1
|
Ramanathan R, Biniwale M. Noninvasive Ventilation. Crit Care Nurs Clin North Am 2024; 36:51-67. [PMID: 38296376 DOI: 10.1016/j.cnc.2023.11.001] [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: 02/08/2024]
Abstract
Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk of bronchopulmonary dysplasia and or mortality. Most commonly used NIV modes include nasal continuous positive airway pressure, bi-phasic modes, such as, bi-level positive airway pressure, nasal intermittent positive pressure ventilation, high flow nasal cannula, noninvasive neurally adjusted ventilatory assist, and nasal high frequency ventilation are discussed in this review.
Collapse
Affiliation(s)
- Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Keck School of Medicine of USC, Los Angeles General Medical Center, 1200 North State Street, IRD-820, Los Angeles, CA 90033, USA.
| | - Manoj Biniwale
- Division of Neonatology, Department of Pediatrics, Keck School of Medicine of USC, Los Angeles General Medical Center, 1200 North State Street, IRD-820, Los Angeles, CA 90033, USA
| |
Collapse
|
2
|
Rauschendorf P, Bou Saba G, Meara GK, Roodaki N, Conde-Agudelo A, Garcia DEC, Burke TF. Effectiveness of a novel bubble CPAP system for neonatal respiratory support at a referral hospital in the Philippines. Front Pediatr 2023; 11:1323178. [PMID: 38161434 PMCID: PMC10757669 DOI: 10.3389/fped.2023.1323178] [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: 10/17/2023] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Aim To examine the impact of introducing and implementing the Vayu bubble continuous positive airway pressure (bCPAP) system on neonatal survival and neonatal respiratory outcomes in a neonatal intensive care unit (NICU) in the Philippines. Methods We compared clinical outcomes of 1,024 neonates before to 979 neonates after introduction of Vayu bCPAP systems into a NICU. The primary outcome was survival to discharge. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated. Analyses were undertaken separately for the entire NICU population and for neonates who received any form of respiratory support. Results The introduction of the Vayu bCPAP system was associated with (1) significant reductions in intubation (aOR: 0.75; 95% CI: 0.58-0.96) and in the use of nasal intermittent positive-pressure ventilation (NIPPV) (aOR: 0.69; 95% CI: 0.50-0.96) among the entire NICU population and (2) a significant increase in survival to discharge (aOR: 1.53; 95% CI: 1.09-2.17) and significant reductions in intubation (aOR: 0.52; 95% CI: 0.38-0.71), surfactant administration (aOR: 0.60; 95% CI: 0.40-0.89), NIPPV use (aOR: 0.52; 95% CI: 0.36-0.76), and a composite neonatal adverse outcome (aOR: 0.60; 95% CI: 0.42-0.84) among neonates who received any form of respiratory support. Conclusion The use of the Vayu bCPAP system in a NICU in the Philippines resulted in significant improvement in neonatal respiratory outcomes.
Collapse
Affiliation(s)
- Paula Rauschendorf
- Vayu Global Health Foundation, Boston, MA, United States
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | | | - Grace K. Meara
- Vayu Global Health Foundation, Boston, MA, United States
| | - Navid Roodaki
- Section of Neonatology, Department of Pediatrics, Ilocos Training and Regional Medical Center, San Fernando City, Philippines
- College of Medicine, Mariano Marcos State University, City of Batac, Philippines
- College of Medicine, University of Northern Philippines, Vigan City, Philippines
| | - Agustin Conde-Agudelo
- Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Daisy Evangeline C. Garcia
- Section of Neonatology, Department of Pediatrics, Ilocos Training and Regional Medical Center, San Fernando City, Philippines
| | - Thomas F. Burke
- Vayu Global Health Foundation, Boston, MA, United States
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
| |
Collapse
|
3
|
Magalhães P, Leme Silva P, Almeida L, DO Carmo Lima M, Fernandes Santos I, Camilo CA, Sena A. Positive pressure ventilation in the weaning of preterm newborns. Minerva Pediatr (Torino) 2023; 75:817-821. [PMID: 32639116 DOI: 10.23736/s2724-5276.20.05677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
BACKGROUND Weaning from invasive mechanical ventilation (IMV) of preterm newborns (PTNB) is one of the critical stages of life support in the Neonatal Intensive Care Unit (NICU). Noninvasive positive pressure ventilation (NPPV) has been used to facilitate weaning from IMV and includes continuous positive airway pressure (CPAP) without or with inspiratory pressure support (bilevel NPPV). Nevertheless, there is little information about their adherence and success rate during weaning process. METHODS In this retrospective cohort study, weaning data from patients admitted to a NICU from the northeast region of Brazil were analyzed. Sample was composed of PTNB submitted to IMV and divided in two groups according to the weaning strategy adopted: bilevel NPPV or NCPAP. Weaning failure was defined as returning to IMV within less than 48 h after extubation. RESULTS Fifty-seven PTNB were included. Majority were females, had caesarean delivery, very low weight upon birth (760-1480 g) and neonatal hypoxemia scores (Apgar) <7 in the first minute. Respiratory distress syndrome occurred in 56.7% of PTNB whilst respiratory infections occurred in 35.1% of patients. Bilevel NPPV was the most chosen modality of weaning. No difference in success rate was found between bilevel NPPV and NCPAP (P=0.17). CONCLUSIONS In this study, the application of noninvasive ventilation in preterm newborns for weaning from IMV was similar success rate between bilevel NPPV and NCPAP.
Collapse
Affiliation(s)
| | | | | | | | | | - Carlos A Camilo
- State University of Londrina, Paraná, Brazil
- University Pitágoras Unopar, Paraná, Brazil
| | - Aline Sena
- Health Institute Elpídio de Almeida, Paraíba, Brazil
| |
Collapse
|
4
|
Fu M, Hu Z, Yu G, Luo Y, Xiong X, Yang Q, Song W, Yu Y, Yang T. Predictors of extubation failure in newborns: a systematic review and meta-analysis. Ital J Pediatr 2023; 49:133. [PMID: 37784184 PMCID: PMC10546653 DOI: 10.1186/s13052-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/04/2023] Open
Abstract
Extubation failure (EF) is a significant concern in mechanically ventilated newborns, and predicting its occurrence is an ongoing area of research. To investigate the predictors of EF in newborns undergoing planned extubation, we conducted a systematic review and meta-analysis. A systematic literature search was conducted in PubMed, Web of Science, Embase, and Cochrane Library for studies published in English from the inception of each database to March 2023. The PRISMA guidelines were followed in all phases of this systematic review. The Risk of Bias Assessment for Nonrandomized Studies tool was used to assess methodological quality. Thirty-four studies were included, 10 of which were overall low risk of bias, 15 of moderate risk of bias, and 9 of high risk of bias. The studies reported 43 possible predictors in six broad categories (intrinsic factors; maternal factors; diseases and adverse conditions of the newborn; treatment of the newborn; characteristics before and after extubation; and clinical scores and composite indicators). Through a qualitative synthesis of 43 predictors and a quantitative meta-analysis of 19 factors, we identified five definite factors, eight possible factors, and 22 unclear factors related to EF. Definite factors included gestational age, sepsis, pre-extubation pH, pre-extubation FiO2, and respiratory severity score. Possible factors included age at extubation, anemia, inotropic use, mean airway pressure, pre-extubation PCO2, mechanical ventilation duration, Apgar score, and spontaneous breathing trial. With only a few high-quality studies currently available, well-designed and more extensive prospective studies investigating the predictors affecting EF are still needed. In the future, it will be important to explore the possibility of combining multiple predictors or assessment tools to enhance the accuracy of predicting extubation outcomes in clinical practice.
Collapse
Affiliation(s)
- Maoling Fu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhenjing Hu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Genzhen Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China.
| | - Ying Luo
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Xiaoju Xiong
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
| | - Qiaoyue Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenshuai Song
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yaqi Yu
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ting Yang
- Department of Nursing, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Qiaokou District, 1095 Jiefang Road, Wuhan, Hubei Province, China
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| |
Collapse
|
5
|
Prakash R, De Paoli AG, Davis PG, Oddie SJ, McGuire W. Bubble devices versus other pressure sources for nasal continuous positive airway pressure in preterm infants. Cochrane Database Syst Rev 2023; 3:CD015130. [PMID: 37009665 PMCID: PMC10064833 DOI: 10.1002/14651858.cd015130] [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: 04/03/2023]
Abstract
BACKGROUND Several types of pressure sources, including underwater bubble devices, mechanical ventilators, and the Infant Flow Driver, are used for providing continuous positive airway pressure (CPAP) to preterm infants with respiratory distress. It is unclear whether the use of bubble CPAP versus other pressure sources is associated with lower rates of CPAP treatment failure, or mortality and other morbidity. OBJECTIVES: To assess the benefits and harms of bubble CPAP versus other pressure sources (mechanical ventilators or Infant Flow Driver) for reducing treatment failure and associated morbidity and mortality in newborn preterm infants with or at risk of respiratory distress. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2023, Issue 1); MEDLINE (1946 to 6 January 2023), Embase (1974 to 6 January 2023), Maternity & Infant Care Database (1971 to 6 January 2023), and the Cumulative Index to Nursing and Allied Health Literature (1982 to 6 January 2023). We searched clinical trials databases and the reference lists of retrieved articles. SELECTION CRITERIA We included randomised controlled trials comparing bubble CPAP with other pressure sources (mechanical ventilators or Infant Flow Driver) for the delivery of nasal CPAP to preterm infants. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Two review authors separately evaluated trial quality, extracted data, and synthesised effect estimates using risk ratio (RR), risk difference (RD), and mean difference. We used the GRADE approach to assess the certainty of the evidence for effects on treatment failure, all-cause mortality, neurodevelopmental impairment, pneumothorax, moderate-severe nasal trauma, and bronchopulmonary dysplasia. MAIN RESULTS We included 15 trials involving a total of 1437 infants. All trials were small (median number of participants 88). The methods used to generate the randomisation sequence and ensure allocation concealment were unclear in about half of the trial reports. Lack of measures to blind caregivers or investigators was a potential source of bias in all of the included trials. The trials took place during the past 25 years in care facilities internationally, predominantly in India (five trials) and Iran (four trials). The studied pressure sources were commercially available bubble CPAP devices versus a variety of mechanical ventilator (11 trials) or Infant Flow Driver (4 trials) devices. Meta-analyses suggest that the use of bubble CPAP compared with mechanical ventilator or Infant Flow Driver CPAP may reduce the rate of treatment failure (RR 0.76, 95% confidence interval (CI) 0.60 to 0.95; (I² = 31%); RD -0.05, 95% CI -0.10 to -0.01; number needed to treat for an additional beneficial outcome 20, 95% CI 10 to 100; 13 trials, 1230 infants; low certainty evidence). The type of pressure source may not affect mortality prior to hospital discharge (RR 0.93, 95% CI 0.64 to 1.36 (I² = 0%); RD -0.01, 95% CI -0.04 to 0.02; 10 trials, 1189 infants; low certainty evidence). No data were available on neurodevelopmental impairment. Meta-analysis suggests that the pressure source may not affect the risk of pneumothorax (RR 0.73, 95% CI 0.40 to 1.34 (I² = 0%); RD -0.01, 95% CI -0.03 to 0.01; 14 trials, 1340 infants; low certainty evidence). Bubble CPAP likely increases the risk of moderate-severe nasal injury (RR 2.29, 95% CI 1.37 to 3.82 (I² = 17%); RD 0.07, 95% CI 0.03 to 0.11; number needed to treat for an additional harmful outcome 14, 95% CI 9 to 33; 8 trials, 753 infants; moderate certainty evidence). The pressure source may not affect the risk of bronchopulmonary dysplasia (RR 0.76, 95% CI 0.53 to 1.10 (I² = 0%); RD -0.04, 95% CI -0.09 to 0.01; 7 trials, 603 infants; low certainty evidence). AUTHORS' CONCLUSIONS: Given the low level of certainty about the effects of bubble CPAP versus other pressure sources on the risk of treatment failure and most associated morbidity and mortality for preterm infants, further large, high-quality trials are needed to provide evidence of sufficient validity and applicability to inform context- and setting-relevant policy and practice.
