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Welch B, Rose R, Myers J, Drayton Jackson M, Lien I, Barbato A. Decreasing early invasive mechanical ventilation exposure in preterm infants: a quality improvement initiative. J Perinatol 2024:10.1038/s41372-024-02098-9. [PMID: 39198555 DOI: 10.1038/s41372-024-02098-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 08/16/2024] [Accepted: 08/19/2024] [Indexed: 09/01/2024]
Abstract
OBJECTIVE To decrease invasive mechanical ventilation exposure in the neonatal intensive care unit (NICU) in the first week of life for preterm infants with the global aim of decreasing bronchopulmonary dysplasia (BPD). METHODS We created a quality improvement (QI) initiative to optimize early non-invasive respiratory support which launched in August 2021. Patients born at <32 weeks gestation and admitted to the NICU on non-invasive respiratory support were included. RESULTS Invasive mechanical ventilation exposure decreased from 38 to 25% with evidence of special cause variation beginning in August 2022. Infants born at ≥26 weeks were most impacted, with a 50% reduction, from 34 to 17%. While BPD rates decreased, there has not yet been evidence of special cause variation. CONCLUSION Invasive mechanical ventilation exposure for infants born at <32 weeks gestation decreased following the creation of a QI initiative focused on optimization and standardization of early non-invasive respiratory support.
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Affiliation(s)
- Blair Welch
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA.
| | - Rebecca Rose
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Jessica Myers
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Meghan Drayton Jackson
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
- Division of Hematology and Oncology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Izlin Lien
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
| | - Alana Barbato
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health, Indiana University Health, Indianapolis, IN, USA
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Roehr CC, Farley HJ, Mahmoud RA, Ojha S. Non-Invasive Ventilatory Support in Preterm Neonates in the Delivery Room and the Neonatal Intensive Care Unit: A Short Narrative Review of What We Know in 2024. Neonatology 2024:1-8. [PMID: 39173610 DOI: 10.1159/000540601] [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: 05/10/2024] [Accepted: 07/22/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND Guidelines recommend non-invasive ventilatory (NIV) support as first-line respiratory support mode in preterm infants as NIV is superior to intubation and mechanical ventilation in preventing death or bronchopulmonary dysplasia. However, with an ever-expanding variety of NIV modes available, there is much debate about which NIV modality should ideally be used, how, and when. The aims of this work were to summarise the evidence on different NIV modalities for both primary and secondary respiratory support: nCPAP, nasal high-flow therapy (nHFT), and nasal intermittent positive airway pressure ventilation (nIPPV), bi-level positive airway pressure (BiPAP), nasal high-frequency oscillatory ventilation (nHFOV), and nasally applied, non-invasive neurally adjusted ventilatory assist (NIV-NAVA) modes, with particular focus on their use in preterm infants. SUMMARY This is a narrative review with reference to published guidelines by European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. nCPAP is currently the most commonly used primary and secondary NIV modality for premature infants. However, there is increasing evidence on the superiority of nIPPV over nCPAP. No beneficial effect was found for BiPAP over nCPAP. For the use of nHFT, nHFOV, and NIV-NAVA, more studies are needed to establish their place in neonatal respiratory care. KEY MESSAGES The superiority of nIPPV over nCPAP needs to be confirmed by contemporaneous trials comparing nCPAP to nIPPV at comparable mean airway pressures. Future trials should study NIV modalities in preterm infants with comparable respiratory pathology and indications, at comparable pressure settings and with different modes of synchronisation. Importantly, future trials should not exclude infants of the smallest gestational ages.
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Affiliation(s)
- Charles C Roehr
- National Perinatal Epidemiology Unit, Oxford Population Health, University of Oxford, Oxford, UK,
- Faculty of Health Sciences, University of Bristol, Bristol, UK,
- Newborn Care, Southmead Hospital, North Bristol Trust, Bristol, UK,
| | - Hannah J Farley
- National Perinatal Epidemiology Unit, Oxford Population Health, University of Oxford, Oxford, UK
| | - Ramadan A Mahmoud
- Department of Pediatrics, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt
| | - Shalini Ojha
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, UK
- Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Chotas W, Edwards EM, Horn D, Soll R, Ehret DEY. Using a simplified Downes score to predict the receipt of surfactant in a highly resourced setting. J Perinatol 2024:10.1038/s41372-024-02086-z. [PMID: 39103471 DOI: 10.1038/s41372-024-02086-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 07/25/2024] [Accepted: 07/29/2024] [Indexed: 08/07/2024]
Abstract
OBJECTIVE The Downes score is a neonatal examination scoring tool frequently used to guide initiation of CPAP, but its ability to predict the need for surfactant has not been assessed. We assessed the extent to which the Downes score predicts the receipt of surfactant. STUDY DESIGN We calculated a simplified Downes score from nursing admission data for infants (≤ 2000 grams, and ≥ 25 weeks' gestation) admitted on CPAP to a highly resourced level III NICU, to assess the predictive value for the receipt of surfactant. RESULTS Fifty-three (31.5%) out of 168 infants admitted on CPAP received surfactant. A simplified Downes score of ≥ 4 predicted the receipt of surfactant with 90.6% sensitivity, 52.2% specificity, 46.6% positive predictive value, 92.3% negative predictive value, and 64.3% accuracy. CONCLUSION The high sensitivity and negative predictive value suggest utility for using the Downes score to help guide clinical decision making regarding surfactant therapy.
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Affiliation(s)
- William Chotas
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA.
| | - Erika M Edwards
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
- Vermont Oxford Network, Burlington, VT, USA
- University of Vermont College of Engineering and Mathematical Sciences, Burlington, VT, USA
| | - Delia Horn
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Roger Soll
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
- Vermont Oxford Network, Burlington, VT, USA
| | - Danielle E Y Ehret
- Department of Pediatrics, University of Vermont Larner College of Medicine, Burlington, VT, USA
- Vermont Oxford Network, Burlington, VT, USA
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Dini G, Ceccarelli S, Celi F. Strategies for the prevention of bronchopulmonary dysplasia. Front Pediatr 2024; 12:1439265. [PMID: 39114855 PMCID: PMC11303306 DOI: 10.3389/fped.2024.1439265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/16/2024] [Indexed: 08/10/2024] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a common morbidity affecting preterm infants and is associated with substantial long-term disabilities. The pathogenesis of BPD is multifactorial, and the clinical phenotype is variable. Extensive research has improved the current understanding of the factors contributing to BPD pathogenesis. However, effectively preventing and managing BPD remains a challenge. This review aims to provide an overview of the current evidence regarding the prevention of BPD in preterm infants, offering practical insights for clinicians.
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Affiliation(s)
- Gianluca Dini
- Neonatal Intensive Care Unit, Santa Maria Hospital, Terni, Italy
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5
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Lamptey NL, Kopec GL, Kaur H, Fischer AM. Comparing Intubation Rates in the Delivery Room by Interface. Am J Perinatol 2024; 41:1424-1431. [PMID: 37257487 DOI: 10.1055/s-0043-1769469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Positive pressure ventilation (PPV) is crucial to the resuscitation of newborns. Although neonates often require PPV at birth, the optimal interface has not been determined. Both binasal prongs and face masks were deemed acceptable by the International Liaison Committee on Resuscitation in 2010 and have been utilized at our center since 2016; however, the choice is by provider preference. Previous studies have suggested that binasal prongs may be more effective than face masks at avoiding intubation in the delivery room. The objective of this study is to compare intubation rates of binasal prongs versus face masks for delivery room resuscitation of neonates born < 30 weeks' gestation. STUDY DESIGN This retrospective study compares delivery room intubation rates by interface for neonates < 30 weeks' gestation born between August 2016 and April 2021 at our level IV neonatal intensive care unit. Exclusion criteria included diagnosis of congenital diaphragmatic hernia, no PPV required, or no resuscitation attempted. Data collected included interface device, demographics, maternal data, delivery room data, admission data, and discharge outcomes. The three interface groups (binasal prongs, face mask, face mask, and binasal prongs) were compared utilizing chi-square, analysis of variance with post hoc analysis, and logistic regression. RESULTS Mean gestational ages and birth weights for the groups were 27.6 weeks and 1,126 g, 25.7 weeks and 839 g, and 27.1 weeks and 1,028 g, respectively. Neonates resuscitated with face masks were 9.9 times more likely to be intubated in the delivery room and 10.8 times more likely to be intubated at 6 hours of life compared with those resuscitated with binasal prongs after logistic regression analysis. CONCLUSION The findings in our study support delivery room resuscitation with binasal prongs as a useful method in reducing the need for intubation both in the delivery room and at 6 hours of life. Further prospective studies are warranted. KEY POINTS · The International Liaison Committee on Resuscitation recommends multiple interface options for neonatal resuscitation.. · Vermont Oxford Network endorses nasal interface for premature infants.. · Binasal prongs are associated with lower intubation rates..
