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Chan CS, Chiu M, Ariyapadi S, Brown LS, Burchfield P, Simcik V, Garcia K, Mazioniene K, Jaleel MA, Wyckoff MH, Kapadia VS, Kakkilaya V. Evaluation of a respiratory care protocol including less invasive surfactant administration in preterm infants. Pediatr Res 2024; 95:1603-1610. [PMID: 38097721 DOI: 10.1038/s41390-023-02963-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND Respiratory care protocol including less invasive śsurfactant administration (LISA) in ≤29 weeks' gestational age (GA) infants introduced in October 2018. METHODS Retrospective study of infants admitted on continuous positive airway pressure (CPAP) October 2018 to December 2021. Maternal and neonatal variables were compared between infants managed on CPAP with and without LISA. Infants who received LISA and subsequently required mechanical ventilation (MV) within 72 h of life (HOL) [LISA failure (LF)] were compared with those who required no MV [LISA success (LS)]. RESULTS 249 infants were admitted on CPAP, 5 were intubated prior to LISA, 143 required LISA and 101 remained on CPAP without surfactant. Of those receiving LISA, 108 were LS and 35 were LF. Compared to LS, LF infants were of lower GA and birth weight, required higher fractional inspired oxygen (FiO2), and CPAP level at birth, admission, one HOL, and an hour after LISA. Moreover, LF infants had higher mortality and morbidity. Together GA ≤ 25 weeks' and FiO2 ≥ 0.3 an hour after LISA best predicted LF. CONCLUSIONS Over 80% of infants admitted on CPAP avoided MV within 72 HOL. Early predictors of LF provide targets for future interventions to decrease need for MV in preterm infants. IMPACT Less invasive surfactant administration (LISA) decreases the need for mechanical ventilation (MV) and improves outcomes. However, some infants require MV within 72 h of life (HOL) despite LISA (LISA failure). Over 80% of ≤29 weeks' gestational age (GA) infants can be successfully managed on CPAP with or without surfactant in the first 72 HOL. A combination of factors including ≤25 weeks' GA and fraction of inspired oxygen ≥0.3 an hour after LISA predict LISA failure. Evaluation of a noninvasive respiratory support strategy including LISA provides targets for intervention to decrease need for MV in preterm infants.
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Affiliation(s)
- Christina S Chan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Melody Chiu
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Swathi Ariyapadi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Patti Burchfield
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kristi Garcia
- Parkland Health and Hospital System, Dallas, TX, USA
| | | | | | - Myra H Wyckoff
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vishal S Kapadia
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Huang TR, Chen HL, Yang ST, Su PC, Chung HW. The Outcomes of Preterm Infants with Neonatal Respiratory Distress Syndrome Treated by Minimally Invasive Surfactant Therapy and Non-Invasive Ventilation. Biomedicines 2024; 12:838. [PMID: 38672192 PMCID: PMC11048199 DOI: 10.3390/biomedicines12040838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
In recent years, the utilization of minimally invasive surfactant therapy (MIST) and Non-invasive ventilation (NIV) as the primary respiratory assistance has become increasingly prevalent among preterm infants with neonatal respiratory distress syndrome (RDS). This study aims to compare the outcomes between MIST administered with nasal continuous positive airway pressure (NCPAP) versus nasal intermittent positive pressure ventilation (NIPPV), with the objective of exploring the respiratory therapeutic benefits of these two approaches. This retrospective study collected data from the neonatal intensive care unit of Kaohsiung Medical University Hospital spanning from January 2016 to June 2021. Infants were divided into two groups based on the type of NIV utilized. The NCPAP group comprised 32 infants, while the NIPPV group comprised 22 infants. Statistical analysis revealed significant differences: the NIPPV group had a smaller gestational age, lower birth weight, higher proportion of female infants, and earlier initiation of MIST. Additionally, the NIPPV group exhibited higher incidence rates of retinopathy of prematurity, longer respiratory support duration, prolonged hospitalization, and mortality. However, upon adjustment, these differences were not statistically significant. Analysis of venous blood gas and respiratory parameter changes indicated that both the NCPAP and NIPPV groups experienced improvements in oxygenation and ventilation following MIST.
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Affiliation(s)
- Tzyy-Rong Huang
- Respiratory Therapy Team, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan;
| | - Hsiu-Lin Chen
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Shu-Ting Yang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
| | - Pin-Chun Su
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
| | - Hao-Wei Chung
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
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Ristovska S. Respiratory Distress Syndrome (RDS) in Newborns with Hypoxic-Ischemic Encephalopathy (HIE). Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2024; 45:19-30. [PMID: 38575384 DOI: 10.2478/prilozi-2024-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Respiratory distress syndrome (RDS) and hypoxic-ischemic encephalopathy (HIE) are frequent causes of death and disability in neonates. This study included newborns between January 2021 and July 2022 at the University Clinic for Gynecology and Obstetrics, Skopje. Up to date criteria for HIE/RDS for term and for preterm infants as well for the severity of HIE/RDS were used in a comprehensive analysis of cranial ultrasonography, neurological status, neonatal infections, Apgar score, bradycardia and hypotension, X-ray of the lungs, FiO2, acid-base status, assisted ventilation and use of surfactant. Three groups were created: HIE with RDS (42 babies), HIE without RDS (30 babies) and RDS without HIE in 38 neonates. All newborns with severe (third) degree of HIE died. Intracranial bleeding was found in 35.7% in the first group and 30% in the second group, and in the third group in 53.3%. The need for surfactant in the HIE group with RDS is 59.5%, and in the RDS group without HIE 84.2%. DIC associated with sepsis was found in 13.1-50% in those groups. In newborns with HIE and bradycardia, the probability of having RDS was on average 3.2 times higher than in those without bradycardia. The application of the surfactant significantly improved the pH, pO2, pCO2, BE and chest X-ray in children with RDS. An Apgar score less than 6 at the fifth minute increases the risk of RDS by 3 times. The metabolic acidosis in the first 24 hours increases the risk of death by 23.6 times. The combination of HIE/ RDS significantly worsens the disease outcome. The use of scoring systems improved the early detection of high risk babies and initiation of early treatment increased the chances for survival without disabilities.
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Affiliation(s)
- Sanja Ristovska
- PJU University Clinic for Gynecology and Obstetrics, Faculty of Medicine, University of "St. Cyril and Methodius", Skopje, RN Macedonia
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Manley BJ, Cripps E, Dargaville PA. Non-invasive versus invasive respiratory support in preterm infants. Semin Perinatol 2024; 48:151885. [PMID: 38570268 DOI: 10.1016/j.semperi.2024.151885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Respiratory insufficiency is almost ubiquitous in infants born preterm, with its incidence increasing with lower gestational age. A wide range of respiratory support management strategies are available for these infants, separable into non-invasive and invasive forms of respiratory support. Here we review the history and evolution of respiratory care for the preterm infant and then examine evidence that has emerged to support a non-invasive approach to respiratory management where able. Continuous positive airway pressure (CPAP) is the non-invasive respiratory support mode currently with the most evidence for benefit. CPAP can be delivered safely and effectively and can commence in the delivery room. Particularly in early life, time spent on non-invasive respiratory support, avoiding intubation and mechanical ventilation, affords benefit for the preterm infant by virtue of a lessening of lung injury and hence a reduction in incidence of bronchopulmonary dysplasia. In recent years, enthusiasm for application of non-invasive support has been further bolstered by new techniques for administration of exogenous surfactant. Methods of less invasive surfactant delivery, in particular with a thin catheter, have allowed neonatologists to administer surfactant without resort to endotracheal intubation. The benefits of this approach appear to be sustained, even in those infants subsequently requiring mechanical ventilation. This cements the notion that any reduction in exposure to mechanical ventilation leads to alleviation of injury to the vulnerable preterm lung, with a long-lasting effect. Despite the clear advantages of non-invasive respiratory support, there will continue to be a role for intubation and mechanical ventilation in some preterm infants, particularly for those born <25 weeks' gestation. It is currently unclear what role early non-invasive support has in this special population, with more studies required.
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Affiliation(s)
- Brett J Manley
- Neonatal Services and Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics, Gynecology and Newborn Health, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Emily Cripps
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia
| | - Peter A Dargaville
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
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Tourneux P, Debillon T, Flamant C, Jarreau PH, Serraz B, Guellec I. Early factors associated with continuous positive airway pressure failure in moderate and late preterm infants. Eur J Pediatr 2023; 182:5399-5407. [PMID: 37750912 PMCID: PMC10746609 DOI: 10.1007/s00431-023-05090-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/20/2023] [Accepted: 06/27/2023] [Indexed: 09/27/2023]
Abstract
To determine the early factors associated with continuous positive airway pressure (CPAP) failure in moderate-to-late preterm infants (32 + 0/7 to 36 + 6/7 weeks' gestation) from the NEOBS cohort study. The NEOBS study was a multi-center, prospective, observational study in 46 neonatal intensive care units in France, which included preterm and late preterm infants with early neonatal respiratory distress. This analysis included a subset of the NEOBS population who had respiratory distress and required ventilatory support with CPAP within the first 24 h of life. CPAP failure was defined as the need for tracheal intubation within 72 h of CPAP initiation. Maternal and neonatal clinical parameters in the delivery room and clinical data at 3 h of life were analyzed. CPAP failure occurred in 45/375 infants (12%), and compared with infants with CPAP success, they were mostly singletons (82.2% vs. 62.1%; p < 0.01), had a lower Apgar score at 10 min of life (9.1 ± 1.3 vs. 9.6 ± 0.8; p = 0.02), and required a higher fraction of inspired oxygen (FiO2; 34.4 ± 15.9% vs. 22.8 ± 4.1%; p < 0.0001) and a higher FiO2*positive end-expiratory pressure (PEEP) (1.8 ± 0.9 vs. 1.1 ± 0.3; p < 0.0001) at 3 h. FiO2 value of 0.23 (R2 = 0.73) and FiO2*PEEP of 1.50 (R2 = 0.75) best predicted CPAP failure. The risk of respiratory distress and early CPAP failure decreased 0.7 times per 1-week increase in gestational age and increased 1.7 times with every one-point decrease in Apgar score at 10 min and 19 times with FiO2*PEEP > 1.50 (vs. ≤ 1.50) at 3 h (R2 of the overall model = 0.83). Conclusion: In moderate-to-late preterm infants, the combination of singleton pregnancy, lower Apgar score at 10 min, and FiO2*PEEP > 1.50 at 3 h can predict early CPAP failure with increased accuracy. What is Known: •Respiratory distress syndrome (RSD) represents an unmet medical need in moderate-to-late preterm births and is commonly treated with continuous positive airway pressure (CPAP) to reduce mortality and the need for additional ventilatory support. • Optimal management of RSD is yet to be established, with several studies suggesting that identification of predictive factors for CPAP failure can aid in the prompt treatment of infants likely to experience this failure. What is New: •Secondary analysis of the observational NEOBS study indicated that oxygen requirements during CPAP therapy, especially the product of fraction of inspired oxygen (FiO2) and positive end-expiratory pressure (PEEP), are important factors associated with early CPAP failure in moderate-to-late term preterm infants. •The combination of a singleton pregnancy, low Apgar score at 10 minutes, and high FiO2*PEEP at 3 hours can predict early CPAP failure with increased accuracy, highlighting important areas for future research into the prevention of CPAP failure.