Collapse
Affiliation(s)
- Raj Prakash
- Paediatrics, York and Scarborough Teaching Hospitals NHS Trust, York, UK
| | | | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
| |
Collapse
|
6
|
Mamidi RR, MacDonald KD, Brumbach BH, Go MDA, McEvoy CT. Nasal continuous positive airway pressure practices in preterm infants: A survey of neonatal providers. J Neonatal Perinatal Med 2023; 16:611-617. [PMID: 38043019 DOI: 10.3233/npm-230006] [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: 12/04/2023]
Abstract
BACKGROUND The standard of care for respiratory support of preterm infants is nasal continuous positive airway pressure (CPAP), yet practices are not standardized. Our aim was to survey CPAP practices in infants < 32 weeks gestation among the American Academy of Pediatrics Neonatal-Perinatal section. METHODS A US, web-based survey inquired about the initiation, management, and discontinuation of CPAP, and chinstrap use and oral feedings on CPAP. RESULTS 857 providers consented. Regarding criteria to discontinue/wean CPAP: 69% use specific respiratory stability criteria; 22% a specific post-menstrual age; 8% responded other. 64% did not have guidelines for CPAP discontinuation; 54% did not have guidelines for CPAP initiation. 66% believe chinstraps improve CPAP efficacy; however, 11% routinely apply a chinstrap. 22% allow oral feeds on CPAP in certain circumstances. CONCLUSION There are meaningful variabilities in CPAP practices among neonatal providers across the US. Given the potential long-term implications this can have on the growth and development of the preterm lung, further evidence-based research is needed in relation to respiratory outcomes to optimize and standardize CPAP strategies.
Collapse
Affiliation(s)
- R R Mamidi
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
| | - K D MacDonald
- Division of Pediatric Pulmonology, Oregon Health & Science University, Portland, OR, USA
| | - B H Brumbach
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - M D A Go
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
| | - C T McEvoy
- Division of Neonatology, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
7
|
Prakash R, De Paoli AG, Oddie SJ, Davis PG, McGuire W. Masks versus prongs as interfaces for nasal continuous positive airway pressure in preterm infants. Cochrane Database Syst Rev 2022; 11:CD015129. [PMID: 36374241 PMCID: PMC9662142 DOI: 10.1002/14651858.cd015129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nasal masks and nasal prongs are used as interfaces for providing continuous positive airway pressure (CPAP) for preterm infants with or at risk of respiratory distress, either as primary support after birth or as ongoing support after endotracheal extubation from mechanical ventilation. It is unclear which type of interface is associated with lower rates of CPAP treatment failure, nasal trauma, or mortality and other morbidity. OBJECTIVES To assess the benefits and harms of nasal masks versus nasal prongs for reducing CPAP treatment failure, nasal trauma, or mortality and other morbidity in newborn preterm infants with or at risk of respiratory distress. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was October 2021. SELECTION CRITERIA We included randomised controlled trials comparing masks versus prongs as interfaces for delivery of nasal CPAP in newborn preterm infants (less than 37 weeks' gestation) with or at risk of respiratory distress. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. treatment failure, 2. all-cause mortality, and 3. neurodevelopmental impairment. Our secondary outcomes were 4. pneumothorax, 5. moderate-severe nasal trauma, 6. bronchopulmonary dysplasia, 7. duration of CPAP use, 8. duration of oxygen supplementation, 9. duration of hospitalisation, 10. patent ductus arteriosus receiving medical or surgical treatment, 11. necrotising enterocolitis, 12. severe intraventricular haemorrhage, and 13. severe retinopathy of prematurity. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 12 trials with 1604 infants. All trials were small (median number of participants 118). The trials occurred after 2001 in care facilities internationally, predominantly in India (eight trials). Most participants were preterm infants of 26 to 34 weeks' gestation who received nasal CPAP as the primary form of respiratory support after birth. The studied interfaces included commonly used commercially available masks and prongs. Lack of measures to blind caregivers or investigators was a potential source of performance and detection bias in all the trials. Meta-analyses suggested that use of masks compared with prongs may reduce CPAP treatment failure (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.58 to 0.90; 8 trials, 919 infants; low certainty). The type of interface may not affect mortality prior to hospital discharge (RR 0.83, 95% CI 0.56 to 1.22; 7 trials, 814 infants; low certainty). There are no data on neurodevelopmental impairment. Meta-analyses suggest that the choice of interface may result in little or no difference in the risk of pneumothorax (RR 0.93, 95% CI 0.45 to 1.93; 5 trials, 625 infants; low certainty). Use of masks rather than prongs may reduce the risk of moderate-severe nasal injury (RR 0.55, 95% CI 0.44 to 0.71; 10 trials, 1058 infants; low certainty). The evidence is very uncertain about the effect on bronchopulmonary dysplasia (RR 0.69, 95% CI 0.46 to 1.03; 7 trials, 843 infants; very low certainty). AUTHORS' CONCLUSIONS The available trial data provide low-certainty evidence that use of masks compared with prongs as the nasal CPAP interface may reduce treatment failure and nasal injury, and may have little or no effect on mortality or the risk of pneumothorax in newborn preterm infants with or at risk of respiratory distress. The effect on bronchopulmonary dysplasia is very uncertain. Large, high-quality trials would be needed to provide evidence of sufficient validity and applicability to inform policy and practice.
Collapse
Affiliation(s)
- Raj Prakash
- York and Scarborough Teaching Hospitals, NHS Trust, York, UK
| | | | - Sam J Oddie
- Bradford Neonatology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
| |
Collapse
|
8
|
Zhu X, Qi H, Feng Z, Shi Y, De Luca D. Noninvasive High-Frequency Oscillatory Ventilation vs Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation as Postextubation Support for Preterm Neonates in China: A Randomized Clinical Trial. JAMA Pediatr 2022; 176:551-559. [PMID: 35467744 PMCID: PMC9039831 DOI: 10.1001/jamapediatrics.2022.0710] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 01/12/2022] [Indexed: 12/15/2022]
Abstract
Importance Several respiratory support techniques are available to minimize the use of invasive mechanical ventilation (IMV) in preterm neonates. It is unknown whether noninvasive high-frequency oscillatory ventilation (NHFOV) is more efficacious than nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) in preterm neonates after their first extubation. Objective To test the hypothesis that NHFOV is more efficacious than NCPAP or NIPPV in reducing IMV after extubation and until neonatal intensive care unit discharge among preterm neonates. Design, Setting, and Participants This multicenter, pathophysiology-based, assessor-blinded, 3-group, randomized clinical trial was conducted in 69 tertiary referral neonatal intensive care units in China, recruiting participants from December 1, 2017, to May 31, 2021. Preterm neonates who were between the gestational age of 25 weeks plus 0 days and 32 weeks plus 6 days and were ready to be extubated were randomized to receive NCPAP, NIPPV or NHFOV. Data were analyzed on an intention-to-treat basis. Interventions The NCPAP, NIPPV, or NHFOV treatment was initiated after the first extubation and lasted until discharge. Main Outcomes and Measures Primary outcomes were total duration of IMV, need for reintubation, and ventilator-free days. These outcomes were chosen to describe the effect of noninvasive ventilation strategy on the general need for IMV. Results A total of 1440 neonates (mean [SD] age at birth, 29.4 [1.8] weeks; 860 boys [59.7%]) were included in the trial. Duration of IMV was longer in NIPPV (mean difference, 1.2; 95% CI, 0.01-2.3 days; P = .04) and NCPAP (mean difference, 1.5 days; 95% CI, 0.3-2.7 days; P = .01) compared with NHFOV. Neonates who were treated with NCPAP needed reintubations more often than those who were treated with NIPPV (risk difference: 8.1%; 95% CI, 2.9%-13.3%; P = .003) and NHFOV (risk difference, 12.5%; 95% CI, 7.5%-17.4%; P < .001). There were fewer ventilator-free days in neonates treated with NCPAP than in those treated with NIPPV (median [25th-75th percentile] difference, -3 [-6 to -1] days; P = .01). There were no differences between secondary efficacy or safety outcomes, except for the use of postnatal corticosteroids (lower in NHFOV than in NCPAP group; risk difference, 7.3%; 95% CI, 2.6%-12%; P = .002), weekly weight gain (higher in NHFOV than in NCPAP group; mean difference, -0.9 g/d; 95% CI, -1.8 to 0 g/d; P = .04), and duration of study intervention (shorter in NHFOV than in NIPPV group; median [25th-75th percentile] difference, -1 [-3 to 0] days; P = .01). Conclusions and Relevance Results of this trial indicated that NHFOV, if used after extubation and until discharge, slightly reduced the duration of IMV in preterm neonates, and both NHFOV and NIPPV resulted in a lower risk of reintubation than NCPAP. All 3 respiratory support techniques were equally safe for this patient population. Trial Registration ClinicalTrials.gov Identifier: NCT03181958.
Collapse
Affiliation(s)
- Xingwang Zhu
- Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics, Chongqing, China
| | - HongBo Qi
- First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhichun Feng
- Affiliated BaYi Children’s Hospital, People's Liberation Army General Hospital, Beijing, China
| | - Yuan Shi
- Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics, Chongqing, China
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Assistance Publique–Hôpitaux de Paris, Paris-Saclay University Hospitals, Medical Centre A. Béclère, Paris, France
- Physiopathology and Therapeutic Innovation, Institut National de la Santé et de la Recherche Médicale U999 Unit, Paris Saclay University, Paris, France
| |
Collapse
|
9
|
Mandhari HA, Al Riyami B, Khan A, Nonoyama M, Rizvi SGA. Risk Factors of Extubation Failure in Intubated Preterm Infants at a Tertiary Care Hospital in Oman. Sultan Qaboos Univ Med J 2022; 22:247-252. [PMID: 35673279 PMCID: PMC9155026 DOI: 10.18295/squmj.8.2021.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 02/10/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives This study aimed to determine extubation failure (EF) rate among intubated preterm infants (<37 weeks gestational age [GA]) admitted to a tertiary care neonatal intensive care unit (NICU) in Oman and identify the risk factors associated with EF. Methods This retrospective study included all intubated preterm infants (<37 weeks GA) admitted to the NICU at Sultan Qaboos University Hospital (SQUH) from January 2013 to December 2017. EF was defined as reintubation within seven days of planned extubation. Demographics, ventilation parameters, blood gas values and other possible risk factors of EF were collected. Statistical analysis included comparisons between EF and extubation success (ES) groups and a binary logistic regression analysis. Results A total of 190 preterm infants were intubated during the study period with 140 eligible for analysis. A total of 106 infants (75.7%) were successfully extubated while 34 (24.3%) failed extubation. GA <28 weeks (P = 0.029), lower 1-minute Apgar score (P = 0.023) and patent ductus arteriosus diagnosis (P = 0.018) were significantly associated with EF. After the multivariate analysis, only GA <28 weeks predicted EF with an adjusted odds ratio of 2.621 (95% confidence interval: 1.118 - 6.146). Conclusion EF rate in preterm infants admitted at the NICU of SQUH was within international rates. GA <28 weeks was the only predictor of the identified extubation failure. Neonatal practitioners need to seriously consider extreme prematurity in the extubation process and consider implementing strategies to decrease extubation failure in this group of fragile infants.
