonatal Skin Condition Score within 7 days of noninvasive ventilation (NIV) and to compare the incidence of injury in NB weighing ≥1,000 g and those weighing <1,000 g at the time of initiation of NIV support.

METHODS

This is a prospective, observational study carried out in a neonatal intensive care unit of a public hospital in Rio Grande do Sul from July 2016 to January 2021. Patients were stratified into two groups at the time of NIV initiation: group 1 (weight ≥1,000 g) and group 2 (weight <1,000 g). To assess the condition of nasal injury, a rating scale called the Neonatal Skin Condition Score was applied during the first seven consecutive days on NIV. Kaplan-Meier, log-rank test, and Cox proportional hazards regression were used to estimate the hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

In total, 184 NB were evaluated. Nasal injury was reported in 55 (30%) NB. The risk of nasal injury was 74% higher in group 2 (19/45) than in group 1 (36/139) (HR: 1.74; 95%CI 0.99-3.03, p=0.048).

CONCLUSION

The incidence of nasal injury in infants submitted to NIV by nasal mask was high, and the risk of this injury was greater in preterm infants weighing <1,000 g.

RAM cannula versus short binasal prongs for nasal continuous positive airway pressure delivery in preterm infants: a randomized, noninferiority trial from low-middle-income country

To determine if RAM cannula is non-inferior to short binasal prongs (SBP) in providing nasal continuous positive airway pressure (CPAP) in preterm infants with respiratory distress syndrome (RDS). In this randomized, open-label, noninferiority trial from a low-middle-income country, we enrolled 254 preterm infants (28-34 weeks gestational age) with RDS who needed CPAP as primary respiratory support. The eligible infants were randomized to either RAM cannula or SBP interface groups. The primary outcome was CPAP failure (defined as the need for intubation or non-invasive positive pressure ventilation) within 72 h of randomization. The noninferiority margin was defined as a 10% or less absolute difference in CPAP failure rates. The secondary outcomes included nasal trauma and adverse events. We analyzed by per-protocol (primary) and intention to treat. CPAP failure has been seen in 25 infants (19.7%) in the RAM cannula group versus 22 (17.3%) in the SBP group (RD -2.36%; 95% CI -11.9 to 7.2 [beyond inferiority margin]; p = 0.6). Moderate and severe nasal trauma was less in RAM cannula (2.4 vs. 8.7%; RR 0.27; 95% CI 0.08-0.95; p 0.028). Duration of CPAP was also significantly shorter in the RAM cannula group (MD -12.4 h; 95% CI -20.34 to -4.46, p 0.017). There were no differences in other adverse events.

CONCLUSIONS

RAM cannula was not non-inferior to SBP in providing CPAP to preterm infants with respiratory distress syndrome.

TRIAL REGISTRATION

Registered at Clinical Trial Registry of India (CTRI/2020/03/024097).

WHAT IS KNOWN

• RAM cannula is used for providing supplemental oxygen therapy. There is conflicting evidence on its efficacy in delivering CPAP support in preterm infants.

WHAT IS NEW

• RAM cannula was not non-inferior to SBP in providing CPAP to preterm infants with respiratory distress syndrome. • RAM cannula causes less nasal trauma than short binasal prongs.

Masks versus prongs as interfaces for nasal continuous positive airway pressure in preterm infants

BACKGROUND

Nasal masks and nasal prongs are used as interfaces for providing continuous positive airway pressure (CPAP) for preterm infants with or at risk of respiratory distress, either as primary support after birth or as ongoing support after endotracheal extubation from mechanical ventilation. It is unclear which type of interface is associated with lower rates of CPAP treatment failure, nasal trauma, or mortality and other morbidity.

OBJECTIVES

To assess the benefits and harms of nasal masks versus nasal prongs for reducing CPAP treatment failure, nasal trauma, or mortality and other morbidity in newborn preterm infants with or at risk of respiratory distress.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was October 2021.

