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

Blinding Assessments in Neonatal Ventilation Meta-Analyses: A Systematic Meta-Epidemiological Review

INTRODUCTION

Randomization and blinding are generally important in randomized trials. In neonatology, blinding of ventilation strategies is unfeasible if not impossible and we hypothesized that its importance has been overestimated, while the peculiarities of the neonatal patient and the specific outcomes have not been considered.

METHODS

For this meta-epidemiological review, we searched PubMed and Scopus databases in November 2023. We included all meta-analyses focusing on ventilation, published in past 5 years, and reporting either mortality or bronchopulmonary dysplasia (BPD) as an outcome. We extracted the information about how the authors had analyzed risk of bias and evidence certainty.

RESULTS

We screened 494 abstracts and included 40 meta-analyses. Overall, 13 of the 40 reviews assessed blinding properly. Australian and European authors were most likely to perform correct assessment of the blinding (p = 0.03) and the use of RoB 2.0 tool was also associated with proper assessment (p < 0.001). In multivariate regression, the use of RoB 2.0 was the only factor associated with a proper assessment (Beta 0.57 [95% confidence interval: 0.29-0.99]). GRADE ratings were performed in 25 reviews, and the authors downgraded the evidence certainty due to risk of bias in 19 of these and none of these reviews performed the blinding assessment correctly.

CONCLUSION

In past neonatal evidence syntheses, the role of blinding has been mostly overestimated, which has led to downgrading of evidence certainty. Objective outcomes (such as mortality and BPD) do not need to be downgraded due to lack of blinding, as the knowledge of the received intervention does not influence the outcome assessment.

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.

Evaluating the Effectiveness of Brief Training for Neonatal Intensive Care Nurses on the Prevention of Medical Device-Related Nasal Pressure Injury

OBJECTIVE

To evaluate the effectiveness of a brief training in medical device-related pressure injury (MDRPI) prevention for neonatal intensive care nurses.

METHODS

This single-group, pretest-posttest quasi-experimental study was conducted between April and October 2021 with 81 nurses working in the neonatal ICU of a city hospital. The participants completed a training program consisting of two 40-minute sessions that used a small-group problem-based learning approach developed in accordance with evidence-based research. Data were collected using a neonatal nurse information form, knowledge of MDRPI in preterm infants form, and training evaluation form, all of which were prepared for this study based on the literature. Data collection was performed before the training and repeated at 1 week and 1 month after the training. Data analysis was performed using the Number Cruncher Statistical System. Descriptive statistics, the Shapiro-Wilk test, Mann-Whitney U test, and Spearman correlation analysis were used.

RESULTS

The participants' mean score on the knowledge of MDRPI in premature infants form was 82.44 ± 7.26 before training and increased significantly to 94.57 ± 5.03 at 1 week and 94.67 ± 3.11 at 1 month after training (P = .001 and P = .001, respectively). No significant relationship was detected between the participants' descriptive characteristics and their knowledge scores before or after the training (P > .05).

CONCLUSIONS

Brief training on the prevention of nasal pressure injury caused by noninvasive ventilation increased nurses' knowledge level.

Predictors of CPAP failure with RAM cannula interface for primary respiratory support in preterm neonates

Background

RAM cannula is used as interface for delivering nasal continuous positive airway pressure (nCPAP) in many neonatal care units though the bench to bedside evidence for its use in clinical settings in lacking.

Methods

In this prospective cohort study from tertiary care neonatal care unit, the primary objective was to determine the rate of CPAP failure using RAM interface, within 72 h of starting of therapy and secondary objective was to look for the incidence and severity of nasal trauma with the use of RAM interface for CPAP delivery. All inborn preterm neonates between 28 and 32 weeks of gestation and weight more than 1000 g who required non-invasive respiratory support within 6 h of life were included in the study.