Collapse
Affiliation(s)
- Hilal Al Mandhari
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Buthina Al Riyami
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Ashfaq Khan
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
| | - Mika Nonoyama
- Department of Respiratory Therapy and Child Health Evaluative Sciences, Hospital for Sick Children, Toronto, Canada
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada
| | - Syed G. A. Rizvi
- Department of Family Medicine & Public Health, Sultan Qaboos University, Muscat, Oman
| |
Collapse
|
10
|
Implementing Volume-targeted Ventilation to Decrease Hypocarbia in Extremely Low Birth Weight Infants during the First Week of Life: A Quality Improvement Project. Pediatr Qual Saf 2021; 6:e398. [PMID: 33977188 PMCID: PMC8104191 DOI: 10.1097/pq9.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 10/22/2020] [Indexed: 11/27/2022] Open
Abstract
Hypocarbia in neonates increases the risk of poor neurodevelopmental outcomes. Volume-targeted ventilation (VTV) is associated with decreased hypocarbia and other respiratory morbidities. We noticed a high incidence of hypocarbia in extremely low birth weight (ELBW; <1,000 g) neonates in our Neonatal Intensive Care Unit. Thus, we undertook a quality improvement project to decrease the incidence of hypocarbia (the occurrence of PCO2 < 35 mm Hg) in ELBW neonates during the first week of life by 50% over 1 year. Methods Our major interventions were employing VTV as the primary mode of mechanical ventilation in neonates less than 28 weeks of gestation or ELBW at birth and increasing staff knowledge regarding hypocarbia. The baseline period spanned May-August 2016. We implemented the interventions in October 2016 and tracked the use of VTV and the incidence of hypocarbia during the first week of life for 12 months. Results We analyzed data on 28 and 77 patients in the baseline and postintervention periods, respectively. The use of VTV increased from 39% to 65%. However, the incidence of hypocarbia was not reduced (57% preintervention vs. 64% postintervention). In the postintervention cohort, the incidence of hypocarbia was comparable between VTV and other modes (60% vs. 70%; 95% confidence interval: -32%, 12%; P = 0.367), but we noted decreased blood gas sampling and earlier extubation in the VTV group (P = 0.002 and P = 0.046, respectively). Conclusions Successfully increasing VTV in our Neonatal Intensive Care Unit did not decrease hypocarbia during the first week of life. However, we observed the safety of VTV and obtained other desirable results.
Collapse
|
11
|
Dumpa V, Bhandari V. Non-Invasive Ventilatory Strategies to Decrease Bronchopulmonary Dysplasia-Where Are We in 2021? CHILDREN-BASEL 2021; 8:children8020132. [PMID: 33670260 PMCID: PMC7918044 DOI: 10.3390/children8020132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 11/16/2022]
Abstract
Recent advances in neonatology have led to the increased survival of extremely low-birth weight infants. However, the incidence of bronchopulmonary dysplasia (BPD) has not improved proportionally, partly due to increased survival of extremely premature infants born at the late-canalicular stage of lung development. Due to minimal surfactant production at this stage, these infants are at risk for severe respiratory distress syndrome, needing prolonged ventilation. While the etiology of BPD is multifactorial with antenatal, postnatal, and genetic factors playing a role, ventilator-induced lung injury is a major, potentially modifiable, risk factor implicated in its causation. Infants with BPD are at a higher risk of developing complications including sepsis, pulmonary arterial hypertension, respiratory failure, and death. Long-term problems include increased risk of hospital readmissions, respiratory infections, and asthma-like symptoms during infancy and childhood. Survivors who have BPD are also at increased risk of poor neurodevelopmental outcomes. While the ultimate solution for avoiding BPD lies in the prevention of preterm births, strategies to decrease its incidence are the need of the hour. It is time to focus on gentler modes of ventilation and the use of less invasive surfactant administration techniques to mitigate lung injury, thereby potentially decreasing the burden of BPD. In this article, we discuss the use of non-invasive ventilation in premature infants, with an emphasis on studies showing an effect on BPD with different modes of non-invasive ventilation. Practical considerations in the use of nasal intermittent positive pressure ventilation are also discussed, considering the significant heterogeneity in clinical practices and management strategies in its use.
Collapse
Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, NYU Long Island School of Medicine, NYU Langone Hospital Long Island, Mineola, NY 11501, USA;
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper Medical School of Rowan University, The Children’s Regional Hospital at Cooper, Camden, NJ 08103, USA
- Correspondence: ; Tel.: +856-342-6156 or +856-342-2000 (ext. 1089752); Fax: +856-342-8007
| |
Collapse
|
12
|
Li Y, Wei Q, Zhao D, Mo Y, Yao L, Li L, Tan W, Pan X, Yao J, Dai W, Zhong D. Non-invasive high-frequency oscillatory ventilation in preterm infants after extubation: a randomized, controlled trial. J Int Med Res 2021; 49:300060520984915. [PMID: 33641473 PMCID: PMC7923990 DOI: 10.1177/0300060520984915] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/04/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the effectiveness and safety of non-invasive high-frequency oscillatory ventilation (NHFOV) in post-extubation preterm infants. METHODS This was a randomized, controlled trial. A total of 149 preterm infants aged between 25 to 34 weeks' gestational age with a birth weight of <1500 g who required invasive mechanical ventilation on admission were included. After extubation, they were randomized to the NHFOV group (n = 47), nasal intermittent positive pressure ventilation (NIPPV) group (n = 51), or nasal continuous positive airway pressure (NCPAP) group (n = 51). We compared the effectiveness and safety among these three groups. RESULTS A total of 139 preterm infants finally completed the study. The reintubation rate was significantly lower in the NHFOV group than in the other groups. The duration of non-invasive ventilation and the length of hospital stay in the NHFOV and NIPPV groups were significantly shorter than those in the NCPAP group. The incidence of bronchopulmonary dysplasia in the NHFOV and NIPPV groups was significantly lower than that in the NCPAP group. The NHFOV group had significantly less nasal injury than the NCPAP group. CONCLUSION As post-extubation respiratory support in preterm infants, NHFOV has a lower reintubation rate compared with NCPAP and NIPPV, without increasing the rate of complications.
Collapse
Affiliation(s)
- Yan Li
- Department of Neonatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Qiufen Wei
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Dan Zhao
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Yan Mo
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Liping Yao
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Lingxiao Li
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Wei Tan
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Xinnian Pan
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Jiayan Yao
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Wei Dai
- Department of Neonatology, Maternity and Child Health Care of Guangxi Zhuang Autonomous Region, Nanning, Guangxi Zhuang Autonomous Region, China
| | - Danni Zhong
- Department of Neonatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi Zhuang Autonomous Region, China
| |
Collapse
|
13
|
Ramaswamy VV, Bandyopadhyay T, Nanda D, Bandiya P, More K, Oommen VI, Gupta A. Efficacy of noninvasive respiratory support modes as postextubation respiratory support in preterm neonates: A systematic review and network meta-analysis. Pediatr Pulmonol 2020; 55:2924-2939. [PMID: 32757365 DOI: 10.1002/ppul.25007] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 07/31/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Multiple noninvasive respiratory support (NRS) modalities are used for postextubation support in preterm neonates. Seven NRS modalities were compared-constant flow continuous positive airway pressure (CPAP) (CF-CPAP) (bubble CPAP; ventilator CPAP), variable flow CPAP (VF-CPAP), high flow nasal cannula (HFNC), synchronized noninvasive positive pressure ventilation (S-NIPPV), nonsynchronized NIPPV (NS-NIPPV), bilevel CPAP (BiPAP), noninvasive high-frequency oscillation ventilation (nHFOV). DESIGN Systematic review and network meta-analysis (NMA) using the Bayesian random-effects approach. MEDLINE, EMBASE, CENTRAL, WHO-ICTRP were searched. MAIN OUTCOME MEASURE Requirement of invasive mechanical ventilation within 7 days of extubation. RESULTS A total of 33 studies with 4080 preterm neonates were included. S-NIPPV, NS-NIPPV, nHFOV, and VF-CPAP were more efficacious in preventing reintubation than CF-CPAP (risk ratio [RR] [95% credible intervals {CrI}]: 0.22 [0.12, 0.35]; 0.44 [0.27, 0.67]; 0.42 [0.18, 0.81]; 0.73 [0.52, 0.99]). Surface under the cumulative ranking curve (SUCRA) value ranked S-NIPPV to be the best postextubation intervention (SUCRA: 0.98). S-NIPPV was more effective than NS-NIPPV, BiPAP, VF-CPAP, and HFNC (RR [95% CrI]: 0.52 [0.24, 0.97]; 0.32 [0.14, 0.64]; 0.30 [0.16, 0.50]; 0.24 [0.12, 0.41]). NS-NIPPV resulted in lesser reintubation compared to VF-CPAP and HFNC (RR [95% CrI]: 0.61 [0.36, 0.97]; 0.49 [0.27, 0.80]). BiPAP, VF-CPAP, and HFNC had comparable efficacies. The overall quality of evidence was very low to moderate. CONCLUSION Results of this NMA indicate that S-NIPPV might be the most effective and CF-CPAP the least effective NRS modality for preventing extubation failure.
Collapse
Affiliation(s)
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Debasish Nanda
- Department of Neonatology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Orissa, India
| | - Prathik Bandiya
- Department of Neonatology, Indira Gandhi Institute of Child Health, Bengaluru, India
| | - Kiran More
- Division of Neonatology, Sidra Medical and Research Center, Doha, Qatar
| | - Vinod Idicula Oommen
- Department Of Neonatology, Newborn Services, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Amit Gupta
- Department Of Neonatology, Newborn Services, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| |
Collapse
|
14
|
Okur N, Buyuktiryaki M, Sari FN, Dizdar EA, Oguz SS. Ventilator-delivered nasal intermittent positive pressure ventilation versus nasal biphasic positive airway pressure following extubation in infants ≤1250 g birth weight: a randomized trial. J Matern Fetal Neonatal Med 2020; 35:752-758. [PMID: 32106721 DOI: 10.1080/14767058.2020.1731462] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background and objective: To determine the effectiveness of ventilator-delivered nasal intermittent positive pressure ventilation and nasal biphasic positive airway pressure (n-BiPAP) after first extubation attempt in infants ≤1250-g birthweight.Methods: This randomized controlled study included mechanically ventilated preterm infants of ≤1250-g birthweight who were randomly assigned to ventilator-delivered NIPPV or n-BiPAP at first extubation within 2 weeks of age. The primary outcome (extubation failure within 96 h following extubation) and secondary outcomes were compared.Results: Extubation failure occurred in 22 of 74 infants in n-BiPAP group and 34 of 75 infants in NIPPV group (OR 0.51, 95% CI: 0.26-1.002; p = .05). Duration of invasive and noninvasive ventilation were found to be similar between groups. Also, there were no significant differences among groups for intraventricular hemorrhage, medically/surgically treated patent ductus arteriosus, necrotizing enterocolitis, BPD or death.Conclusion: Sustained extubation in infants ≤1250-g birthweight and <2 weeks age did not differ between ventilator-delivered NIPPV and n-BiPAP.Trial registration: Clinical Trials.gov under identifier NCT02842190.
Collapse
Affiliation(s)
- Nilufer Okur
- Ankara City Hospital, NICU, University of Health Sciences, Ankara, Turkey
| | | | - Fatma Nur Sari
- Ankara City Hospital, NICU, University of Health Sciences, Ankara, Turkey
| | | | - Serife Suna Oguz
- Ankara City Hospital, NICU, University of Health Sciences, Ankara, Turkey
| |
Collapse
|
15
|
Nasef N, Rashed HM, Aly H. Practical aspects on the use of non-invasive respiratory support in preterm infants. Int J Pediatr Adolesc Med 2020; 7:19-25. [PMID: 32373698 PMCID: PMC7193067 DOI: 10.1016/j.ijpam.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Preterm infants frequently present with respiratory insufficiency requiring respiratory assistance. Invasive mechanical ventilation has been associated with several short and long term complications. Therefore, the practice of early use of non-invasive ventilation has been adopted. Nasal CPAP proved efficacy as an initial therapy for preterm infants. Non-invasive positive pressure ventilation is an alternative used to mitigate CPAP failure in infants with apnea or increased work of breathing. High flow nasal cannula gained popularity primarily due to the ease of its use, despite multiple prominent trials that demonstrated its inferiority. Bi-level positive airway pressure and neurally adjusted non-invasive ventilatory are used in infants with apnea and increased work of breathing. The effectiveness of non invasive ventilation tools can be augmented by having a proper protocol for initiation, weaning, skin care, positioning, and developmental care during their application.