SELECTION CRITERIA

We included randomised controlled trials comparing masks versus prongs as interfaces for delivery of nasal CPAP in newborn preterm infants (less than 37 weeks' gestation) with or at risk of respiratory distress.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. treatment failure, 2. all-cause mortality, and 3. neurodevelopmental impairment. Our secondary outcomes were 4. pneumothorax, 5. moderate-severe nasal trauma, 6. bronchopulmonary dysplasia, 7. duration of CPAP use, 8. duration of oxygen supplementation, 9. duration of hospitalisation, 10. patent ductus arteriosus receiving medical or surgical treatment, 11. necrotising enterocolitis, 12. severe intraventricular haemorrhage, and 13. severe retinopathy of prematurity. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 12 trials with 1604 infants. All trials were small (median number of participants 118). The trials occurred after 2001 in care facilities internationally, predominantly in India (eight trials). Most participants were preterm infants of 26 to 34 weeks' gestation who received nasal CPAP as the primary form of respiratory support after birth. The studied interfaces included commonly used commercially available masks and prongs. Lack of measures to blind caregivers or investigators was a potential source of performance and detection bias in all the trials. Meta-analyses suggested that use of masks compared with prongs may reduce CPAP treatment failure (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 8 trials, 919 infants; low certainty). The type of interface may not affect mortality prior to hospital discharge (RR 0.83, 95% CI 0.56 to 1.22; 7 trials, 814 infants; low certainty). There are no data on neurodevelopmental impairment. Meta-analyses suggest that the choice of interface may result in little or no difference in the risk of pneumothorax (RR 0.93, 95% CI 0.45 to 1.93; 5 trials, 625 infants; low certainty). Use of masks rather than prongs may reduce the risk of moderate-severe nasal injury (RR 0.55, 95% CI 0.44 to 0.71; 10 trials, 1058 infants; low certainty). The evidence is very uncertain about the effect on bronchopulmonary dysplasia (RR 0.69, 95% CI 0.46 to 1.03; 7 trials, 843 infants; very low certainty).

AUTHORS' CONCLUSIONS

The available trial data provide low-certainty evidence that use of masks compared with prongs as the nasal CPAP interface may reduce treatment failure and nasal injury, and may have little or no effect on mortality or the risk of pneumothorax in newborn preterm infants with or at risk of respiratory distress. The effect on bronchopulmonary dysplasia is very uncertain. Large, high-quality trials would be needed to provide evidence of sufficient validity and applicability to inform policy and practice.

Workflow to develop 3D designed personalized neonatal CPAP masks using iPhone structured light facial scanning

Background

Continuous positive airway pressure (CPAP) is a common mode of respiratory support used in neonatal intensive care units. In preterm infants, nasal CPAP (nCPAP) therapy is often delivered via soft, biocompatible nasal mask suitable for long-term direct skin contact and held firmly against the face. Limited sizes of nCPAP mask contribute to mal-fitting related complications and adverse outcomes in this fragile population. We hypothesized that custom-fit nCPAP masks will improve the fit with less skin pressure and strap tension improving efficacy and reducing complications associated with nCPAP therapy in neonates.

Methods

After IRB approval and informed consent, we evaluated several methods to develop 3D facial models to test custom 3D nCPAP masks. These methods included camera-based photogrammetry, laser scanning and structured light scanning using a Bellus3D Face Camera Pro and iPhone X running either Bellus3D FaceApp for iPhone, or Heges application. This data was used to provide accurate 3D neonatal facial models. Using CAD software nCPAP inserts were designed to be placed between proprietary nCPAP mask and the model infant’s face. The resulted 3D designed nCPAP mask was form fitted to the model face. Subsequently, nCPAP masks were connected to a ventilator to provide CPAP and calibrated pressure sensors and co-linear tension sensors were placed to measures skin pressure and nCPAP mask strap tension.

Results

Photogrammetry and laser scanning were not suited to the neonatal face. However, structured light scanning techniques produced accurate 3D neonatal facial models. Individualized nCPAP mask inserts manufactured using 3D printed molds and silicon injection were effective at decreasing surface pressure and mask strap pressure in some cases by more than 50% compared to CPAP masks without inserts.