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Affiliation(s)
- Pierre Tourneux
- Neonatal Intensive Care Unit, University Hospital Center of Amiens, Jules Verne University of Picardy, Amiens, France.
| | - Thierry Debillon
- Neonatology Intensive Care Unit, University Hospital of Grenoble, Grenoble, France
| | - Cyril Flamant
- Neonatal Intensive Care Unit, University Hospital of Nantes, Nantes, France
| | - Pierre-Henri Jarreau
- Neonatal Intensive Care Unit of Port-Royal, AP-HP,, University of Paris , Paris, France
| | | | - Isabelle Guellec
- Neonatal and Paediatric Intensive Care Unit, University Hospital of L'Archet, Nice, France
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Kloonen RMJS, Varisco G, de Kort E, Andriessen P, Niemarkt HJ, van Pul C. Predicting CPAP failure after less invasive surfactant administration (LISA) in preterm infants by machine learning model on vital parameter data: a pilot study. Physiol Meas 2023; 44:115005. [PMID: 37939392 DOI: 10.1088/1361-6579/ad0ab6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/07/2023] [Indexed: 11/10/2023]
Abstract
Objective. Less invasive surfactant administration (LISA) has been introduced to preterm infants with respiratory distress syndrome on continuous positive airway pressure (CPAP) support in order to avoid intubation and mechanical ventilation. However, after this LISA procedure, a significant part of infants fails CPAP treatment (CPAP-F) and requires intubation in the first 72 h of life, which is associated with worse complication free survival chances. The aim of this study was to predict CPAP-F after LISA, based on machine learning (ML) analysis of high resolution vital parameter monitoring data surrounding the LISA procedure.Approach. Patients with a gestational age (GA) <32 weeks receiving LISA were included. Vital parameter data was obtained from a data warehouse. Physiological features (HR, RR, peripheral oxygen saturation (SpO2) and body temperature) were calculated in eight 0.5 h windows throughout a period 1.5 h before to 2.5 h after LISA. First, physiological data was analyzed to investigate differences between the CPAP-F and CPAP-Success (CPAP-S) groups. Next, the performance of two types of ML models (logistic regression: LR, support vector machine: SVM) for the prediction of CPAP-F were evaluated.Main results. Of 51 included patients, 18 (35%) had CPAP-F. Univariate analysis showed lower SpO2, temperature and heart rate variability (HRV) before and after the LISA procedure. The best performing ML model showed an area under the curve of 0.90 and 0.93 for LR and SVM respectively in the 0.5 h window directly after LISA, with GA, HRV, respiration rate and SpO2as most important features. Excluding GA decreased performance in both models.Significance. In this pilot study we were able to predict CPAP-F with a ML model of patient monitor signals, with best performance in the first 0.5 h after LISA. Using ML to predict CPAP-F based on vital signals gains insight in (possibly modifiable) factors that are associated with LISA failure and can help to guide personalized clinical decisions in early respiratory management.
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Affiliation(s)
- R M J S Kloonen
- Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands
- Maxima Medical Centre Veldhoven, Department of Clinical Physics, Po Box 7777, 5600 MB, The Netherlands
| | - G Varisco
- Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands
| | - E de Kort
- Maxima Medical Centre Veldhoven, Department of Pediatrics, Po Box 7777, 5600 MB, The Netherlands
| | - P Andriessen
- Maxima Medical Centre Veldhoven, Department of Pediatrics, Po Box 7777, 5600 MB, The Netherlands
| | - H J Niemarkt
- Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands
- Maxima Medical Centre Veldhoven, Department of Pediatrics, Po Box 7777, 5600 MB, The Netherlands
| | - C van Pul
- Eindhoven University of Technology, PO Box 513, 5600 MB Eindhoven, The Netherlands
- Maxima Medical Centre Veldhoven, Department of Clinical Physics, Po Box 7777, 5600 MB, The Netherlands
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Raimondi F, Dolce P, Veropalumbo C, Sierchio E, Gregorio Hernandez R, Rodriguez Fanjul J, Meneghin F, Raschetti R, Bonadies L, Corsini I, Alonso Ojembarrena A, Salomè S, Rodeño Fernandez L, Sanchez Luna M, Lista G, Mosca F, Dani C, Baraldi E, Giordano L, Davis PG, Capasso L. External Validation of a Multivariate Model for Targeted Surfactant Replacement. Neonatology 2023; 121:17-24. [PMID: 37883936 DOI: 10.1159/000532083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/11/2023] [Indexed: 10/28/2023]
Abstract
INTRODUCTION Early targeted surfactant therapy for preterm infants is recommended but the best criteria to personalize treatment are unclear. We validate a previously published multivariate prognostic model based on gestational age (GA), lung ultrasound score (LUS), and oxygen saturation to inspire oxygen fraction ratio (SatO2/FiO2) using an independent data set. METHODS Pragmatic, observational study in 10 Italian and Spanish NICUs, including preterm babies (250 and 336 weeks divided into 3 GA intervals) with clinical signs of respiratory distress syndrome and stabilized on CPAP. LUS and SatO2/FiO2 were collected soon after stabilization. Their prognostic accuracy was evaluated on the subsequent surfactant administration by a rigorously masked physician. RESULTS One hundred seventy-five infants were included in the study. Surfactant was given to 74% infants born at 25-27 weeks, 38.5% at 28-30 weeks, and 26.5% at 31-33 weeks. The calibration curve comparing the validation and the development populations showed significant overlap with an intercept = 0.08, 95% CI (-0.34; 0.5) and a slope = 1.53, 95% CI (1.07-1.98). The validation cohort had a high predictive accuracy. Its ROC curve showed an AUC = 0.95, 95% CI (0.91-0.99) with sensitivity = 0.93, 95% CI (0.83-0.98), specificity = 0.81, 95% CI (0.73-0.88), PPV = 0.76, 95% CI (0.65-0.84), NPV = 0.95, 95% CI (0.88-0.98). LUS ≥9 demonstrated the highest sensitivity (0.91, 95% CI [0.82-0.97]) and specificity = 0.81, 95% CI (0.72-0.88) as individual predictor. LUS and SatO2/FiO2 prognostic performances varied with GA. CONCLUSION We validated a prognostic model based on LUS and Sat/FiO2 to facilitate early, customized surfactant administration that may improve respiratory management of preterm neonates.
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Affiliation(s)
- Francesco Raimondi
- Division of Neonatology, Department of Translational Medical Sciences, Naples, Italy
| | - Pasquale Dolce
- Department of Public Health, Università Federico II di Napoli, Naples, Italy
| | - Claudio Veropalumbo
- Division of Neonatology, Department of Translational Medical Sciences, Naples, Italy
| | | | - Rebeca Gregorio Hernandez
- Neonatology Division, Instituto de Investigación Sanitaria Hospital General Universitario Gregorio Marañón, Complutense University of Madrid, Madrid, Spain
| | - Javier Rodriguez Fanjul
- Neonatal Intensive Care Unit, Department of Paediatrics, Hospital Germans Triasi Pujol, Autonomous University of Barcelona, Badalona, Spain
| | | | - Roberto Raschetti
- Department of Clinical Sciences and Community Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Luca Bonadies
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Iuri Corsini
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | | | - Serena Salomè
- Division of Neonatology, Department of Translational Medical Sciences, Naples, Italy
| | | | - Manuel Sanchez Luna
- Neonatology Division, Instituto de Investigación Sanitaria Hospital General Universitario Gregorio Marañón, Complutense University of Madrid, Madrid, Spain
| | | | - Fabio Mosca
- Department of Clinical Sciences and Community Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Eugenio Baraldi
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | | | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Letizia Capasso
- Division of Neonatology, Department of Translational Medical Sciences, Naples, Italy
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Bhandari V, Black R, Gandhi B, Hogue S, Kakkilaya V, Mikhael M, Moya F, Pezzano C, Read P, Roberts KD, Ryan RM, Stanford RH, Wright CJ. RDS-NExT workshop: consensus statements for the use of surfactant in preterm neonates with RDS. J Perinatol 2023; 43:982-990. [PMID: 37188774 PMCID: PMC10400415 DOI: 10.1038/s41372-023-01690-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To provide the best clinical practice guidance for surfactant use in preterm neonates with respiratory distress syndrome (RDS). The RDS-Neonatal Expert Taskforce (RDS-NExT) initiative was intended to add to existing evidence and clinical guidelines, where evidence is lacking, with input from an expert panel. STUDY DESIGN An expert panel of healthcare providers specializing in neonatal intensive care was convened and administered a survey questionnaire, followed by 3 virtual workshops. A modified Delphi method was used to obtain consensus around topics in surfactant use in neonatal RDS. RESULT Statements focused on establishing RDS diagnosis and indicators for surfactant administration, surfactant administration methods and techniques, and other considerations. After discussion and voting, consensus was achieved on 20 statements. CONCLUSION These consensus statements provide practical guidance for surfactant administration in preterm neonates with RDS, with a goal to contribute to improving the care of neonates and providing a stimulus for further investigation to bridge existing knowledge gaps.