Collapse
Affiliation(s)
- Nehad Nasef
- Neonatal Intensive Care Unit, Mansora University Children's Hospital, Mansoura, Egypt.,Department of Pediatrics, Faculty of Medicine, University of Mansoura, Egypt
| | - Hend Me Rashed
- School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| |
Collapse
|
16
|
Chen L, Wang L, Ma J, Feng Z, Li J, Shi Y. Nasal High-Frequency Oscillatory Ventilation in Preterm Infants With Respiratory Distress Syndrome and ARDS After Extubation: A Randomized Controlled Trial. Chest 2020; 155:740-748. [PMID: 30955572 DOI: 10.1016/j.chest.2019.01.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/09/2018] [Accepted: 01/02/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Nasal high-frequency oscillatory ventilation (NHFOV) has been described as supplying the combined advantages of nasal CPAP (NCPAP) and HFOV. However, its effect on preterm infants needs to be further elucidated. Our objective was to assess whether NHFOV could reduce intubation and Pco2 levels as compared with NCPAP during the postextubation phase in preterm infants. METHODS This was a single-center, randomized, controlled trial, and it was registered at clinicaltrials.gov (NCT03140891) and conducted between May 2017 and May 2018. Ventilated infants born at less than 37 weeks' gestational age and ready to be extubated were included and randomized to either the NHFOV or NCPAP group. Primary outcomes were the incidence of reintubation within 1 week and the Pco2 level within 6 h. RESULTS A total of 206 preterm infants were included. Of them, 127 (61.7%) were diagnosed with respiratory distress syndrome, 53 (25.7%) with ARDS, and 26 (12.6%) with both respiratory distress syndrome and ARDS. Comparing with NCPAP, NHFOV significantly reduced the reintubation rate (16:87 vs 35:68; 95% CI, 0.18-0.70; P = .002), especially in the subgroup with a gestational age of ≤ 32 weeks (12:34 vs 25:20; 95% CI, 0.12-0.68; P = .004). The Pco2 level was also significant lower in the NHFOV group (49.6 ± 8.7 vs 56.9 ± 9.9; 95% CI, -9.95 to -4.80; P = < .001). Moreover, NHFOV significantly reduced the reintubation rate in preterm infants with ARDS (10:33 vs 21:15; 95% CI, 0.08-0.57; P = .002). CONCLUSIONS NHFOV was shown to be superior to NCPAP in avoiding reintubation, especially in very preterm infants and those infants diagnosed with ARDS. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03140891; URL: www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Long Chen
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Wang
- Department of Pediatrics, Daping Hospital of the Army Medical University, Chongqing, China
| | - Juan Ma
- Department of Pediatrics, Daping Hospital of the Army Medical University, Chongqing, China
| | - Zhichun Feng
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China
| | - Jie Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China; Department of Pediatrics, Daping Hospital of the Army Medical University, Chongqing, China.
| |
Collapse
|
17
|
|
18
|
Abu-Shaweesh JM, Khasawneh W, Tang AS, Worley S, Saker F. Compared to CPAP extubation to non-invasive ventilation is associated with higher risk of bronchopulmonary dysplasia in extremely low birth weight infants. J Neonatal Perinatal Med 2020; 13:183-188. [PMID: 31658069 DOI: 10.3233/npm-190354] [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: 06/10/2023]
Abstract
OBJECTIVE While non-invasive ventilation (NIV) has been associated with improved extubation rates, its impact on bronchopulmonary dysplasia (BPD) remains unclear. METHOD In this retrospective, chart review study of infants admitted to the Cleveland Clinic, we aimed to compare the incidence of BPD among extremely low birth weight (ELBW) infants extubated to continuous positive pressure (CPAP) versus those extubated to NIV via RAM cannula or biphasic CPAP. Data collected included demographics, ventilatory modes, extubation data, and presence of complications. Infants extubated to either CPAP or NIV were compared using Wilcoxon rank- sum and Chi-square tests, and data were corrected using logistic regression models. Data are presented as medians. RESULTS A total of 120 infants were included, of whom 62% were extubated to NIV. The incidence of BPD was significantly lower in the CPAP group vs NIV (57% vs. 78%, p = 0.011). Infants in the CPAP group were heavier (birth weight (BWT) of 833 vs 724 grams, p = 0.005), more mature (gestation age (GA) 27 vs 25 weeks, p < 0.001) and were extubated significantly earlier (2 vs 8 days, p < 0.001). After adjusting for BWT and GA, NIV continued to be significantly associated with higher incidence of BPD among those extubated on the first day of life (odds ratio 5.9; 95% CI: 1.2-29.1, p = 0.029). CONCLUSION This study concludes that, as compared to CPAP, early use of NIV is associated with higher risk of BPD in ELBW infants. Further investigation using prospective studies is recommended to validate these findings.
Collapse
Affiliation(s)
- J M Abu-Shaweesh
- Department of Pediatrics, Cleveland Clinic Children's, Cleveland, OH, USA
| | - W Khasawneh
- Department of Pediatrics, Jordan University of Science and Technology, Irbid, Jordan
| | - A S Tang
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - S Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - F Saker
- Department of Pediatrics, Cleveland Clinic Children's, Cleveland, OH, USA
| |
Collapse
|
19
|
Cao H, Li H, Zhu X, Wang L, Yi M, Li C, Chen L, Shi Y. Three non-invasive ventilation strategies for preterm infants with respiratory distress syndrome: a propensity score analysis. Arch Med Sci 2020; 16:1319-1326. [PMID: 33224330 PMCID: PMC7667431 DOI: 10.5114/aoms.2020.93541] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/15/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION The present study was designed and conducted to compare the efficacy between nasal continuous positive airway pressure (NCPAP), nasal intermittent positive-pressure ventilation (NIPPV), and noninvasive high-frequency oscillatory ventilation (NHFOV) as the primary noninvasive ventilation in preterm infants with respiratory distress syndrome (RDS). MATERIAL AND METHODS This multicenter retrospective cohort study was performed using data from four tertiary neonatal intensive care units (NICUs) in China between 2016 and 2018. 512 preterm infants with RDS who received early non-invasive ventilation (NIV) were analyzed. Propensity score analysis with 1 : 1 matching was performed with the nearest neighbor matching method using calipers of width equal to 0.1 of the standard deviation of the logit of the propensity score. The primary outcome was the need for intubation and invasive mechanical ventilation (IMV) within the first 7 days after birth. Secondary outcomes were days of hospitalization, predischarge mortality, rate of retinopathy of prematurity (ROP) > stage II, rate of bronchopulmonary dysplasia (BPD) at 36 weeks post-menstrual age, rate of air leaks, rate of intraventricular hemorrhage (IVH) ≥ grade 3, and rate of necrotizing enterocolitis (NEC) ≥ stage II. RESULTS Propensity score matching identified 126 infants in each cohort (NHFOV vs. NIPPV), 96 infants in each cohort (NHFOV vs. NCPAP), 134 infants in each cohort (NIPPV vs. NCPAP) respectively. The need for IMV was significantly lower in the NHFOV as compared with NCPAP and NIPPV groups respectively (13/126 vs. 27/126, p = 0.016; 9/96 vs. 20/96, p = 0.027), while no difference was observed between NIPPV and NCPAP groups (25/134 vs. 25/134, p = 0.805). However, the number of days of hospitalization in NIPPV was significantly lower than that of the NCPAP group (24.8 ±14.6 days vs. 33.2 ±20.2 days p = 0.002). In subgroup analyses, the need for IMV was significantly lower in the NHFOV group than in the NCPAP and NIPPV group (7 : 79 vs. 15 : 74; 95% CI: 1.00-6.836; p = 0.044 and 11 : 102 vs. 22 : 98; 95% CI: 1.092-5.251; p = 0.026), and there was no difference between NIPPV and NCPAP in the preterm infants at ≤ 32 weeks' gestational age. There were no significant differences among three groups (p > 0.05 respectively) regarding secondary outcomes. CONCLUSIONS In this multicenter retrospective cohort study, NHFOV significantly reduced the need for IMV within the first 7 days as compared to NCPAP and NIPPV in the treatment of preterm infants with RDS without increasing the incidence of adverse events. However, NIPPV was not found to be superior to NCPAP for decreasing the need for IMV in the treatment of preterm infants with RDS.
Collapse
Affiliation(s)
- Huiling Cao
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children’s Hospital of Chongqing Medical University; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Huanhuan Li
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children’s Hospital of Chongqing Medical University; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xingwang Zhu
- Department of Pediatrics, Jiulongpo People’s Hospital, Chongqing, China
| | - Li Wang
- Department of Pediatrics, Daping Hospital and Research Institute of Surgery, Army Military Medical University, Chongqing, China
| | - Ming Yi
- Department of Pediatrics, Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Chuanfeng Li
- Department of Pediatrics, Qujing Maternal and Child Health Hospital, Yunnan, China
| | - Long Chen
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children’s Hospital of Chongqing Medical University; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, Ministry of Education Key Laboratory of Child Development and Disorders; National Clinical Research Center for Child Health and Disorders; China International Science and Technology Cooperation base of Child development and Critical Disorders; Children’s Hospital of Chongqing Medical University; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| |
Collapse
|
20
|
Shi Y, Muniraman H, Biniwale M, Ramanathan R. A Review on Non-invasive Respiratory Support for Management of Respiratory Distress in Extremely Preterm Infants. Front Pediatr 2020; 8:270. [PMID: 32548084 PMCID: PMC7270199 DOI: 10.3389/fped.2020.00270] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Abstract
Majority of extremely preterm infants require positive pressure ventilatory support at the time of delivery or during the transitional period. Most of these infants present with respiratory distress (RD) and continue to require significant respiratory support in the neonatal intensive care unit (NICU). Bronchopulmonary dysplasia (BPD) remains as one of the major morbidities among survivors of the extremely preterm infants. BPD is associated with long-term adverse pulmonary and neurological outcomes. Invasive mechanical ventilation (IMV) and supplemental oxygen are two major risk factors for the development of BPD. Non-invasive ventilation (NIV) has been shown to decrease the need for IMV and reduce the risk of BPD when compared to IMV. This article reviews respiratory management with current NIV support strategies in extremely preterm infants both in delivery room as well as in the NICU and discusses the evidence to support commonly used NIV modes including nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), bi-level positive pressure (BI-PAP), high flow nasal cannula (HFNC), and newer NIV strategies currently being studied including, nasal high frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Randomized, clinical trials have shown that early NIPPV is superior to NCPAP to decrease the need for intubation and IMV in preterm infants with RD. It is also important to understand that selection of the device used to deliver NIPPV has a significant impact on its success. Ventilator generated NIPPV results in significantly lower rates of extubation failures when compared to Bi-PAP. Future studies should address synchronized NIPPV including NIV-NAVA and early rescue use of NHFV in the respiratory management of extremely preterm infants.
Collapse
Affiliation(s)
- Yuan Shi
- Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hemananda Muniraman
- Department of Pediatrics, Creighton School of Medicine, Omaha, NE, United States
| | - Manoj Biniwale
- Neonatology Association Limited, Obstetrix Medical Group of Phoenix, Mednax, Arizona, AZ, United States
| | - Rangasamy Ramanathan
- Division of Neonatology, LAC+USC Medical Center, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
21
|
Abstract
Numerous advances in neonatal care have improved outcomes in preterm infants. Antenatal steroids, through their ability to promote lung maturation and function, have led to significant improvements in death, intraventricular hemorrhage, necrotizing enterocolitis, and respiratory distress syndrome. For years, exogenous surfactant administration has been used in conjunction with antenatal steroids to further improve outcomes for preterm infants. However, as continuous positive airway pressure has been shown to be effective in treating respiratory distress syndrome, it has become less clear how exogenous surfactant should be used. Novel approaches combining these therapies may lead to further improvement in clinical outcome.
