Lung UltrasouNd Guided surfactant therapy in preterm infants: an international multicenter randomized control trial (LUNG study)

BACKGROUND

The management of respiratory distress syndrome (RDS) in premature newborns is based on different types of non-invasive respiratory support and on surfactant replacement therapy (SRT) to avoid mechanical ventilation as it may eventually result in lung damage. European guidelines currently recommend SRT only when the fraction of inspired oxygen (FiO2) exceeds 0.30. The literature describes that early SRT decreases the risk of bronchopulmonary dysplasia (BPD) and mortality. Lung ultrasound score (LUS) in preterm infants affected by RDS has proven to be able to predict the need for SRT and different single-center studies have shown that LUS may increase the proportion of infants that received early SRT. Therefore, the aim of this study is to determine if the use of LUS as a decision tool for SRT in preterm infants affected by RDS allows for the reduction of the incidence of BPD or death in the study group.

METHODS/DESIGN

In this study, 668 spontaneously-breathing preterm infants, born at 25+0 to 29+6 weeks' gestation, in nasal continuous positive airway pressure (nCPAP) will be randomized to receive SRT only when the FiO2 cut-off exceeds 0.3 (control group) or if the LUS score is higher than 8 or the FiO2 requirements exceed 0.3 (study group) (334 infants per arm). The primary outcome will be the difference in proportion of infants with BPD or death in the study group managed compared to the control group.

DISCUSSION

Based on previous published studies, it seems that LUS may decrease the time to administer surfactant therapy. It is known that early surfactant administration decreases BPD and mortality. Therefore, there is rationale for hypothesizing a reduction in BPD or death in the group of patients in which the decision to administer exogenous surfactant is based on lung ultrasound scores.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05198375 . Registered on 20 January 2022.

Study protocol: treatment with caffeine of the very preterm infant in the delivery room: a feasibility study

INTRODUCTION

Early treatment with caffeine in the delivery room has been proposed to decrease the need for mechanical ventilation (MV) by limiting episodes of apnoea and improving respiratory mechanics in preterm infants. Thus, the purpose of this feasibility study is to verify the hypothesis that intravenous or enteral administration of caffeine can be performed in the preterm infant in the delivery room.

METHODS AND ANALYSIS

In this multicentre prospective study, infants with 25⁺⁰-29⁺⁶ weeks of gestational age will be enrolled and randomised to receive 20 mg/kg of caffeine citrate intravenously, via the umbilical vein, or enterally, through an orogastric tube, within 10 min of birth. Caffeine plasma level will be measured at 60±15 min after administration and 60±15 min before the next dose (5 mg/kg). The primary endpoint will be evaluation of the success rate of intravenous and enteral administration of caffeine in the delivery room. Secondary endpoints will be the comparison of success rate of intravenous versus oral administration and the evaluation of the need for MV in treated infants. In the absence of previous references, we arbitrarily decided to study 20 infants treated with intravenous caffeine and 20 infants treated with enteral caffeine. Primary endpoint will be evaluated measuring the success rate of intravenous and enteral caffeine administration which will be considered a success when it is followed by the achievement of the caffeine therapeutic level (8-25 µg/mL) 60±15 min before administration of the second dose.

ETHICS AND DISSEMINATION

The study has been approved by the Italian Medicines Agency (AIFA: AIFA/RSC/P/32755) and by Comitato Etico Pediatrico Regione Toscana. The results will be published in peer-reviewed academic journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier NCT04044976; EudraCT number 2018-003626-91.

SARS-CoV-2 infection and neonates: a review of evidence and unresolved questions

SARS-CoV-2 infection in the neonatal period poses previously unmet challenges to obstetricians and neonatologists, but several key questions are yet to be answered. Few cases of presumed in utero vertical transmission of the virus from infected mothers to fetuses have been reported, but stronger evidence is needed, from larger datasets with multiple biospecimens rigorously analyzed. Whether acquired before or after birth, SARS-CoV-2 infection in neonates can be symptomatic, but our comprehension of neonatal immune response and the subsequent clinical characteristics of COVID-19 in early life are incomplete. Finally, the pandemic challenged several dogmas regarding the management of mother-infant dyads, and again more robust data are needed to support the formulation of evidence-based guidelines. Here, we briefly summarize existing evidence and key unresolved questions about SARS-CoV-2 infection and COVID-19 in the neonatal period.

Changes in respiratory mechanics at birth in preterm infants: A pilot study

OBJECTIVE

We aimed to measure lung mechanics at birth by the forced oscillation technique (FOT) for assessment of the initial degree of lung aeration and the short-term aeration changes after applying different respiratory support strategies.