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Affiliation(s)
- Vineet Bhandari
- The Children's Regional Hospital at Cooper/Cooper Medical School of Rowan University, Camden, NJ, USA.
| | | | - Bheru Gandhi
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | | | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Fernando Moya
- Division of Wilmington Pediatric Subspecialists, Department of Pediatrics, UNC School of Medicine, Wilmington, NC, USA
| | - Chad Pezzano
- Department of Cardio-Respiratory Services Pediatric -Albany Medical Center, Albany, NY, USA
| | - Pam Read
- AESARA Inc., Chapel Hill, NC, USA
| | | | - Rita M Ryan
- UH Rainbow Babies and Children's Hospital -Case Western Reserve University, Cleveland, OH, USA
| | | | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA
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Abdallah Y, Mkony M, Noorani M, Moshiro R, Bakari M, Manji K. CPAP failure in the management of preterm neonates with respiratory distress syndrome where surfactant is scarce. A prospective observational study. BMC Pediatr 2023; 23:211. [PMID: 37138252 PMCID: PMC10155133 DOI: 10.1186/s12887-023-04038-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/26/2023] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The mainstay in the management of preterm neonates with respiratory distress syndrome (RDS) include early Continuous Positive Airway Pressure (CPAP), timely surfactant replacement and mechanical ventilation. Preterm neonates with RDS who fail CPAP are at higher risk for chronic lung disease as well as death. Unfortunately, in low resource settings CPAP may be the only treatment available for these neonates. OBJECTIVE To determine the prevalence of CPAP failure among premature newborns with RDS and associated factors. METHODS We conducted a prospective observational study over the first 72 h of life on 174 preterm newborns with RDS receiving CPAP at Muhimbili National Hospital (MNH). At MNH newborns with Silverman Andersen Score (SAS) of ≥ 3 are commenced on CPAP; surfactant and mechanical ventilation are very scarce. Study newborns not maintaining oxygen saturation > 90% or with SAS score ≥ 6 despite being on 50% oxygen and PEEP of 6 cmH2O and those with > 2 episodes of apnoea needing stimulation or positive pressure ventilation in 24 h were considered as CPAP failure. The prevalence of CPAP failure was determined as a percentage and factors associated were determined by logistic regression. A p-value of < 0.05 was considered significant and 95% confidence interval was used. RESULTS Of the enrolled newborns, 48% were male and 91.4% were in-born. The mean gestational age and weight were 29 weeks (range 24-34 weeks) and 1157.7 g (range 800-1500 g) respectively. Of the mothers 44 (25%) received antenatal corticosteroids. Overall CPAP failure was 37.4% and among those weighing ≤ 1200g, it was 44.1% . Most failure occurred within the first 24 h. No factor was identified to be independently associated with CPAP failure. Mortality among those who failed CPAP was 33.8% and 12.8% among those who did not. CONCLUSIONS In resource limited settings like ours with low up take of antenatal corticosteroids and scarce surfactant replacement a significant portion of preterm neonates especially those weighing ≤ 1200 g with RDS fail CPAP therapy.
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Affiliation(s)
- Yaser Abdallah
- Department of Paediatrics and Child Health, Aga Khan University, P.o Box 38129, Dar es Salaam, Tanzania.
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda.
| | - Martha Mkony
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mariam Noorani
- Department of Paediatrics and Child Health, Aga Khan University, P.o Box 38129, Dar es Salaam, Tanzania
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Robert Moshiro
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Mohamed Bakari
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Karim Manji
- Department of Paediatrics and Child Health, Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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10
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Capasso L, Pacella D, Migliaro F, Salomè S, Grasso F, Corsini I, De Luca D, Davis PG, Raimondi F. Can lung ultrasound score accurately predict surfactant replacement? A systematic review and meta-analysis of diagnostic test studies. Pediatr Pulmonol 2023; 58:1427-1437. [PMID: 36717970 DOI: 10.1002/ppul.26337] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/30/2022] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinical and radiographic criteria are traditionally used to determine the need for surfactant therapy in preterm infants. Lung ultrasound is a bedside test that offers a rapid, radiation-free, alternative to this approach. OBJECTIVE To conduct a systematic review and meta-analysis to determine the accuracy of a lung ultrasound score (LUS) in identifying infants who would receive at least one surfactant dose. Secondary aims were to evaluate the predictive accuracy for ≥2 doses and the accuracy of a different image classification system based on three lung ultrasound profiles. METHODS PubMed, SCOPUS, Biomed Central, and the Cochrane library between January 2011 and December 2021 were searched. Full articles enrolling preterm neonates who underwent lung ultrasound to predict surfactant administration were assessed and analyzed following Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) and QUADAS-2 guidelines. RESULTS Seven prospective studies recruiting 697 infants met the inclusion criteria. Risk of bias was generally low. Oxygen requirement, clinical and radiographic signs of respiratory distress syndrome were used as reference standards for surfactant replacement. The summary receiver operator characteristic (sROC) curve for LUS predicting first surfactant dose showed an area under the curve (AUC) = 0.88 (95% confidence interval [CI]: 0.82-0.91); optimal specificity and sensitivity (Youden index) were 0.83 and 0.81 respectively. Pooled estimates of sensitivity, specificity, diagnostic odds ratio, negative predictive value, and positive predictive value for LUS predicting the first surfactant dose were 0.89 (0.82-0.95), 0.86 (0.78-0.95), 3.78 (3.05-4.50), 0.92 (0.87-0.97), 0.79 (0.65-0.92). The sROC curve for the accuracy of Type 1 lung profile in predicting first surfactant dose showed an AUC of 0.88; optimal specificity and sensitivity were both 0.86. Two studies addressing the predictive accuracy of LUS for ≥2 surfactant doses had high heterogeneity and were unsuitable to combine in a meta-analysis. DISCUSSION Despite current significant variation in LUS thresholds, lung ultrasound is highly predictive of the need for early surfactant replacement. This evidence was derived from studies with homogeneous patient characteristics and low risk of bias.
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Affiliation(s)
- Letizia Capasso
- Division of Neonatology, Department of Translational Medical Sciences, Università Federico II di Napoli, Naples, Italy
| | - Daniela Pacella
- Department of Public Health, Università Federico II di Napoli, Naples, Italy
| | - Fiorella Migliaro
- Division of Neonatology, Department of Translational Medical Sciences, Università Federico II di Napoli, Naples, Italy
| | - Serena Salomè
- Division of Neonatology, Department of Translational Medical Sciences, Università Federico II di Napoli, Naples, Italy
| | - Fiorentino Grasso
- Division of Neonatology, Department of Translational Medical Sciences, Università Federico II di Napoli, Naples, Italy
| | - Iuri Corsini
- Careggi Hospital, Università di Firenze, Florence, Italy
| | - Daniele De Luca
- Service de Pediatrie et Reanimation Neonatale Hopital "A. Beclere"-Paris Saclay University Hospitals, APHP, Paris, France
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Francesco Raimondi
- Division of Neonatology, Department of Translational Medical Sciences, Università Federico II di Napoli, Naples, Italy
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11
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Sweet DG. When to treat with surfactant? Arch Dis Child Fetal Neonatal Ed 2023:archdischild-2022-325061. [PMID: 37185271 DOI: 10.1136/archdischild-2022-325061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023]
Affiliation(s)
- David G Sweet
- Neonatal Unit, Royal Maternity Hospital, Belfast, Belfast, UK
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12
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Im JE, Park S, Kim YJ, Yoon SA, Lee JH. Predicting the need for intubation within 3 h in the neonatal intensive care unit using a multimodal deep neural network. Sci Rep 2023; 13:6213. [PMID: 37069174 PMCID: PMC10106895 DOI: 10.1038/s41598-023-33353-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 04/12/2023] [Indexed: 04/19/2023] Open
Abstract
Respiratory distress is a common chief complaint in neonates admitted to the neonatal intensive care unit. Despite the increasing use of non-invasive ventilation in neonates with respiratory difficulty, some of them require advanced airway support. Delayed intubation is associated with increased morbidity, particularly in urgent unplanned cases. Early and accurate prediction of the need for intubation may provide more time for preparation and increase safety margins by avoiding the late intubation at high-risk infants. This study aimed to predict the need for intubation within 3 h in neonates initially managed with non-invasive ventilation for respiratory distress during the first 48 h of life using a multimodal deep neural network. We developed a multimodal deep neural network model to simultaneously analyze four time-series data collected at 1-h intervals and 19 variables including demographic, physiological and laboratory parameters. Evaluating the dataset of 128 neonates with respiratory distress who underwent non-invasive ventilation, our model achieved an area under the curve of 0.917, sensitivity of 85.2%, and specificity of 89.2%. These findings demonstrate promising results for the multimodal model in predicting neonatal intubation within 3 h.
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Affiliation(s)
- Jueng-Eun Im
- Biomedical Engineering, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Seung Park
- Biomedical Engineering, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Yoo-Jin Kim
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Chungdae-ro 1, Seowon-gu, Cheongju, 28644, Republic of Korea
| | - Shin Ae Yoon
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Chungdae-ro 1, Seowon-gu, Cheongju, 28644, Republic of Korea.
| | - Ji Hyuk Lee
- Department of Pediatrics, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Chungdae-ro 1, Seowon-gu, Cheongju, 28644, Republic of Korea
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13
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Kakkilaya V, Gautham KS. Should less invasive surfactant administration (LISA) become routine practice in US neonatal units? Pediatr Res 2023; 93:1188-1198. [PMID: 35986148 PMCID: PMC9389478 DOI: 10.1038/s41390-022-02265-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
The harmful effects of mechanical ventilation (MV) on the preterm lung are well established. Avoiding MV at birth and stabilization on continuous positive airway pressure (CPAP) decreases the composite outcome of death or bronchopulmonary dysplasia. Although preterm infants are increasingly being admitted to the neonatal intensive care unit on CPAP, centers differ in the ability to manage infants primarily on CPAP. Over the last decade, less invasive surfactant administration (LISA), a method of administering surfactant with a thin catheter, has been devised and has been shown to decrease the need for MV and improve outcomes compared to surfactant administration via an endotracheal tube following intubation. While LISA has been widely adopted in Europe and other countries, its use is not widespread in the United States. This article provides a summary of the existing evidence on LISA, and practical guidance for US units choosing to implement a change of practice incorporating optimization of CPAP and LISA. IMPACT: The accumulated body of evidence for less invasive surfactant administration (LISA), a widespread practice in other countries, justifies its use as an alternative to intubation and surfactant administration in US neonatal units. This article summarizes the current evidence for LISA, identifies gaps in knowledge, and offers practical tips for the implementation of LISA as part of a comprehensive non-invasive respiratory support strategy. This article will help neonatal units in the US develop guidelines for LISA, provide optimal respiratory support for infants with respiratory distress syndrome, improve short- and long-term outcomes of preterm infants, and potentially decrease costs of NICU care.