Collapse
Affiliation(s)
- Roger F Soll
- Department of Pediatrics, Neonatal-Perinatal Medicine, Larner College of Medicine, University of Vermont, 89 Beaumont Avenue, Burlington, VT 05405, USA.
| | - Whittney Barkhuff
- Department of Pediatrics, Neonatal-Perinatal Medicine, Larner College of Medicine, University of Vermont, 89 Beaumont Avenue, Burlington, VT 05405, USA
| |
Collapse
|
22
|
Ekhaguere O, Patel S, Kirpalani H. Nasal Intermittent Mandatory Ventilation Versus Nasal Continuous Positive Airway Pressure Before and After Invasive Ventilatory Support. Clin Perinatol 2019; 46:517-536. [PMID: 31345544 DOI: 10.1016/j.clp.2019.05.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Continuous positive airway pressure (CPAP), noninvasive intermittent positive pressure ventilation (NIPPV), and heated humidified high-flow nasal cannula (HHFNC) are modes of noninvasive respiratory support used in neonatal practice. These modes of noninvasive respiratory support may obviate mechanical ventilation, prevent extubation failure, and reduce the risk of developing bronchopulmonary dysplasia. Although the physiologic bases of CPAP and HHFNC are well delineated, and their modes and practical application consistent, those of NIPPV are unproven and varied. Available evidence suggests that NIPPV is superior to CPAP as a primary and postextubation respiratory support in preterm infants.
Collapse
Affiliation(s)
- Osayame Ekhaguere
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University, Riley Hospital for Children at Indiana University Health, 1030 West Michigan Street, C4600, Indianapolis, IN 46202, USA.
| | - Shama Patel
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, Indiana University, Riley Hospital for Children at Indiana University Health, 1030 West Michigan Street, C4600, Indianapolis, IN 46202, USA
| | - Haresh Kirpalani
- Department of Pediatrics, Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| |
Collapse
|
23
|
Lee BK, Shin SH, Jung YH, Kim EK, Kim HS. Comparison of NIV-NAVA and NCPAP in facilitating extubation for very preterm infants. BMC Pediatr 2019; 19:298. [PMID: 31462232 PMCID: PMC6712684 DOI: 10.1186/s12887-019-1683-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/21/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Various types of noninvasive respiratory modalities that lead to successful extubation in preterm infants have been explored. We aimed to compare noninvasive neurally adjusted ventilatory assist (NIV-NAVA) and nasal continuous positive airway pressure (NCPAP) for the postextubation stabilization of preterm infants. METHODS This retrospective study was divided into two distinct periods, between July 2012 and June 2013 and between July 2013 and June 2014, because NIV-NAVA was applied beginning in July 2013. Preterm infants of less than 30 weeks GA who had been intubated with mechanical ventilation for longer than 24 h and were weaned to NCPAP or NIV-NAVA after extubation were enrolled. Ventilatory variables and extubation failure were compared after weaning to NCPAP or NIV-NAVA. Extubation failure was defined when infants were reintubated within 72 h of extubation. RESULTS There were 14 infants who were weaned to NCPAP during Period I, and 2 infants and 16 infants were weaned to NCPAP and NIV-NAVA, respectively, during Period II. At the time of extubation, there were no differences in the respiratory severity score (NIV-NAVA 1.65 vs. NCPAP 1.95), oxygen saturation index (1.70 vs. 2.09) and steroid use before extubation. Several ventilation parameters at extubation, such as the mean airway pressure, positive end-expiratory pressure, peak inspiratory pressure, and FiO2, were similar between the two groups. SpO2 and pCO2 preceding extubation were comparable. Extubation failure within 72 h after extubation was observed in 6.3% of the NIV-NAVA group and 37.5% of the NCPAP group (P = 0.041). CONCLUSIONS The data in the present showed promising implications for using NIV-NAVA over NCPAP to facilitate extubation.
Collapse
Affiliation(s)
- Byoung Kook Lee
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
| |
Collapse
|
24
|
Shi Y, De Luca D. Continuous positive airway pressure (CPAP) vs noninvasive positive pressure ventilation (NIPPV) vs noninvasive high frequency oscillation ventilation (NHFOV) as post-extubation support in preterm neonates: protocol for an assessor-blinded, multicenter, randomized controlled trial. BMC Pediatr 2019; 19:256. [PMID: 31349833 PMCID: PMC6659219 DOI: 10.1186/s12887-019-1625-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 07/12/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Various noninvasive respiratory support modalities are available in neonatal critical care in order to minimize invasive ventilation. Continuous positive airway pressure (CPAP) is the more commonly used but noninvasive positive pressure ventilation (NIPPV) seems more efficacious in the early post-extubation phase, although it is not clear if NIPPV may influence longterm outcomes. A recently introduced alternative is noninvasive high frequency oscillatory ventilation (NHFOV) which might be especially useful in babies needing high constant distending pressure. Preterm neonates may receive these respiratory supports for several weeks. Nonetheless, no data are available for the longterm use of NIPPV and NHFOV; few data exist on NHFOV and clinical outcomes, although its safety and suitability are reported in a number of preliminary short-term studies. METHODS We designed an assessor-blinded, multicenter, three-arms, parallel, pragmatic, randomized, controlled trial with a superiority design, investigating the use of CPAP vs NIPPV vs NHFOV during the whole stay in neonatal intensive care units in China. Since safety data will also be analyzed it may be considered a phase II/III trial. Moreover, subgroup analyses will be performed on patients according to prespecified criteria based on physiopathology traits: these subgroup analyses should be considered preliminary. At least 1440 neonates are supposed to be enrolled. The trial has been designed with the collaboration of international colleagues expert in NHFOV, who will also perform an interim analysis at the about 50% of the enrolment. DISCUSSION The study is applying the best trial methodology to neonatal ventilation, a field where it is often difficult to do so for practical reasons. Nonetheless, ours is also a physiology-driven trial, since interventions are applied based on physiological perspective, in order to use ventilatory techniques at their best. The pragmatic design will increase generalizability of our results but subgroup analyses according to predefined physiopathological criteria are also previewed trying to have some advantages of an explanatory design. Since not all clinicians are well versed in all respiratory techniques, the training is pivotal. We intend to apply particular care to train the participating units: a specific 3-month period and several means have been dedicated to this end. TRIAL REGISTRATION NCT03181958 (registered on June 9, 2017).
Collapse
Affiliation(s)
- Yuan Shi
- Department of Neonatology, Children’s Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, 400014 China
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, “A.Béclère” Medical Center, South Paris University Hospitals, AP-HP, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
- Institute of Anesthesiology and Critical Care, Catholic University of the Sacred Heart, Rome, Italy
| |
Collapse
|
25
|
Li J, Li X, Huang X, Zhang Z. Noninvasive high-frequency oscillatory ventilation as respiratory support in preterm infants: a meta-analysis of randomized controlled trials. Respir Res 2019; 20:58. [PMID: 30876411 PMCID: PMC6420773 DOI: 10.1186/s12931-019-1023-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 03/06/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Noninvasive high-frequency oscillatory ventilation (nHFOV), a relatively new modality, is gaining popularity despite scarce evidence. This meta-analysis was designed to evaluate the efficacy and safety of nHFOV as respiratory support in premature infants. METHODS We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL from inception of the database to January 2019. All published randomized controlled trials (RCTs) evaluating the effect of nHFOV therapy with nasal continuous positive airway pressure (nCPAP) or biphasic nCPAP (BP-CPAP) in newborns for respiratory support were included. All meta-analyses were performed using Review Manager 5.3. RESULTS A total of 8 RCTs involving 463 patients were included. The meta-analysis estimated a lower risk of intubation (relative risk = 0.50, 95% confidence interval of 0.36 to 0.70) and more effective clearance of carbon dioxide (weighted mean difference = - 4.61, 95% confidence interval of - 7.94 to - 1.28) in the nHFOV group than in the nCPAP/BP-CPAP group. CONCLUSIONS Our meta-analysis of RCTs suggests that nHFOV, as respiratory support in preterm infants, significantly remove carbon dioxide and reduce the risk of intubation compared with nCPAP/BP-CPAP. The appropriate parameter settings for different types of noninvasive high-frequency ventilators, the effect of nHFOV in extremely preterm infants, and the long-term safety of nHFOV need to be assessed in large trials.
Collapse
Affiliation(s)
- Jing Li
- Department of Neonatology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, China, No. 261 Huansha Road, Hangzhou City, Zhejiang, 310002, China
| | - Xiaoxia Li
- Department of Neonatology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, China, No. 261 Huansha Road, Hangzhou City, Zhejiang, 310002, China
| | - Xianmei Huang
- Department of Neonatology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, China, No. 261 Huansha Road, Hangzhou City, Zhejiang, 310002, China
| | - Zhiqun Zhang
- Department of Neonatology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, China, No. 261 Huansha Road, Hangzhou City, Zhejiang, 310002, China.
| |
Collapse
|
26
|
Silva MGF, Gregório ML, de Godoy MF. Does heart rate variability improve prediction of failed extubation in preterm infants? J Perinat Med 2019; 47:252-257. [PMID: 30183667 DOI: 10.1515/jpm-2017-0375] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/16/2018] [Indexed: 11/15/2022]
Abstract
Background Prematurity and its respective comorbidities may result in longer periods of mechanical ventilation in intensive care units (ICU). A method for the assessment of organic maturity would be useful for this population. Heart rate variability (HRV), as an indicator of homeostasis, is a well-established tool for this approach. The objective of the study was to assess HRV in intubated preterm infants in ICU immediately prior to extubation and correlate HRV with clinical evaluation outcomes. Methods A total of 46 preterm infants, 13 (28.2%) males, were prospectively studied and divided into a group with failed extubation (FEG: n=11) and a group with successful extubation (SEG: n=35). HRV was evaluated in time, frequency and nonlinear domains with a Polar RS800 device. HRV measurements were assessed with Kubios HRV Premium Software and statistically analyzed with the StatsDirect Statistical Software, version 1.9.2015 (2002). P<0.05 values were considered as statistically significant. Results There were no significant differences between heart rate variables of failed and successful extubation when analyzing the total group. However, the analysis of the sub-group of preterm infants weighing less than 1000 g showed a clear differentiation between the groups, when the nonlinear variables (approximate entropy, sample entropy and multiscale entropy 1, 2 and 3) were used, demonstrating that the group with successful extubation shows greater complexity and, therefore, relatively greater autonomic stability. Conclusion HRV was effective in predicting failed extubation in preterm infants when evaluated in a nonlinear domain and in preterm infants weighing less than 1000 g.
Collapse
Affiliation(s)
- Marciali Gonçalves Fonseca Silva
- Department of Pediatrics and Pediatric Surgery Surgery - Sao Jose do Rio Preto Medical School (FAMERP), São José do Rio Preto, SP, Brazil
| | - Michele Lima Gregório
- Transdisciplinary Nucleus for the Study of Chaos and Complexity (NUTECC - FAMERP), São José do Rio Preto, SP, Brazil
| | - Moacir Fernandes de Godoy
- Transdisciplinary Nucleus for the Study of Chaos and Complexity (NUTECC - FAMERP), São José do Rio Preto, SP, Brazil.,Professor, Department of Cardiology and Cardiovascular Surgery, Sao Jose do Rio Preto Medical School (FAMERP), Av. Brigadeiro Faria Lima, 5416, CEP: 15090-000, São José do Rio Preto, SP, Brazil
| |
Collapse
|
27
|
Zhu XW, Shi Y, Shi LP, Liu L, Xue J, Ramanathan R. Non-invasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: Study protocol for a multi-center prospective randomized controlled trial. Trials 2018; 19:319. [PMID: 29898763 PMCID: PMC6001134 DOI: 10.1186/s13063-018-2673-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 05/04/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) is associated with the development of adverse pulmonary and non-pulmonary outcomes in very premature infants. Various modes of non-invasive respiratory support are increasingly being used to decrease the incidence of bronchopulmonary dysplasia. The aim of this trial is to compare the effect of non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) in preterm infants with respiratory distress syndrome (RDS) as a primary non-invasive ventilation support mode. METHODS/DESIGN In this multi-center randomized controlled trial, 300 preterm infants born at a gestational age of 266/7 to 336/7 weeks with a diagnosis of RDS will be randomized to NHFOV or NCPAP as a primary mode of non-invasive respiratory support. The study will be conducted in 18 tertiary neonatal intensive care units in China. The primary outcome is the need for IMV during the first 7 days after enrollment in preterm infants randomized to the two groups. The prespecified secondary outcomes include days of hospitalization, days on non-invasive respiratory support, days on IMV, days on supplemental oxygen, mortality, need for a surfactant, severe retinopathy of prematurity requiring laser treatment or surgery, patent ductus arteriosus needing ligation, bronchopulmonary dysplasia, abdominal distention, air leak syndromes, intraventricular hemorrhage (≥ grade 3), spontaneous intestinal perforation, necrotizing enterocolitis (≥II stage), and nasal trauma. Other secondary outcomes include Bayley Scales of Infant Development at 18-24 months of corrected age. DISCUSSION In recent decades, several observational studies have compared the effects of NHFOV and NCPAP in neonates as a rescue mode or during weaning from IMV. To our knowledge, this will be the first multi-center prospective, randomized controlled trial to evaluate NHFOV as a primary mode in preterm infants with RDS in China or any other part of the world. Our trial may help to establish guidelines for NHFOV in preterm infants with RDS to minimize the need for IMV, and to decrease the significant pulmonary and non-pulmonary morbidities associated with IMV. TRIAL REGISTRATION ClinicalTrials.gov, NCT03099694 . Registered on 4 April 2017.