METHODS

Eighteen preterm infants (gestational age = 29-36 week) were randomized to receive either continuous positive airway pressure (CPAP) at 5 cmH₂ O only or combined with a sustained inflation (SI; 15 seconds at 25 cmH₂ O after 5 seconds of CPAP) at birth. We assessed the respiratory system reactance at 5 Hz (X_5; increases with lung volume recruitment at a given distending pressure) at 2, 40, and 150 seconds after initiation of CPAP. k-Means clustering of the initial X₅ value (X_5,i ) stratified newborn into either infants with lower (lowerX_5,i ; X₅  < -280 cmH₂ O*s/L) and higher (higherX_5,i ; X₅  > -240 cmH₂ O*s/L) initial degree of lung volume recruitment.

RESULTS

Initial values were highly heterogeneous. In the LowerX_5,i group, X₅ increased with time, with SI-patients showing significantly higher values at 150 seconds than the non-SI group (X₅  = -89 ± 27 cmH₂ O vs -274 ± 58 cmH₂ O). In the higherX_5,i group, X₅ did not improve with time, regardless of the respiratory strategy, suggesting a lack of lung recruitment. Moreover, 75% of infants receiving SI in the higherX_5,i group experienced a transient loss of aeration after the maneuver.

CONCLUSIONS

Preterm newborns present initially with highly heterogeneous lung aeration at birth that significantly impacts the effectiveness of the subsequent lung volume recruitment strategy. FOT may represent a valuable tool for individualizing a respiratory resuscitation at birth as it is noninvasive and may be applied simultaneously to respiratory support.

Nasal high-frequency oscillatory ventilation and CO2 removal: A randomized controlled crossover trial

OBJECTIVE

To compare short-term application of nasal high-frequency oscillatory ventilation (nHFOV) with nasal continuous positive airway pressure (nCPAP).

WORKING HYPOTHESIS

nHFOV improves CO₂ removal with respect to nCPAP in preterm infants needing noninvasive respiratory support and persistent oxygen supply after the first 72 h of life.

STUDY DESIGN

Multicenter non-blinded prospective randomized crossover study.

PATIENT SELECTION

Thirty premature infants from eight tertiary neonatal intensive care units, of mean ± SD 26.4 ± 1.8 weeks of gestational age and 921 ± 177 g of birth weight.

METHODOLOGY

Infants were randomly allocated in a 1:1 ratio to receive a starting treatment mode of either nCPAP or nHFOV delivered by the ventilator CNO (Medin, Germany), using short binasal prongs of appropriate size. A crossover design with four 1-h treatment periods was used, such that each infant received both treatments twice. The primary outcome was the mean transcutaneous partial pressure of CO₂ (TcCO₂ ) value during the 2-h cumulative period of nHFOV compared with the 2-h cumulative period of nCPAP.

RESULTS

Significantly lower TcCO₂ values were observed during nHFOV compared with nCPAP: 47.5 ± 7.6 versus 49.9 ± 7.2 mmHg, respectively, P = 0.0007. A different TcCO₂ behavior was found according to the random sequence: in patients starting on nCPAP, TcCO₂ significantly decreased from 50.0 ± 8.0 to 46.6 ± 7.5 mmHg during nHFOV (P = 0.001). In patients starting on nHFOV, TcCO₂ slightly increased from 48.5 ± 7.8 to 49.9 ± 6.7 mmHg during nCPAP (P = 0.13).

CONCLUSIONS

nHFOV delivered through nasal prongs is more effective than nCPAP in improving the elimination of CO₂ .

New Insights on Early Patterns of Respiratory Disease among Extremely Low Gestational Age Newborns

BACKGROUND

The analysis of early patterns of lung disease among preterm infants may help to identify predictors of pulmonary deterioration.

OBJECTIVES

To analyze FIO2 requirement in the first 14 days of life among preterm infants and to find predictors of bronchopulmonary dysplasia (BPD).

METHODS

Retrospective cohort study.

SETTING

3 Italian level III NICUs.

POPULATION

infants born between 240/7 and 276/7 weeks' gestational age (GA) who survived to 14 days. A consecutive sample of 588 infants was analyzed. Daily mode FIO2 in the first 2 weeks of life were analyzed according to the criteria defined by Laughon et al. [Pediatrics 2009;123:1124-1131], who found 3 early respiratory patterns: consistently low FIO2 (LowFIO2), pulmonary deterioration (PD), and early persistent pulmonary deterioration (EPPD). Factors associated with pulmonary deterioration were studied by univariate and multivariate analysis.