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Affiliation(s)
- Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Kanekal Suresh Gautham
- Division of Neonatology, Department of Pediatrics, Nemours Children's Health, Orlando, FL, USA
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14
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Ishigami AC, Meneses J, Alves JG, Carvalho J, Cavalcanti E, Bhandari V. Nasal intermittent positive pressure ventilation as a rescue therapy after nasal continuous positive airway pressure failure in infants with respiratory distress syndrome. J Perinatol 2023; 43:311-316. [PMID: 36631566 DOI: 10.1038/s41372-023-01600-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 12/11/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Evaluate whether nasal intermittent positive-pressure ventilation (NIPPV) as rescue therapy after initial nasal continuous positive airway (NCPAP) failure reduces need for invasive mechanical ventilation (IMV) in infants with respiratory distress syndrome (RDS). DESIGN Retrospective cohort involving 156 preterm infants who failed initial NCPAP and were then submitted to NIPPV rescue therapy and classified into NIPPV success or failure, according to need for IMV. RESULT Of all infants included, 85 (54.5%) were successfully rescued with NIPPV while 71 (45.5%) failed. The NIPPV success group had significantly lower rates of bronchopulmonary dysplasia, peri/intraventricular hemorrhage, patent ductus arteriosus and greater survival without morbidities (all p ≤ 0.01). Infants who failed NIPPV had earlier initial NCPAP failure (p = 0.09). In final logistic regression model, birthweight ≤1000 g and need for surfactant remained significant factors for NIPPV failure. CONCLUSION NIPPV rescue therapy reduced the need for IMV in infants that failed NCPAP and was associated with better outcomes.
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Affiliation(s)
- Ana Catarina Ishigami
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Jucille Meneses
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil.
| | - João Guilherme Alves
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Juliana Carvalho
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Emídio Cavalcanti
- Division of Neonatology, Instituto de Medicina Integral Professor Fernando Figueira, IMIP, Recife, Brazil
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper, Camden, NJ, USA.,Cooper Medical School of Rowan University, Camden, NJ, USA
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15
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 115] [Impact Index Per Article: 115.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help 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 by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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16
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Boix H, Fernández C, Serrano Martín MDM, Arruza L, Concheiro A, Gimeno A, Sánchez A, Rite S, Jiménez F, Méndez P, Agüera JJ. Failure of early non-invasive ventilation in preterm infants with respiratory distress syndrome in current care practice in Spanish level-III neonatal intensive care units - a prospective observational study. Front Pediatr 2023; 11:1098971. [PMID: 36896404 PMCID: PMC9989254 DOI: 10.3389/fped.2023.1098971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Despite advances in respiratory distress syndrome (RDS) management over the past decade, non-invasive ventilation (NIV) failure is frequent and associated with adverse outcomes. There are insufficient data on the failure of different NIV strategies currently used in clinical practice in preterm infants. Methods This was a prospective, multicenter, observational study of very preterm infants [gestational age (GA) <32 weeks] admitted to the neonatal intensive care unit for RDS that required NIV from the first 30 min after birth. The primary outcome was the incidence of NIV failure, defined as the need for mechanical ventilation for <72 h of life. Secondary outcomes were risk factors associated with NIV failure and complication rates. Results The study included 173 preterm infants with a median GA of 28 (IQR 27-30) weeks and a median birth weight of 1,100 (IQR 800-1,333) g. The incidence of NIV failure was 15.6%. In the multivariate analysis, lower GA (OR, 0.728; 95% CI, 0.576-0.920) independently increased the risk of NIV failure. Compared to NIV success, NIV failure was associated with higher rates of unfavorable outcomes, including pneumothorax, intraventricular hemorrhage, periventricular leukomalacia, pulmonary hemorrhage, and a combined outcome of moderate-to-severe bronchopulmonary dysplasia or death. Conclusion NIV failure occurred in 15.6% of the preterm neonates and was associated with adverse outcomes. The use of LISA and newer NIV modalities most likely accounts for the reduced failure rate. Gestational age remains the best predictor of NIV failure and is more reliable than the fraction of inspired oxygen during the first hour of life.
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Affiliation(s)
- Hector Boix
- Division of Neonatology, Hospital Universitario Dexeus, Barcelona, Spain
| | - Cristina Fernández
- Department of Neonatology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Luis Arruza
- Department of Neonatology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ana Concheiro
- Department of Neonatology, Álvaro Cunqueiro University Hospital, Vigo, Spain
| | - Ana Gimeno
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Ana Sánchez
- Department of Neonatology, Hospital Universitario La Paz, Madrid, Spain
| | - Segundo Rite
- Division of Neonatology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Francisco Jiménez
- Department of Neonatology and Neonatal Intensive Care Unit, Hospital Infantil Universitario Virgen del Rocio, Seville, Spain
| | - Paula Méndez
- Division of Paediatrics, Section of Neonatology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Juan José Agüera
- Department of Paediatrics, Neonatology Section, Virgen de la Arrixaca, University Hospital, Murcia, Spain
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17
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Federici C, Fornaro G, Roehr CC. Cost-saving effect of early less invasive surfactant administration versus continuous positive airway pressure therapy alone for preterm infants with respiratory distress syndrome. Eur J Hosp Pharm 2022; 29:346-352. [PMID: 33658228 PMCID: PMC9614139 DOI: 10.1136/ejhpharm-2020-002465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/22/2020] [Accepted: 02/09/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Early rescue surfactant therapy using less invasive surfactant administration (LISA) can reduce the need for mechanical ventilation and avoid complications in preterm infants with respiratory distress syndrome. The purpose of this study was to estimate the budget impact of LISA compared with management based on continuous positive airway pressure (CPAP) alone and rescue surfactant therapy in case of CPAP failure. METHODS A budget impact model was built comparing LISA with CPAP alone in order to estimate the potential resource consumption and budget impact from the perspective of the National Health Service in England. A literature review was conducted to populate the model. Deterministic and probabilistic sensitivity analyses were conducted to characterise the existing uncertainty and to explore the contribution of individual model parameters to the overall budget impact. RESULTS Early rescue with LISA is expected to reduce resource consumption and costs compared with conservative therapy based on CPAP alone for preterm infants born at 25-32 weeks gestation. Savings are higher for preterm infants of 25-28 weeks (expected budget impact -£5146 per case, 95% credible interval (CrI) -£22 403 to £13, probability of being cost saving 97.4%) than for preterm infants of 29-32 weeks (-£176, 95% CrI -£4279 to £339, probability of being cost saving 85%). The impact of bronchopulmonary dysplasia (BPD) and intraventricular haemorrhage on resource consumption and the expected reduction in the incidence of BPD with LISA are the most influential parameters on the budget. CONCLUSIONS Early rescue with LISA used in preterm infants with respiratory distress syndrome and fraction of inspired oxygen ≥0.3 is expected to be cost saving compared with management based on CPAP alone, particularly in those born at 25-28 weeks gestation.
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Affiliation(s)
- Carlo Federici
- CERGAS - Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milano, Lombardia, Italy
| | - Giulia Fornaro
- CERGAS - Centre for Research on Health and Social Care Management, SDA Bocconi School of Management, Milano, Lombardia, Italy
| | - Charles Christopher Roehr
- Department of Paediatrics, Medical Sciences Division, University of Oxford, Oxford, UK
- Newborn Services, Women's Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
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18
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Wright CJ, Glaser K, Speer CP, Härtel C, Roehr CC. Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools? J Pediatr 2022; 247:138-146. [PMID: 35429507 DOI: 10.1016/j.jpeds.2022.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/27/2021] [Accepted: 04/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Charles C Roehr
- Southmead Hospital, North Bristol NHS Trust, University of Bristol, Dept. Pediatrics, Faculty of Health Science, Bristol, UK; National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford Oxfordshire, UK.
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19
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Wang L, Li J, Yu Y, Huang L, Huang X, Fan X, Zhang X, Zhang C, Liu Q, Sun A, Zhang Y, Cao Y, Xu P, Liu X, Wu J, Yang Z, Sun R, Ren X, Li J, Wan X, Qiu B, Niu S, Zhu R, Wang X, Zhang Y, Gao Y, Deng L, Shi J, Bi M. Initial respiratory support modality and outcome in preterm infants with less than 32 weeks of gestation in China: A multicentre retrospective cohort study. Paediatr Perinat Epidemiol 2022; 36:390-398. [PMID: 34431114 PMCID: PMC9291106 DOI: 10.1111/ppe.12801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND For initial respiratory management, continuous positive airway pressure (CPAP) is increasingly used for preterm infants, especially for gestational age less than 32 weeks. However, neonatologists are concerned about the potential risks of CPAP support failure. OBJECTIVES To examine the association between different initial respiratory support modalities and the outcomes of preterm infants at <32 weeks of gestation across multiple neonatal intensive care units (NICU) in China. METHODS This study was carried out over a period of 12 months in 2018. Unadjusted relative risks (RR) for demographic and clinical characteristics were calculated for CPAP failure and CPAP success in the total cohort using log-linear model based on generalised estimating equations for clustered observations. RESULTS Among 1560 preterm infants delivered at <32 weeks, the incidence of CPAP failure was 10.3%. After adjustment for demographic and clinical factors, the relative risk of mortality (RR 7.54, 95% CI 5.56, 10.44), pneumothorax (RR 9.85, 95% CI 2.89, 61.53), pulmonary haemorrhage (RR 7.78, 95% CI 4.51, 14.64) and BPD (RR 3.65, 95% CI 3.65, 4.51) were considerably higher for infants in the CPAP failure group than those in the CPAP-S group. However, the risk of poor outcomes in CPAP failure infants was similar to that of those in the initial mechanical ventilation (MV) group. CONCLUSIONS Continuous positive airway pressure failure was associated with an increased risk of mortality and major morbidities, including BPD, pulmonary haemorrhage and pneumothorax, and was comparable to the risk associated with initial MV.