Collapse
Affiliation(s)
- Xing-Wang Zhu
- Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, 400042 China
- Jiulongpo People’s Hospital, Chongqing, 400024 China
| | - Yuan Shi
- Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, 400042 China
| | - Li-Ping Shi
- The Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, 310000 China
| | - Ling Liu
- Guiyang Maternity and Child Health Care Hospital, Guiyang, 550000 China
| | - Jiang Xue
- The Second Hospital of Shandong University, Jinan, 250000 China
| | - Rangasamy Ramanathan
- LAC+USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA USA
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, CA 90033 USA
| |
Collapse
|
28
|
Wright CJ, Sherlock L, Sahni R, Polin RA. Preventing Continuous Positive Airway Pressure Failure: Evidence-Based and Physiologically Sound Practices from Delivery Room to the Neonatal Intensive Care Unit. Clin Perinatol 2018; 45:257-271. [PMID: 29747887 PMCID: PMC5953203 DOI: 10.1016/j.clp.2018.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Routine use of continuous positive airway pressure (CPAP) to support preterm infants with respiratory distress is an evidenced-based strategy to decrease incidence of bronchopulmonary dysplasia. However, rates of CPAP failure remain unacceptably high in very premature neonates, who are at high risk for developing bronchopulmonary dysplasia. Using the GRADE framework to assess the quality of available evidence, this article reviews strategies aimed at decreasing CPAP failure, starting with delivery room interventions and followed through to system-based efforts in the neonatal intensive care unit. Despite best efforts, some very premature neonates fail CPAP. Also reviewed are predictors of CPAP failure in this vulnerable population.
Collapse
Affiliation(s)
- Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Laurie Sherlock
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Rakesh Sahni
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Richard A. Polin
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| |
Collapse
|
29
|
Non-invasive ventilation and surfactant treatment as the primary mode of respiratory support in surfactant-deficient newborn piglets. Pediatr Res 2018; 83:904-914. [PMID: 29320485 DOI: 10.1038/pr.2018.5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/24/2017] [Indexed: 01/28/2023]
Abstract
BackgroundNasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV), forms of non-invasive ventilation (NIV) for respiratory support, are increasingly being chosen as the initial treatment for neonates with surfactant (SF) deficiency. Our objective was to compare NCPAP with NIPPV with or without SF administration as a primary mode of ventilation.MethodsTwenty-four newborn piglets with SF-deficient lung injury produced by repetitive bronchoalveolar lavages were randomly assigned to NCPAP or NIPPV, with or without SF administration (InSurE method). We evaluated pulmonary, systemic (hemodynamic and oxygen metabolism), and cerebral effects.ResultsSF-deficient piglets developed respiratory distress (FiO2:1, pH<7.2, PaCO2>70 mm Hg, PaO2<70 mm Hg, and Cdyn<0.5 ml/cmH2O/kg). Gradual improvements in pulmonary status were observed in both NIV groups, with NIPPV achieving lower lung inflammation markers and injury scores. Both SF-treated groups obtained significantly better respiratory outcomes than groups not treated with SF before NIV. All NIV-treated groups showed low brain injury scores.ConclusionIn spontaneously breathing SF-deficient newborn piglets, NIPPV is a suitable NIV strategy. SF administration in combination with NCPAP or NIPPV improves pulmonary status providing extra protection against pulmonary injury. No injury to the developing brain was observed to be associated with these NIV strategies, with or without SF therapy.
Collapse
|
30
|
Tana M, Lio A, Tirone C, Aurilia C, Tiberi E, Serrao F, Purcaro V, Corsello M, Catenazzi P, D'Andrea V, Barone G, Ricci C, Pastorino R, Vento G. Extubation from high-frequency oscillatory ventilation in extremely low birth weight infants: a prospective observational study. BMJ Paediatr Open 2018; 2:e000350. [PMID: 30498796 PMCID: PMC6242018 DOI: 10.1136/bmjpo-2018-000350] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/02/2018] [Accepted: 10/10/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To evaluate if weaning from high-frequency oscillatory ventilation (HFOV) directly to a non-invasive mode of respiratory support is feasible and results in successful extubation in extremely low birth weight (ELBW) infants. DESIGN Prospective observational study. SETTING Tertiary neonatal intensive care unit. PATIENTS One hundred and eight ELBW infants of 26.2±1.4 weeks of gestational age (GA) directly extubated from HFOV. INTERVENTIONS All infants were managed with elective HFOV and received surfactant after a recruitment HFOV manoeuvre. Extubation was attempted at mean airways pressure (MAP) ≤6 cm H2O with FiO2 ≤0.25. After extubation, all infants were supported by nasal continuous positive airway pressure (6-8 cm H2O). MAIN OUTCOME MEASURES Extubation failure (clinical deterioration requiring reintubation) was defined as shorter than 7 days. RESULTS Ninety patients (83%) were successfully extubated and 18 (17%) required reintubation. No significant differences were found between the two groups in terms of birth weight, day of life and weight at the time of extubation. Multivariable analysis showed that GA (OR 1.71; 95% CI 1.04, 2.08) and higher MAP prior to surfactant (OR 1.51; 95% CI 1.06, 2.15) were associated with successful extubation. CONCLUSIONS In ELBW infants, direct extubation from HFOV at MAP ≤6 cm H2O with FiO2 ≤0.25 is feasible. Our extubation success rate (83%) is higher than conventional mechanical ventilation in this very vulnerable class of infants.
Collapse
Affiliation(s)
- Milena Tana
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandra Lio
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Chiara Tirone
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Aurilia
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Eloisa Tiberi
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Serrao
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Velia Purcaro
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Mirta Corsello
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Piero Catenazzi
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vito D'Andrea
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Barone
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cinzia Ricci
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Roberta Pastorino
- Section of Hygiene, Institute of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Vento
- Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Scienze della salute della donna e del bambino, Università Cattolica del Sacro Cuore, Rome, Italy
| |
Collapse
|
31
|
Respiratory severity score and extubation readiness in very low birth weight infants. Pediatr Neonatol 2017; 58:523-528. [PMID: 28539199 DOI: 10.1016/j.pedneo.2016.12.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 10/07/2016] [Accepted: 12/04/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The respiratory severity score (RSS) is a byproduct of mean airway pressure (MAP) and fraction of inspired oxygen (FiO2). We sought to determine whether RSS could be used as a screening tool to predict extubation readiness in very low birth weight (VLBW) infants. METHODS In a retrospective cohort study, medical records of all VLBW infants admitted to our unit (6/1/09-2/28/12) were reviewed for infants' demographics, prenatal characteristics, and medication use. Also, records were reviewed for unplanned vs. planned extubation, blood gas, ventilator parameters and signs of severe respiratory failure [RF, defined as partial pressure of carbon dioxide (pCO2) > 65, pH < 7.20, FiO2 > 50%, and MAP > 10 cm] on the day of extubation. RESULTS During the study period 31% (45/147) failed extubation. Overall, infants who failed extubation had a lower birth weight (BW) and gestational age (GA), and on the day of extubation had a higher RSS and percentage of having one or more signs of severe RF. In a logistic regression model, adjusting for BW, GA, RSS and RF, RSS remained the only risk factor associated with extubation failure [adjusted OR 1.63 (95% CI: 1.10-2.40); p = 0.01]. RSS had a sensitivity of 0.86 (95% CI: 0.72-0.94) at a cutoff of 1.26 and a specificity of 0.88 (95% CI: 0.80-0.94) at a cutoff of 2.5. There was no difference in extubation failure between unplanned vs. planned extubation [41% (9/22) vs. 29% (36/125); p = 0.25]. CONCLUSION An elevated RSS is associated with extubation failure. Successful unplanned extubation is common in VLBW infants.
Collapse
|
32
|
Markers of Successful Extubation in Extremely Preterm Infants, and Morbidity After Failed Extubation. J Pediatr 2017; 189:113-119.e2. [PMID: 28600154 PMCID: PMC5657557 DOI: 10.1016/j.jpeds.2017.04.050] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/20/2017] [Accepted: 04/24/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To identify variables associated with successful elective extubation, and to determine neonatal morbidities associated with extubation failure in extremely preterm neonates. STUDY DESIGN This study was a secondary analysis of the National Institute of Child Health and Human Development Neonatal Research Network's Surfactant, Positive Pressure, and Oxygenation Randomized Trial that included extremely preterm infants born at 240/7 to 276/7 weeks' gestation. Patients were randomized either to a permissive ventilatory strategy (continuous positive airway pressure group) or intubation followed by early surfactant (surfactant group). There were prespecified intubation and extubation criteria. Extubation failure was defined as reintubation within 5 days of extubation. RESULTS Of 1316 infants in the trial, 1071 were eligible; 926 infants had data available on extubation status; 538 were successful and 388 failed extubation. The rate of successful extubation was 50% (188/374) in the continuous positive airway pressure group and 63% (350/552) in the surfactant group. Successful extubation was associated with higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within the first 24 hours of age and prior to extubation, lower partial pressure of carbon dioxide prior to extubation, and non-small for gestational age status after adjustment for the randomization group assignment. Infants who failed extubation had higher adjusted rates of mortality (OR 2.89), bronchopulmonary dysplasia (OR 3.06), and death/ bronchopulmonary dysplasia (OR 3.27). CONCLUSIONS Higher 5-minute Apgar score, and pH prior to extubation, lower peak fraction of inspired oxygen within first 24 hours of age, lower partial pressure of carbon dioxide and fraction of inspired oxygen prior to extubation, and nonsmall for gestational age status were associated with successful extubation. Failed extubation was associated with significantly higher likelihood of mortality and morbidities. TRIAL REGISTRATION ClinicalTrials.gov: NCT00233324.
Collapse
|
33
|
Zhu XW, Zhao JN, Tang SF, Yan J, Shi Y. Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with moderate-severe respiratory distress syndrome: A preliminary report. Pediatr Pulmonol 2017; 52:1038-1042. [PMID: 28672094 DOI: 10.1002/ppul.23755] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effect of noninvasive high-frequency oscillatory ventilation (nHFOV) with nasal continuous positive airway pressure (nCPAP) in preterm infants with moderate-severe respiratory distress syndrome (RDS) after surfactant administration via INSURE (intubation, surfactant, extubation) method on the need for invasive mechanical ventilation (IMV). METHODS A total of 81 infants with a gestational age (GA) of 28-34 weeks were eligible and were randomized to nCPAP (n = 42) or to nHFOV (n = 39). The need for IMV was the primary outcome. The incidence of bronchopulmonary dysplasia (BPD), occurrence of intraventricular hemorrhage (IVH), and air leaks, and mortality were considered as secondary outcomes. RESULT A total 76 infants finally completed the study. The need for IMV was significantlylower in the nHFOV group compared with the nCPAP group(24.3% vs 56.4%, P < 0.01). The incidence of IVH, air leaks or BPD was similar between the two groups. In addition, the mortality rate was not statistically different. CONCLUSION In this prospective, randomized controlled study, nHFOV significantly reduced the need for IMV as compared with nCPAP in preterm infants with moderate-severe RDS without increase in adverse effects.