Conclusions

We found that readily available structured light scanning devices such as the iPhone X are a low cost, safe, rapid, and accurate tool to develop accurate models of preterm infant facial topography. Structured light scanning developed 3D nCPAP inserts applied to commercially available CPAP masks significantly reduced skin pressure and strap tension at clinically relevant CPAP pressures when utilized on model neonatal faces. This workflow maybe useful at producing individualized nCPAP masks for neonates reducing complications due to misfit.

Home High-Flow Nasal Cannula Therapy in Children with Congenital Heart Disease

High-flow nasal cannula (HFNC) therapy has been applied in the perioperative respiratory care for children with congenital heart disease and respiratory problems. However, the information about the feasibility of home HFNC therapy remains lacking among them. We retrospectively reviewed 5 children with congenital heart disease and respiratory problems who underwent home HFNC therapy, and evaluated their feasibility and safety. Age and weight at the introduction of home HFNC therapy were 19 (2-119) months and 5.3 (3.1-11.4) kg, respectively. All subjects had chromosomal anomaly including trisomy 18 in 3 and trisomy 21 in 2 subjects. Cardiac diagnoses included ventricular septal defect in 3, tetralogy of Fallot with complete atrioventricular septal defect in one, and pulmonary atresia with ventricular septal defect in another subject. Other comorbidities involved pulmonary hypertension in 4, micrognathia in 4, West syndrome in one, and bronchial asthma in one subject. Respiratory manifestations involved cyanosis due to upper airway obstruction in 2 and central hypopnea in 2, and recurrent pneumonia in one subject. After home HFNC therapy, systemic oxygen saturation significantly increased from 60 (40-78)% to 83 (83-96)% (P = 0.04), while heart rate and blood partial pressure of carbon dioxide were significantly decreased. There was no adverse event relevant to home HFNC during the follow-up period of 12 (5-49) months. Among them, one patient subsequently underwent tracheotomy at 11 years of age, and two patients weaned to conventional home oxygen therapy at 7 and 23 months of age. Home HFNC is safe and feasible in children with congenital heart disease and respiratory problems.

Risk factors for prolonged mechanical ventilation in neonates following gastrointestinal surgery

Background

Prolonged mechanical ventilation (MV) should be avoided in neonates. Noninvasive ventilation (NIV) can facilitate weaning from MV but has risks for patients immediately following foregut surgery due to the potential risk of anastomotic leak. We evaluated the risk factors for prolonged MV following intestinal surgery in neonates.

Methods

We retrospectively reviewed 253 neonates undergoing intestinal surgery in 2017-2018 to identify risk factors for prolonged MV, and determine the correlation between NIV and anastomotic leak in a tertiary neonatal intensive care unit that performs the greatest number of neonatal surgeries in Ontario.

Results

The most common diagnoses were necrotizing enterocolitis/spontaneous intestinal perforation (NEC/SIP) 21%, intestinal atresia 16%, esophageal atresia/tracheoesophageal fistula 14%, ano-rectal malformation 13%, malrotation/volvulus 11%, gastroschisis 9% and omphalocele 4%. The median (IQR) duration of MV post-surgery was 3 (1-8) days with 25.7 % (n=65) of neonates on MV for >7 days. Compared to infants on MV post-surgery for ≤7 days, those with MV>7 days were of lower gestational age, birth weight and weight at surgery, but a higher proportion underwent stoma creation, had a longer duration of opioid administration and higher rates of moderate to severe bronchopulmonary dysplasia (BPD) and mortality (P<0.05). Generalized linear regression analysis showed lower gestational age (GA) and longer opioid administration were associated with longer duration of MV (P<0.001), but indication for surgery, weight at surgery and stoma creation didn't correlate with longer duration of MV (P>0.05). Of the 122 patients handled by one-stage resection with primary anastomosis, 22.1% (n=27) received NIV with 74.1% (n=20) commenced on NIV after 7 days post-surgery, anastomotic leak was detected in 2.5 % (3/122) patients and didn't correlate with NIV.

