Neonatal nasal deformities secondary to nasal continuous positive airway pressure

Knowledge, Practice, and Associated Factors Towards Supplemental Oxygen Therapy Among Nurses Working in Neonatal Intensive Care Units in Public Hospitals of Addis Ababa, Ethiopia, 2022: A Cross-Sectional Study

Purpose

Proper administration of oxygen therapy for hospitalized newborns is undoubtedly essential. World Health Organization estimates that approximately 1.4 million deaths worldwide each year are due to inappropriate administration of oxygen, but its administration in clinical practice is usually inappropriate due to lack of knowledge and practice. Therefore, the aim of this study was to determine the level of knowledge, practice and associated factors related to supplemental oxygen therapy among nurses working in neonatal intensive care units.

Methods

An institutional cross-sectional study was conducted with 166 randomly selected respondents using a self-administered questionnaire for data collection. Bivariate and multivariable analyses were performed using SPSS version 26. Variables with a p-value of <0.25 in the bivariate analysis were included in the multivariable logistic regression, and statistical significance was ensured by a p-value <0.05 with 95% CI.

Results

One hundred and sixty-six nurses took part in this study, with a response rate of 96%. Of these, 60.8% had good knowledge and 54.2% had good practice in supplemental oxygen therapy. In the multivariable logistic regression analysis, work experience was significantly associated with knowledge (AOR: 5.40; 95% CI: 2.12-13.73)) and practice (AOR = 3.69, 95% CI: 1.30-10.44)) of supplemental oxygen therapy. Level of knowledge (AOR=2.92, 95% CI: (1.24-6.86)) and educational status (AOR=6.51, 95% CI (1.34-31.55)) were also significantly associated with the practice of supplemental oxygen therapy with a p < 0.05.

Conclusion

Approximately 40% and 46% of nurses in this study had poor knowledge and practice of supplemental oxygen therapy. This figure is shocking and shows a large gap in the knowledge and practice of supplemental oxygen therapy that requires urgent action. Educational status, professional experience and level of knowledge were found to be associated with good knowledge and professional experience with good practice in relation to supplemental oxygen therapy.

A multicenter, randomized controlled, non-inferiority trial, comparing nasal continuous positive airway pressure with nasal intermittent positive pressure ventilation as primary support before minimally invasive surfactant administration for preterm infants with respiratory distress syndrome (the NIV-MISA-RDS trial): Study protocol

BACKGROUND

Non-invasive ventilation (NIV) treatment has been developed to minimize lung damage and to avoid invasive mechanical ventilation (IMV) in preterm infants, especially in those with a gestational age of <30 weeks. Our hypothesis is that for preterm infants <30 weeks with potential to develop respiratory distress syndrome (RDS), nasal continuous positive airway pressure (NCPAP) is non-inferior to the nasal intermittent positive pressure ventilation (NIPPV) as primary respiratory support before minimal invasive surfactant administration (MISA).

METHODS AND DESIGN

The NIV-MISA-RDS trial is planned as an unblinded, multicenter, randomized, non-inferiority trial at 14 tertiary neonatal intensive care units (NICUs) in China. Eligible infants are preterm infants of 24-29⁺⁶ weeks of gestational age who have spontaneous breaths at birth and require primary NIV support for RDS. Infants are randomized 1:1 to treatment with either NCPAP or NIPPV once admitted into NICUs. If an infant presents progressively aggravated respiratory distress and is clinically diagnosed as having RDS, pulmonary surfactant will be supplemented by MISA in the first 2 h of life. The primary outcome is NIV treatment failure within 72 h after birth. With a specified non-inferiority margin of 10%, using a two-sided 95% CI and 80% power, the study requires 480 infants per group (in total 960 infants).

DISCUSSION

Current evidence shows that NIV and MISA may be the most effective strategy for minimizing IMV in preterm infants with RDS. However, there are few large randomized controlled trials to compare the effectiveness of NCPAP and NIPPV as the primary respiratory support after birth and before surfactant administration. We will conduct this trial to test the hypothesis that NCPAP is not inferior to NIPPV as the initial respiratory support in reducing the use of IMV in premature infants who have spontaneous breaths after birth and who do not require intubation in the first 2 h after birth. The study will provide clinical data for the selection of the initial non-invasive ventilation mode in preterm infants with a gestational age of <30 weeks with spontaneous breaths after birth.