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Affiliation(s)
- Li Wang
- The First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina,Eyast Branch of Provincial Hospital Affiliated to Shandong UniversityJinanChina
| | - Jia‐hui Li
- The First Affiliated Hospital of Shandong First Medical UniversityJinanChina
| | - Yong‐hui Yu
- Eyast Branch of Provincial Hospital Affiliated to Shandong UniversityJinanChina
| | - Lei Huang
- Shandong Provincial Maternal and Child Health Care HospitalCheeloo College of MedicineShandong UniversityJinanChina
| | | | - Xiu‐fang Fan
- Jinan Maternity and Child Healthcare HospitalJinanChina
| | | | | | | | - Ai‐rong Sun
- Linyi Maternal and Child Health Care HospitalLinyiChina
| | - Yong‐feng Zhang
- Affiliated Hospital of Weifang Medical UniversityWeifangChina
| | | | - Ping Xu
- Liaocheng People's HospitalLiaochengChina
| | | | - Jing‐cai Wu
- Maternity and Child Health Care of ZaozhuangZaozhuangChina
| | | | | | - Xue‐yun Ren
- Affiliated Hospital of Jining Medical CollegeJiningChina
| | - Jing Li
- The Second Affiliated Hospital of Shandong First Medical UniversityJinanChina
| | - Xiao‐li Wan
- Jinan second Maternity and Child Health Care HospitalJinanChina
| | | | - Shi‐ping Niu
- Zibo Maternal and Child Health HospitalZiboChina
| | | | - Xiao‐kang Wang
- Central Branch of Provincial Hospital Affiliated to Shandong UniversityJinanChina
| | | | | | | | - Jing Shi
- Liaocheng Second People's HospitalLiaochengChina
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20
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Choi EK, Park KH, Choi BM. Association of delayed initiation of non-invasive respiratory support with pulmonary air leakage in outborn late-preterm and term neonates. Eur J Pediatr 2022; 181:1651-1660. [PMID: 35006375 DOI: 10.1007/s00431-021-04317-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022]
Abstract
UNLABELLED The frequency of non-invasive respiratory support use has increased in neonates of all gestational ages with respiratory distress (RD). However, the impact of delayed initiation of non-invasive respiratory support in outborn neonates remains poorly understood. This study aimed to identify the impact of the delayed initiation of non-invasive respiratory support in outborn, late-preterm, and term neonates. Medical records of 277 infants (gestational age of ≥ 35 weeks) who received non-invasive respiratory support as primary respiratory therapy < 24 h of age between 2016 and 2020 were retrospectively reviewed. Factors associated with respiratory adverse outcomes were investigated in 190 outborn neonates. Infants with RD were divided into two groups: mild (fraction of inspired oxygen [FiO2] ≤ 0.3) and moderate-to-severe RD (FiO2 > 0.3), depending on their initial oxygen requirements from non-invasive respiratory support. The median time for the initiation of non-invasive respiratory support at a tertiary center was 3.5 (2.2-5.0) h. Male sex, a high oxygen requirement (FiO2 > 0.3), high CO2 level, and respiratory distress syndrome were significant factors associated with adverse outcomes. Subgroup analysis revealed that in the moderate-to-severe RD group, delayed commencement of non-invasive respiratory support (≥ 3 h) was significantly associated with pulmonary air leakage (p = 0.033). CONCLUSION Our study shows that outborn neonates with moderate-to-severe RD, who were treated with delayed non-invasive respiratory support, were associated with an increased likelihood of pulmonary air leakage. Additional prospective studies are required to establish the optimal timing and methods of non-invasive respiratory support for outborn, late-preterm, and term infants. WHAT IS KNOWN • Non-invasive respiratory support is widely used in neonates of all gestational ages. • Little is known on the impact of delayed initiation of non-invasive respiratory support in outborn, late preterm, and term neonates. WHAT IS NEW • Male sex, high oxygen requirement (FiO2 >0.3), high initial CO2 level, and respiratory distress syndrome significantly correlated with adverse outcomes. • Outborn late-preterm and term neonates with high oxygen requirement who were treated with delayed non-invasive respiratory support indicated an increased likelihood of pulmonary air leakage.
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Affiliation(s)
- Eui Kyung Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyu Hee Park
- Department of Pediatrics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung Min Choi
- Department of Pediatrics, Korea University College of Medicine, Seoul, Republic of Korea.
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21
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Fernandez-Gonzalez SM, Sucasas Alonso A, Ogando Martinez A, Avila-Alvarez A. Incidence, Predictors and Outcomes of Noninvasive Ventilation Failure in Very Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2022; 9:426. [PMID: 35327798 PMCID: PMC8947251 DOI: 10.3390/children9030426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
Non-invasive ventilation (NIV) is now considered the first-line treatment for respiratory distress syndrome in preterm infants. We aimed to evaluate the rates of non-invasive ventilation failure rate in very preterm infants, as well as to identify its predictors and associated outcomes. We designed a single-center retrospective cohort study including infants ≤32 weeks gestational age and ≤1500 g. The NIV failure was defined as the need for intubation at <72 h of life. After applying inclusion and exclusion criteria, 154 patients were included in the study, with a mean GA of 29.7 ± two weeks. The NIV failure rate was 16.2% (n = 25) and it was associated with lower bronchopulmonary dysplasia (BPD)-free survival (OR 0.08; 95% CI 0.02−0.32) and higher incidence of intraventricular hemorrhage > II (OR 6.22; 95% CI 1.36−28.3). These infants were significantly smaller in GA and weight. Higher FiO2 during resuscitation (OR 1.14; 95% CI 1.06−1.22) and after surfactant administration (OR 1.17; 95% CI 1.05−1.31) represented independent risk factors for NIV failure. In conclusion, NIV failure is frequent and it could be predicted by a higher oxygen requirement during resuscitation and a modest response to surfactant therapy. Importantly, this NIV failure is associated with worse clinical outcomes.
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Affiliation(s)
- Sara M. Fernandez-Gonzalez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Andrea Sucasas Alonso
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Alicia Ogando Martinez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Alejandro Avila-Alvarez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
- A Coruña Biomedical Research Institute (INIBIC), 15006 A Coruña, Spain
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22
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Szczapa T, Karpiński Ł, Szczapa-Krenz H, Witosław B, Adamczak A, Moczko J, Miechowicz I, Niedbalski P, Szymankiewicz-Bręborowicz M, Mazela J. Cerebral oxygenation and bioelectrical activity in preterm infants during surfactant replacement therapy with porcine and bovine preparations. Arch Med Sci 2022; 18:652-658. [PMID: 35591822 PMCID: PMC9103386 DOI: 10.5114/aoms.2020.96722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/28/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Surfactant replacement therapy (SRT) might cause acute changes in cerebral oxygenation and alteration of brain bioelectrical activity. Varying physiologic responses and clinical outcomes were observed when different surfactant preparations were instilled to treat neonatal respiratory distress syndrome (RDS). MATERIAL AND METHODS Neonates born at 26-30 weeks of gestation with RDS requiring intubation and mechanical ventilation were randomized to SRT either with poractant alfa (A) or beractant (B). Saturation (SpO2), heart rate (HR), cerebral tissue oxygenation (StO2) and amplitude-integrated electroencephalography (aEEG) were simultaneously recorded prior to and up to 4 h after SRT. RESULTS Mean SpO2, HR and StO2 values were comparable between groups at baseline and after SRT. There were differences in mean aEEG voltage before SRT, but amplitudes were within a range considered as normal in both groups. Immediately after SRT and at a few single post-intervention time points mean aEEG voltage was higher in the beractant group. There was a significant difference in the percentage of time with the aEEG signal < 5 μV after SRT between groups (mean 25.7% (A) vs. 16.5% (B), p < 0.05). Quantity of bursts per minute and mean length of inter-burst intervals (IBI) in the aEEG recording varied insignificantly but there was a significant difference in the percentage of IBI > 30 s between groups (52.5% (A) vs. 36.6% (B), p <0.05). CONCLUSIONS This is the first study assessing brain bioelectrical function and oxygenation while using two different surfactant preparations in a neonate. Cerebral effects of SRT are observed regardless of the type of surfactant, but their magnitude may depend on the preparation and/or dosing used.
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Affiliation(s)
- Tomasz Szczapa
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Łukasz Karpiński
- Department of Neonatal Infectious Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - Hanna Szczapa-Krenz
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Beata Witosław
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Aleksandra Adamczak
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Jerzy Moczko
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | - Izabela Miechowicz
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Marta Szymankiewicz-Bręborowicz
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
| | - Jan Mazela
- Department of Neonatal Infectious Diseases, Poznan University of Medical Sciences, Poznan, Poland
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Szczapa T, Kwapień P, Merritt TA. Neonatal Applications of Heliox: A Practical Review. Front Pediatr 2022; 10:855050. [PMID: 35359907 PMCID: PMC8960277 DOI: 10.3389/fped.2022.855050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/09/2022] [Indexed: 11/21/2022] Open
Abstract
Heliox is a mixture of helium and oxygen that may be utilized as an alternative to air-oxygen during the ventilatory support in the neonate. Special physical properties of Heliox, particularly low density, allow for improved gas flow and diffusion. First reports of Heliox use in the pediatric population were published in 1930s; however, this therapy has never gained widespread popularity despite its described beneficial effects. Historically, this was largely due to technical challenges associated with Heliox ventilation that significantly limited its use and realization of large-scale clinical trials. However, nowadays several commercially available ventilators allow easy and safe ventilation with both conventional and non-invasive modes. In the era of minimally invasive respiratory interventions in the newborn Heliox could be seen as a therapy that may potentially decrease the risk of non-invasive ventilation failure. This review presents pathophysiologic rationale for the use of Heliox in the newborn, and summarizes available data regarding applications of Heliox in the setting of neonatal intensive care unit based on clinical studies and findings from animal models. Mechanisms of action and practical aspects of Heliox delivery are thoroughly discussed. Finally, future research directions for neonatal use of Heliox are proposed.