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Affiliation(s)
- Naa-Lamle Lamptey
- Department of Pediatrics, OSF Saint Francis Medical Center, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, Illinois
| | - Gretchen L Kopec
- Division of Neonatology, OSF Saint Francis Medical Center, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, Illinois
| | - Harveen Kaur
- University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Ashley M Fischer
- Division of Neonatology, OSF Saint Francis Medical Center, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, Illinois
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Tamai K, Matsumoto N, Yorifuji T, Takeuchi A, Nakamura M, Nakamura K, Kageyama M. Delivery room intubation and neurodevelopment among extremely preterm infants. Pediatr Res 2024; 95:1897-1902. [PMID: 38212388 DOI: 10.1038/s41390-023-02993-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/08/2023] [Accepted: 11/18/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND The impact of delivery room intubation (DRI) on neurodevelopment in extremely preterm infants remains unclear. METHODS We retrospectively analyzed data for infants born at 24-27 gestational weeks between 2003 and 2018. The primary outcome was neurodevelopmental impairment (NDI), defined as cerebral palsy or hearing, visual, or cognitive impairment at age 3 years. Secondary outcomes were NDI components and death before and after discharge from the neonatal intensive care unit. We conducted robust Poisson regression analyses, adjusting for perinatal confounders. RESULTS The full cohort included 4397 infants with NDI data, of whom 3703 were intubated in the delivery room and 694 were not intubated in the delivery room. The mean gestational age and birth weight were 26.0 ± 1.1 weeks and 778 ± 184 g for infants with DRI and 26.6 ± 1.0 weeks and 873 ± 184 g for infants without DRI. Compared with infants without DRI, those with DRI had a higher risk for NDI (32.4% vs. 23.3%; adjusted risk ratio 1.18, 95% confidence interval: 1.01-1.37). There were no differences in secondary outcomes between infants with and without DRI. CONCLUSIONS DRI was associated with an increased risk for NDI at age 3 years among extremely preterm infants. IMPACT Few studies have examined the impact of delivery room intubation on neurodevelopment in infants born extremely preterm, and the results have been inconsistent. A total of 4397 infants born at 24-27 gestational weeks who had neurodevelopmental data at age 3 years were included in the present study. The present study found that delivery room intubation was associated with an increased risk for neurodevelopmental impairment at age 3 years among extremely preterm infants.
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Affiliation(s)
- Kei Tamai
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan.
| | - Naomi Matsumoto
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihito Takeuchi
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Makoto Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
| | - Kazue Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misao Kageyama
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, Okayama, Japan
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Zapata HA, Becker HL, Lasarev MR, Fort P, Guthrie SO, Kaluarachchi DC. Respiratory Severity Score during the First 3 Hours of Life as a Predictor for Failure of Noninvasive Respiratory Support and Need for Late Rescue Surfactant Administration. Am J Perinatol 2024; 41:e2613-e2621. [PMID: 37619600 DOI: 10.1055/s-0043-1772747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
OBJECTIVE Preterm infants often develop failure of noninvasive respiratory support. These infants miss the advantages of early rescue surfactant therapy. In this study, we evaluate the utility of respiratory severity score (RSS) during the first 3 hours of life (HOL) as a predictor for failure of noninvasive respiratory support. STUDY DESIGN We conducted a post hoc analysis of infants between 23 and 40 weeks' gestational age who received usual care in the AERO-02 clinical trial. Univariate and multivariable logistic regression analysis were used to assess whether the RSS summary measures were associated with the odds of surfactant administration. RESULTS Study involved 146 infants. Sixty-four infants (45%) received surfactant within the first 72 hours. Administration of surfactant was associated with the mean RSS (p < 0.01) and the linear trend (p < 0.01). CONCLUSION We demonstrated that RSS during the first 3 HOL can predict failure of noninvasive respiratory support and need for late rescue surfactant administration. Optimal RSS cutoffs for early rescue surfactant therapy need to be determined in large cohort studies. KEY POINTS · Early recognition of infants at risk of failure of noninvasive ventilation is important to prevent complications.. · It is desirable to identify patients who would benefit from early rescue surfactant treatment.. · RSS in first 3 hours can be used as a predictor of failure of noninvasive respiratory support..
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Affiliation(s)
- Henry A Zapata
- Division of Neonatology, Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Heather L Becker
- Department of Respiratory Therapy, UnityPoint-Meriter, Madison, Wisconsin
| | - Michael R Lasarev
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
| | - Prem Fort
- Division of Neonatology, Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Peterburg, Florida
| | - Scott O Guthrie
- Division of Neonatology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Dinushan C Kaluarachchi
- Division of Neonatology, Department of Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin
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O'Neil A, Schumacher B, Dorr S, Jarding L. Customized Silicone Foam Dressing Under Noninvasive Ventilation and Skincare Bundle to Reduce Hospital-Acquired Pressure Injuries in Neonates. Neonatal Netw 2024; 43:165-175. [PMID: 38816221 DOI: 10.1891/nn-2023-0070] [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: 06/01/2024]
Abstract
In a sixty-eight-bed level-IV NICU, an increased incidence of hospital-acquired pressure injuries (HAPIs) from noninvasive ventilation (NIV) devices was identified. The aim of this quality improvement project was to decrease HAPIs from NIV by 10%. A literature review and the Plan-Do-Study-Act were implemented. The intervention included a customized silicone foam dressing under NIV, an NIV skincare bundle, and multidisciplinary support. Hospital-acquired pressure injury rates were tracked over 3 years postinterventions. The incidence of HAPIs declined by 20% from 0.2 per 1,000 patient days to 0.05 per 1,000 patient days. Relative risk was 4.6 times greater prior to intervention (p = .04). Continuous positive airway pressure (CPAP) failure was not noted and measured by the percentage of patients on ventilators pre- and postintervention. Customized silicone foam dressings under NIV, NIV skincare bundle, and multidisciplinary team support may decrease HAPIs in neonates without CPAP failure.
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Huang TR, Chen HL, Yang ST, Su PC, Chung HW. The Outcomes of Preterm Infants with Neonatal Respiratory Distress Syndrome Treated by Minimally Invasive Surfactant Therapy and Non-Invasive Ventilation. Biomedicines 2024; 12:838. [PMID: 38672192 PMCID: PMC11048199 DOI: 10.3390/biomedicines12040838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
In recent years, the utilization of minimally invasive surfactant therapy (MIST) and Non-invasive ventilation (NIV) as the primary respiratory assistance has become increasingly prevalent among preterm infants with neonatal respiratory distress syndrome (RDS). This study aims to compare the outcomes between MIST administered with nasal continuous positive airway pressure (NCPAP) versus nasal intermittent positive pressure ventilation (NIPPV), with the objective of exploring the respiratory therapeutic benefits of these two approaches. This retrospective study collected data from the neonatal intensive care unit of Kaohsiung Medical University Hospital spanning from January 2016 to June 2021. Infants were divided into two groups based on the type of NIV utilized. The NCPAP group comprised 32 infants, while the NIPPV group comprised 22 infants. Statistical analysis revealed significant differences: the NIPPV group had a smaller gestational age, lower birth weight, higher proportion of female infants, and earlier initiation of MIST. Additionally, the NIPPV group exhibited higher incidence rates of retinopathy of prematurity, longer respiratory support duration, prolonged hospitalization, and mortality. However, upon adjustment, these differences were not statistically significant. Analysis of venous blood gas and respiratory parameter changes indicated that both the NCPAP and NIPPV groups experienced improvements in oxygenation and ventilation following MIST.
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Affiliation(s)
- Tzyy-Rong Huang
- Respiratory Therapy Team, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan;
| | - Hsiu-Lin Chen
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung 80708, Taiwan
| | - Shu-Ting Yang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
| | - Pin-Chun Su
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
| | - Hao-Wei Chung
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung 80756, Taiwan; (S.-T.Y.); (P.-C.S.); (H.-W.C.)
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Yaremenko AV, Pechnikova NA, Porpodis K, Damdoumis S, Aggeli A, Theodora P, Domvri K. Association of Fetal Lung Development Disorders with Adult Diseases: A Comprehensive Review. J Pers Med 2024; 14:368. [PMID: 38672994 PMCID: PMC11051200 DOI: 10.3390/jpm14040368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Fetal lung development is a crucial and complex process that lays the groundwork for postnatal respiratory health. However, disruptions in this delicate developmental journey can lead to fetal lung development disorders, impacting neonatal outcomes and potentially influencing health outcomes well into adulthood. Recent research has shed light on the intriguing association between fetal lung development disorders and the development of adult diseases. Understanding these links can provide valuable insights into the developmental origins of health and disease, paving the way for targeted preventive measures and clinical interventions. This review article aims to comprehensively explore the association of fetal lung development disorders with adult diseases. We delve into the stages of fetal lung development, examining key factors influencing fetal lung maturation. Subsequently, we investigate specific fetal lung development disorders, such as respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), congenital diaphragmatic hernia (CDH), and other abnormalities. Furthermore, we explore the potential mechanisms underlying these associations, considering the role of epigenetic modifications, transgenerational effects, and intrauterine environmental factors. Additionally, we examine the epidemiological evidence and clinical findings linking fetal lung development disorders to adult respiratory diseases, including asthma, chronic obstructive pulmonary disease (COPD), and other respiratory ailments. This review provides valuable insights for healthcare professionals and researchers, guiding future investigations and shaping strategies for preventive interventions and long-term care.
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Affiliation(s)
- Alexey V. Yaremenko
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
| | - Nadezhda A. Pechnikova
- Laboratory of Chemical Engineering A’, School of Chemical Engineering, Faculty of Engineering, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (N.A.P.); (A.A.)
- Saint Petersburg Pasteur Institute, Saint Petersburg 197101, Russia
| | - Konstantinos Porpodis
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
| | - Savvas Damdoumis
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
| | - Amalia Aggeli
- Laboratory of Chemical Engineering A’, School of Chemical Engineering, Faculty of Engineering, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (N.A.P.); (A.A.)
| | - Papamitsou Theodora
- Laboratory of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Kalliopi Domvri
- Oncology Unit, Pulmonary Department, George Papanikolaou Hospital, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (K.P.); (S.D.)
- Laboratory of Histology-Embryology, School of Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
- Pathology Department, George Papanikolaou Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece
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Matlock DN, Ratcliffe SJ, Courtney SE, Kirpalani H, Firestone K, Stein H, Dysart K, Warren K, Goldstein MR, Lund KC, Natarajan A, Demissie E, Foglia EE. The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation. Trials 2024; 25:201. [PMID: 38509583 PMCID: PMC10953115 DOI: 10.1186/s13063-024-08038-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation. METHODS This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer. DISCUSSION The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites. TRIAL REGISTRATION www. CLINICALTRIALS gov , trial identifier NCT05446272 , registered July 6, 2022.
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Affiliation(s)
- David N Matlock
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 512-5B, Little Rock, AR, 72205, USA.