Conclusions

Lower GA and longer opioid administration were risk factors for prolonged MV in neonates following intestinal surgery. Further research is needed to investigate modifiable practices around pain assessment/ventilation in these patients, and the correlation between NIV and anastomotic leak.

Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review

BACKGROUND

Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required.

METHODS

A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted.

RESULTS

179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions.

CONCLUSIONS

Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.

Evidence-based interventions to reduce mortality among preterm and low-birthweight neonates in low-income and middle-income countries: a systematic review and meta-analysis

Background

Preterm birth is the leading cause of under-five-mortality worldwide, with the highest burden in low-income and middle-income countries (LMICs). The aim of this study was to synthesise evidence-based interventions for preterm and low birthweight (LBW) neonates in LMICs, their associated neonatal mortality rate (NMR), and barriers and facilitators to their implementation. This study updates all existing evidence on this topic and reviews evidence on interventions that have not been previously considered in current WHO recommendations.

Methods

Six electronic databases were searched until 3 March 2020 for randomised controlled trials reporting NMR of preterm and/or LBW newborns following any intervention in LMICs. Risk ratios for mortality outcomes were pooled where appropriate using a random effects model (PROSPERO registration number: CRD42019139267).

Results

1236 studies were identified, of which 49 were narratively synthesised and 9 contributed to the meta-analysis. The studies included 39 interventions in 21 countries with 46 993 participants. High-quality evidence suggested significant reduction of NMR following antenatal corticosteroids (Pakistan risk ratio (RR) 0.89; 95% CI 0.80 to 0.99|Guatemala 0.74; 0.68 to 0.81), single cord (0.65; 0.50 to 0.86) and skin cleansing with chlorhexidine (0.72; 0.55 to 0.95), early BCG vaccine (0.64; 0.48 to 0.86; I² 0%), community kangaroo mother care (OR 0.73; 0.55 to 0.97; I² 0%) and home-based newborn care (preterm 0.25; 0.14 to 0.48|LBW 0.42; 0.27 to 0.65). No effects on perinatal (essential newborn care 1.02; 0.91 to 1.14|neonatal resuscitation 0.95; 0.84 to 1.07) or 7-day NMR (essential newborn care 1.03; 0.83 to 1.27|neonatal resuscitation 0.92; 0.77 to 1.09) were observed after training birth attendants.

Conclusion

The findings of this study encourage the implementation of additional, evidence-based interventions in the current (WHO) guidelines and to be selective in usage of antenatal corticosteroids, to reduce mortality among preterm and LBW neonates in LMICs. Given the global commitment to end all preventable neonatal deaths by 2030, continuous evaluation and improvement of the current guidelines should be a priority on the agenda.

Nasal mask vs binasal prongs for nasal continuous positive airway pressure in preterm infants: A systematic review and meta-analysis

OBJECTIVE

To investigate the effect of nasal continuous positive airway pressure (NCPAP) given with nasal masks (NM) compared with binasal prongs (BNP) on the incidence of intubation within 72 hours in preterm infants (primary outcome) via meta-analysis of clinical studies.

DATA SOURCES

We searched for randomized clinical trials (RCTs) or quasi-RCTs in Medline, PubMed, and Web of Science from inception through 4 December 2019.

DATA EXTRACTION/SYNTHESIS

Two independent co-authors extracting data performed the meta-analysis using a fixed-effect model to yield pooled relative risk (RR) and its 95% confidence interval (CI) for each outcome. We used Cochrane GRADE to evaluate the evidence quality.

RESULTS

Eleven RCTs met the inclusion criteria. The meta-analysis showed NCPAP provided via NM significantly reduced the rate of intubation within 72 hours (RR, 0.72; 95% CI, 0.58-0.90; nine studies; GRADE-moderate) and nasal trauma (RR, 0.64; 95% CI, 0.55-0.74; GRADE-low) compared with NCPAP provided via BNP. Also, NCPAP via NM significantly reduced surfactant treatment (RR, 0.85; 95% CI, 0.74-0.97; GRADE-very low) and bronchopulmonary dysplasia (RR, 0.47; 95% CI, 0.23-0.95; GRADE-low) compared with BNP in a setting where NCPAP was used as the primary support in respiratory distress syndrome. No statistically significant differences were noted between groups in secondary outcomes except increased NCPAP duration when NCPAP given with NM compared with BNP (mean difference [days], 1.78; 95% CI, 1.67-1.89; GRADE-low).