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Affiliation(s)
- Tomasz Szczapa
- Department of Newborns' Infectious Diseases, Chair of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - Patryk Kwapień
- Department of Neonatology, Chair of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
| | - T Allen Merritt
- Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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24
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Dell'Orto V, Nobile S, Correani A, Marchionni P, Giretti I, Rondina C, Burattini I, Palazzi ML, Carnielli VP. Early nasal continuous positive airway pressure failure prediction in preterm infants less than 32 weeks gestational age suffering from respiratory distress syndrome. Pediatr Pulmonol 2021; 56:3879-3886. [PMID: 34610212 DOI: 10.1002/ppul.25678] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/11/2021] [Accepted: 09/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early continuous positive airway pressure (CPAP) and surfactant replacement are effective treatments for neonatal respiratory distress syndrome (RDS). CPAP is the first line in preterm infants needing respiratory support, with surfactant replacement in case of CPAP failure (CPAP-F). OBJECTIVES To analyze incidence and factors associated with CPAP-F in preterm infants with RDS. DESIGN, SETTING AND PATIENTS Single-center retrospective database analysis (2004-2017) of inborn infants, gestational age (GA) 24 + 0/7-31 + 6/7 weeks, not intubated on admission to the neonatal intensive care unit, managed with CPAP. CPAP-F was defined as intubation and surfactant administration in the first 72 h of life; CPAP success (CPAP-S) was CPAP alone without need for additional RDS treatments. Demographic, respiratory, and clinical data associated with CPAP-F were studied using logistic regression analysis. RESULTS A total of 562 infants met the inclusion criteria: 252 (44.8%) were CPAP-F and 310 (55.2%) were CPAP-S. The CPAP-F, compared to CPAP-S group, had lower GA and birth weight, and were less likely to receive antenatal steroids or to be vaginal births. Logistic regression showed that the fraction of inspired oxygen (FiO2 ) ≥ 0.23 between 180 and 240 min of life (FiO2 180-240 min) was the strongest factor associated with CPAP-F (odds ratio: 16.01 [95% confidence interval: 10.34-24.81]). CONCLUSION FiO2 180-240 min was highly predictive of CPAP-F in preterm infants. With this model for surfactant administration/CPAP-F, 11.2% of infants would have unnecessarily received treatment, but importantly, 27.7% would have been treated much earlier, with a potential reduction in air leaks and duration of mechanical ventilation.
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Affiliation(s)
- Valentina Dell'Orto
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Stefano Nobile
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy.,Department of Mother, Child and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Alessio Correani
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Paolo Marchionni
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Ilaria Giretti
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Clementina Rondina
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Ilaria Burattini
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Maria L Palazzi
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Virgilio P Carnielli
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy.,Department of Odontostomatologic and Specialized Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
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25
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Dani C. Nasal Continuous Positive Airway Pressure and High-Flow Nasal Cannula Today. Clin Perinatol 2021; 48:711-724. [PMID: 34774205 DOI: 10.1016/j.clp.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study reviews the mechanisms of action and physiologic effects of nasal continuous positive airway pressure (nCPAP) and high-flow nasal cannula (HFNC) in preterm infants with respiratory distress syndrome, discusses the main characteristics of available devices and patients' interfaces, reports on risk of failure and possible adverse effects, and summarizes clinical evidence regarding effectiveness for preventing mechanical ventilation as primary respiratory support or after extubation in the neonatal intensive care unit. nCPAP is preferred to HFNC as primary mode of noninvasive respiratory support in preterm infants with respiratory distress syndrome, whereas HFNC is an effective alternative to nCPAP after extubation.
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Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy; Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
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26
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Kakkilaya VB, Weydig HM, Smithhart WE, Renfro SD, Garcia KM, Brown CM, He H, Wagner SA, Metoyer GC, Brown LS, Kapadia VS, Savani RC, Jaleel MA. Decreasing Continuous Positive Airway Pressure Failure in Preterm Infants. Pediatrics 2021; 148:peds.2020-014191. [PMID: 34552000 DOI: 10.1542/peds.2020-014191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks' gestational age (GA). METHODS A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks' GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre-OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). RESULTS Of the 216 infants ≤29 weeks' GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks' GA (46% vs 3%; P < .01). CONCLUSIONS Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.
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Affiliation(s)
- Venkatakrishna B Kakkilaya
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heather M Weydig
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - William E Smithhart
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Cari M Brown
- Parkland Hospital and Health System, Dallas, Texas
| | - Henry He
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Vishal S Kapadia
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rashmin C Savani
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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27
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Effects of heliox and non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm infants. Sci Rep 2021; 11:15778. [PMID: 34349223 PMCID: PMC8338984 DOI: 10.1038/s41598-021-95444-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/23/2021] [Indexed: 12/02/2022] Open
Abstract
Due to its unique properties, helium–oxygen (heliox) mixtures may provide benefits during non-invasive ventilation, however, knowledge regarding the effects of such therapy in premature infants is limited. This is the first report of heliox non-invasive neurally adjusted ventilatory assist (NIV-NAVA) ventilation applied in neonates born ≤ 32 weeks gestational age. After baseline NIV-NAVA ventilation with a standard mixture of air and oxygen, heliox was introduced for 3 h, followed by 3 h of air-oxygen. Heart rate, peripheral capillary oxygen saturation, cerebral oxygenation, electrical activity of the diaphragm (Edi) and selected ventilatory parameters (e.g., respiratory rate, peak inspiratory pressure) were continuously monitored. We found that application of heliox NIV-NAVA in preterm infants was feasible and associated with a prompt and significant decrease of Edi suggesting reduced respiratory effort, while all other parameters were stable throughout the study, and had similar values during heliox and air-oxygen ventilation. This therapy may potentially enhance the efficacy of non-invasive respiratory support in preterm neonates and reduce the number of infants progressing to ventilatory failure.
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28
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Anne RP, Murki S. Noninvasive Respiratory Support in Neonates: A Review of Current Evidence and Practices. Indian J Pediatr 2021; 88:670-678. [PMID: 34075532 PMCID: PMC8169393 DOI: 10.1007/s12098-021-03755-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/26/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Rajendra Prasad Anne
- Department of Neonatology, Newborn Unit, Fernandez Hospitals, Unit 2, Hyderguda, Hyderabad, Telangana, India
| | - Srinivas Murki
- Department of Neonatology, Newborn Unit, Paramita Children's Hospital, Kothapet, L B Nagar, Hyderabad, Telangana, 500074, India.
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29
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Radicioni M, Leonardi A, Lanciotti L, Rinaldi VE, Bini V, Camerini PG. How to improve CPAP failure prediction in preterm infants with RDS: a pilot study. Eur J Pediatr 2021; 180:709-716. [PMID: 32562055 DOI: 10.1007/s00431-020-03700-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/18/2020] [Accepted: 05/21/2020] [Indexed: 01/22/2023]
Abstract
We aimed to test the diagnostic accuracy in predicting continuous positive airway pressure (CPAP) failure in premature infants with respiratory distress syndrome (RDS) by integrating oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) (SF ratio) with the measurement of peak velocity of the right diaphragmatic excursions (RD-PV), during the inspiration (I-Peak) and expiratory (E-Peak) phases, performed by pulsed-wave Tissue Doppler imaging. This is a prospective, observational pilot study conducted over a 2-year period. Neonates at ≤ 32 weeks gestation supported by early CPAP were eligible. Natural surfactant was delivered via a minimally invasive technique. We performed serial measurements of SF ratio and RD-PV during the early post-natal hours to test the accuracy in predicting surfactant administration as well as invasive ventilation support within 72 h from birth because of the RDS worsening. Of 56 preterm infants enrolled, 34 (61%) failed CPAP support. SF ratio showed a significant inverse relationship with both Silverman-Andersen score at birth (rho = - 0.417; P = .001) and RD-PV [E-Peak] (rho = - 0.361; P = .007). We achieved a high accuracy in predicting CPAP failure (AUC = 95%; 95% CI, 89-100%) by integrating gender, SF ratio, and RD-PV [E-Peak] at the restricted, multivariate analysis.Conclusions: SF ratio and RD-PV, as measured by pulsed-wave Tissue Doppler, may help physicians to improve their confidence in optimizing therapeutic options in preterm infants with RDS. What is Known: • Continuous positive airway pressure is the recommended first-line treatment for respiratory distress syndrome in preterm infants, but failure rates remain unacceptably high. • Choosing the optimal treatment in terms of non-invasive ventilation effectiveness and timeliness of surfactant administration for these patients is often challenging, also due to our inability to identify a worsening respiratory failure. What is New: • The integration of oxygen saturation, as measured by SpO2/FiO2, with right diaphragm peak motion velocities, as measured by pulsed-wave tissue Doppler, allows for high prediction accuracy of non-invasive ventilation support failure in premature infants at risk of respiratory distress syndrome. • These measurements may help physicians in providing optimal supportive therapy for these patients.
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Affiliation(s)
- Maurizio Radicioni
- Department of Neonatal Intensive Care Unit and Neonatal Pathology, S. Maria della Misericordia Hospital of Perugia, Piazzale Giorgio Menghini 1, 06129, Perugia, Italy.
| | | | | | | | - Vittorio Bini
- Department of Medicine, University of Perugia, Perugia, Italy
| | - Pier Giorgio Camerini
- Department of Neonatal Intensive Care Unit and Neonatal Pathology, S. Maria della Misericordia Hospital of Perugia, Piazzale Giorgio Menghini 1, 06129, Perugia, Italy
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30
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Aldecoa-Bilbao V, Balcells-Esponera C, Herranz Barbero A, Borràs-Novell C, Izquierdo Renau M, Iriondo Sanz M, Salvia Roigés M. Lung ultrasound for early surfactant treatment: Development and validation of a predictive model. Pediatr Pulmonol 2021; 56:433-441. [PMID: 33369257 DOI: 10.1002/ppul.25216] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/15/2020] [Accepted: 12/01/2020] [Indexed: 12/15/2022]
Abstract
AIM To develop and validate a feasible predictive model for early surfactant treatment in very preterm infants (VPI) admitted with respiratory distress syndrome (RDS). METHODS Preterm infants less than 32 weeks of gestation with RDS and stabilized with noninvasive ventilation in delivery room were recruited (January 2018-April 2020). Clinical data, chest X-ray (CXR) score, respiratory support, oxygen saturation/fraction of inspired oxygen ratio (SF ratio), lung ultrasound (LUS) score, and diaphragmatic thickening fraction (DTF) were recorded at 60-120 min of life. Oxygen threshold for surfactant administration was fraction of inspired oxygen more than 30%; ultrasound findings were blinded. Logistic regression models using a stepwise selection of variables were developed in the derivation cohort. Coefficients from these models were applied to the validation cohort and a diagnostic performance was calculated. RESULTS A total of 144 VPI with a mean gestational age of 28.7 ± 2.2 weeks were included (94 into the derivation cohort, 50 into the validation cohort); 37 required surfactant treatment (25.7%). Gestational age, SF ratio, LUS score, CXR score, and Silverman score were related to surfactant administration (R2 = .823). Predictors included in the final model for surfactant administration were SF ratio and LUS score (R2 = .783) with an area under the receiver operating characteristic (AUC) = 0.97 (95% confidence interval [CI]: 0.93-1.00) in the derivation cohort and an AUC = 0.95 (95% CI: 0.85-0.99) in the validation cohort. By applying our predictive model, 26 patients (70.2%) would have been treated with surfactant earlier than 2 h of life. CONCLUSION The predictive model showed a high diagnostic performance and could be of value to optimize early respiratory management in VPI with RDS.