- University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | | | | | - Haresh Kirpalani
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- McMaster University, Hamilton, ON, Canada
| | | | | | - Kevin Dysart
- Nemours Children's Health Wilmington, Philadelphia, PA, USA
| | - Karen Warren
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Aruna Natarajan
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ejigayehu Demissie
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth E Foglia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Aliyev F, Kayki G, Annakkaya Kocyigit T, İyigun İ, Yigit S. Lung ultrasound scores within the first 3 days of life to predict respiratory outcomes. Pediatr Pulmonol 2024; 59:662-668. [PMID: 38131470 DOI: 10.1002/ppul.26804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/15/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
BACKROUND Lung ultrasound (LUS) is a rapid and simple method to evaluate preterm babies with respiratory distress. Lately, LUS has also been reported as an accurate predictor for bronchopulmonary dysplasia (BPD). OBJECTIVES The aim of the study was to investigate the relationship between the LUS scores within the first 3 days of life and respiratory outcomes including the need and the duration of invasive mechanical ventilation, and development of BPD. METHODS It was a retrospective observational study. Preterm infants younger than 32 weeks were included at an academic tertiary Neonatal Intensive Care Unit between 2018 and 2023. LUS was performed within the first 3 days. Each lung was divided into three regions and defined as a score of 0 to 3 points; the total score was obtained by adding the six regional scores. LUS scores were noted in two groups as the highest and lowest scores. Statistical analyses were done to predict respiratory outcomes. RESULTS Total 218 patients were enrolled; 40, 17, and 18 infants had mild, moderate, and severe BPD, respectively. BPD did not develop in 143 patients. Within the first 3 days, the highest and lowest LUS scores significantly predicted moderate-to-severe BPD (p < .001) (area under receiver operating characteristic [ROC] curve, 0.684-0.913; area under ROC curve 0.647-0.902; respectively). High LUS scores were also related with the need of mechanical ventilation (p < .001). There was not a significant correlation between the duration of mechanical ventilation and the LUS scores. Regression analysis revealed that the highest LUS scores within the first 3 days of life, sepsis, and the presence of hemodynamically significant patent ductus arteriosus (hsPDA) were significantly associated with the severity of BPD. CONCLUSIONS In preterm babies, the LUS scores were useful to predict BPD and the need of invasive ventilation in long term. However, it was not related with the length of invasive ventilation.
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Affiliation(s)
- Ferid Aliyev
- Department of Pediatrics, Division of Neonatology, Hacettepe University, Ankara, Turkey
| | - Gozdem Kayki
- Department of Pediatrics, Division of Neonatology, Hacettepe University, Ankara, Turkey
| | | | - İrem İyigun
- Department of Pediatrics, Division of Neonatology, Hacettepe University, Ankara, Turkey
| | - Sule Yigit
- Department of Pediatrics, Division of Neonatology, Hacettepe University, Ankara, Turkey
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13
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Manley BJ, Cripps E, Dargaville PA. Non-invasive versus invasive respiratory support in preterm infants. Semin Perinatol 2024; 48:151885. [PMID: 38570268 DOI: 10.1016/j.semperi.2024.151885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Respiratory insufficiency is almost ubiquitous in infants born preterm, with its incidence increasing with lower gestational age. A wide range of respiratory support management strategies are available for these infants, separable into non-invasive and invasive forms of respiratory support. Here we review the history and evolution of respiratory care for the preterm infant and then examine evidence that has emerged to support a non-invasive approach to respiratory management where able. Continuous positive airway pressure (CPAP) is the non-invasive respiratory support mode currently with the most evidence for benefit. CPAP can be delivered safely and effectively and can commence in the delivery room. Particularly in early life, time spent on non-invasive respiratory support, avoiding intubation and mechanical ventilation, affords benefit for the preterm infant by virtue of a lessening of lung injury and hence a reduction in incidence of bronchopulmonary dysplasia. In recent years, enthusiasm for application of non-invasive support has been further bolstered by new techniques for administration of exogenous surfactant. Methods of less invasive surfactant delivery, in particular with a thin catheter, have allowed neonatologists to administer surfactant without resort to endotracheal intubation. The benefits of this approach appear to be sustained, even in those infants subsequently requiring mechanical ventilation. This cements the notion that any reduction in exposure to mechanical ventilation leads to alleviation of injury to the vulnerable preterm lung, with a long-lasting effect. Despite the clear advantages of non-invasive respiratory support, there will continue to be a role for intubation and mechanical ventilation in some preterm infants, particularly for those born <25 weeks' gestation. It is currently unclear what role early non-invasive support has in this special population, with more studies required.
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Affiliation(s)
- Brett J Manley
- Neonatal Services and Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics, Gynecology and Newborn Health, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Emily Cripps
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia
| | - Peter A Dargaville
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
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14
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He Y, Zhang M, Tang J, Liu W, Hu Y, Shi J, Wang H, Xiong T, Zhang L, Ying J, Mu D. A retrospective cohort study on mortality, morbidity, and care practices for 1750 very low birth weight infants, 2016-2021. Chin Med J (Engl) 2024:00029330-990000000-00967. [PMID: 38404117 DOI: 10.1097/cm9.0000000000002923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Very low birth weight (VLBW) infants are the key populations in neonatology, wherein morbidity and mortality remain major challenges. METHODS A retrospective cohort study conducted aiming to analyze the clinical characteristics of VLBW in our hospital between January 2016 and December 2021. Neonates with a birth weight of <1500 g were included. Mortality, care practices, and major morbidities were analyzed, and compared with that of previous 7 years (2009-2015). RESULTS Of the total 1750 VLBW, 1386 infants born with birth weight between 1000-1499 g and 364 were below 1000 g, 42.9% (751/1750) required delivery room resuscitation, 53.9% (943/1750) received non-invasive ventilation only, 38.2% (669/1750) received invasive ventilation; 1517 VLBW infants received complete treatment. Among them, 60.1% (912/1517) of neonates had neonatal respiratory distress syndrome (NRDS), 28.7% (436/1517) had bronchopulmonary dysplasia (BPD), 22.0% (334/1517) had apnea, 11.1% (169/1517) had culture-confirmed sepsis, 8.4% (128/1517) had pulmonary hemorrhage, 7.6% (116/1517) had severe intraventricular hemorrhage (IVH)/periventricular leukomalacia (PVL), 5.7% (87/1517) had necrotizing enterocolitis (NEC), 2.0% (31/1517) had severe retinopathy of prematurity. The total and in-hospital mortality rates were 9.7% (169/1750) and 3.0% (45/1517), respectively. The top three diagnoses of death among those who had received complete treatment were sepsis, NRDS, and NEC. In 2009-2015, 1146 VLBW were enrolled and 895 infants received complete treatment. The incidences of apnea, IVH, and IVH stage ≥3/PVL, were higher in 2009-2015 compared with those in 2016-2021, while the incidences of NRDS and BPD were characterized by significant increases in 2016-2021. The total and in-hospital mortality rates were 16.7% (191/1146) and 5.6% (50/895) respectively in 2009-2015. CONCLUSION Among VLBW infants born in 2016-2021, the total and in-hospital mortality rates were lower than those of neonates born in 2009-2015. Incidences of NRDS and BPD increased in 2016-2021, which affected the survival rates and long-term prognosis of VLBW.
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Affiliation(s)
- Yang He
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Meng Zhang
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan 610041, China
| | - Jun Tang
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Wanxiu Liu
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Yong Hu
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Jing Shi
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Hua Wang
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Tao Xiong
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Li Zhang
- Department of Neonatology, West China Second Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan 610041, China
| | - Dezhi Mu
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan 610041, China
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15
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Ness TE, Tabb ZJ, Malek J, Placencia FX. Uninformed Origins: Should We Be Advising Parents on the Source of Medicines and Therapies? HEALTH CARE ANALYSIS 2023; 31:186-195. [PMID: 37535146 DOI: 10.1007/s10728-023-00458-8] [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] [Accepted: 07/09/2023] [Indexed: 08/04/2023]
Abstract
Respecting patient autonomy through the process of soliciting informed consent is a cornerstone of clinical ethics. In pediatrics, until a child becomes an adult or legally emancipated, that ethical tenet takes the form of respect for parental decision-making authority. In instances of respecting religious beliefs, doing so is not always apparent and sometimes the challenge lies not only in the healthcare provider's familiarity of religious restrictions but also their knowledge of medical interventions themselves which might conflict with those restrictions. We examine a case of a newborn receiving animal-derived surfactant, a common scenario in neonatology, and present considerations for providers to weigh when confronting when such an intervention might conflict with parent's religious beliefs. We end with strategizing ways to address this issue as a medical community.
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Affiliation(s)
- Tara E Ness
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA.
- Texas Childrens Hospital, Houston, TX, USA.
| | - Zachary J Tabb
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Texas Childrens Hospital, Houston, TX, USA
| | - Janet Malek
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Frank X Placencia
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
- Texas Childrens Hospital, Houston, TX, USA
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16
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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.
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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
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17
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Glaser K, Bamat NA, Wright CJ. Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature. Arch Dis Child Fetal Neonatal Ed 2023; 108:554-560. [PMID: 36600473 PMCID: PMC10246486 DOI: 10.1136/archdischild-2022-324530] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today's neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIV and early surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Nicolas A Bamat
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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18
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Lockyear C, Coe K, Greenberg RG, Clark RH, Aleem S. Trends in morbidities of late preterm infants in the neonatal intensive care unit. J Perinatol 2023; 43:1379-1384. [PMID: 37393396 DOI: 10.1038/s41372-023-01705-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 05/20/2023] [Accepted: 06/15/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVE To characterize demographics and trends in length of stay (LOS), morbidities, and mortality in late preterm infants. STUDY DESIGN Cohort study of infants born between 34 0/7 and 36 6/7 weeks gestation between 1999 and 2018 without major congenital anomalies at Pediatrix Medical Group neonatal intensive care units (NICUs). RESULTS 307,967 infants from 410 NICUs met inclusion criteria. The median (25th-75th percentile) LOS was 11 (8-16) days in the entire period. Postmenstrual age (PMA) at discharge increased during the cohort for all gestational ages (p < 0.001). There was a decrease in invasive ventilation, receipt of phototherapy, and reflux medications observed (p < 0.001). CONCLUSION In this large cohort, given 20 years of time for medical advancement, there was no significant improvement in the LOS of late preterm infants. All infants had an increased PMA at discharge, despite multiple practice changes that were observed.