Results

The enroled cohort of 250 neonates had mean gestational age of 30.73 ± 1.32 weeks and mean birth weight of 1410 ± 210 g. CPAP failure rate with the use of RAM interface was 31.2% (78/250) in the overall cohort. The failure rate was higher in subgroup of gestation between 28 and 30 week (52.1%) in comparison with the 31-32-week gestation (18.2%; p-value = 0.0001). Nasal trauma was present in 36 (14%) neonates; of whom 33 (91%) had mild and 2 (6%) and 1 (3%) had moderate and severe, respectively. On multivariate analysis, birth weight less than 1250 g, incomplete antenatal steroids, need for PEEP more than 5 cm & FiO2 > 30% at onset of distress and administration of surfactant were found be statistically significantly associated with CPAP failure with RAM interface.

Conclusion

The clinical outcomes with the use of RAM interface for CPAP administration are comparable to those with other interfaces with lesser incidence of nasal injury. The results of this study warrant future randomized trials to compare different CPAP interfaces for clinical outcomes and nasal injuries from the developing countries.

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.

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.

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.

Systematic rotation versus continuous application of 'nasal prongs' or 'nasal mask' in preterm infants on nCPAP: a randomized controlled trial

To compare whether alternate rotation of nasal mask with nasal prongs every 8 h as compared to continuous use of either interface alone decreases the incidence of nasal injury in preterm infants receiving nasal Continuous Positive Airway Pressure (nCPAP). This was an open-label, three-arm, stratified randomized controlled trial where infants < 35 weeks receiving nCPAP were randomized into three groups using two different nasal interfaces (continuous prongs group, continuous mask group, and rotation group). All infants were assessed for nasal injury six hours post-removal of nCPAP using grading suggested by Fischer et al. The nursing care was uniform across all three groups. Intention-to-treat analysis was done. Fifty-seven infants were enrolled, with nineteen in each group. The incidence of nasal injury was 42.1% vs. 47.4% vs. 68.4% in the rotation group, continuous mask, and continuous prongs groups, respectively (P = 0.228). On adjusted analysis (gestational age, birth weight, and duration of nCPAP therapy), the incidence of nasal injury was significantly less in the rotation group as compared to continuous prongs group (Adjusted Odds Ratio [AOR], 95% confidence interval [CI]; 0.10 [0.01-0.69], P = 0.02) and a trend towards lesser nasal injury as compared to continuous mask group (AOR, 95% CI; 0.15 [0.02-1.08], P = 0.06). However, there was no significant difference in incidence of nasal injuries between continuous prongs versus continuous mask group (P = 0.60). The need for surfactant, nCPAP failure rate, duration of nCPAP, and common neonatal co-morbidities were similar across all three groups.   Conclusion: Systematic rotation of nasal mask with nasal prongs significantly reduced nasal injury among preterm infants on nCPAP as compared to continuous use of nasal prongs alone without affecting nCPAP failure rate.   Trial registration: CTRI/2019/01/017320, registered on 31/01/2019. What is Known: • Use of nasal mask as an interface for nasal Continuous Positive Airway Pressure decreases nasal injury as compared to nasal prongs. What is New: • Rotation of nasal prongs and nasal mask interfaces alternately every 8 h may reduce the nasal injury even further as compared to either interface alone.

Respiratory management in the premature neonate

INTRODUCTION

Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes.

AREAS COVERED

Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed.

EXPERT OPINION

Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.

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.

A Three-Arm Randomized, Controlled Trial of Different Nasal Interfaces on the Safety and Efficacy of Nasal Intermittent Positive-Pressure Ventilation in Preterm Newborns

OBJECTIVES

To compare the safety and efficacy of different nasal interfaces for delivering non invasive positive pressure ventilation (NIPPV) in preterm neonates.

METHODS

In this three-arm parallel group stratified nonblinded randomized trial involving 210 preterm neonates the participants were randomly allocated to 'nasal mask', 'nasal prongs' and '4 hourly rotation of masks and prongs' groups in a 1:1:1 ratio. The groups were further stratified by gestational age (26-31^6/7 wk versus 32-36^6/7 wk) and indication of NIPPV (primary versus post extubation). Primary outcome was incidence of NIPPV failure within 72 h of initiation. Secondary outcomes were moderate/severe nasal injury, requirement of surfactant post randomization, total duration of respiratory support, duration of NICU stay, common neonatal morbidities and mortality.