CONCLUSION

Among premature infants, NCPAP provided with NM is more effective in preventing intubation and mechanical ventilation within 72 hours of initiating the support compared with NCPAP provided with BNP.

Impact of Systematic Training and CPAP Checklist in the Prevention of NCPAP Related Nasal Injuries in Neonates- A Quality Improvement Study

OBJECTIVE

Nasal continuous positive airway pressure (NCPAP) related nasal injury in neonates is a type of device-related pressure injury and is a common event with the varying incidence in different hospitals. Understanding and adhering to the recommendation of the manufacturer in fixing the NCPAP interface is vital for the prevention of nasal injuries. A quality improvement initiative was undertaken to decrease the incidence of NCPAP related nasal injuries in a Level 3 neonatal unit by using a customized NCPAP checklist and application of the checklist using Plan-Do-Study-Act (PDSA) cycles.

METHODS

A baseline audit was conducted for two months. An evidence-based checklist was formed by a quality improvement team and was exercised by a designated CPAP nurse using videos, small seminars, handouts, and hands-on training. Modifications in the checklist were done during the study using three PDSA cycles.

RESULTS

A total of 129 babies with a median gestational age of 31 wk (IQR: 28-34 wk), median birth weight of 1320 g (IQR: 1030-1842 g) were studied. The mean duration of NCPAP was 5.4 d. The incidence of CPAP injuries decreased from 91 per 1000 CPAP days to 8 per 1000 CPAP days over 8 mo. The compliance with fixing NCPAP as per recommendation improved from 35% to 95% during the study with p values <0.05.

CONCLUSIONS

Nurses training based on a structured checklist and highlighting important features of standardized NCPAP care helps in preventing NCPAP related nasal injury.

Randomized trial of mask or prongs for nasal intermittent mandatory ventilation in term infants with transient tachypnea of the newborn

BACKGROUND

The aim of this study was to compare nasal masks (NM) with binasal prongs (NP) for applying nasal intermittent mandatory ventilation (NIMV) by assessing the duration of respiratory distress, rate of intubation, and nasal trauma in term infants with transient tachypnea of the newborn (TTN).

METHODS

Infants with a gestational age ≥37 weeks and birthweight ≥2,000 g who had NIMV administered for TTN were enrolled. We randomly allocated 80 neonates to the NM (n = 40) or NP (n = 40) group. Duration of respiratory distress was the primary outcome of this study.

RESULTS

There were no statistically significant differences between the groups for the duration of tachypnea and NIMV (P = 0.94 and P = 0.13, respectively). No significant differences were observed between the two groups in terms of duration of oxygen supplementation and length of hospitalization (P = 0.72 and P = 0.70, respectively). The incidence of any grade of trauma and moderate trauma (grade II) was significantly higher in the NP group than in the NM group (P = 0.004 and P = 0.04, respectively). The rate of NIMV failure and other complications, including pneumothorax, pneumonia and feeding intolerance, was not significantly different in the groups.

CONCLUSIONS

In term infants with TTN, delivering NIMV using NP in comparison to using NM appears to be similar with regard to the duration of respiratory distress and preventing intubation. However, the use of NP involves a greater risk of trauma than that of NM.

Systematic Reviews in Neonatal Respiratory Care: Are Some Conclusions Misleading?

An increasing amount of information is currently available in neonatal respiratory care. Systematic reviews are an important tool for clinical decision-making. The challenge is to combine studies that address a specific clinical question and have similar characteristics in terms of populations, interventions, comparators, and outcomes, so that their combined results provide a more precise estimate of the effect that can be validly extrapolated into clinical practice. The concept of heterogeneity is reviewed, emphasizing that it should be considered in a wider perspective and not just as a mere statistical test. A case is made of how well-designed studies of the neonatal respiratory literature, when equivocally combined, can provide very precise but potentially biased results. Systematic reviews in this field and others should be rigorously peer-reviewed before publication to avoid misleading readers to potentially biased conclusions.