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Affiliation(s)
| | - Kristi Coe
- Duke School of Nursing, Duke University, Durham, NC, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Reese H Clark
- Pediatrix Center for Research, Education, Quality, and Safety, Sunrise, FL, USA
| | - Samia Aleem
- Department of Pediatrics, Duke University, Durham, NC, USA.
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19
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Kribs A, Roberts KD, Trevisanuto D, O'Donnell C, Dargaville PA. Surfactant delivery strategies to prevent bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151813. [PMID: 37805275 DOI: 10.1016/j.semperi.2023.151813] [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: 10/09/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the most devastating morbidities of preterm infants. Antenatal factors like growth restriction and inflammation are risk factors for its development. Use of oxygen and positive pressure ventilation, which are often necessary to treat respiratory distress syndrome (RDS), increase the risk for development of BPD. Continuous positive airway pressure (CPAP) as primary respiratory support allows for avoidance of positive pressure ventilation in many cases but may lead to a delay of surfactant administration which is a proven therapy for RDS. Several alternative surfactant delivery strategies, including nebulization of surfactant, pharyngeal instillation of surfactant, delivery of surfactant via supraglottic airway device or surfactant delivery via a thin endotracheal catheter have been described which allow for the benefit of surfactant therapy while on CPAP. This review reports available data and discusses the existing evidence of their value in preventing BPD as well as further research directions.
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Affiliation(s)
- Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Faculty of medicine, Cologne, Germany.
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Colm O'Donnell
- School of Medicine, University College Dublin, Dublin, Ireland; Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
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20
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Abstract
Interest in 'resurrecting' the lifeless by supporting breathing has been described since ancient times. For centuries, methods of resuscitating animals, then humans and specifically the 'lifeless' neonate were debated and discussed. Over time, with experimentation and worldwide collaboration, endotracheal tubes and laryngoscopes specific to the newborn were created and their use refined. This historical work has meant that today, the neonatal community focuses on refining the science and the art of intubation for the benefit of the newborn; who, where, when and how to intubate, with what devices and medications, bringing about significant change in the area of neonatal intubation. Recent work has focused on alternatives to neonatal intubation as the risks of endotracheal intubation and mechanical ventilation have become clearer. Appreciating the history of neonatal intubation and its (somewhat cyclical) changes over time can show us how far we've come and how far we can still go in the resuscitation and respiratory support of newborns.
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Affiliation(s)
- Lucy E Geraghty
- Neonatal Unit, National Maternity Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Ireland.
| | - Eoin Ó Curraín
- Neonatal Unit, National Maternity Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Ireland.
| | - Lisa K McCarthy
- Neonatal Unit, National Maternity Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Ireland.
| | - Colm P F O'Donnell
- Neonatal Unit, National Maternity Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Ireland.
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21
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Tamai K, Matsumoto N, Yorifuji T, Takeuchi A, Nakamura M, Nakamura K, Kageyama M. Delivery room intubation and severe intraventricular hemorrhage in extremely preterm infants without low Apgar scores: A Japanese retrospective cohort study. Sci Rep 2023; 13:14990. [PMID: 37696821 PMCID: PMC10495461 DOI: 10.1038/s41598-023-41010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/20/2023] [Indexed: 09/13/2023] Open
Abstract
The purpose of this study was to assess the associations between delivery room intubation (DRI) and severe intraventricular hemorrhage (IVH), as well as other neonatal outcomes, among extremely preterm infants without low Apgar scores using data from a large-scale neonatal registry data in Japan. We analyzed data for infants born at 24-27 gestational weeks between 2003 and 2019 in Japan using robust Poisson regression. Infants with low Apgar scores (≤ 1 at 1 min or ≤ 3 at 5 min) were excluded. The primary outcome was severe IVH. Secondary outcomes were other neonatal morbidities and mortality. The full cohort included 16,081 infants (intubation cohort, 13,367; no intubation cohort, 2714). The rate of DRI increased over time (78.6%, 2003-2008; 83.4%, 2009-2014; 87.8%, 2015-2019), while the rate of severe IVH decreased (7.1%, 2003-2008; 5.7%, 2009-2014; 5.3%, 2015-2019). Infants with DRI had a higher risk of severe IVH than those without DRI (6.8% vs. 2.3%; adjusted risk ratio, 1.86; 95% confidence interval, 1.33-2.58). The results did not change substantially when stratified by gestational age. Despite conflicting changes over time in DRI and severe IVH, DRI was associated with an increased risk of severe IVH among extremely preterm infants in Japan.
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Affiliation(s)
- Kei Tamai
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan.
| | - Naomi Matsumoto
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Yorifuji
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Akihito Takeuchi
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Makoto Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
| | - Kazue Nakamura
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
- Department of Epidemiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Misao Kageyama
- Division of Neonatology, Okayama Medical Center, National Hospital Organization, 1711-1 Tamasu, Kita-Ku, Okayama, 701-1192, Japan
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22
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Kakoo Brioso E, Moscoso J, Malveiro D, Aguiar M, Tuna M. Bronchopulmonary Dysplasia: A Five-Year Retrospective Cohort Study on Differences in Clinical Characteristics and Morbidities According to Severity Grading. Cureus 2023; 15:e42720. [PMID: 37654925 PMCID: PMC10466257 DOI: 10.7759/cureus.42720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Bronchopulmonary dysplasia (BPD) is the most common complication associated with extreme prematurity. Although several criteria defining severity were developed over time, there are a few studies describing the differences in BPD phenotype and neonatal morbidities and complications between severity groups. We aimed to describe these differences in BPD patients of a neonatal intensive care unit (NICU). METHODS We conducted an observational retrospective cohort study through a medical record review over a five-year period. Participants were newborns admitted to an NICU who were diagnosed with BPD. We performed a descriptive statistical analysis of gestational complications and the use of antenatal corticosteroid therapy, birth-related data, and complications throughout the NICU stay, as well as the respiratory support used. We also compared different severity groups across these variables. The patients were divided into severe and non-severe BPD using the severity criteria of the 2001 NICHD/NHLBI/ORD consensus workshop. RESULTS A total of 101 newborns with BPD participated in the study and 73 had data on BPD severity. The median gestational age was 27 weeks, ranging from 23 to 32 weeks. Of these 73 newborns, 36 had mild BPD (49.3%), 10 had moderate BPD (13.7%), and 27 had severe BPD (37.0%). When comparing severe and non-severe BPD, we found that extreme prematurity, extremely low birth weight, and small size for gestational age were more frequent in the severe BPD group (p-value=0.012, p-value<0.001, and p-value=0.012, respectively). Infants with severe BPD had a longer duration of invasive ventilation than those with mild or moderate BPD (p-value<0.001). Late sepsis, necrotizing enterocolitis, severe brain injury, and retinopathy of prematurity were more frequent in severe BPD (p-value=0.017, p-value=0.045, p-value=0.033, p-value=0.003, respectively). DISCUSSION Previously published evidence describing causal links between BPD development and comorbidities exists but data on their impact on BPD severity are scarce. In our study, severe BPD seemed to be associated with a higher frequency of comorbidities and complications. Further studies are needed to ascertain the impact of each morbidity on the severity of BPD and if measures to prevent them could lead to potentially milder BPD disease.
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Affiliation(s)
- Estela Kakoo Brioso
- Pediatrics, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
- Pediatrics, Hospital De Cascais Dr. José De Almeida, Lisbon, PRT
| | - Joana Moscoso
- Pediatrics, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
| | | | - Marta Aguiar
- Pediatrics, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
| | - Madalena Tuna
- Pediatrics, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
- Comprehensive Health Research Center, Nova Medical School, Lisbon, PRT
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23
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Sanlorenzo LA, Hatch LD. Developing a Respiratory Quality Improvement Program to Prevent and Treat Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit. Clin Perinatol 2023; 50:363-380. [PMID: 37201986 DOI: 10.1016/j.clp.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Improvements in respiratory care have resulted in improved outcomes for preterm infants over the past three decades. To target the multifactorial nature of neonatal lung diseases, neonatal intensive care units (NICUs) should consider developing comprehensive respiratory quality improvement programs that address all drivers of neonatal respiratory disease. This article presents a potential framework for developing a quality improvement program to prevent bronchopulmonary dysplasia in the NICU. Drawing on available research and quality improvement reports, the authors discuss key components, measures, drivers, and interventions that should be considered when building a respiratory quality improvement program devoted to preventing and treating bronchopulmonary dysplasia.
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Affiliation(s)
- Lauren A Sanlorenzo
- Department of Pediatrics, Division of Neonatology, Columbia University Medical Center, 3959 Broadway Avenue, New York, NY 10032, USA
| | - Leon Dupree Hatch
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, 4413 VCH, 2200 Children's Way, Nashville, TN 37232, USA; Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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Dou C, Yu YH, Zhuo QC, Qi JH, Huang L, Ding YJ, Yang DJ, Li L, Li D, Wang XK, Wang Y, Qiao X, Zhang X, Zhang BJ, Jiang HY, Li ZL, Reddy S. Longer duration of initial invasive mechanical ventilation is still a crucial risk factor for moderate-to-severe bronchopulmonary dysplasia in very preterm infants: a multicentrer prospective study. World J Pediatr 2023; 19:577-585. [PMID: 36604390 PMCID: PMC10198849 DOI: 10.1007/s12519-022-00671-w] [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: 08/16/2022] [Accepted: 12/01/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVES We aimed to evaluate the risk factors for moderate-to-severe bronchopulmonary dysplasia (BPD) and focus on discussing its relationship with the duration of initial invasive mechanical ventilation (IMV) in very preterm neonates less than 32 weeks of gestational age (GA). METHODS We performed a prospective cohort study involving infants born at 23-31 weeks of GA who were admitted to 47 different neonatal intensive care unit (NICU) hospitals in China from January 2018 to December 2021. Patient data were obtained from the Sina-northern Neonatal Network (SNN) Database. RESULTS We identified 6538 very preterm infants, of whom 49.5% (3236/6538) received initial IMV support, and 12.6% (823/6538) were diagnosed with moderate-to-severe BPD symptoms. The median duration of initial IMV in the moderate-to-severe BPD group was 26 (17-41) days, while in the no or mild BPD group, it was 6 (3-10) days. The incidence rate of moderate-to-severe BPD and the median duration of initial IMV were quite different across different GAs. Multivariable logistic regression analysis showed that the onset of moderate-to-severe BPD was significantly associated with the duration of initial IMV [adjusted odds ratio (AOR): 1.97; 95% confidence interval (CI): 1.10-2.67], late-onset neonatal sepsis (LONS), and patent ductus arteriosus (PDA). CONCLUSION In this multicenter cohort study, the duration of initial IMV was still relatively long in very premature infants, and the longer duration of initial IMV accounts for the increased risk of moderate-to-severe BPD.