CLINICAL TRIAL REGISTRATION

https://register.clinicaltrials.gov, identifier: NCT05137340.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

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

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

Factors influencing delivered mean airway pressure during nasal CPAP with the RAM cannula

OBJECTIVE

To measure mean airway pressure (MAP) delivered through the RAM Cannula® when used with a ventilator in CPAP mode as a function of percent nares occlusion in a simulated nasal interface/test lung model and to compare the results to MAPs using a nasal continuous positive airway pressure (NCPAP) interface with nares fully occluded.

STUDY DESIGN

An artificial airway model was connected to a spontaneous breathing lung model in which MAP was measured at set NCPAP levels between 4 and 8 cmH2 O provided by a Dräger Evita XL® ventilator and delivered through three sizes of RAM cannulae. Measurements were performed with varying leakage at the nasal interface by decreasing occlusion from 100% to 29%, half-way prong insertion, and simulated mouth leakage. Comparison measurements were made using the Dräger BabyFlow® NCPAP interface with a full nasal seal.

RESULTS

With simulated mouth closed, the Dräger interface delivered MAPs within 0.5 cmH2 O of set CPAP levels. For the RAM cannula, with 60-80% nares occlusion, overall delivered MAPs were 60 ± 17% less than set CPAP levels (P < 0.001). Further, MAP decreased progressively with decreasing percent nares occlusion. The simulated open mouth condition resulted in significantly lower MAPs to <1.7 cmH2 O. The one-half prong insertion depth condition, with closed mouth, yielded MAPs approximately 35 ± 9% less than full insertion pressures (P < 0.001).

CONCLUSIONS

In our bench tests, the RAM interface connected to a ventilator in NCPAP mode failed to deliver set CPAP levels when applied using the manufacturer recommended 60-80% nares occlusion, even with closed mouth and full nasal prong insertion conditions.

Noninvasive Ventilation for Preterm Twin Neonates with Respiratory Distress Syndrome: A Randomized Controlled Trial

Noninvasive ventilation has been proven to be effective strategies for reducing the need for endotracheal ventilation in preterm infant with respiratory distress syndrome (RDS), however the best option needs to be further determined. A single center, paired design, randomized, controlled trial was conducted between Jan 2011 and July 2014. Preterm twins with RDS were included. One of a pair was randomized to NIPPV, while another to NCPAP. Surfactant was administrated as rescue treatment. The primary outcome was the need for endotracheal ventilation. The secondary outcomes were the complications. 143 pairs were randomized and 129 pairs finished the trial. The rates of endotracheal ventilation did not differ significantly between NIPPV and NCPAP groups (11.9% vs 19.6%, P = 0.080). This difference was not observed in the subgroup of infants who received surfactant therapy (11.1% vs 19.7%, P = 0.087). No secondary outcomes also differed significantly between the two groups. NIPPV did not result in a significantly lower incidence of intubation as compared with NCPAP in preterm twins with RDS.

Late presenting nasal deformities after nasal continuous positive airway pressure injury: 33-year experience

PURPOSE

This study was designed to characterize the resultant nasal deformities seen in adolescent and adult patients who sustained nasal continuous positive airway pressure (nCPAP) injuries during their NICU admission.

PATIENTS AND METHODS

Data from patients who sustained nCPAP injury in the NICU and seen for plastic surgery evaluation at one institution over the past 33 years was collected. Exclusion criteria were patients with additional nasal trauma after nCPAP injury. A retrospective review was performed, including demographics, time of initial injury, surgical timing, associated medical history, nasal function and photographs. Deformities were characterized according to aesthetic nasal subunit location and secondary nasal deformities. Outcome measures included the need and type of surgical correction, presence of airway obstruction, and surgical complications.

RESULTS

11 patients were included; the average age was 13.9±4.6 years. The average gestational age was 26.5±1.6 weeks. All of the nasal deformities included the inferior third of nose. The nasal soft triangle and columella were the most common subunits affected. Three patients had combined deformities with involvement of at least two nasal subunits. All injuries resulted in secondary nasal deformities, including nostril asymmetry, columellar asymmetry, nasal tip deviation, lack of projection and nasal airway obstruction. All patients required at least two operative interventions for treatment. Mean age of initial reconstruction was 7.2 years. Despite surgical intervention, secondary deformities and nasal airway obstruction was still present.

CONCLUSION

Late presenting nCPAP injury deformities most commonly affect the lower third of the nose and can result in a myriad of secondary nasal deformities. The nasal soft triangle and columella were the most commonly involved subunits. Secondary deformities involved the nasal aesthetic subunits adjacent to the primarily affected areas, resulting in asymmetry as well as nasal airway obstruction. Most patients required staged open nasal reconstruction with composite grafts.