Collapse
Affiliation(s)
- Xing-Wang Zhu
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China.,Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neonatology, Jiulongpo People's Hospital, Chongqing, China
| | - Jin-Ning Zhao
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China
| | - Shi-Fang Tang
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China
| | - Jun Yan
- Department of Neonatology, Jiulongpo People's Hospital, Chongqing, China
| | - Yuan Shi
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China.,Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
34
|
Kraaijenga JV, de Waal CG, Hutten GJ, de Jongh FH, van Kaam AH. Diaphragmatic activity during weaning from respiratory support in preterm infants. Arch Dis Child Fetal Neonatal Ed 2017; 102:F307-F311. [PMID: 27799323 DOI: 10.1136/archdischild-2016-311440] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 09/28/2016] [Accepted: 10/07/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine if weaning from nasal continuous positive airway pressure (nCPAP) to lesser supportive low flow nasal cannula (LFNC) results in a change in electrical activity of the diaphragm in preterm infants. DESIGN Prospective observational study. SETTING Neonatal intensive care unit. PATIENTS Stable preterm infants weaned from nCPAP to LFNC (1 L/min). MAIN OUTCOME MEASURES Change in diaphragmatic activity, expressed as amplitude, peak and tonic activity, measured by transcutaneous electromyography (dEMG) from 30 min before (baseline) until 180 min after weaning. Subgroup analysis was performed based on success or failure of the weaning attempt. RESULTS Fifty-nine preterm infants (gestational age: 29.0±2.4 weeks, birth weight: 1210±443 g) accounting for 74 weaning attempts were included. A significant increase in dEMG amplitude (median, IQR: 21.3%, 3.6-41.4), peak (22.1%, 8.7-40.5) and tonic activity (14.3%, -1.9-38.1) was seen directly after weaning. This effect slowly decreased over time. Infants failing the weaning attempt tended to have a higher diaphragmatic activity than those successfully weaned. CONCLUSIONS Weaning from nCPAP to LFNC leads to an increase in diaphragmatic activity measured by dEMG and is most prominent in preterm infants failing the weaning attempt. dEMG monitoring might be a useful parameter to guide weaning from respiratory support in preterm infants.
Collapse
Affiliation(s)
- Juliette V Kraaijenga
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
35
|
Wang SH, Liou JY, Chen CY, Chou HC, Hsieh WS, Tsao PN. Risk Factors for Extubation Failure in Extremely Low Birth Weight Infants. Pediatr Neonatol 2017; 58:145-150. [PMID: 27349301 DOI: 10.1016/j.pedneo.2016.01.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Revised: 12/17/2015] [Accepted: 01/15/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Although antenatal steroids and early use nasal continuous positive airway pressure (NCPAP) have significantly improved outcomes of neonatal respiratory distress syndrome, intubation with ventilator support is still commonly required in extremely low birth weight (ELBW) infants. The optimal timing of extubation in ELBW infants remains unclear. METHODS We retrospectively analyzed all ELBW preterm infants who were admitted to our neonatal intensive care unit (NICU) from January 2009 to December 2013. Demographic, ventilation, and arterial blood gas analysis results prior to and 2 hours after extubation were collected. Extubation failure was defined as reintubation due to deterioration of respiratory condition within 7 days after extubation. Risk factors for extubation failure were analyzed. RESULTS In total, 173 ELBW infants were born and admitted to our NICU during these 5 years. Among these 173 infants, 77 (44.5%) used NCPAP only during their hospitalization (20 diagnosed with chronic lung disease (CLD), 25.9%). Among the 95 patients that required intubation, 27 patients expired so extubation was not attempted. Sixteen of 68 (23.5%) survival cases required reintubation within 7 days after extubation. We found that gestational age, birth body weight, and sex ratio did not differ between the successful extubation group and the failed extubation group. Univariate analysis showed that the failed extubation group had a lower arterial pH right before and 2 hours after extubation, with a lower bicarbonate level after extubation. Further multivariate logistic regression analysis revealed an association between poor acid-base homeostasis 2 hours after extubation (pH < 7.3 and HCO3 < 18 mM/L) and extubation failure (odds ratio 4.56 and 6.187 and 95% confidence interval: 1.263∼16.462 and 1.68∼22.791, respectively). CONCLUSION This study shows that nearly half of ELBW infants do not require intubation. Among ELBW infants who require invasive ventilator support, those who have lower postextubation arterial pH and bicarbonate levels are at high risk of extubation failure.
Collapse
Affiliation(s)
- Shih-Hsin Wang
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan; Department of Pediatrics, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Jyun-You Liou
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Chien-Yi Chen
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Hung-Chieh Chou
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Wu-Shiun Hsieh
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan
| | - Po-Nien Tsao
- Department of Pediatrics, National Taiwan University Hospital Children's Hospital, Taipei, Taiwan; The Research Center for Developmental Biology and Regenerative Medicine, National Taiwan University, Taipei, Taiwan.
| |
Collapse
|
36
|
Chandrasekaran A, Thukral A, Jeeva Sankar M, Agarwal R, Paul VK, Deorari AK. Nasal masks or binasal prongs for delivering continuous positive airway pressure in preterm neonates-a randomised trial. Eur J Pediatr 2017; 176:379-386. [PMID: 28091776 DOI: 10.1007/s00431-017-2851-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 01/02/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
Abstract
UNLABELLED The objective of this study was to compare the efficacy and safety of continuous positive airway pressure (CPAP) delivered using nasal masks with binasal prongs. We randomly allocated 72 neonates between 26 and 32 weeks gestation to receive bubble CPAP by either nasal mask (n = 37) or short binasal prongs (n = 35). Primary outcome was mean FiO2 requirement at 6, 12 and 24 h of CPAP initiation and the area under curve (AUC) of FiO2 against time during the first 24 h (FiO2 AUC0-24). Secondary outcomes were the incidence of CPAP failure and nasal trauma. FiO2 requirement at 6, 12 and 24 h (mean (SD); 25 (5.8) vs. 27.9 (8); 23.8 (4.5) vs. 25.4 (6.8) and 22.6 (6.8) vs. 22.7 (3.3)) as well as FiO2 AUC0-24 (584.0 (117.8) vs. 610.6 (123.6)) were similar between the groups. There was no difference in the incidence of CPAP failure (14 vs. 20%; relative risk 0.67; 95% confidence interval 0.24-1.93). Incidence of severe nasal trauma was lower with the use of nasal masks (0 vs. 31%; p < .001). CONCLUSIONS Nasal masks appear to be as efficacious as binasal prongs in providing CPAP. Masks are associated with lower risk of severe nasal trauma. TRIAL REGISTRATION CTRI2012/08/002868 What is Known? • Binasal prongs are better than single nasal and nasopharyngeal prongs for delivering continuous positive airway pressure (CPAP) in preventing need for re-intubation. • It is unclear if they are superior to newer generation nasal masks in preterm neonates requiring CPAP. What is New? • Oxygen requirement during the first 24 h of CPAP delivery is comparable with use of nasal masks and binasal prongs. • Use of nasal masks is, however, associated with significantly lower risk of severe grades of nasal injury.
Collapse
Affiliation(s)
- Aparna Chandrasekaran
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Anu Thukral
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - M Jeeva Sankar
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ramesh Agarwal
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Vinod K Paul
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Ashok K Deorari
- Newborn Health Knowledge Centre, ICMR Center for Advanced Research in Newborn Health, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| |
Collapse
|
37
|
Spasojevic S, Doronjski A. Risk factors associated with failure of extubation in very-low-birth-weight newborns. J Matern Fetal Neonatal Med 2017; 31:300-304. [DOI: 10.1080/14767058.2017.1285884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Slobodan Spasojevic
- Department of Intensive Care, Institute of Child and Youth Healthcare of Vojvodina, Novi Sad, Serbia
- Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Aleksandra Doronjski
- Department of Intensive Care, Institute of Child and Youth Healthcare of Vojvodina, Novi Sad, Serbia
- Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| |
Collapse
|
38
|
Binmanee A, El Helou S, Shivananda S, Fusch C, Mukerji A. Use of high noninvasive respiratory support pressures in preterm neonates: a single-center experience. J Matern Fetal Neonatal Med 2017; 30:2838-2843. [PMID: 27892756 DOI: 10.1080/14767058.2016.1265931] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To describe the incidence, indications and clinical outcomes following high pressures on noninvasive respiratory support (NRS) in preterm neonates. STUDY DESIGN Retrospective cohort study of all neonates with BW <1.500 g admitted from July 2012 to June 2014 and placed on high noninvasive respiratory support (NRS), defined as mean airway pressure ≥10 cm H2O for at least 12 continuous hours using nasal continuous positive airway pressure (NCPAP) and/or nasal high-frequency ventilation (NIHFV). Clinical and physiological outcomes following high NRS were ascertained. Median (IQR) and percentages were used to describe continuous and categorical data, respectively. RESULTS There were 131 instances of high NRS use in 70 of 315 eligible infants. Most common indication was post-extubation, observed in 37% (49/131) of high NRS instances. Intubation was avoided in 71% (93/131) of instances in the first 7 days following high NRS initiation. There were no physiological perturbations in heart rate, blood pressure or oxygen requirement. Furthermore, there were no instances of lung hyperinflation, pneumothoraces or spontaneous intestinal perforation following high NRS. CONCLUSION The use of high NRS pressure was followed by avoidance of intubation in the majority of cases without adverse effects. Further research on high NRS use including its indications, clinical outcomes and safety profile is warranted.
Collapse
Affiliation(s)
| | - Salhab El Helou
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
| | | | - Christoph Fusch
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
| | - Amit Mukerji
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
| |
Collapse
|
39
|
Abstract
Continuous positive airway pressure (CPAP) systems can be broadly grouped into continuous flow or variable flow devices. Bubble CPAP (bCPAP) is a continuous flow device and has physiologic properties that could facilitate gas exchange. Its efficacy has been reported to be similar to variable flow CPAP systems when used as a primary mode of respiratory support. Post-extubation bCPAP is reported to significantly reduce extubation failure rates among preterm infants ventilated for less than 2 week when compared to Infant flow driver CPAP (variable flow). bCPAP has been successfully used in resource-poor settings. The success on CPAP is however dependant on good nursing care and clear management protocols for weaning and escalation of care.
Collapse
Affiliation(s)
- Samir Gupta
- Department of Paediatrics, University Hospital of North Tees, Durham University, Hardwick road, Stockton-on-Tees, TS19 8PE, United Kingdom.
| | - Steven M Donn
- Division of Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan Health System, 1540 East Hospital Drive, Ann Arbor, MI 48109, USA
| |
Collapse
|
40
|
Nasal Intermittent Positive Pressure Ventilation for Preterm Neonates: Synchronized or Not? Clin Perinatol 2016; 43:799-816. [PMID: 27837760 DOI: 10.1016/j.clp.2016.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Although continuous positive airway pressure (CPAP) is an effective strategy to prevent invasive ventilation, failure rates are high and many babies require endotracheal intubation. Prolonged exposure to mechanical ventilation is linked with bronchopulmonary dysplasia and other morbidities. Different techniques of nasal intermittent positive pressure ventilation (NIPPV) have been proposed as an alternative to CPAP. Bilevel NIPPV and conventional mechanical ventilator-driven NIPPV are used in clinical practice. Both methods differ substantially in pressures and cycling times, potentially affecting their mechanism of action. This review focuses on noninvasive ventilation strategies, their physiologic effects, impact on clinical outcome parameters, and effects of synchronization.
Collapse
|
41
|
Wright CJ, Polin RA. Noninvasive Support: Does It Really Decrease Bronchopulmonary Dysplasia? Clin Perinatol 2016; 43:783-798. [PMID: 27837759 DOI: 10.1016/j.clp.2016.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Noninvasive support of preterm infants with respiratory distress is an evidenced-based strategy to decrease the incidence of bronchopulmonary dysplasia. Continuous positive airway pressure (CPAP) is the only noninvasive strategy with sufficient evidence to support its use in acute respiratory distress syndrome. It is unclear if one method for delivering CPAP is superior to another. Future research will focus on strategies (eg, sustained lung inflation, and administration of surfactant using a thin plastic catheter) that increase the likelihood of success with CPAP, especially in infants with a gestational age of less than 26 weeks.