Assessment of resistance of nasal continuous positive airway pressure interfaces

OBJECTIVE

To compare the resistance of interfaces used for the delivery of nasal continuous positive airway pressure (CPAP) in neonates, as measured by the generated system pressure at fixed gas flows, in an in vitro setting.

DESIGN

Gas flows of 6, 8 and 10 L/min were passed through three sizes of each of a selection of available neonatal nasal CPAP interfaces (Hudson prong, RAM Cannula, Fisher & Paykel prong, Infant Flow prong, Fisher & Paykel mask, Infant Flow mask). The expiratory limb was occluded and pressure differential measured using a calibrated pressure transducer.

RESULTS

Variation in resistance, assessed by mean pressure differential, was seen between CPAP interfaces. Binasal prong interfaces typically had greater resistance at the smallest assessed sizes, and with higher gas flows. However, Infant Flow prongs produced low pressures (<1.5 cmH₂O) at all sizes and gas flows. RAM Cannula had a high resistance, producing a pressure >4.5 cmH₂O at all sizes and gas flows. Both nasal mask interfaces had low resistance at all assessed sizes and gas flows, with recorded pressure <1 cmH₂O in all cases.

CONCLUSIONS

There is considerable variation in measured resistance of available CPAP interfaces at gas flows commonly applied in clinical neonatal care. Use of interfaces with high resistance may result in a greater drop in delivered airway pressure in comparison to set circuit pressure, which may have implications for clinical efficacy. Device manufacturers and clinicians should consider CPAP interface resistance prior to introduction into routine clinical care.

To compare nasal mask with binasal prongs in delivering continuous positive airway pressure for reducing need of invasive ventilation: randomized controlled trial

AIMS

To compare nasal mask with binasal prongs in delivering bubble continuous positive airway pressure (CPAP) for reducing need of invasive ventilation in VLBW infants: randomized controlled trial.

METHODS

In this randomized control trial 178 infants were enrolled, 90 were randomized to nasal mask group and 88 to nasal prong group for delivering bubble CPAP. Preterm neonates between 26 and 32 weeks of gestational age requiring CPAP for respiratory distress within 6 h of life were assessed for eligibility and were included if neonates had spontaneous respiratory efforts with respiratory distress in the form of tachypnea (respiratory rate >60/min), intercostal/subcostal retractions, grunting (audible with/without stethoscope), Silverman Anderson score ≥3, increased respiratory efforts or cyanosis. Infants received either nasal mask or binasal prongs for delivery of bubble CPAP. The primary outcome was the need for mechanical ventilation in first 72 h of life.

RESULTS

Baseline characteristics were comparable between the two groups. There was significant reduction in incidence of CPAP failure [15 (16.6%) versus 26 (29.5%); RR 0.47 (95% CI 0.23-0.97), p = .04]; nasal trauma (any grade) [14 (15.9%) versus 38 (43.2%); RR 0.26 (95% CI 0.12-0.52), p = .0002]; nasal trauma grade I [12 (13.3%) versus 23 (26.1%); RR 0.43 (95% CI 0.20-0.94), p = .03]; nasal trauma grade II [1 (1.1%) versus 10 (11.3%); RR 0.08 (95% CI 0.01-0.70), p = .02]; nasal trauma severe grade (II and III) [2 (2.2%) versus 15 (17.0%);RR 0.11 (95% CI 0.02-0.49), p = .004] and bronchopulmonary dysplasia [4 (4.4%) versus 12 (13.6%); RR 0.30 (95% CI 0.10-0.95), p = .04] in nasal mask group when compared to nasal prong group.