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Affiliation(s)
- Cong Dou
- Department of Neonatology, Maternal and Child Health Care Hospital of Shandong Province, Shandong University, Jinan, 250014, China
| | - Yong-Hui Yu
- Department of Neonatology, Shandong Provincial Hospital affiliated to Shandong First Medical University, HuaiYin District, No. 324, Jingwu Road, Jinan, 250021, China.
- Department of Neonatology, Shandong Provincial Hospital, Shandong University, HuaiYin District, No. 324, Jingwu Road, Jinan, 250021, China.
| | - Qing-Cui Zhuo
- Department of Neonatology, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Jian-Hong Qi
- Department of Neonatology, Shandong Provincial Hospital affiliated to Shandong First Medical University, HuaiYin District, No. 324, Jingwu Road, Jinan, 250021, China
| | - Lei Huang
- Department of Neonatology, Shandong Provincial Maternal and Child Health Care Hospital, Jinan, 250014, China
| | - Yan-Jie Ding
- Department of Neonatology, Yantai Yuhuangding Hospital, Yantai, 264000, China
| | - De-Juan Yang
- Department of Neonatology, The First Affiliated Hospital of Shandong First Medical University, Jinan, 250014, China
| | - Li Li
- Department of Neonatology, Linyi People's Hospital, Linyi, 276000, China
| | - Dan Li
- Department of Neonatology, Liaocheng People's Hospital, Liaocheng, 252000, China
| | - Xiao-Kang Wang
- Department of Neonatology, Shandong Provincial Hospital affiliated to Shandong First Medical University, HuaiYin District, No. 324, Jingwu Road, Jinan, 250021, China
| | - Yan Wang
- Department of Neonatology, The Affiliated Taian City Central Hospital of Qingdao University, Taian, 271000, China
| | - Xin Qiao
- Department of Neonatology, Jinan Maternity and Child Healthcare Hospital, Jinan, 250001, China
| | - Xiang Zhang
- Department of Neonatology, Hebei Petro China Central Hospital, Langfang, 065000, China
| | - Bing-Jin Zhang
- Department of Neonatology, Shengli Olifield Central Hospital, Dongying, 257000, China
| | - Hai-Yan Jiang
- Department of Neonatology, The Third Hospital of Baogang Group, Baotou, 014000, China
| | - Zhong-Liang Li
- Department of Neonatology, W.F. Maternal and Child Health Hospital, Weifang, 261011, China
| | - Simmy Reddy
- Cheeloo College of Medicine, Shandong University, Jinan, 250000, China
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Wright CJ, Glaser K, Speer CP, Härtel C, Roehr CC. Reply. J Pediatr 2023; 257:113363. [PMID: 36828344 DOI: 10.1016/j.jpeds.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Charles C Roehr
- Medical Sciences, Division, Nuffield Department of Population Health, University of Oxford, National Perinatal Epidemiology Unit, Oxford, Oxfordshire, United Kingdom
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Lamary M, Bertoni CB, Schwabenbauer K, Ibrahim J. Neonatal Golden Hour: a review of current best practices and available evidence. Curr Opin Pediatr 2023; 35:209-217. [PMID: 36722754 DOI: 10.1097/mop.0000000000001224] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE OF REVIEW Recommendations made by several scientific bodies advocate for adoption of evidence-based interventions during the first 60 min of postnatal life, also known as the 'Golden Hour', to better support the fetal-to-neonatal transition. Implementation of a Golden Hour protocol leads to improved short-term and long-term outcomes, especially in extremely premature and extreme low-birth-weight (ELBW) neonates. Unfortunately, several recent surveys have highlighted persistent variability in the care provided to this vulnerable population in the first hour of life. RECENT FINDINGS Since its first adoption in the neonatal ICU (NICU) in 2009, published literature shows a consistent benefit in establishing a Golden Hour protocol. Improved short-term outcomes are reported, including reductions in hypothermia and hypoglycemia, efficiency in establishing intravenous access, and timely initiation of fluids and medications. Additionally, long-term outcomes report decreased risk for bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH) and retinopathy of prematurity (ROP). SUMMARY Critical to the success and sustainability of any Golden Hour initiative is recognition of the continuous educational process involving multidisciplinary team collaboration to ensure coordination between providers in the delivery room and beyond. Standardization of practices in the care of extremely premature neonates during the first hour of life leads to improved outcomes. VIDEO ABSTRACT http://links.lww.com/MOP/A68 .
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Affiliation(s)
| | - C Briana Bertoni
- Division of Newborn Medicine, UPMC Magee-Womens Hospital/Children's Hospital of Pittsburgh, USA
| | - Kathleen Schwabenbauer
- Division of Newborn Medicine, UPMC Magee-Womens Hospital/Children's Hospital of Pittsburgh, USA
| | - John Ibrahim
- Division of Newborn Medicine, UPMC Magee-Womens Hospital/Children's Hospital of Pittsburgh, USA
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Kakkilaya V, Gautham KS. Should less invasive surfactant administration (LISA) become routine practice in US neonatal units? Pediatr Res 2023; 93:1188-1198. [PMID: 35986148 PMCID: PMC9389478 DOI: 10.1038/s41390-022-02265-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
The harmful effects of mechanical ventilation (MV) on the preterm lung are well established. Avoiding MV at birth and stabilization on continuous positive airway pressure (CPAP) decreases the composite outcome of death or bronchopulmonary dysplasia. Although preterm infants are increasingly being admitted to the neonatal intensive care unit on CPAP, centers differ in the ability to manage infants primarily on CPAP. Over the last decade, less invasive surfactant administration (LISA), a method of administering surfactant with a thin catheter, has been devised and has been shown to decrease the need for MV and improve outcomes compared to surfactant administration via an endotracheal tube following intubation. While LISA has been widely adopted in Europe and other countries, its use is not widespread in the United States. This article provides a summary of the existing evidence on LISA, and practical guidance for US units choosing to implement a change of practice incorporating optimization of CPAP and LISA. IMPACT: The accumulated body of evidence for less invasive surfactant administration (LISA), a widespread practice in other countries, justifies its use as an alternative to intubation and surfactant administration in US neonatal units. This article summarizes the current evidence for LISA, identifies gaps in knowledge, and offers practical tips for the implementation of LISA as part of a comprehensive non-invasive respiratory support strategy. This article will help neonatal units in the US develop guidelines for LISA, provide optimal respiratory support for infants with respiratory distress syndrome, improve short- and long-term outcomes of preterm infants, and potentially decrease costs of NICU care.
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Affiliation(s)
- Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Kanekal Suresh Gautham
- Division of Neonatology, Department of Pediatrics, Nemours Children's Health, Orlando, FL, USA
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28
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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.
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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
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Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside. CHILDREN 2023; 10:children10030535. [PMID: 36980093 PMCID: PMC10047523 DOI: 10.3390/children10030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.
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Eyo TJ, Aguirre D, Gowda H. EBNEO Commentary: Nasal high-flow therapy during neonatal endotracheal intubation. Acta Paediatr 2023; 112:571-572. [PMID: 36564956 DOI: 10.1111/apa.16629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/01/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Teim Jengoa Eyo
- Neonatal Intensive Care Unit, Heartlands Hospital, Birmingham, UK
| | - Diana Aguirre
- Neonatal Intensive Care Unit, Heartlands Hospital, Birmingham, UK
| | - Harsha Gowda
- Neonatal Intensive Care Unit, Heartlands Hospital, Birmingham, UK
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31
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Ibrahim J, Vats K. History of Neonatal Resuscitation: From Uncivilized to Evidence-based Practices. Neoreviews 2023; 24:e57-e66. [PMID: 36720687 DOI: 10.1542/neo.24-2-e57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Neonatal resuscitation, an early and critical intervention in human life, has dramatically evolved. This procedure has gone through phases from uncivilized practices that were sometimes based on myths to the current evidence-based approaches. In this review, we will shed light on the evolution of neonatal resuscitation from early centuries to the current day. Our goal is to highlight the value of clinical research and its role in invalidating hazardous practices and establishing evidence-based guidelines.