RESULTS

Primary analysis revealed that mask group was superior to prongs and rotation groups in terms of reduction in NIPPV failure within 72 h (8.6%, 24.3%, 22.8%, p = 0.033), decreased incidence of moderate/severe nasal injury (8.6%, 22.8%, 11.4% p = 0.038), decreased requirement of surfactant (20%, 38.6%, 42.8%, p = 0.01) and reduction in total duration of respiratory support [median (interquartile range)-6 (3, 10) d, 7.7 (4.9, 19.2) d, 7 (5.5, 18.5) d, p = 0.005]. Post hoc analysis confirmed that nasal mask was superior to prongs with respect to primary outcome (p = 0.012) and also reduced surfactant requirement compared to both prongs (p = 0.015) and rotation (p = 0.003) groups. Other pairwise comparisons were not statistically significant.

CONCLUSIONS

Administering NIPPV by nasal mask significantly decreases the incidence of NIPPV failure within first 72 h compared to nasal prongs and also reduces the requirement of surfactant compared to both prongs and rotation groups.

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.

Do newborn infants exhale through the CPAP system? Secondary analysis of a randomised cross-over trial

BACKGROUND

During nasal continuous positive airway pressure (nCPAP) treatment in neonates, leakage is inevitable and can lead to reduced distending pressure in the lungs of the infant. In current practice, neither leakage nor expiratory flow is measured, which makes it difficult to assess if exhalation is through the device or entirely through leakages.

OBJECTIVE

To examine if infants treated with nCPAP exhale through the CPAP system.

DESIGN AND SETTING

Secondary data analyses from the ToNIL trial on leakages during nCPAP treatment. We retrospectively examined respiratory curves for the 50 infants included in the trial, using NI LabVIEW 2015. Each infant was measured with both prongs and nasal masks. A flow recording was classified as exhalation through the system if more than 50% of all expirations showed reverse flow, each for a minimum duration of 0.1 s.

PATIENTS

50 infants were included, born with a mean gestational age (GA) of 34 weeks, median birth weight of 1948 g and mean age at measurement 6.5 days. Inclusion criteria were CPAP treatment and a postmenstrual age (PMA) of 28-42 weeks.

RESULTS

In our measurements, 32/50 infants exhaled through the CPAP system in at least one recording with either nasal mask or prongs. Leakages exceeding 0.3 L/min were seen in 97/100 recordings.

CONCLUSIONS

During nCPAP treatment, infants can exhale through the CPAP system and leakage was common. Measuring expiratory flows and leakages in clinical settings could be valuable in optimising CPAP treatment of infants.

TRIAL REGISTRATION NUMBER

NCT03586856.

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.

Interface leakage during neonatal CPAP treatment: a randomised, cross-over trial

OBJECTIVE

To determine leakage for two neonatal continuous positive airway pressure (CPAP) interfaces and evaluate leak-corrective manoeuvres.

DESIGN

The ToNIL (Trial of NCPAP Interface Leakage) study was a randomised, clinical, cross-over trial with data collection between August 2018 and October 2019. The primary outcome was blinded to the treating staff.

SETTING

One secondary, 8-bed neonatal intensive care unit (NICU) and three larger (>15 beds), academic NICU referral centres.

PATIENTS

Newborn infants with CPAP were screened (n=73), and those with stable spontaneous breathing, low oxygen requirement, postmenstrual age (PMA) over 28 weeks and no comorbidities were eligible. In total, 50 infants were included (median PMA 33 completed weeks).

INTERVENTIONS

Leakage was measured for both prongs and nasal mask, before and after leak-corrective manoeuvres. Interface application was performed in a randomised order by a nurse, blinded to the measured leakage.

MAIN OUTCOME MEASURES

30 s average leakage, measured in litres per minute (LPM).

RESULTS

Analyses showed a significantly lower leakage (mean difference 0.86 LPM, 95% CI 0.07 to 1.65) with prongs (median 2.01 LPM, IQR 1.00-2.80) than nasal mask (median 2.45 LPM, IQR 0.99-5.11). Leak-corrective manoeuvres reduced leakage significantly for both prongs (median 1.22 LPM, IQR 0.54-1.87) and nasal mask (median 2.35 LPM, IQR 0.76-4.75).