A trial comparing noninvasive ventilation strategies in preterm infants

BACKGROUND

To reduce the risk of bronchopulmonary dysplasia in extremely-low-birth-weight infants, clinicians attempt to minimize the use of endotracheal intubation by the early introduction of less invasive forms of positive airway pressure.

METHODS

We randomly assigned 1009 infants with a birth weight of less than 1000 g and a gestational age of less than 30 weeks to one of two forms of noninvasive respiratory support--nasal intermittent positive-pressure ventilation (IPPV) or nasal continuous positive airway pressure (CPAP)--at the time of the first use of noninvasive respiratory support during the first 28 days of life. The primary outcome was death before 36 weeks of postmenstrual age or survival with bronchopulmonary dysplasia.

RESULTS

Of the 497 infants assigned to nasal IPPV for whom adequate data were available, 191 died or survived with bronchopulmonary dysplasia (38.4%), as compared with 180 of 490 infants assigned to nasal CPAP (36.7%) (adjusted odds ratio, 1.09; 95% confidence interval, 0.83 to 1.43; P=0.56). The frequencies of air leaks and necrotizing enterocolitis, the duration of respiratory support, and the time to full feedings did not differ significantly between treatment groups.

CONCLUSIONS

Among extremely-low-birth-weight infants, the rate of survival to 36 weeks of postmenstrual age without bronchopulmonary dysplasia did not differ significantly after noninvasive respiratory support with nasal IPPV as compared with nasal CPAP. (Funded by the Canadian Institutes of Health Research; NIPPV ClinicalTrials.gov number, NCT00433212; Controlled-Trials.com number, ISRCTN15233270.).

Humidified high flow nasal cannulae: current practice in Australasian nurseries, a survey

AIM

Humidified High Flow Nasal Cannula (HHFNC) has been increasingly adopted as a new means of respiratory support throughout the world. However, evidence to support its safety and efficacy is limited. The aim of the present survey was to determine current practices regarding the usage of HHFNC by neonatologists in Australia and New Zealand.

METHODS

Surveys were sent to all 167 neonatologists identified by the list of centres in the Australia and New Zealand Neonatal Network.

RESULTS

A total of 157 surveys were sent to valid email addresses: 111 (71%) responded of which 105 (67%) had completed the questionnaire. HHFNC is used in 17 (63%) of neonatal intensive care units in Australia and New Zealand. It is most commonly used to reduce nasal trauma (91%) and provide continuous positive airways pressure (62%). The main perceived benefits of HHFNC were the easier application and care of the infant (86%), and improved tolerance by the baby (84%). Rain out leading to fluid instillation into the upper airway (59%) was the most common problem.

CONCLUSION

This survey has provided a snapshot of the practice of HHFNC usage in Australia and New Zealand in 2010 and has revealed that HHFNC use is widespread and that clinical practices are diverse. The majority of neonatologists acknowledge that there is limited evidence to support its efficacy and safety, and would be happy to participate in clinical trials to address how best to deliver HHFNC.

Iatrogenic skin injury in the neonatal intensive care unit

Although neonatal care has become more and more meticulous with significant changes in technology in the neonatal intensive care unit (NICU) in the past 50 years, iatrogenic cutaneous injuries continue to occur. Although the incidence of severe injuries is decreasing because the more difficult procedures are being replaced by improved techniques, skin injuries have not yet been completely eliminated. However, the nature and causes of cutaneous injuries have changed, and the injuries are frequent but generally minor. The major risk factors are low birth weight, gestational age, length of stay, a central venous line, mechanical ventilation, and support with continuous positive airway pressure. The rate of iatrogenic events is about 57% at gestational ages of 24-27 weeks, compared with 3% at term. There are no current comprehensive reviews of iatrogenic cutaneous injury. The purpose of this review is to describe the iatrogenic cutaneous injuries that may occur in the newborns as a consequence of perinatal and postnatal medical procedures. With increased survival of extremely-low-birth-weight (ELBW) infants and changing modes of management in the NICU, neonatologists must make every effort to recognize injuries and prevent their occurrence in the NICU.

Effects of nasal continuous positive airway pressure and cannula use in the neonatal intensive care unit setting

OBJECTIVE

To investigate the effects of nasal continuous positive airway pressure (CPAP) and cannula use in the neonatal intensive care unit.