RESULTS

Forty percent of infants had low FIO2, 18% had pulmonary deterioation, 21% had early persistent pulmonary deterioration, and 21% had a previously unreported pattern (pulmonary improvement, PI). The prevalence of BPD was 7% in the LowFIO2 group, 28% in the PI group, 44% in the PD group, and 62% in the EPPD group (p = 0.000). Infants with lung deterioration were more frequently males (OR = 2.019, CI: 1.319-3.090, p = 0.001), had lower GA (OR = 0.945, CI: 0.915-0.975, p = 0.000), higher incidence of severe respiratory distress syndrome (OR = 2.956, CI: 1.430-6.112, p = 0.003), and lack of postnatal caffeine (OR = 0.167, CI: 0.052-0.541, p = 0.003).

CONCLUSIONS

We report 4 distinct patterns of early respiratory disease associated with significantly different prevalence of BPD and discuss risk factors for lung deterioration.

Oxygen administration at birth in preterm infants: a retrospective analysis

OBJECTIVE

The aim of the study was to retrospectively investigate the association between initial oxygen concentration in delivery room and short-term outcomes in preterm infants.

METHODS

Data from infants needing neonatal resuscitation, born at our department between January 2008 and December 2011, were analyzed. Patients were divided into three groups based on gestational age: between 32 and 36 weeks, between 31 and 28 weeks, and below 28 weeks.

RESULTS

The administration of each additional unit of oxygen up to 50% showed an association with a 5% increased need for mechanical ventilation (MV) in the neonatal intensive care unit in infants between 32 and 36 weeks [adjusted odds ratio 1.1, 95% confidence interval (CI) 1.04-1.1] and infants between 28 and 31 weeks (adjusted odds ratio 1.12, 95% CI 1.08-1.44). On the contrary, in infants below 28 weeks, increasing initial concentration of supplementary oxygen did not show any association with MV.

CONCLUSIONS

Initial oxygen concentration seems to be associated with increased MV in the NICU. Our observations further stress the need for randomized controlled studies in order to obtain definitive recommendations for the optimal initial oxygen concentration during neonatal resuscitation of preterm infants.

Positional effects on lung mechanics of ventilated preterm infants with acute and chronic lung disease

BACKGROUND

The role of prone position in preterm infants has not been completely clarified. We investigated prone versus supine posture-related changes in respiratory system resistance (Rrs) and reactance (Xrs) measured by the Forced Oscillation Technique (FOT) in mechanically ventilated preterm newborns.

METHODS

Patients were studied in the supine versus prone positions in random order. Oxygen saturation, transcutaneous partial pressure of oxygen (ptcO2 ), carbon dioxide (ptcCO2 ), Rrs and Xrs were measured in each position.

RESULTS

Nine patients with respiratory distress syndrome (RDS) and nine with evolving broncho-pulmonary dysplasia (BPD) were studied. Rrs was, on average, 9.8 (1.3, 18.3 as 95%CI) cmH2 O*s/l lower in the prone compared to the supine position (P = 0.02), while no differences in Xrs, ptcO2 , ptcCO2 , and breathing pattern were observed between postures. Only patients with evolving BPD showed a significant reduction of Rrs from 69.0 ± 27.4 to 53.0 ± 16.7 cmH2 O*s/l, P = 0.01. No significant correlations were found between changes in lung mechanics and ptcO2 , ptcCO2 , or breathing pattern.

CONCLUSIONS

On short-term basis, prone positioning does not offer significant advantages in lung mechanics in mechanically ventilated infants with RDS, while it is associated with lower Rrs values in patients with evolving BPD.

[Therapy with high-flow nasal prongs in preterm infants]

Despite of improved survival of premature infants, the incidence of long-term pulmonary complications, mostly associated with ventilation-induced lung injury, remains high. Non invasive ventilation (NIV) is able to reduce the adverse effects of mechanical ventilation. Although nasal continuous positive airway pressure (NCPAP) is an effective mode of NIV, traumatic nasal complications and intolerance of the nasal interface are common. Recently high flow nasal cannula (HFNC) is emerging as an efficient, better tolerated form of NIV, allowing better access to the baby's face, which may improve nursing, feeding and bonding. The aim of this review is to discuss the available evidence of effectiveness and safety of HFNC in preterm newborns with respiratory distress syndrome (RDS). It is known that distending pressure generated by HFNC increases with increasing flow rate and decreasing infant size and varies according to the amount of leaks by nose and mouth. The effects of HFNC on lung mechanics, its clinical efficacy and safety are still insufficiently investigated. In conclusion, there is a growing evidence of the feasibility of HFNC as an alternative mode of NIV. However, further larger randomized trials are required, before being able to recommend HFNC in the treatment of moderate respiratory distress of preterm infants.