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Affiliation(s)
- John Ibrahim
- Newborn Division, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kalyani Vats
- Newborn Division, Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA
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32
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Matsyura O, Besh L, Borysiuk O, Besh O, Kondratyuk M, Sorokopud O, Zubchenko S. EFFICACY OF PRIMARY REHABILITATION MEASURES ASSOCIATED WITH THE DEVELOPMENT OF RECURRENT BRONCHIAL OBSTRUCTION SYNDROME IN YOUNG CHILDREN WITH RESPIRATORY DISORDERS IN NEONATAL PERIOD. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:17-25. [PMID: 36883485 DOI: 10.36740/wlek202301102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The aim: To improve primary prophylactic measures associated with the development and progression of recurrent bronchial obstruction syndrome in young children, who had suffered respiratory disorders in neonatal period. PATIENTS AND METHODS Materials and methods: Algorithm of primary prophylactic measures implied adequate balanced nutrition, sanation of living conditions, restriction of contact with infectious agents, sanation of chronic foci of infection, systematic training and general fitness. The investigation included 160 young children (1 day - 3 years of age). The basic group (n=80) involved children, who had experienced respiratory disorders in neonatal period and received appropriate respiratory therapy (artificial ventilation and / or spontaneous breathing with continuous positive airway pressure and supply of free oxygen), control group - children, who did not have respiratory disorders and respiratory therapy (n=80). RESULTS Results: Conducted investigation throughout 12-month monitoring enabled to record the development of recurrent bronchial obstruction syndrome in 43 children (respectively, 30 - 37.50% patients of the basic group versus 13 - 16.25% of control group; p 0.05), could not be obtained. CONCLUSION Conclusions: Comparative analysis within groups did not show a reliable difference in the development of recurrent bronchial obstruction syndrome in children (р>0.05), which can be explained by partial following of doctor's recommendations. There is the need in further study of the issue involving more patients for a longer period of monitoring.
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Affiliation(s)
- Oksana Matsyura
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | - Lesya Besh
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | - Olena Borysiuk
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | - Olesia Besh
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
| | | | - Olena Sorokopud
- DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY, LVIV, UKRAINE
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Mowitz ME, Gao W, Sipsma H, Zuckerman P, Wong H, Ayyagari R, Sarda SP. Burden of Comorbidities and Healthcare Resource Utilization Among Medicaid-Enrolled Extremely Premature Infants. JOURNAL OF HEALTH ECONOMICS AND OUTCOMES RESEARCH 2022; 9:147-155. [PMID: 36619291 PMCID: PMC9790150 DOI: 10.36469/001c.38847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 10/14/2022] [Indexed: 06/17/2023]
Abstract
Background: The effect of gestational age (GA) on comorbidity prevalence, healthcare resource utilization (HCRU), and all-cause costs is significant for extremely premature (EP) infants in the United States. Objectives: To characterize real-world patient characteristics, prevalence of comorbidities, rates of HCRU, and direct healthcare charges and societal costs among premature infants in US Medicaid programs, with respect to GA and the presence of respiratory comorbidities. Methods: Using International Classification of Diseases, Ninth/Tenth Revision, Clinical Modification codes, diagnosis and medical claims data from 6 state Medicaid databases (1997-2018) of infants born at less than 37 weeks of GA (wGA) were collected retrospectively. Data from the index date (birth) up to 2 years corrected age or death, stratified by GA (EP, ≤28 wGA; very premature [VP], >28 to <32 wGA; and moderate to late premature [M-LP], ≥32 to <37 wGA), were compared using unadjusted and adjusted generalized linear models. Results: Among 25 573 premature infants (46.1% female; 4462 [17.4%] EP; 2904 [11.4%] VP; 18 207 [71.2%] M-LP), comorbidity prevalence, HCRU, and all-cause costs increased with decreasing GA and were highest for EP. Total healthcare charges, excluding index hospitalization and all-cause societal costs (US dollars), were 2 to 3 times higher for EP than for M-LP (EP $74 436 vs M-LP $27 541 and EP $28 504 vs M-LP $15 892, respectively). Conclusions: Complications of preterm birth, including prevalence of comorbidities, HCRU, and costs, increased with decreasing GA and were highest among EP infants during the first 2 years in this US analysis.
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Affiliation(s)
| | - Wei Gao
- Analysis Group, Inc., Boston, Massachusetts
| | | | | | | | | | - Sujata P Sarda
- Global Evidence and Outcomes, Takeda Pharmaceutical Company Limited, Lexington, Massachusetts
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Spencer BL, Mychaliska GB. Milestones for clinical translation of the artificial placenta. Semin Fetal Neonatal Med 2022; 27:101408. [PMID: 36437184 DOI: 10.1016/j.siny.2022.101408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Despite significant advances in the treatment of prematurity, premature birth results in significant mortality and morbidity. In particular, extremely low gestational age newborns (ELGANs) defined as <28 weeks estimated gestational age (EGA) suffer from disproportionate mortality and morbidity. A radical paradigm shift in the treatment of prematurity is to recreate fetal physiology using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). Over the past 15 years, tremendous advances have been made in the laboratory confirming long-term support and organ protection and ongoing development. The major milestones to clinical application are miniaturization, anticoagulation, clinical risk stratification, specialized critical care protocols, a regulatory path and a strategy and platform to translate technology to the bedside. Currently, several groups are addressing the remaining milestones for clinical translation.
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Affiliation(s)
- Brianna L Spencer
- Department of Surgery, University of Michigan, 2101 Taubman Center 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's Hospital, 1540 E Hospital Dr, Ann Arbor, MI, 48109, USA.
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35
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Mahmoud RA, Schmalisch G, Oswal A, Christoph Roehr C. Non-invasive ventilatory support in neonates: An evidence-based update. Paediatr Respir Rev 2022; 44:11-18. [PMID: 36428196 DOI: 10.1016/j.prrv.2022.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/22/2022] [Indexed: 12/14/2022]
Abstract
Non-invasive ventilatory support (NIV) is considered the gold standard in the care of preterm infants with respiratory distress syndrome (RDS). NIV from birth is superior to mechanical ventilation (MV) for the prevention of death or bronchopulmonary dysplasia (BPD), with a number needed to treat between 25 and 35. Various methods of NIV are available, some of them extensively researched and with well proven efficacy, whilst others are needing further research. Nasal continuous positive airway pressure (nCPAP) has replaced routine invasive mechanical ventilation (MV) for the initial stabilization and the treatment of RDS. Choosing the most suitable form of NIV and the most appropriate patient interface depends on several factors, including gestational age, underlying lung pathophysiology and the local facilities. In this review, we present the currently available evidence on NIV as primary ventilatory support to preventing intubation and for secondary ventilatory support, following extubation. We review nCPAP, nasal high-flow cannula, nasal intermittent positive airway pressure ventilation, bi-level positive airway pressure, nasal high-frequency oscillatory ventilation and nasal neurally adjusted ventilatory assist modes. We also discuss most suitable NIV devices and patient interfaces during resuscitation of the newborn in the delivery room.
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Affiliation(s)
- Ramadan A Mahmoud
- Department of Pediatrics, Sohag Faculty of Medicine, Sohag University, Egypt; Department of Neonatology, Maternity and Child Hospital, Al-kharj, Saudi Arabia
| | - Gerd Schmalisch
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Abhishek Oswal
- Newborn Care, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Charles Christoph Roehr
- Newborn Care, Southmead Hospital, North Bristol Trust, Bristol, UK; University of Bristol, Faculty of Medicine, Bristol, UK.
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36
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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.
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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
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Bronicki RA, Benitz WE, Buckley JR, Yarlagadda VV, Porta NFM, Agana DO, Kim M, Costello JM. Respiratory Care for Neonates With Congenital Heart Disease. Pediatrics 2022; 150:189881. [PMID: 36317970 DOI: 10.1542/peds.2022-056415h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ronald A Bronicki
- Baylor College of Medicine, Section of Critical Care Medicine and Cardiology, Texas Children's Hospital, Houston, Texas
| | - William E Benitz
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, California
| | - Jason R Buckley
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
| | - Vamsi V Yarlagadda
- Stanford School of Medicine, Division of Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | - Nicolas F M Porta
- Northwestern University Feinberg School of Medicine, Division of Neonatology, Pediatric Pulmonary Hypertension Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Devon O Agana
- Mayo Clinic College of Medicine and Science, Department of Anesthesiology and Pediatric Critical Care Medicine, Mayo Eugenio Litta Children's Hospital, Rochester, Minnesota
| | - Minso Kim
- University of California San Francisco School of Medicine, Division of Critical Care, University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | - John M Costello
- Medical University of South Carolina, Divison of Pediatric Cardiology, Shawn Jenkins Children's Hospital, Charleston, South Carolina
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Watterberg KL, Carlo WA, Brion LP, Cotten CM, Higgins RD. Overview of the neonatal research network: History, contributions, challenges, and future. Semin Perinatol 2022; 46:151634. [PMID: 35786518 PMCID: PMC10996928 DOI: 10.1016/j.semperi.2022.151634] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Neonatal Research Network (NRN) has been a leader in neonatal research since 1986. In this chapter we review its history and achievements in (1) continuing observation of populations, treatments, short and longer-term outcomes, and trends over time; (2) "negative studies" (trials with non-significant primary outcomes) and trials stopped for futility or adverse events, which have influenced practice and subsequent trial design; and, (3) landmark trials that have changed neonatal care. Its consistent framework has enabled the NRN to be a pioneer in conducting longer-term, school-age follow-up. Leveraging its established infrastructure, the NRN has also partnered with other NIH institutes, governmental agencies, and industry to more effectively advance neonatal care. As current examples of its evolution with changing times, the Network has instituted a process to open specific network trials to external institutions and is adding a parent and participant component to future endeavors.
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Affiliation(s)
- Kristi L Watterberg
- Department of Pediatrics, University of New Mexico Health Sciences Center, Albuquerque, NM, USA.
| | - Waldemar A Carlo
- Division of Neonatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luc P Brion
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Raleigh, NC, USA
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Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States; Division of Newborn Medicine, Harvard Medical School, Boston MA, United States.
| | - Justin Goldstein
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford CA, United States
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States,Division of Newborn Medicine, Harvard Medical School, Boston MA, United States
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Wang L, Zhang M, Yi Q. Surfactant without Endotracheal Tube Intubation (SurE) versus Intubation-Surfactant-Extubation (InSurE) in Neonatal Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:6225282. [PMID: 36159566 PMCID: PMC9507732 DOI: 10.1155/2022/6225282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/11/2022] [Accepted: 09/01/2022] [Indexed: 11/18/2022]
Abstract
Neonatal respiratory distress syndrome (NRDS) is generally treated with surfactant by intubation-surfactant-extubation (InSurE) technique, an invasive method of surfactant administration. Surfactant without endotracheal tube intubation (SurE) is a noninvasive technique that avoids intubation and has been found to have improved the delivery of exogenous surfactants, thereby decreasing lung damage in neonates. This systematic review aimed to provide insights into the efficacy of SurE over InSurE in neonates who received respiratory support and to evaluate the progression and onset of concurrent diseases after treatment. The CENTRAL, PubMed, and Embase databases were searched for data collection. In all, 21 research articles were eligible, comprising 19,976 study participants. The data showed a significant reduction in the composite outcome of stage 2 necrotizing enterocolitis, bronchopulmonary dysplasia, and onset of hemodynamically significant patent ductus arteriosus when treated with SurE. The trend towards lower pneumothorax rates with SurE was also evident. These findings were robust due to the sensitivity analyses performed. There were no differences in the outcome of death or rates of other neonatal morbidities. Overall, SurE was identified as a better substitute for InSurE to treat neonates with RDS.