DESIGN

Cross-sectional study.

SETTING

Tertiary care children's hospital.

PATIENTS

One hundred patients (200 nasal cavities), younger than 1 year, who received at least 7 days of nasal CPAP (n = 91) or cannula supplementation (n = 9) in the neonatal intensive care unit.

INTERVENTIONS

External nasal examination and anterior nasal endoscopy with photographic documentation.

MAIN OUTCOME MEASURES

The incidence and characteristics of internal and external nasal findings of patients with nasal CPAP or cannula use.

RESULTS

Nasal complications were seen in 12 of the 91 patients (13.2%) with at least 7 days of nasal CPAP exposure, while no complications were seen in the 9 patients with nasal cannula use alone. The external nasal finding of columellar necrosis, seen in 5 patients (5.5%), occurred as early as 10 days after nasal CPAP use. Incidence of intranasal findings attributed to CPAP use, in the 182 nostrils examined, included ulceration in 6 nasal cavities (3.3%), granulation in 3 nasal cavities (1.6%), and vestibular stenosis in 4 nasal cavities (2.2%). Intranasal complications were seen as early as 8 to 9 days after nasal CPAP administration. Nasal complications from CPAP were associated with lower Apgar scores at 1 (P = .02) and 5 (P = .06) minutes.

CONCLUSIONS

External or internal complications of nasal CPAP can be relatively frequent (13.2%) and can occur early, and patients with lower Apgar scores may be at higher risk. Close surveillance for potential complications should be considered during nasal CPAP use.

Children With Respiratory Distress Treated With High-Flow Nasal Cannula

High-flow nasal cannula (HFNC) therapy is a treatment for respiratory distress in neonates and children. In the present study, we assessed its effectiveness, comfort, and possible mechanism of action. Methods: We reviewed records of 46 patients treated with HFNC and estimated the modified COMFORT score (7 to 35 units), the respiratory clinical scale (0 to 12 units), and the oxygen saturation level. Data were collected at time 0 (before the use of high-flow), time 2 (60 to 90 min post-application), and at time 3 (8 to 12 hours post-application). Furthermore, we measured the nasopharyngeal pressure while on continuous positive air pressure (CPAP) as well as the differences in ‘‘lung expansion’’ demonstrated by the prestudy and post-study chest x-ray. Results: There were significant improvements in the modified COMFORT score (F1,45 = 40.03, P < .05), respiratory clinical scale (F1.69,76.15 = 121.19, P < .05), and oxygen saturation (F2,90 = 101.54, P < .05). Application of HFNC therapy created a significant average positive expiratory pressure of 4.0 ± 1.99 (SE) cm H2O. X-rays taken after initiation of HFNC showed either improved aeration of the lungs or no changes in 40 of 46 patients. Mechanical ventilation was needed in 5 of 46 patients. Conclusion: Our study indicates that high-flow nasal cannula improves the respiratory scale score, the oxygen saturation, and the patient’s COMFORT scale. Its mechanism of action is application of mild positive airway pressure and lung volume recruitment.

Prevention of nasal injuries secondary to NCPAP application in the ELBW infant

Improved technology and management approaches that have reduced bronchopulmonary dysplasia (BPD) have decreased mortality and morbidity in extremely low birth weight (ELBW) infants. Early extubation to nasal continuous positive airway pressure (NCPAP) decreases the complications associated with long-term oral/nasal endotracheal intubation, including BPD, ventilator-associated pneumonia, volutrauma, subglottic stenosis, oral palatal grooves, and nasal septum erosion. Research and anecdotal evidence have shown that iatrogenic injuries to the nose also occur with extended time on NCPAP. Research observing associations between the patient interface and nasal injury has shown duration of therapy to be the most significant risk factor. Immature skin and developing nasal structures place ELBW infants at increased risk for injury. The challenge for NICU caregivers is maintaining the ELBW infant on NCPAP for extended periods without nasal injury. Appropriate protocols, practice guidelines, and staff education can decrease these injuries.

Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) is used to support preterm infants recently extubated, those experiencing significant apnoea of prematurity and those with respiratory distress soon after birth as an alternative to intubation and ventilation. This review focuses exclusively on identifying the most effective pressure source and interface for NCPAP delivery in preterm infants.

OBJECTIVES

To determine which technique of pressure generation and which type of nasal interface for NCPAP delivery most effectively reduces the need for additional respiratory support in preterm infants extubated to NCPAP following intermittent positive pressure ventilation (IPPV) for respiratory distress syndrome (RDS) or in those treated with NCPAP soon after birth.