CONCLUSIONS

Large leakages were common for both interfaces, less with prongs. Simple care manoeuvres reduced leakage for both interfaces. This is the first report of absolute leakage for nasal interfaces and should encourage further studies on leakage during CPAP treatment.

[Guidelines for neonatal skin management in the neonatal intensive care unit (2021)]

Neonates are easily suffering from local or systematic infections due to their vulnerable skin barrier function, which leads to the increasing risk of death. Therefore, it is important to protect neonatal skin integrity and prevent neonatal skin injury in the neonatal intensive care unit (NICU). Based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) and current evidence, the guidelines for neonatal skin management in the NICU were developed to provide recommendations on routine skin care and prevention and treatment of iatrogenic skin injury of neonates for health care providers.

Noninvasive Respiratory Support in Neonates: A Review of Current Evidence and Practices

Respiratory distress is a common problem seen in neonates, both preterm and full term. Appropriate use of respiratory support can be life-saving in these neonates. While invasive ventilation is unavoidable in some situations, noninvasive ventilation may be sufficient in several neonates. In this review article, the authors have summarized the current evidence and the best practices to deliver effective noninvasive respiratory support.

Bubble Nasal Continuous Positive Airway Pressure (bNCPAP): An Effective Low-Cost Intervention for Resource-Constrained Settings

Preterm birth complications are responsible for almost one-third of the global neonatal mortality burden, and respiratory distress syndrome remains the single most common cause of these preventable deaths. Since its inception, almost half a century ago, nasal continuous positive airway pressure (NCPAP) has evolved to become the primary modality for neonatal respiratory care in both the developed and developing world. Although evidence has demonstrated the effectiveness of low-cost bubble NCPAP in reducing newborn mortality, its widespread use is yet to be seen in resource-constrained settings. Moreover, many tertiary hospitals in developing countries still utilise an inexpensive locally assembled bNCPAP system of unknown efficacy and safety. This review provides a brief overview of the history, physiological benefits, indications, contraindications, and complications of bNCPAP. Evidence regarding the effectiveness of low-cost bNCPAP in the neonatal intensive care unit is also summarised. The article further details a locally assembled bNCPAP system used in resource-constrained settings and highlights the care package for neonates receiving bNCPAP, failure criteria, and strategies for weaning.

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.

Basic principles of neonatal bubble CPAP: effects on CPAP delivery and imposed work of breathing when altering the original design

BACKGROUND

The original bubble continuous positive airway pressure (bCPAP) design has wide-bore tubing and a low-resistance interface. This creates a stable airway pressure that is reflected by the submersion depth of the expiratory tubing. Several systems with alterations to the original bCPAP design are now available. Most of these are aimed for use in low-income and middle-income countries and have not been compared with the original design.

OBJECTIVE

We identified three major alterations to the original bCPAP design: (1) resistance of nasal interface, (2) volume of dead space and (3) diameter of expiratory tubing. Our aim was to study the effect of these alterations on CPAP delivery and work of breathing in a mechanical lung model. Dead space should always be avoided and was not further tested.

METHODS

The effect of nasal interface resistance and expiratory tubing diameter was evaluated with simulated breathing in a mechanical lung model without interface leakage. The main outcome was delivered CPAP and imposed work of breathing.

RESULTS

High-resistance interfaces and narrow expiratory tubing increased the work of breathing. Additionally, narrow expiratory tubing resulted in higher CPAP levels than indicated by the submersion depth.

CONCLUSION

Our study shows the significant effect on CPAP delivery and imposed work of breathing when using high-resistance interfaces and narrow expiratory tubing in bCPAP systems. New systems should include low-resistance interfaces and wide-bore tubing and be compared with the original bCPAP. Referring to all systems that bubble as bCPAP is misleading and potentially hazardous.

Comparison of delivered distending pressures in the oropharynx in preterm infant on bubble CPAP and on three different nasal interfaces

OBJECTIVE

To compare the level of continuous positive airway pressure (CPAP) delivered by three different CPAP delivery interfaces (RAM cannula system, Hudson prongs, and nasal mask) in preterm neonates with respiratory distress.