Diagnosis of BPH and treatment of LUTS among GPs: a European survey

AIMS OF THE STUDY

This survey was conducted in France, Germany, Italy, Spain and UK, with the aim to assess diagnosis and therapy of BPH patients in clinical practice.

METHODS USED TO CONDUCT THE STUDY

A selected cohort of 455 general practitioners (GPs) in Europe were asked to report information on BPH patients with lower urinary tract symptoms (LUTS), including patient characteristics, diagnostic procedures, severity of illness, symptoms duration and underlying conditions. The GPs provided data relating to 886 patients.

RESULTS OF THE STUDY

The diagnostic work-up included description of symptoms (74.9-85.1%), rectal examination (55.4-82.1%) and the determination of PSA (79.1-94.7%). Transrectal sonography was popular in Italy and France (51.1% and 55.9%, respectively), less so in Germany (15.3%) and Spain (13.1%) and not at all in the UK (2.3%). At diagnosis, the most common symptom was nocturia (71-88%), followed by frequency (15-79%), urgency (43-68%) and weak stream (47-64%). The most common combination was the triad nocturia-frequency-feeling of incomplete emptying (22-31%). The mean ± SD LUTS severity score was similar in all countries: The main aim of treatment was the resolution of nocturia, which had an average score that reflected an important need (> 3.5) closely followed by frequency (3.3-3.9).

CONCLUSIONS DRAWN FROM THE STUDY AND CLINICAL IMPLICATIONS

This survey has shown that the most common LUTS is nocturia. Analyses of the symptoms' pattern revealed that the most common combination appears to be the triad nocturia-frequency-feeling of incomplete emptying. An association between LUTS and heart disease, diabetes and hypertension suggests that the pharmacological treatment should be devoid of effects on the cardiovascular system. With alpha blockers as first line treatment of LUTS, respondents were more concerned with hypotensive episodes resulting in falls, rather than about other typical side effects (e.g. ejaculation disorders and lowered libido). The survey highlights educational needs in diagnostics.

Nasal continuous positive airway pressure with heliox in preterm infants with respiratory distress syndrome

OBJECTIVE

To assess the therapeutic effects of breathing a low-density helium and oxygen mixture (heliox, 80% helium and 20% oxygen) in premature infants with respiratory distress syndrome (RDS) treated with nasal continuous positive airway pressure (NCPAP).

METHODS

Infants born between 28 and 32 weeks of gestational age with radiologic findings and clinical symptoms of RDS and requiring respiratory support with NCPAP within the first hour of life were included. These infants were randomly assigned to receive either standard medical air (control group) or a 4:1 helium and oxygen mixture (heliox group) during the first 12 hours of enrollment, followed by medical air until NCPAP was no longer needed.

RESULTS

From February 2008 to September 2010, 51 newborn infants were randomly assigned to two groups, 24 in the control group and 27 in the heliox group. NCPAP with heliox significantly decreased the risk of mechanical ventilation in comparison with NCPAP with medical air (14.8% vs 45.8%).

CONCLUSIONS

Heliox increases the effectiveness of NCPAP in the treatment of RDS in premature infants.

[Respiratory failure in "late preterm" infants: a retrospective cohort study]

OBJECTIVE

To evaluate the incidence and characteristics of the respiratory failure in late preterm infants.

STUDY DESIGN

Retrospective data analysis in years 2006-2007 in late preterm infants (GA 34(+0)-36(+6) weeks) with respiratory failure, admitted at a tertiary level NICU.

RESULT

Data from 1011 late preterm infants, which accounted for 7% of all deliveries and 65% of preterm births were analyzed; 29% (292/1011) required intensive care and 13% (136/1011) presented respiratory failure (16% of all ventilated infants in the period). In late preterms with respiratory failure 23% (32/136) were treated with prenatal steroids 46% (62/136) with non -invasive ventilation (nasal continuous positive airways pressure = nCPAP) while 41% (56/136) were intubated and received exogenous surfactant. Mean days of ventilation were 5.3 +/- 6.5 (0.5-55); 3.7% (5/136) developed bronchopulmonary dysplasia defined as oxygen-dependency at 36 postconceptional age and mortality was 1.5% (2/136).

CONCLUSION

Respiratory failure incidence and characteristics in late preterms suggest their peculiarity and relevance in neonatal intensive care.