SEARCH STRATEGY

The strategy included searches of MEDLINE (1966 - 2006), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 4, 2006) CINAHL, abstracts from conference proceedings, cross-referencing of previous reviews and the use of expert informants.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing different techniques of NCPAP pressure generation and/or nasal interfaces in preterm infants extubated to NCPAP following IPPV for RDS or treated with NCPAP soon after birth.

DATA COLLECTION AND ANALYSIS

Data was extracted and analysed by the first three authors. Dichotomous results were analysed using the relative risk (RR), risk difference (RD) and number needed to treat (NNT).

MAIN RESULTS

1. Preterm infants being extubated to NCPAP following a period of IPPV for RDS:Meta-analysis of the results from Davis 2001 and Roukema 1999a demonstrated that short binasal prongs are more effective at preventing re-intubation than single nasal or nasopharyngeal prongs [typical RR 0.59 (CI: 0.41, 0.85), typical RD -0.21 (CI: -0.35, -0.07), NNT 5 (CI: 3, 14)]. In one study comparing short binasal prong devices (Sun 1999), the re-intubation rate was significantly lower with the Infant Flow Driver than with the Medicorp prong [RR 0.33 (CI: 0.17, 0.67), RD -0.32 (CI: -0.49, -0.15), NNT 3 (CI: 2, 7)]. The other study comparing short binasal prong devices (Infant Flow Driver versus INCA prongs, Stefanescu 2003) demonstrated no significant difference in the re-intubation rate but did show a significant reduction in the total days in hospital in the Infant Flow Driver group [MD -12.60 (95% CI: -22.81, -2.39) days].2. Preterm infants primarily treated with NCPAP soon after birth:In the one trial identified, Mazzella 2001 found a significantly lower oxygen requirement and respiratory rate in those randomised to short binasal prongs when compared with CPAP delivered via nasopharyngeal prong. The requirement for intubation beyond 48 hours from randomisation was not assessed.3. Studies randomising preterm infants to different NCPAP systems using broad inclusion criteriaThe studies of Rego 2002 and Buettiker 2004 did not examine the primary outcomes of this review. Of the secondary outcomes, Rego 2002 demonstrated a significantly higher incidence of nasal hyperaemia with the use of the Argyle prong compared with Hudson prongs [RR 2.39 (95% CI: 1.27, 4.50), RD 0.28 (95% CI: 0.10, 0.46)]. One study comparing different techniques of pressure generation is awaiting further assessment as it is currently available in abstract form only.

AUTHORS' CONCLUSIONS

Short binasal prong devices are more effective than single prongs in reducing the rate of re-intubation. Although the Infant Flow Driver appears more effective than Medicorp prongs the most effective short binasal prong device remains to be determined. The improvement in respiratory parameters with short binasal prongs suggests they are more effective than nasopharyngeal CPAP in the treatment of early RDS. Further studies incorporating longer-term outcomes are required. Studies are also needed to determine the optimal pressure source for the delivery of NCPAP.

Neonatal nasal intermittent positive pressure ventilation: what do we know in 2007?

Although neonatal nasal intermittent positive pressure ventilation (NIPPV) is widely used today, its place in neonatal respiratory support is yet to be fully defined. Current evidence indicates that NIPPV after extubation of very premature infants reduces the rate of reintubation. However, much is still not known about NIPPV including its mechanisms of action. It may improve pulmonary mechanisms, tidal volume and minute ventilation but more studies are required to confirm these findings. There is some evidence that NIPPV marginally improves gas exchange. More research is needed to establish which device is best, what settings to use or whether to use synchronised rather than non-synchronised NIPPV, and about the way to wean NIPPV. Future studies should enrol sufficient infants to detect uncommon serious complications and include long-term follow up to determine important neurodevelopment and pulmonary outcomes.

Primary respiratory support in preterm infants with cleft lip and palate

OBJECTIVE

Preterm infants with respiratory distress are routinely treated by application of nasal mask continuous positive airway pressure. In preterm infants with cleft lip and palate, nasal mask attachment is not feasible due to air leakage through the cleft defect. Here, we describe a modified continuous positive airway pressure application method that overcomes this problem.