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Affiliation(s)
- Lirong Wang
- Department of Neonatology, YongZhou Central Hospital, Yongzhou, Hunan 425100, China
| | - Min Zhang
- Department of Neonatology, YongZhou Central Hospital, Yongzhou, Hunan 425100, China
| | - Qingfeng Yi
- Department of Neonatology, YongZhou Central Hospital, Yongzhou, Hunan 425100, China
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41
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Long-term burden of respiratory complications associated with extreme prematurity: An analysis of US Medicaid claims. Pediatr Neonatol 2022; 63:503-511. [PMID: 35817695 DOI: 10.1016/j.pedneo.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/17/2022] [Accepted: 05/25/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Infants born extremely premature (EP) (<28 weeks gestational age) are at high risk of complications, particularly bronchopulmonary dysplasia (BPD), which can develop into chronic lung disease (CLD). METHODS The burden of respiratory complications in EP infants up to 2 years corrected age (CA) was evaluated using real-world data from the US Medicaid program. Data recorded between 1997 and 2018 on EP infants without major congenital malformations were collected from Medicaid records of six states. EP infants were divided into three cohorts: BPD, CLD, and without BPD or CLD. The incidence of respiratory conditions, respiratory medication use, and healthcare resource utilization were compared between the BPD cohort and CLD cohort versus the cohort without BPD or CLD, using unadjusted and adjusted generalized linear models. RESULTS A total of 4462 EP infants were identified (17.4% of all premature infants in the database). Of these, BPD and CLD were diagnosed in 61.9% and 72.1%, respectively, and 14.5% were diagnosed with neither BPD nor CLD. Compared with infants without BPD or CLD, infants with BPD or CLD had more complications and a longer length of birth hospitalization stay. Respiratory distress syndrome was the most frequently reported complication (94.6%, 92.5%, and 82.3% of EP infants in the BPD, CLD, and without BPD or CLD cohorts, respectively). After the birth hospitalization, respiratory conditions, respiratory medication use, and incidence rates of rehospitalizations, emergency room visits, and outpatient visits were higher for infants with BPD or CLD. Rehospitalization occurred in 50.5%, 51.6%, and 27.3% of EP infants with BPD, CLD, or without BPD or CLD, respectively; most hospitalizations occurred for respiratory-related reasons. CONCLUSION In this analysis of a large population of EP infants up to 2 years CA, respiratory conditions were prevalent after the birth hospitalization and were associated with high rates of medication and healthcare resource utilization.
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Nussbaum C, Lengauer M, Puchwein-Schwepcke AF, Weiss VBN, Spielberger B, Genzel-Boroviczény O. Noninvasive Ventilation in Preterm Infants: Factors Influencing Weaning Decisions and the Role of the Silverman-Andersen Score. CHILDREN 2022; 9:children9091292. [PMID: 36138599 PMCID: PMC9497739 DOI: 10.3390/children9091292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 11/24/2022]
Abstract
The factors influencing weaning of preterm infants from noninvasive ventilation (NIV) are poorly defined and the weaning decisions are often driven by subjective judgement rather than objective measures. To standardize quantification of respiratory effort, the Silverman-Andersen Score (SAS) was included in our nursing routine. We investigated the factors that steer the weaning process and whether the inclusion of the SAS would lead to more stringent weaning. Following SAS implementation, we prospectively evaluated 33 neonates born ≤ 32 + 0 weeks gestational age. Age-, weight- and sex-matched infants born before routine SAS evaluation served as historic control. In 173 of 575 patient days, NIV was not weaned despite little respiratory distress (SAS ≤ 2), mainly due to bradycardias (60% of days without weaning), occurring alone (40%) or in combination with other factors such as apnea/desaturations. In addition, “soft factors” that are harder to grasp impact on weaning decisions, whereas the SAS overall played a minor role. Consequently, ventilation times did not differ between the groups. In conclusion, NIV weaning is influenced by various factors that override the absence of respiratory distress limiting the predictive value of the SAS. An awareness of the factors that influence weaning decisions is important as prolonged use of NIV has been associated with adverse outcome. Guidelines are necessary to standardize NIV weaning practice.
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Affiliation(s)
- Claudia Nussbaum
- Division of Neonatology, Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
- Correspondence: ; Tel.: +49-89-4400-32220
| | - Maximilian Lengauer
- Division of Neonatology, Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
| | - Alexandra F. Puchwein-Schwepcke
- Division of Neonatology, Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
- Department of Pediatric Neurology and Developmental Medicin, University of Basel Children’s Hospital, 4056 Basel, Switzerland
| | - Veronique B. N. Weiss
- Division of Neonatology, Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
| | - Benedikt Spielberger
- Division of Neonatology, Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
| | - Orsolya Genzel-Boroviczény
- Division of Neonatology, Department of Pediatrics, Dr. von Hauner Children’s Hospital, University Hospital, LMU Munich, 80337 Munich, Germany
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43
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Handley SC, Salazar EG, Greenberg LT, Foglia EE, Lorch SA, Edwards EM. Variation and Temporal Trends in Delivery Room Management of Moderate and Late Preterm Infants. Pediatrics 2022; 150:188540. [PMID: 35851607 PMCID: PMC9721105 DOI: 10.1542/peds.2021-055994] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Although delivery room (DR) intervention decreases with increasing gestational age (GA), little is known about DR management of moderate and late preterm (MLP) infants. METHODS Using the Vermont Oxford Network database of all NICU admissions, we examined the receipt of DR interventions including supplemental oxygen, positive pressure ventilation, continuous positive airway pressure, endotracheal tube ventilation, chest compressions, epinephrine, and surfactant among MLP infants (30 to 36 weeks') without congenital anomalies born from 2011 to 2020. Pneumothorax was examined as a potential resuscitation-associated complication. Intervention frequency was assessed at the infant- and hospital-level, stratified by GA and over time. RESULTS Overall, 55.3% of 616 110 infants (median GA: 34 weeks) from 483 Vermont Oxford Network centers received any DR intervention. Any DR intervention frequency decreased from 89.7% at 30 weeks to 44.2% at 36 weeks. From 2011 to 2020, there was an increase in the provision of continuous positive airway pressure (17.9% to 47.8%, P ≤.001) and positive pressure ventilation (22.9% to 24.9%, P ≤.001) and a decrease in endotracheal tube ventilation (6.9% to 4.0% P ≤.001), surfactant administration (3.5% to 1.3%, P ≤.001), and pneumothorax (1.9% to 1.6%, P ≤.001). Hospital rates of any DR intervention varied (median 54%, interquartile range 47% to 62%), though the frequency was similar across hospitals with different NICU capabilities after adjustment. CONCLUSIONS The DR management of MLP infants varies at the individual- and hospital-level and is changing over time. These findings illustrate the differing interpretation of resuscitation guidelines and emphasize the need to study MLP infants to improve evidence-based DR care.
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Affiliation(s)
- Sara C. Handley
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA;,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA;,Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - Elizabeth G. Salazar
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA;,Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - Lucy T. Greenberg
- Vermont Oxford Network, Burlington, VT;,Department of Mathematics and Statistics, The University of Vermont, Burlington, VT
| | - Elizabeth E. Foglia
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA;,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Scott A. Lorch
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, PA;,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA;,Leonard Davis Institute of Health Economics, Philadelphia, PA
| | - Erika M. Edwards
- Vermont Oxford Network, Burlington, VT;,Department of Pediatrics, The Robert Larner MD, College of Medicine, The University of Vermont, Burlington, VT;,Department of Mathematics and Statistics, The University of Vermont, Burlington, VT
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44
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Dougherty D, Cham P, Church JT. Management of Extreme Prematurity (Manuscript for Seminars in Pediatric Surgery). Semin Pediatr Surg 2022; 31:151198. [PMID: 36038216 DOI: 10.1016/j.sempedsurg.2022.151198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
| | - Parul Cham
- Clinical Assistant Professor of Pediatrics, University of Michigan
| | - Joseph T Church
- Assistant Professor of Surgery, UPMC Children's Hospital of Pittsburgh.
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45
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Decreasing Intubation for Ineffective Ventilation after Birth for Very Low Birth Weight Neonates. Pediatr Qual Saf 2022; 7:e580. [PMID: 35928022 PMCID: PMC9345641 DOI: 10.1097/pq9.0000000000000580] [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: 09/15/2021] [Accepted: 06/25/2022] [Indexed: 11/18/2022] Open
Abstract
Despite recommendations promoting noninvasive delivery room (DR) ventilation, local historical preterm DR noninvasive ventilation rates were low (50%−64%). Project aims were to improve DR noninvasive ventilation rate in very low birth weight (VLBW) neonates (<1500 g) with a focus on decreasing DR intubations for ineffective positive pressure ventilation (PPV).