METHODS

Preterm neonates with gestation between 28 weeks and 34 weeks and birth weight more than or equal to 1000 g and requiring nasal CPAP for respiratory distress were eligible for the study. During the study period, consecutive infants requiring CPAP were started on Hudson prongs or RAM cannula or nasal mask in that order. We measured the mean oropharyngeal pressure, which approximates the applied CPAP level. Oropharyngeal pressures in the recruited neonates were measured between 24 and 48 hours of postnatal age, when stable and in sleep or quiet awake state. Comparison of the delivered oropharyngeal pressures when on three different nasal interfaces at the same set flow rate and at set CPAP of 5 cm or 6 cm of H₂ O was the primary outcome.

RESULTS

Data was analyzed from 30 neonates in each group. We found that measured oropharyngeal pressures were less than set CPAP level in all three studied interfaces. Maximum drop in oropharyngeal pressure was observed with use of RAM cannula with measured oropharyngeal pressures being 1.1 and 1.2 cm H₂ O less than set CPAP of 5 and 6 cm H₂ O respectively. Pharyngeal pressure best correlated to set CPAP level with the use of nasal mask.

CONCLUSION

None of the nasal interfaces delivered oropharyngeal pressure equivalent to the set CPAP. However, nasal mask delivered oropharyngeal pressure best matched to the set CPAP.

Non-invasive Respiratory Support of the Premature Neonate: From Physics to Bench to Practice

Premature births continue to rise globally with a corresponding increase in various morbidities among this population. Rates of respiratory distress syndrome and the consequent development of Bronchopulmonary Dysplasia (BPD) are highest among the extremely preterm infants. The majority of extremely low birth weight premature neonates need some form of respiratory support during their early days of life. Invasive modes of respiratory assistance have been popular amongst care providers for many years. However, the practice of prolonged invasive mechanical ventilation is associated with an increased likelihood of developing BPD along with other comorbidities. Due to the improved understanding of the pathophysiology of BPD, and technological advances, non-invasive respiratory support is gaining popularity; whether as an initial mode of support, or for post-extubation of extremely preterm infants with respiratory insufficiency. Due to availability of a wide range of modalities, wide variations in practice exist among care providers. This review article aims to address the physical and biological basis for providing non-invasive respiratory support, the current clinical evidence, and the most recent developments in this field of Neonatology.

Practical aspects on the use of non-invasive respiratory support in preterm infants

Preterm infants frequently present with respiratory insufficiency requiring respiratory assistance. Invasive mechanical ventilation has been associated with several short and long term complications. Therefore, the practice of early use of non-invasive ventilation has been adopted. Nasal CPAP proved efficacy as an initial therapy for preterm infants. Non-invasive positive pressure ventilation is an alternative used to mitigate CPAP failure in infants with apnea or increased work of breathing. High flow nasal cannula gained popularity primarily due to the ease of its use, despite multiple prominent trials that demonstrated its inferiority. Bi-level positive airway pressure and neurally adjusted non-invasive ventilatory are used in infants with apnea and increased work of breathing. The effectiveness of non invasive ventilation tools can be augmented by having a proper protocol for initiation, weaning, skin care, positioning, and developmental care during their application.

Less invasive surfactant administration: a word of caution

Surfactant is a cornerstone of neonatal critical care, and the presumed less (or minimally) invasive techniques for its administration have been proposed to reduce invasiveness of neonatal critical care interventions. These techniques are generally known as less invasive surfactant administration (LISA) and have quickly gained popularity in some neonatal intensive care units. Despite the increase in the use of LISA, we believe that the pathobiological background supporting its possible clinical benefits is unclear. Similarly, it is unclear whether there are any ignored drawbacks, as LISA has been tested in only a few trials and some physiopathological issues seem to have gone unnoticed. Active research is warranted to fill these knowledge gaps before LISA can be firmly recommended. In this Viewpoint, we provide an in-depth analysis of LISA techniques, based on physiological and pathobiological factors, followed by a critical appraisal of available clinical data, and highlight some possible future research directions.

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.