DESIGN AND SUBJECTS

Observation study, university neonatal intensive care unit. The neonates (n = 4) were between 28 and 33 weeks' gestation and weighed 1160 to 1680 g at birth. Immediately after birth, infants with unilateral cleft lip and palate (n = 3) were respiratory stabilised by a Medijet generator using a nasal tube. To minimise the pressure cap, hydrocolloid bandages were adhered over the total cleft defect. Immediately after orthodontic passive palatal plates insertion (within 27 hours of life), the nasal tube was removed and continuous positive airway pressure was applied through a nasal mask covering the complete nose of the infant.

RESULTS

The system proved suitable for patients with unilateral cleft lip and palate for whom the generated nasal mask continuous positive airway pressure remained constant between 5 to 7 cm of water but failed in the patient with bilateral cleft lip and palate. None of the patients had to be ventilated due to respiratory failure, and all survived to discharge.

CONCLUSION

Preterm infants with unilateral, but not bilateral cleft lip and palate, can be successfully stabilised using the described nasal mask continuous positive airway pressure system, thereby avoiding primary intubation and its associated risk of complications.

Nasal continuous positive airway pressure from high flow cannula versus Infant Flow for Preterm infants

OBJECTIVE

To compare the feasibility of continuous positive airway pressure (CPAP) support generated by high flow nasal cannula with conventional CPAP for prevention of reintubation among preterm infants with a birth weight of <or=1,250 g.

STUDY DESIGN

Preterm infants were randomized to CPAP generated via high flow cannula or the Infant Flow Nasal CPAP System (VIASYS, Conshohocken, PA, USA) at extubation. Primary outcome was incidence of reintubation within 7 days. Secondary outcomes included change in oxygen use and frequency of apnea and bradycardias postextubation.

RESULTS

Forty neonates were randomized. Twelve of 20 infants randomized to high flow cannula CPAP were reintubated compared to three of 20 using Infant Flow (P=0.003). The high flow cannula group had increased oxygen use and more apneas and bradycardias postextubation.

CONCLUSIONS

CPAP delivered by high flow nasal cannula failed to maintain extubation status among preterm infants <or=1,250 g as effectively as Infant Flow CPAP.

Morphine-related apnoea in CPAP-treated preterm neonates

BACKGROUND

Morphine can be used to treat pain in preterm neonates with CPAP because of its analgetic potency; however, it is known to induce apnoea.

AIM

To evaluate this risk of apnoea.

METHODS

We retrospectively analysed 91 preterm neonates with CPAP who received morphine intravenously. The incidence of apnoea 4 h before and after morphine administration was compared. The data were analysed for three dosage groups (<0.01, 0.01-0.03 and 0.03 mg/kg) and according to the incidence of apnoea before morphine application.

RESULTS

In the whole group (gestational age 29.1+/-2.9 wk, morphine dosage 0.017+/-0.01 mg/kg) we did not find differences in apnoea before and after morphine (0.9+/-1.8 vs 1.1+/-1.8 apnoea). The only significant increase in apnoea was seen in the subgroup of patients receiving > 0.03 mg/kg (0.3+/-0.67 vs 1.5+/-2.5 apnoea). Interestingly, we found a significantly delayed increase in apnoea in the fourth hour.

CONCLUSION

Morphine in preterm infants with CPAP is not widely accepted practice until further randomized studies evaluate efficacy and safety. Morphine in a low dosage (<or=0.03 mg/kg) did not significantly increase the apnoea rate in CPAP-treated preterm infants. For clinical work, it is very important to note that morphine-related apnoea may appear with a delay of approximately 4 h.

Treatment strategy for iatrogenic nasal vestibular stenosis in young children

Iatrogenic nasal vestibular stenosis is an uncommon complication of supportive care in neonates. There is minimal literature describing this entity; previous treatment strategies focus on correction with local flaps or skin grafts. We describe symptomatic iatrogenic vestibular stenosis treated successfully with endoscopic lysis of synechiae and nasal stenting. Three children with nasal stenosis were identified from 2003 to 2004 at a large academic tertiary care medical center. All patients were born premature (25-34 weeks). Two developed vestibular stenosis after extended use of nasal CPAP; one developed unilateral nasal stenosis 4 years after use of a nasal feeding tube. Age at time of surgical repair was from 4 months to 5 years. Two patients (4 and 5 months) presented with nasal airway obstruction, and difficulty breathing during feeding. One patient (5 years) presented with right-sided nasal obstruction and nasal whistling. Endoscopic lysis of nasal synechiae and release of vestibular scarring was performed in all three cases without complication. Nasal stenting with a modified endotracheal tube was used for 4-6 weeks. Topical Mitomycin C was utilized in two patients. All patients had complete resolution of airway symptoms after stent removal and all three remain asymptomatic 1 year after repair with no recurrence of vestibular stenosis. Nasal vestibular stenosis is a rare complication following supportive care in premature infants, causing airway and feeding difficulties in the obligate nasal breather. This can be successfully corrected with endoscopic repair, nasal stenting and application of Mitomycin C.