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46
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Dobryanskyy DO, Menshykova AO, Salabay ZV, Detsyk OY. Neonatal Preterm Respiratory Care in Ukraine: An Observational Study of Outcomes in Relation to Timing and Methods of Surfactant Treatment. Am J Perinatol 2022; 39:889-896. [PMID: 33152767 DOI: 10.1055/s-0040-1719183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Timely and effective noninvasive respiratory support and surfactant administration are the key determinants of clinical outcomes in very preterm infants. The objective of this study was to evaluate the impact of the changes in clinical practice of surfactant administration on clinical outcomes and the incidence of continuous positive airway pressure (CPAP) failure defined as the need for mechanical ventilation (MV) during the first 5 days of life in preterm infants <32 weeks. STUDY DESIGN One hundred sixty-five outborn very preterm infants with respiratory distress syndrome (RDS), initially managed on CPAP, were enrolled in a retrospective cohort study. Fifty-two infants treated with surfactant using less invasive or INSURE technique were included in the surfactant group. One hundred thirteen control infants received surfactant only in case of CPAP failure. RESULTS The study groups were similar in gestational age, rates of main obstetric complications, and antenatal steroid prophylaxis. The rate of cesarean delivery was significantly higher but birth weight and need for resuscitation were lower in infants from the surfactant group. Fifty-five infants with CPAP failure (49%) received surfactant after initiation of MV in the control group in comparison with 52 (100%) in the surfactant group (p < 0.001). The incidence of CPAP failure was significantly higher in the control group (49 vs. 27%; p < 0.01) and it occurred earlier (median [interquartile range age: 4 [2-5] vs. 47 [36-99] hours, respectively; p < 0.001). Early surfactant administration significantly and independently affected the probability of CPAP failure (adjusted odds ratio: 0.29, 95% confidence interval: 0.13-0.67; p < 0.01). There were no differences in morbidities between the groups, but CPAP failure was significantly associated with higher morbidity and mortality. CONCLUSION Adherence to the European RDS guidelines with early rescue, less invasive surfactant administration in very preterm infants decreased the probability of CPAP failure which was significantly associated with higher morbidity and mortality. KEY POINTS · Early surfactant decreases the probability of CPAP failure.. · Timing and methods of surfactant administration are important.. · Randomized comparisons of prophylactic LISA and CPAP are needed..
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Affiliation(s)
- Dmytro O Dobryanskyy
- Department of Pediatrics No. 2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Anna O Menshykova
- Department of Pediatrics No. 2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine.,Neonatal Intensive Care Unit, Lviv Regional Clinical Hospital, Lviv, Ukraine
| | - Zoriana V Salabay
- Neonatal Intensive Care Unit, Lviv Regional Clinical Hospital, Lviv, Ukraine
| | - Olga Y Detsyk
- Neonatal Progressive Care Unit, Lviv Regional Clinical Hospital, Lviv, Ukraine
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47
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Sur A, Paria A. Weaning of invasive ventilation in the neonatal intensive care: Towards standardising practice: A narrative review. J Paediatr Child Health 2022; 58:962-968. [PMID: 35474623 DOI: 10.1111/jpc.15995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/06/2022] [Accepted: 04/10/2022] [Indexed: 11/29/2022]
Abstract
To present a physiological algorithmic approach to weaning of invasive ventilation in the neonatal intensive care, focusing mainly on the preterm infant. Review of literature, consensus guidelines, expert commentaries and practice guidelines from individual units. Weaning of ventilation for extubation in the neonatal population must follow certain criteria but needs individualising based on disease process, timeline and physiology. Algorithms based on scenarios and modes of ventilation used might aid the clinician on the floor for decision-making process.
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Affiliation(s)
- Amitava Sur
- Department of Neonatology, Lancashire Women and Newborn Centre, East Lancashire Hospital NHS Trust, Burnley, England, United Kingdom
| | - Anshuman Paria
- Department of Neonatology, Lancashire Women and Newborn Centre, East Lancashire Hospital NHS Trust, Burnley, England, United Kingdom
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48
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Whitesel E, Goldstein J, Lee HC, GuptaMMSc M. Quality Improvement for Neonatal Resuscitation and Delivery Room Care. SEMINARS IN SPINE SURGERY 2022:100961. [PMID: 35574250 PMCID: PMC9080026 DOI: 10.1016/j.semss.2022.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
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Affiliation(s)
- Emily Whitesel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Henry C Lee
- Stanford University School of Medicine, Stanford, CA
| | - Munish GuptaMMSc
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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49
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Keerthan RM, Nagaseshu P, Gopalan G, Kachroo K, Sharma J. A systematic review, meta-analysis and economic evaluation on Neonatal cpap. COMPUTATIONAL AND MATHEMATICAL BIOPHYSICS 2022. [DOI: 10.1515/cmb-2022-0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The review mainly focuses on the goals to evaluate the clinical and cost effectiveness of neonatal CPAP in a decrease of Mortality, Length of Stay, Respiratory support, Extubation and Intubation. Introduction: Inclusion criteria: This review is conducted in neonates with respiratory failure, Pneumonia sepsis, necrotizing infections, Pneumothorax, Broncho pulmonary distress, respiratory distress syndrome (RDS), COVID-19, and other comorbidities also included.
Methods: The databases like PubMed, Google Scholar, and Cochrane were used in this review. Depending on inclusion criteria the full-text articles were assessed and chosen studies were recovered by methodological quality.
Results: one twenty-six studies are retrieved which met the inclusion criteria and the extracted studies were pooled statistically and their outcomes were measured. All the studies explain the efficacy of CPAP by reducing Mortality, Length of Stay, Respiratory support, Extubation and Intubation.
Conclusion: Currently the evidence states that CPAP reduces Mortality, Length of Stay, Respiratory support, Extubation and Intubation
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Affiliation(s)
- RM. Keerthan
- Kalam Institute of Health Technology, Andhra Pradesh MedTech Zone , Visakhapatnam , India
| | - Pudi Nagaseshu
- Kalam Institute of Health Technology, Andhra Pradesh MedTech Zone , Visakhapatnam , India
| | - Greeshma Gopalan
- Kalam Institute of Health Technology, Andhra Pradesh MedTech Zone , Visakhapatnam , India
| | - Kavita Kachroo
- Kalam Institute of Health Technology, Andhra Pradesh MedTech Zone , Visakhapatnam , India
| | - Jitendra Sharma
- Kalam Institute of Health Technology, Andhra Pradesh MedTech Zone , Visakhapatnam , India
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Wang L, Li J, Yu Y, Huang L, Huang X, Fan X, Zhang X, Zhang C, Liu Q, Sun A, Zhang Y, Cao Y, Xu P, Liu X, Wu J, Yang Z, Sun R, Ren X, Li J, Wan X, Qiu B, Niu S, Zhu R, Wang X, Zhang Y, Gao Y, Deng L, Shi J, Bi M. Initial respiratory support modality and outcome in preterm infants with less than 32 weeks of gestation in China: A multicentre retrospective cohort study. Paediatr Perinat Epidemiol 2022; 36:390-398. [PMID: 34431114 PMCID: PMC9291106 DOI: 10.1111/ppe.12801] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND For initial respiratory management, continuous positive airway pressure (CPAP) is increasingly used for preterm infants, especially for gestational age less than 32 weeks. However, neonatologists are concerned about the potential risks of CPAP support failure. OBJECTIVES To examine the association between different initial respiratory support modalities and the outcomes of preterm infants at <32 weeks of gestation across multiple neonatal intensive care units (NICU) in China. METHODS This study was carried out over a period of 12 months in 2018. Unadjusted relative risks (RR) for demographic and clinical characteristics were calculated for CPAP failure and CPAP success in the total cohort using log-linear model based on generalised estimating equations for clustered observations. RESULTS Among 1560 preterm infants delivered at <32 weeks, the incidence of CPAP failure was 10.3%. After adjustment for demographic and clinical factors, the relative risk of mortality (RR 7.54, 95% CI 5.56, 10.44), pneumothorax (RR 9.85, 95% CI 2.89, 61.53), pulmonary haemorrhage (RR 7.78, 95% CI 4.51, 14.64) and BPD (RR 3.65, 95% CI 3.65, 4.51) were considerably higher for infants in the CPAP failure group than those in the CPAP-S group. However, the risk of poor outcomes in CPAP failure infants was similar to that of those in the initial mechanical ventilation (MV) group. CONCLUSIONS Continuous positive airway pressure failure was associated with an increased risk of mortality and major morbidities, including BPD, pulmonary haemorrhage and pneumothorax, and was comparable to the risk associated with initial MV.
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Affiliation(s)
- Li Wang
- The First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina,Eyast Branch of Provincial Hospital Affiliated to Shandong UniversityJinanChina
| | - Jia‐hui Li
- The First Affiliated Hospital of Shandong First Medical UniversityJinanChina
| | - Yong‐hui Yu
- Eyast Branch of Provincial Hospital Affiliated to Shandong UniversityJinanChina
| | - Lei Huang
- Shandong Provincial Maternal and Child Health Care HospitalCheeloo College of MedicineShandong UniversityJinanChina
| | | | - Xiu‐fang Fan
- Jinan Maternity and Child Healthcare HospitalJinanChina
| | | | | | | | - Ai‐rong Sun
- Linyi Maternal and Child Health Care HospitalLinyiChina
| | - Yong‐feng Zhang
- Affiliated Hospital of Weifang Medical UniversityWeifangChina
| | | | - Ping Xu
- Liaocheng People's HospitalLiaochengChina
| | | | - Jing‐cai Wu
- Maternity and Child Health Care of ZaozhuangZaozhuangChina
| | | | | | - Xue‐yun Ren
- Affiliated Hospital of Jining Medical CollegeJiningChina
| | - Jing Li
- The Second Affiliated Hospital of Shandong First Medical UniversityJinanChina
| | - Xiao‐li Wan
- Jinan second Maternity and Child Health Care HospitalJinanChina
| | | | - Shi‐ping Niu
- Zibo Maternal and Child Health HospitalZiboChina
| | | | - Xiao‐kang Wang
- Central Branch of Provincial Hospital Affiliated to Shandong UniversityJinanChina
| | | | | | | | - Jing Shi
- Liaocheng Second People's HospitalLiaochengChina
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