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Affiliation(s)
- Victoria Aldecoa-Bilbao
- Department of Neonatology, Hospital Clínic Barcelona. BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Carla Balcells-Esponera
- Department of Neonatology, Hospital Sant Joan de Déu. BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Ana Herranz Barbero
- Department of Neonatology, Hospital Clínic Barcelona. BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Cristina Borràs-Novell
- Department of Neonatology, Hospital Clínic Barcelona. BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Montserrat Izquierdo Renau
- Department of Neonatology, Hospital Sant Joan de Déu. BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
| | - Martín Iriondo Sanz
- Department of Neonatology, Hospital Sant Joan de Déu. BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, University of Barcelona (UB), Barcelona, Spain
| | - MªDolors Salvia Roigés
- Department of Neonatology, Hospital Clínic Barcelona. BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Barcelona, Spain
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Szymański P, Kruczek P, Hożejowski R, Wais P. Modified lung ultrasound score predicts ventilation requirements in neonatal respiratory distress syndrome. BMC Pediatr 2021; 21:17. [PMID: 33407270 PMCID: PMC7785923 DOI: 10.1186/s12887-020-02485-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/20/2020] [Indexed: 01/23/2023] Open
Abstract
Background We propose a modified lung ultrasound (LUS) score in neonates with respiratory distress syndrome (RDS), which includes posterior instead of lateral lung fields, and a 5-grade rating scale instead of a 4-grade rating scale. The purpose of this study was to evaluate the reproducibility of the rating scale and its correlation with blood oxygenation and to assess the ability of early post-birth scans to predict the mode of respiratory support on day of life 3 (DOL 3). As a secondary objective, the weight of posterior scans in the overall LUS score was assessed. Methods We analyzed 619 serial lung scans performed in 70 preterm infants < 32 weeks gestation and birth weight < 1500 g. Assessments were performed within 24 h of birth (LUS0) and on days 2, 3, 5, 7, 10, 14, 21 and 28. LUS scores were correlated with oxygen saturation over fraction of inspired oxygen (S/F) and mode of respiratory support. Interrater agreement was determined with the intraclass correlation coefficient (ICC) and Cronbach’s alpha. Probabilities of the need for various respiratory support modes on DOL 3 were assessed with ordinal logistic regression. Least square (ls) means of the posterior and anterior pulmonary field scores were compared. Results The LUS score correlated significantly with S/F (Spearman rho = −0.635; p < 0.0001) and had excellent interrater agreement (ICC = 0.94, 95% CI 0.93–0.95; Cronbach’s alpha = 0.99). Significant predictors of ventilation requirements on DOL 3 were LUS0 (p < 0.016) and birth weight (BW) (p < 0.001). In the ROC analysis, LUS0 had high reliability in prognosing invasive ventilation on DOL 3 (AUC = 0.845 (95% DeLong CI: 0.738–0.951; p < 0.001)). Invasive ventilation was the most likely mode of respiratory support for LUS0 scores: ≥7 (in infants with BW 900 g), ≥ 10 (in infants with BW 1050 g) and ≥ 15 (in infants with BW 1280 g). Posterior fields exhibited significantly higher average scores than anterior fields. Respective ls means (confidence levels) were 4.0 (3.8–4.1) vs. 2.2 (2.0–2.4); p < 0.001. Conclusions Post-birth LUS predicts ventilation requirements on DOL 3. Scores of posterior pulmonary fields have a predominant weight in the overall LUS score.
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Affiliation(s)
- Piotr Szymański
- Department of Pediatrics, Jagiellonian University Medical College, Cracow, Poland.,Present address: Department of Neonatology, Ujastek Medical Center, ul. Ujastek 3, 31-752, Cracow, Poland
| | - Piotr Kruczek
- Department of Pediatrics, Jagiellonian University Medical College, Cracow, Poland. .,Present address: Department of Neonatology, Ujastek Medical Center, ul. Ujastek 3, 31-752, Cracow, Poland.
| | | | - Piotr Wais
- Department of Informatics, Carpathian State University in Krosno, Krosno, Poland
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Kruczek P, Krajewski P, Hożejowski R, Szczapa T. FiO 2 Before Surfactant, but Not Time to Surfactant, Affects Outcomes in Infants With Respiratory Distress Syndrome. Front Pediatr 2021; 9:734696. [PMID: 34671585 PMCID: PMC8520978 DOI: 10.3389/fped.2021.734696] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/02/2021] [Indexed: 12/18/2022] Open
Abstract
Aim: To establish the impact of oxygen requirement before surfactant (SF) and time from birth to SF administration on treatment outcomes in neonatal respiratory distress syndrome (RDS). Methods: We conducted a post-hoc analysis of data from a prospective cohort study of 500 premature infants treated with less invasive surfactant administration (LISA). LISA failure was defined as the need for early (<72 h of life) mechanical ventilation (MV). Baseline clinical characteristic parameters, time to SF, and fraction of inspired oxygen (FiO2) prior to SF were all included in the multifactorial logistic regression model that explained LISA failure. Results: LISA failed in 114 of 500 infants (22.8%). The median time to SF was 2.1 h (IQR: 0.8-6.7), and the median FiO2 prior to SF was 0.40 (IQR: 0.35-0.50). Factors significantly associated with LISA failure were FiO2 prior to SF (OR 1.03, 95% CI 1.01-1.04) and gestational age (OR 0.82, 95 CI 0.75-0.89); both p <0.001. Time to SF was not an independent risk factor for therapy failure (p = 0.528) or the need for MV at any time during hospitalization (p = 0.933). Conclusions: The FiO2 before SF, but not time to SF, influences the need for MV in infants with RDS. While our findings support the relevance of FiO2 in SF prescription, better adherence to the recommended FiO2 threshold for SF (0.30) is required in daily practice.
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Affiliation(s)
- Piotr Kruczek
- Department of Neonatology, Ujastek Medical Center, Cracow, Poland
| | - Paweł Krajewski
- Department of Neonatology, University Center for Mother and Newborn's Health, Warsaw, Poland
| | | | - Tomasz Szczapa
- Department of Neonatology, Neonatal Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
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Glaser K, Wright CJ. Indications for and Risks of Noninvasive Respiratory Support. Neonatology 2021; 118:235-243. [PMID: 33902052 PMCID: PMC8178193 DOI: 10.1159/000515818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 01/20/2023]
Abstract
Within the last decades, therapeutic advances have significantly improved the survival of extremely preterm infants. In contrast, the incidence of major neonatal morbidities, including bronchopulmonary dysplasia, has not declined. Given the well-established relationship between exposure to invasive mechanical ventilation and neonatal lung injury, neonatologists have sought for effective strategies of noninvasive respiratory support in high-risk infants. Continuous positive airway pressure has replaced invasive mechanical ventilation for the initial stabilization and the treatment of respiratory distress syndrome. Today, noninvasive respiratory support has been adopted even in the tiniest babies with the highest risk of lung injury. Moreover, different modes of noninvasive respiratory support supplemented by a number of adjunctive measures and rescue strategies have entered clinical practice with the goal of preventing intubation or reintubation. However, does this unquestionably important paradigm shift to strategies focused on noninvasive support lull us into a false sense of security? Can we do better in (i) identifying those very immature preterm infants best equipped for noninvasive stabilization, can we improve (ii) determinants of failure of noninvasive respiratory support in the individual infant and underlying etiology, and can we enhance (iii) success of noninvasive respiratory support and (iv) better prevent ultimate harm to the developing lung? With increased survival of infants at the highest risk of developing lung injury and an unchanging burden of bronchopulmonary dysplasia, we should question indiscriminate use of noninvasive respiratory support and address the above issues.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
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Anderson CD, Webb E, Lampe GE, Clark T, Williams HL, Hillman NH. Interhospital Transport of Infants on Bubble Continuous Positive Airway Pressure via Ground and Air. Air Med J 2020; 39:458-463. [PMID: 33228894 DOI: 10.1016/j.amj.2020.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/26/2020] [Accepted: 09/19/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the use of a respiratory protocol for the interhospital transport of infants with respiratory distress on bubble continuous positive airway pressure (bCPAP) and provide information on the safety of bCPAP during transport via ground and helicopter. METHODS We evaluated a retrospective cohort study of neonates (gestational age 22-41 weeks) transported to our level 4 neonatal intensive care unit (NICU) before (n = 529) and after implementing (n = 540) protocols for increasing bCPAP and intubation criteria. Infants were evaluated for intubation before transport, the safety of transport, and the need for intubation shortly after arrival in the NICU. RESULTS After initiating the protocols, less infants received mechanical ventilation, and more infants received bCPAP for transport via ground and helicopter. Upon arrival to the NICU, infants using the protocols had lower fraction of inspired oxygen and higher continuous positive airway pressures, and similar numbers required intubations in the first 12 hours. There were no differences in the rate of pneumothoraces. CONCLUSIONS bCPAP can be used on both ground and helicopter transport of very small infants. Respiratory protocols decreased mechanical ventilation during transport without increasing the need for intubation within 12 hours of arrival.
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Affiliation(s)
- Connie D Anderson
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO
| | - Ellen Webb
- Neonatal Transport Team, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Glorine E Lampe
- Neonatal Transport Team, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Toni Clark
- Neonatal Transport Team, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Howard L Williams
- SSM Health Systems, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO
| | - Noah H Hillman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO; Neonatal Transport Team, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO.