Nasal breathing and continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA)

Although nasal continuous positive airway pressure (nCPAP) treatment is the most efficient therapy for obstructive sleep apnea (OSA), compliance with therapy is poor because of several side effects. Among these adverse effects some are related to the reactions of the nose to nCPAP which are briefly described. In a long-term survey of 109 OSA patients, 80.6% continued nCPAP for at least 3 years until the last follow-up. Follow-up ranged between 0.8 and 109 months with a mean time of 43 (SD +/- 24.7) months. Among all patients treated with nCPAP, only 46.6% met our criteria for long-term compliance, defined as a mean use of the CPAP machine for at least 5 hours per night. Within the objective measures such as age, body mass index, neck circumference, nasal airflow, apnea-hypopnea index, minimal oxygen saturation, and level of nCPAP pressure, no predictive factor for daily use of nCPAP could be found. However, pretherapeutic daytime somnolence (measured by visual analogue scale and Epworth Sleepiness Scale) and its improvement obtained from the therapy showed a significant effect on the daily use of the CPAP machine.

Nasal CPAP for neonates: what do we know in 2003?

Despite the acknowledged clinical usefulness of nasal CPAP, uncertainties regarding aspects of its application remain. Clinical indications for the application of nasal CPAP vary greatly between institutions. Furthermore, defining the optimal nasal CPAP system is complicated by the multiplicity of nasal CPAP devices and techniques available to the clinician. This review aims to identify what we know about nasal CPAP and what important questions remain.

Newer experience with CPAP

Progress in neonatal intensive care is closely linked to improvements in the management of respiratory failure in small infants. Current modalities of ventilatory assistance range from more benign continuous positive airway pressure (CPAP) to various modes of mechanical ventilation (including high frequency ventilation). The advent of less invasive methods of delivering CPAP has permitted earlier treatment of infants with respiratory distress syndrome and avoided the need for mechanical ventilation. Children's Hospital of New York (Columbia University) places all spontaneously breathing infants on nasal prong CPAP as the first mode of respiratory support. The early initiation of nasal prong CPAP in combination with a tolerance to elevated PCO(2) levels has reduced the incidence of chronic lung disease to <5% in infants weighing less than 1500g. This report will present an historical review and summarize the experience with CPAP at Columbia and other centres. In addition, it reviews the clinical applications and physiological effects of CPAP in preterm infants with respiratory distress syndrome.

In vitro comparison of nasal continuous positive airway pressure devices for neonates

OBJECTIVE

To compare the resistance in vitro of different devices used for the delivery of nasal continuous positive airway pressure (NCPAP) in neonates.

DESIGN

Flows of 4-8 litres/min were passed through a selection of neonatal NCPAP devices (single prong, Duotube, Argyle prong, Hudson prong, Infant Flow Driver), and the resultant fall in pressure measured using a calibrated pressure transducer.

RESULTS

The decrease in pressure (cm H(2)O) for each device (size in parentheses) at a constant flow of 6 litres/min was: Duotube: (2.5), 21; (3.0), 6.2; (3.5), 2.3; single prong: (2.5), 4.4; (3.0), 2.1; (3.5), 1.2; Argyle prong: (XS), 3.6; (S), 1.9; (L), 1.5; Hudson prong: (0), 3.1; (1), 1.8; (2), 0.6; (3), 0.4; (4), 0.3; Infant Flow Driver: (small), 0.3; (medium), -0.3; (large), -0.5.

CONCLUSIONS

A large variation in the potential fall in pressure may occur in the clinical setting. Devices with short double prongs had the lowest resistance to flow. These results have implications in the selection of the optimal device/s for clinical application and for future comparisons in randomised trials of NCPAP in neonates.

Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates

BACKGROUND

Nasal continuous positive airway pressure (NCPAP) is used to support preterm infants recently extubated, those experiencing significant apnoea of prematurity and those with respiratory distress soon after birth as an alternative to intubation and ventilation. This review will focus exclusively on identifying the most effective pressure source and interface for NCPAP delivery in preterm infants.