Collapse
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Perinatal Research Center, Children's Hospital Colorado, University of Colorado School of Medicine, Mail Stop F441, 13243 East 23rd Avenue, Aurora, CO 80045, USA.
| | - Richard A Polin
- Department of Pediatrics, Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY 10032, USA
| |
Collapse
|
42
|
Dysart KC. Physiologic Basis for Nasal Continuous Positive Airway Pressure, Heated and Humidified High-Flow Nasal Cannula, and Nasal Ventilation. Clin Perinatol 2016; 43:621-631. [PMID: 27837748 DOI: 10.1016/j.clp.2016.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Noninvasive support modalities have become ever more present in the care of newborns with a wide variety of disease processes. As clinicians have continued to avoid intubation and mechanical ventilation in preterm and term infants, the technologies available to support these groups have grown. Despite this rapid growth they can be broken down into 3 large categories of support, all attempting to deliver both flow and pressure to the nasopharynx supporting both phases of spontaneous breathing. The goal of all of the therapies is to stabilize a heterogeneous group of disorders with some common pathologies and avoid invasive support modalities.
Collapse
Affiliation(s)
- Kevin C Dysart
- Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
| |
Collapse
|
43
|
Komatsu DFR, Diniz EMDA, Ferraro AA, Ceccon MEJR, Vaz FAC. Randomized controlled trial comparing nasal intermittent positive pressure ventilation and nasal continuous positive airway pressure in premature infants after tracheal extubation. Rev Assoc Med Bras (1992) 2016; 62:568-574. [DOI: 10.1590/1806-9282.62.06.568] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 07/26/2016] [Indexed: 11/22/2022] Open
Abstract
Summary Objective: To analyze the frequency of extubation failure in premature infants using conventional mechanical ventilation (MV) after extubation in groups subjected to nasal intermittent positive pressure ventilation (nIPPV) and continuous positive airway pressure (nCPAP). Method: Seventy-two premature infants with respiratory failure were studied, with a gestational age (GA) ≤ 36 weeks and birth weight (BW) > 750 g, who required tracheal intubation and mechanical ventilation. The study was controlled and randomized in order to ensure that the members of the groups used in the research were chosen at random. Randomization was performed at the time of extubation using sealed envelopes. Extubation failure was defined as the need for re-intubation and mechanical ventilation during the first 72 hours after extubation. Results: Among the 36 premature infants randomized to nIPPV, six (16.6%) presented extubation failure in comparison to 11 (30.5%) of the 36 premature infants randomized to nCPAP. There was no statistical difference between the two study groups regarding BW, GA, classification of the premature infant, and MV time. The main cause of extubation failure was the occurrence of apnea. Gastrointestinal and neurological complications did not occur in the premature infants participating in the study. Conclusion: We found that, despite the extubation failure of the group of premature infants submitted to nIPPV being numerically smaller than in premature infants submitted to nCPAP, there was no statistically significant difference between the two modes of ventilatory support after extubation.
Collapse
|
44
|
Guerin C, Bailey SM, Mally PV, Rojas M, Bhutada A, Rastogi S. Randomized control trial comparing physiologic effects in preterm infants during treatment with nasal continuous positive airway pressure (NCPAP) generated by Bubble NCPAP and Ventilator NCPAP: a pilot study. J Perinat Med 2016; 44:655-61. [PMID: 26352079 DOI: 10.1515/jpm-2015-0209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/09/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Nasal continuous positive airway pressure (NCPAP) is an accepted form of non-invasive ventilation in preterm infants. Few, if any, studies have shown an advantage of one type of NCPAP over another. It has been theorized that bubble-generated NCPAP may be advantageous for the preterm neonate versus traditionally used ventilator-generated NCPAP. The aim of this study was to examine for any short-term differences in physiologic parameters in preterm subjects receiving these two different methods of NCPAP. METHODS We conducted a randomized, prospective, cross-over pilot study of preterm infants being treated with NCPAP in the neonatal intensive care unit. Subjects were continuously monitored for several physiologic parameters including heart rate, respiratory rate, oxygen saturation, cerebral tissue oxygen saturation and cerebral fractional oxygen extraction using routine neonatal monitors and near-infrared spectroscopy (NIRS) while on 2 h of bubble NCPAP and 2 h of ventilator NCPAP. Subjects were randomized to be monitored while either starting on bubble NCPAP and then switching to ventilator NCPAP or starting on ventilator NCPAP and switching to bubble NCPAP. RESULTS Eighteen subjects were included. We found no statistically significant difference in any of the physiologic parameters while subjects were receiving bubble NCPAP versus ventilator NCPAP during the monitoring time periods. While on bubble NCPAP, subjects showed a trend toward decreasing respiratory rate and decreasing cerebral fractional oxygen extraction over time, but this did not reach statistical significance. CONCLUSION There appears to be no difference in immediate physiologic effects between bubble NCPAP and ventilator NCPAP. This does not preclude the possibility of potential long-term differences, but any differences seen would likely be based on mechanisms that take more time to develop. A larger prospective trial is warranted to confirm our findings.
Collapse
|
45
|
Wright CJ, Polin RA, Kirpalani H. Continuous Positive Airway Pressure to Prevent Neonatal Lung Injury: How Did We Get Here, and How Do We Improve? J Pediatr 2016; 173:17-24.e2. [PMID: 27025910 DOI: 10.1016/j.jpeds.2016.02.059] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/25/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Richard A Polin
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia at the University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
46
|
Ishihara C, Ibara S, Ohsone Y, Kato E, Tokuhisa T, Yamamoto Y, Maede Y, Kuwahara T, Minakami H. Effects of infant flow Bi-NCPAP on apnea of prematurity. Pediatr Int 2016; 58:456-60. [PMID: 26620042 DOI: 10.1111/ped.12854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/02/2015] [Accepted: 11/16/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infant flow biphasic nasal continuous positive airway pressure (Bi-NCPAP) and regular NCPAP (Re-NCPAP) are equally useful with respect to the rate of successful weaning from mechanical ventilation. It remains unclear, however, whether Bi-NCPAP or Re-NCPAP is more effective for reducing apnea of prematurity (AOP). METHODS A multicenter randomized controlled study was conducted of 66 infants assigned to receive Bi-NCPAP and 66 assigned to receive Re-NCPAP for respiratory support after extubation. Primary outcome was the number of AOP events during the 48 h observation period after successful extubation, defined as no reintubation and no adverse events associated with the use of NCPAP during the observation period. The secondary outcome was successful extubation. Reintubation was at the discretion of the attending physician. RESULTS Baseline characteristics were similar between the two groups. The number of AOP events during the 48 h observation period was significantly lower in infants with Bi-NCPAP than in those with Re-NCPAP (5.2 ± 6.5 vs 10.3 ± 10.9 per infant, respectively; P = 0.002). The rate of successful extubation tended to be greater in those with Bi-NCPAP than in those with Re-NCPAP (92.4%, 61/66 vs 80.3%, 53/66, respectively; P = 0.074). Adverse events occurred in only one of 132 infants: erosive dermatitis developed on the nose after application of Re-NCPAP. The risk of reintubation did not differ significantly between the two groups (7.6%, 5/66 for Bi-NCPAP vs 18.2%, 12/66 for Re-NCPAP; P = 0.117). CONCLUSIONS Bi-NCPAP was superior to Re-NCPAP for reduction of AOP following extubation.
Collapse
Affiliation(s)
- Chie Ishihara
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan
| | - Satoshi Ibara
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan
| | - Yoshiteru Ohsone
- Department of Neonatology, Kimitsu Chuo Hospital, Kisarazu, Japan
| | - Eiji Kato
- Department of Neonatology, Funabashi Central Hospital, Funabashi, Japan
| | - Takuya Tokuhisa
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan.,Department of Neonatology, Fukuda Hospital, Kumamoto, Japan
| | - Yutaka Yamamoto
- Department of Neonatology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Yoshinobu Maede
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan.,Department of Neonatology, Fukuda Hospital, Kumamoto, Japan
| | - Takako Kuwahara
- Department of Neonatology, Perinatal Medical Center, Kagoshima City Hospital, Kagoshima, Japan
| | - Hisanori Minakami
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| |
Collapse
|
47
|
Abstract
Nasal continuous positive airway pressure (CPAP) is increasingly used for respiratory support in preterm babies at birth and after extubation from mechanical ventilation. Various CPAP devices are available for use that can be broadly grouped into continuous flow and variable flow. There are potential physiologic differences between these CPAP systems and the choice of a CPAP device is too often guided by individual expertise and experience rather than by evidence. When interpreting the evidence clinicians should take into account the pressure generation sources, nasal interface, and the factors affecting the delivery of pressure, such as mouth position and respiratory drive. With increasing use of these devices, better monitoring techniques are required to assess the efficacy and early recognition of babies who are failing and in need of escalated support.
Collapse
|
48
|
Sahni R, Schiaratura M, Polin RA. Strategies for the prevention of continuous positive airway pressure failure. Semin Fetal Neonatal Med 2016; 21:196-203. [PMID: 26936186 DOI: 10.1016/j.siny.2016.02.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Progress in neonatal intensive care is closely linked to improvements in the management of respiratory failure in preterm infants. Current modalities of respiratory support range from the more benign continuous positive airway pressure (CPAP) to various modes of mechanical ventilation. Data from recent randomized control trials suggest that the use of nasal (n)CPAP as the initial mode of respiratory support in critically ill very low birth weight infants is associated with a lower incidence of chronic lung disease. The practice of early initiation of nasal-prong CPAP in all spontaneously breathing infants at Columbia University has resulted in very low rates of chronic lung disease for decades. Many institutions have attempted to replicate the practices and results at Columbia University. However, success rates with nCPAP are highly variable, which may in part be attributable to how well it is utilized. With recent renewed interest in non-invasive respiratory support, particularly bubble nCPAP, it is essential to evaluate strategies for the prevention of CPAP failure. This review discusses strategies that address these issues and shares the practical aspects for replicating success with bubble nCPAP. In addition, it reviews desirable features, major components, and physiological consequences of various bubble CPAP systems along with clinical experience of CPAP use.
Collapse
Affiliation(s)
- Rakesh Sahni
- Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Maria Schiaratura
- NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Richard A Polin
- Columbia University College of Physicians and Surgeons, New York, NY, USA.
| |
Collapse
|
49
|
Abstract
BACKGROUND The use of noninvasive ventilation is a constantly evolving treatment option for respiratory disease in the premature infant. The goals of these noninvasive ventilation techniques are to improve gas exchange in the premature infant's lungs and to minimize the need for intubation and invasive mechanical ventilation. PURPOSE The goals of this article are to consider various uses of nasal interfaces, discuss skin care and developmental positioning concerns faced by the bedside nurse, and discuss the medical management aimed to reduce morbidity and mortality. This article explores the nursing role, the advances in medical strategies for noninvasive ventilation, and the team approach to noninvasive ventilation use in this population. SEARCH STRATEGY Search strategy included a literature review on medical databases, such as EBSCOhost, CINAHL, PubMed, and NeoReviews. FINDINGS Innovative products, nursing research on developmental positioning and skin care, and advanced medical management have led to better and safer outcomes for premature infants requiring noninvasive ventilation. IMPLICATIONS FOR PRACTICE The medical focus of avoiding long-term mechanical ventilation would not be possible without the technology to provide noninvasive ventilation to these premature infants and the watchful eye of the nurse in terms of careful positioning, preventing skin breakdown and facial scarring, and a proper seal to maximize ventilation accuracy. IMPLICATIONS FOR RESEARCH This article encourages nursing-based research to quantify some of the knowledge about skin care and positioning as well as research into most appropriate uses for noninvasive ventilation devices.
Collapse
|
50
|
Choi EM, Park JH, Kim CS, Lee SL. Pulmonary Outcomes of Early Extubation in Extremely Premature Infants (Gestational Age: 25–26 Weeks) with Synchronized Nasal Intermittent Positive-Pressure Ventilation. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.2.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Eun Mi Choi
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Deagu, Korea
| | - Jae Hyun Park
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Deagu, Korea
| | - Chun Soo Kim
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Deagu, Korea
| | - Sang Lak Lee
- Department of Pediatrics, Keimyung University Dongsan Medical Center, Deagu, Korea
| |
Collapse
|