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Feng SYS, Rao S, Patole S. A survey on criteria for intubation in moderate to late preterm infants with respiratory distress. Pediatr Pulmonol 2020; 55:2970-2982. [PMID: 32886426 DOI: 10.1002/ppul.25054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/14/2020] [Accepted: 08/26/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Majority of preterm infants do well with continuous positive airway pressure (CPAP) as the sole respiratory management; but some require endotracheal intubation and surfactant administration. While intubation is needed predominantly in extremely preterm infants (<28 weeks); some of the more mature preterm infants also require it. Currently, there are no clear guidelines regarding indications for endotracheal intubation in such infants. AIMS To understand the current practice regarding "criteria for intubation" in moderate to late preterm infants with respiratory distress. METHODS A survey of neonatologists in Australia New Zealand Neonatal Network (ANZNN) was conducted between April and June 2019. RESULTS At least one neonatologist each from 29 of the 30 tertiary ANZNN Neonatal Intensive Care Units (NICUs) responded to the survey. In total, 118/200 (59%) neonatologists responded. The most common criteria for intubation were CPAP = 8 cmH2 O (61%), pH < 7.2 (55%), pCO2 > 70 mmHg (48%), FiO2 > 40% (40%), chest retractions (48%), more than two episodes of apnea requiring intervention (54%), and chest X-ray (CXR) showing moderate-severe hyaline membrane disease (HMD, 49%). CONCLUSION While there were variations in practice, nearly 50% of the neonatologists shared a common threshold with regards to the CPAP level, FiO2 , blood gas parameters, and clinical and radiological findings. The results of this survey will help in designing future randomized controlled trials (RCTs) on this subject.
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Affiliation(s)
- Susan Y S Feng
- Neonatal Directorate, King Edward Memorial Hospital and Perth Children's Hospital, Subiaco, Western Australia, Australia
| | - Shripada Rao
- Neonatal Directorate, King Edward Memorial Hospital and Perth Children's Hospital, Subiaco, Western Australia, Australia
| | - Sanjay Patole
- Neonatal Directorate, King Edward Memorial Hospital and Perth Children's Hospital, Subiaco, Western Australia, Australia
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Szczapa T, Hożejowski R, Krajewski P. Implementation of less invasive surfactant administration in clinical practice-Experience of a mid-sized country. PLoS One 2020; 15:e0235363. [PMID: 32628732 PMCID: PMC7337349 DOI: 10.1371/journal.pone.0235363] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/13/2020] [Indexed: 11/18/2022] Open
Abstract
Objective There are differences in the adoption rates of less invasive surfactant administration (LISA) worldwide. We aimed to describe and analyze the process of LISA introduction at the country level. Methods A standardized training program (33 courses covering >500 neonatologists) was followed by a cohort study. Data regarding consecutive LISA procedures were acquired over 12 months in 31 tertiary neonatal centers, using a dedicated on-line platform. Results Of 500 LISA procedures, 75% were performed by specialists and 25% by residents. The mean percentage share of LISA in all surfactant therapies was 24%, which represents a 6-fold increase compared to previous years. After 12 months, 76% of the procedures were rated “easy/very easy” vs 59% at baseline (p<0.05). Surfactant re-treatment rate was 15%. Twenty-three percent of infants required mechanical ventilation within 72 hours of life. Oxygen desaturation and surfactant reflux were the most frequent complications. Unlike previous reports describing exclusive use of nasal continuous positive airway pressure (nCPAP) during LISA, majority of procedures (63%) were carried out using nasal intermittent positive pressure ventilation (NIPPV) or Bilevel Positive Airway Pressure (BiPAP). Efficacy of LISA with NIPPV or BiPAP was not significantly different from that with nCPAP (22.4% vs 24.5% of cases requiring intubation). Ventilation was provided with nasal cannulas or nasal masks (90%) and rarely with “RAM” cannulas or nasopharyngeal tubes. Rigid catheters were preferred (88.4%); tracheal insertion was successful at first attempt in 87% of cases. Majority of infants (79%) received no premedication prior to the procedure and almost all were given caffeine citrate. Median time of instillation was 1.5 minutes. Conclusions The LISA procedure does not appear to be technically difficult to master. Training combining theory with practical exercises is an efficient implementation strategy. Variations in adoption rates indicate the need for additional, more personalized teachings in some centers.
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Affiliation(s)
- Tomasz Szczapa
- Department of Neonatology, Poznan University of Medical Sciences, Poznan, Poland
- * E-mail:
| | | | - Paweł Krajewski
- Department of Neonatology, University Center for Mother and Newborn’s Health, Warsaw, Poland
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Królak-Olejnik B, Hożejowski R, Szczapa T. Dose Effect of Poractant Alfa in Neonatal RDS: Analysis of Combined Data from Three Prospective Studies. Front Pediatr 2020; 8:603716. [PMID: 33330292 PMCID: PMC7732442 DOI: 10.3389/fped.2020.603716] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/02/2020] [Indexed: 11/23/2022] Open
Abstract
Aim: To evaluate the effect of the initial dose of poractant alfa on clinical outcomes in neonatal respiratory distress syndrome (RDS) and to assess adherence to treatment guidelines recommending a dose of 200 mg/kg. Methods: Records of neonates who received poractant alfa with a less invasive technique (LISA) or with the INtubate-SURfactant-Extubate (INSURE) technique were retrieved from the aggregated datasets of three prospective RDS studies conducted between 2015 and 2019. The impact of poractant dose on neonatal outcomes was analyzed by multivariate logistic regression. The primary endpoint was the need for early (<72 h of life) mechanical ventilation (MV). Typical complications of prematurity and the need for surfactant retreatment were secondary endpoints. Deviation from the 200 mg/kg dose of surfactant was a measure of compliance with the treatment guidelines. As a complementary analysis, the rates of adverse outcomes were compared for infants receiving high (200 mg/kg ±10%) and low (100 mg/kg ±10%) doses of poractant. Results: Of 994 eligible infants, 574 received poractant alfa with LISA, and 420 received poractant with INSURE. A logistic regression model using data from all 994 infants showed that the surfactant dose had a significant effect on reducing the need for MV and retreatment; the respective odds ratios were 0.92 (95% CI: 0.90-0.95) and 0.93 (95% CI: 0.90-0.96) per 10-mg/kg dose increment of poractant alfa. This dose effect was observed across all gestational age ranges and in infants treated with LISA. In newborns treated with INSURE, the dose of surfactant only influenced the rates of retreatment (p = 0.036) but not MV (p = 0.170). No impact on other neonatal outcomes was observed. In the subset of infants who received high (N = 502) and low (N = 58) doses of poractant, the high-dose group had lower rates of MV (34 vs. 48%, p = 0.042) and lower rates of retreatment (11 vs. 21%, p = 0.045). Surfactant underdosage increased with gestational age and ranged from a minimum of -3 mg/kg in <26 weeks to a maximum of -23.5 mg/kg in >32 weeks. Conclusions: The initial dose of poractant alfa significantly impacts the need for invasive ventilation and retreatment. More mature newborns are at a greater risk of underdosing.
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Affiliation(s)
| | | | - Tomasz Szczapa
- Department of Neonatology, Biophysical Monitoring and Cardiopulmonary Therapies Research Unit, Poznan University of Medical Sciences, Poznan, Poland
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Okello F, Egiru E, Ikiror J, Acom L, Loe K, Olupot-Olupot P, Burgoine K. Reducing preterm mortality in eastern Uganda: the impact of introducing low-cost bubble CPAP on neonates <1500 g. BMC Pediatr 2019; 19:311. [PMID: 31484567 PMCID: PMC6724283 DOI: 10.1186/s12887-019-1698-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 08/27/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Complications of prematurity are the leading cause of deaths in children under the age of five. The predominant reason for these preterm deaths is respiratory distress syndrome (RDS). In low-income countries (LICs) there are limited treatment options for RDS. Due to their simplicity and affordability, low-cost bubble continuous positive airway pressure (bCPAP) devices have been introduced in neonatal units in LICs to treat RDS. This study is the first observational study from a LIC to compare outcomes of very-low-birth-weight (VLBW) neonates in pre- and post-CPAP periods. METHODS This was a retrospective study of VLBW neonates (weight < 1500 g) in Mbale Regional Referral Hospital Neonatal Unit (MRRH-NNU), a government hospital in eastern Uganda. It aimed to measure the outcome of VLBW neonates in two distinct study periods: A 14-month period beginning at the opening of MRRH-NNU and covering the period until bCPAP was introduced (pre-bCPAP) and an 18-month period following the introduction of bCPAP (post-bCPAP). After the introduction of bCPAP, it was applied to preterm neonates with RDS when clinically indicated and if a device was available. Clinical features and outcomes of all neonates < 1500 g were compared before and after the introduction of bCPAP. RESULTS The admission records of 377 VLBW neonates < 1500 g were obtained. One hundred fifty-eight were admitted in the pre-bCPAP period and 219 in the post-bCPAP period. The mortality rate in the pre- bCPAP period was 39.2% (62/158) compared with 26.5% (58/219, P = 0.012) in the post-bCPAP period. Overall, there was a 44% reduction in mortality (OR 0.56, 95%CI 0.36-0.86, P = 0.01). There were no differences in birthweight, sex, presence of signs of respiratory distress or apnoea between the two groups. CONCLUSION Specialized and resource-appropriate neonatal care, that appropriately addresses the challenges of healthcare provision in LICs, has the potential to reduce neonatal deaths. The use of a low-cost bCPAP to treat RDS in VLBW neonates resulted in a significant improvement in their survival in a neonatal unit in eastern Uganda. Since RDS is one of the leading causes of neonatal mortality, it is possible that this relatively simple and affordable intervention could have a huge impact on global neonatal mortality.
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Affiliation(s)
- F Okello
- Mbale Campus, Busitema University, P.O.Box 1460, Mbale, Uganda
- Varimetrics Group Limited, P. O Box 2190, Mbale, Uganda
| | - E Egiru
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - J Ikiror
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - L Acom
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda
| | - Ksm Loe
- Diamedica UK Ltd, Grange Hill Industrial Estate, Bratton Fleming, UK
| | - P Olupot-Olupot
- Mbale Campus, Busitema University, P.O.Box 1460, Mbale, Uganda
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda
| | - K Burgoine
- Mbale Clinical Research Institute, P.O. Box 1966, Mbale, Uganda.
- Neonatal Unit, Mbale Regional Referral Hospital, P.O. Box 1966, Mbale, Uganda.
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