OBJECTIVES

In preterm infants extubated to NCPAP following intermittent positive pressure ventilation (IPPV) for respiratory distress syndrome (RDS) or in those treated with NCPAP soon after birth, which technique of pressure generation and which type of nasal interface for NCPAP delivery most effectively reduces the need for additional respiratory support?

SEARCH STRATEGY

The strategy included searches of MEDLINE (1966-2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002), CINAHL, abstracts from conference proceedings, cross-referencing of previous reviews and the use of expert informants.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing different techniques of NCPAP pressure generation and/or nasal interfaces in preterm infants extubated to NCPAP following IPPV for RDS or treated with NCPAP soon after birth.

DATA COLLECTION AND ANALYSIS

Data was extracted and analysed by the first three authors. Dichotomous results were analysed using the relative risk (RR), risk difference (RD) and number needed to treat (NNT).

MAIN RESULTS

1. Preterm infants being extubated to NCPAP following a period of IPPV for RDS: Meta-analysis of the results from Davis 2001 and Roukema 1999a demonstrated that short binasal prongs are more effective at preventing re-intubation than single nasal or nasopharyngeal prongs [typical RR 0.59 (CI: 0.41, 0.85), typical RD -0.21 (CI: -0.35, -0.07), NNT 5 (CI: 3, 14)]. In the single study comparing short binasal prong devices (Sun 1999) the re-intubation rate was significantly lower with the Infant Flow Driver than with the Medicorp prong [RR 0.33 (CI: 0.17, 0.67), RD -0.32 (CI: -0.49, -0.15), NNT 3 (CI: 2, 7)]. 2. Preterm infants primarily treated with NCPAP soon after birth: The one trial identified, Mazzella 2001, found a significantly lower oxygen requirement and respiratory rate in those randomised to short binasal prongs when compared with CPAP delivered via nasopharyngeal prong. The requirement for intubation beyond 48 hours from randomisation was not assessed. No studies comparing different techniques of pressure generation were identified.

REVIEWER'S CONCLUSIONS

Short binasal prong devices are more effective than single prongs in reducing the rate of re-intubation. Although the Infant Flow Driver appears more effective than Medicorp prongs the most effective short binasal prong device remains to be determined. The improvement in respiratory parameters with short binasal prongs suggests they are more effective than nasopharyngeal CPAP in the treatment of early RDS. Further studies incorporating longer-term outcomes are required. Studies are also needed to determine the optimal pressure source for the delivery of NCPAP.

Risks and benefits of therapies for apnoea in premature infants

Apnoea in infants can result from a wide range of causes, and requires thorough evaluation before deciding on appropriate treatment. Continuous monitoring of premature infants with apnoea is mandatory in order to define the pathophysiology and type of apnoea; selection of treatment involves careful assessment of aetiology, as well as efficacy and tolerability in each individual case. The objective of treatment is to prevent the deleterious consequences of apnoeas that last >20 seconds and/or are associated with bradycardia, cyanosis or pallor, and occur more often than once an hour over a 12-hour period. Apnoea management involves both pharmacological and nonpharmacological treatment. We suggest methylxanthines as first-line therapy for idiopathic apnoeas; evidence suggests that caffeine is better tolerated and as efficacious as theophylline (since it is particularly efficacious against the 'central' component of idiopathic apnoea of prematurity). If treatment fails, additional measures such as doxapram may be appropriate when hypoventilation is present, or nasal continuous positive airway pressure when upper airway instability or obstructive apnoeas are predominant. Apnoea prophylaxis is an additional reason to advocate prenatal maturation with betamethasone. Weaning from treatment is attempted 4 to 5 days after complete resolution of apnoea, beginning with the last treatment introduced. Monitoring should be maintained for 4 to 5 days to detect any relapse of recurrent and severe apnoeas, which would lead to the resumption of the most recently withdrawn treatment.

Comprehensive primary care follow-up for premature infants

Advances in perinatal and neonatal care have led to an increased incidence of survival of premature infants. Although most premature infants have normal outcomes, they are at increased risk for morbidity and mortality and require comprehensive primary care follow-up after they are discharged from the hospital. This article will review guidelines for general follow-up of premature infants and the associated problems related to prematurity. General follow-up is performed by the pediatric nurse practitioner, with subspecialty consultant referrals as needed. Knowledge of the problems of prematurity and treatment regimes will assist the pediatric nurse practitioner in providing high-quality care to these high-risk infants.