CONCLUSION

Nasal mask leads to significant reduction in need for mechanical ventilation in initial 72 h.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update

As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

Mask versus Prongs for Nasal Continuous Positive Airway Pressure in Preterm Infants: A Systematic Review and Meta-Analysis

Nasal continuous positive airway pressure (NCPAP) is an effective method of respiratory support for preterm infants. Nasal masks and binasal prongs are two interfaces available to deliver NCPAP, and it is unclear if one is superior to the other. We conducted a systematic review and meta-analysis, using the methodology recommended by the Cochrane Collaboration, to compare the efficacy and safety of nasal masks versus binasal prongs to deliver NCPAP in preterm infants <37 weeks of gestation. Ovid MEDLINE, Embase, Scopus, the Cochrane database, and PubMed were searched in February 2019. Seven trials met the inclusion criteria. Among preterm infants requiring NCPAP, the use of a nasal mask, compared to nasal prongs, decreased the rate of NCPAP failure within 72 h (RR 0.72, 95% CI 0.53-0.97; number needed to treat for an additional beneficial outcome [NNTB] 12.5, 95% CI 7.1-100; 5 trials, 576 participants; low-certainty evidence) and the incidence of nasal injury (RR 0.71, 95% CI 0.59-0.85; NNTB 8.3, 95% CI 5.6-16.7; 6 trials, 665 participants; low-certainty evidence). In a subgroup of preterm infants requiring NCPAP after resuscitation at birth, the use of a nasal mask decreased the incidence of moderate-to-severe bronchopulmonary dysplasia (RR 0.47, 95% CI 0.23-0.95; NNTB 16.7, 95% CI 9.1-100; 4 trials, 395 participants; very-low-certainty evidence) and the need for subsequent surfactant administration (RR 0.78, 95% CI 0.64-0.96; NNTB 8.33, 95% CI 4.54-33.33; 4 trials, 395 participants; low-certainty evidence). The use of nasal masks for preterm infants requiring NCPAP was associated with a reduction in NCPAP failure, need for surfactant administration, and moderate-to-severe bronchopulmonary dysplasia (low- to very-low-certainty evidence). Given the potential clinical benefit and minimal risk associated with a change in patient interface, nasal masks should be considered the preferred interface for NCPAP delivery in preterm infants.

Turkish Neonatal Society guideline on the management of respiratory distress syndrome and surfactant treatment

Respiratory distress syndrome is the leading cause of respiratory failure in preterm infants. The incidence and severity of respiratory distress syndrome are inversely related to the gestational age of the newborn. The major underlying pathophysiologic mechanisms are surfactant deficiency and anatomic, structural immaturity of the lung. Recent improvements such as antenatal steroid treatment to enhance pulmonary maturity, appropriate resuscitation facilitated by placental transfusion and immediate use of continuous positive airway pressure for alveolar recruitment, early rescue administration of surfactant, ventilation with gentler modes to minimize damage to the immature lungs, and the other supportive therapies have significantly decreased respiratory distress syndrome-related morbidity and mortality. This guideline was addressed to overview the mentioned improvements in order to standardize respiratory distress syndrome management in neonatal intensive care units in Turkey.

Effectiveness and safety of nasal mask versus binasal prongs for providing continuous positive airway pressure in preterm infants-A systematic review and meta-analysis

Continuous positive airway pressure (CPAP) delivered via binasal prongs has been the cornerstone of respiratory management in preterm infants. Though effective, the use of binasal prongs is associated with nasal trauma, and CPAP failure. To overcome these issues, nasal masks are increasingly used to deliver CPAP in preterm infants. The aim was to conduct a systematic review of randomized controlled trials (RCTs) comparing nasal mask versus binasal prongs to deliver CPAP in preterm infants. Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index of Nursing, and Allied Health Literature, and E-abstracts from the Pediatric Academic Society meetings were searched in May 2017. All RCTs comparing nasal mask versus binasal prongs for delivering CPAP in preterm infants were included. Primary outcome was CPAP failure (need for mechanical ventilation within 72 h of initiating CPAP). Secondary outcomes included duration of CPAP, moderate to severe nasal trauma, any nasal trauma, pneumothorax, severe IVH, bronchopulmonary dysplasia at 36 weeks postmenstrual age, and mortality. Five RCTs with low risk of bias were included. Nasal mask significantly decreased the risk of CPAP failure (4 RCTs [N = 459]; relative risk [RR]: 0.63; 95% confidence interval [CI]: 0.45-0.88; P=.007; I2 = 0%, NNT: 9), and the incidence of moderate to severe nasal trauma (3 RCTs [N = 275], RR: 0.41; 95%CI, 0.24-0.72; P = 0.002; I2 = 74%, NNT: 6). Other outcomes did not differ significantly between the groups. Compared to binasal prongs, nasal mask may provide a safe and effective alternative by minimizing the risk of CPAP failure in preterm infants needing CPAP support.

Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review

OBJECTIVE

Binasal prongs are the most commonly used interface for the delivery of nasal positive airway pressure (CPAP) to preterm infants. However, they are associated with pressure-related nasal injury, which causes pain and discomfort. Nasal injury may necessitate a change in interface and occasionally damage is severe enough to require surgical repair. We aim to determine the incidence and risk factors for nasal injury in preterm infants, and to provide clinicians with strategies to effectively prevent and treat it.

DESIGN

We conducted a systematic search of databases including MEDLINE (PubMed including the Cochrane Library), EMBASE, CINAHL and Scopus. Included studies enrolled human preterm infants and were published prior to 20 February 2017.

RESULTS

Forty-five studies were identified, including 14 ra ndomised controlled trials, 10 observational studies, two cohort studies, eight case reports and 11 reviews. The incidence of nasal injury in preterm infants ranged from 20-100%. Infants born <30 weeks' gestation are at highest risk. Strategies shown to reduce nasal injury included: nasal barrier dressings (2 studies, n=244, risk ratio (RD) -0.12, 95%, CI - 0.20 to -0.04), nasal high flow therapy as an alternative to binasal prong CPAP (7 studies, n=1570, risk difference (RD) -0.14, 95% CI -0.17 to -0.10), and nasal masks rather than binasal prongs (5 studies, n=544, RR 0.80, 95% CI 0.64 to 1.00).

CONCLUSIONS AND RELEVANCE

Nasal injury is common in preterm infants born <30 weeks' gestational age receiving CPAP via binasal prongs. Larger randomised trials are required to fully evaluate strategies to reduce nasal injury.

Heated Humidified High-Flow Nasal Cannula for Weaning from Continuous Positive Airway Pressure in Preterm Infants: A Randomized Controlled Trial

BACKGROUND

Heated humidified high-flow nasal cannula (HHHFNC) therapy has been widely used in preterm infants. However, evidence to support its use as a continuous positive airway pressure (CPAP) weaning method is still controversial.

OBJECTIVES

We aimed to compare time to wean directly off CPAP vs. weaning by using HHHFNC.

METHODS

Infants with a gestational age (GA) of <32 weeks who met the predefined criteria for weaning off CPAP, i.e. with a CPAP of ≤6 cm H2O and a fraction of inspired oxygen (FiO2) of ≤0.3 for at least 24 h, were randomly assigned to wean by using HHHFNC or wean directly from CPAP. In the HHHFNC group, flow rate was reduced by 1 liter/min every 24 h to 2-3 liters/min depending on body weight (i.e. < or ≥1,000 g), and then HHHFNC was discontinued. In the CPAP group, pressure was reduced by 1 cm H2O every 24 h until stable on CPAP 4 cm H2O and then discontinued. The primary outcome was the time it took to wean off the use of the CPAP or HHHFNC devices.

RESULTS

One-hundred and one infants were enrolled, 51 in the HHHFNC and 50 in the CPAP group. Both groups had similar demographics and respiratory conditions before enrollment. There was no difference in time to successfully wean between the 2 groups [median (IQR): 11 (4-21) days in the HHHFNC group vs. 11 (4-29) days in the CPAP group; p = 0.12]. There were no differences in morbidities or related complications. Infants in the HHHFNC group had significantly less nasal trauma (20 vs. 42%; p = 0.01).

CONCLUSIONS

In our study, the time to wean off CPAP using HHHFNC was not different from when weaning directly from CPAP.