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Abdel-Latif ME, Tan O, Fiander M, Osborn DA. Non-invasive high-frequency ventilation in newborn infants with respiratory distress. Cochrane Database Syst Rev 2024; 5:CD012712. [PMID: 38695628 PMCID: PMC11064768 DOI: 10.1002/14651858.cd012712.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Respiratory distress occurs in up to 7% of newborns, with respiratory support (RS) provided invasively via an endotracheal (ET) tube or non-invasively via a nasal interface. Invasive ventilation increases the risk of lung injury and chronic lung disease (CLD). Using non-invasive strategies, with or without minimally invasive surfactant, may reduce the need for mechanical ventilation and the risk of lung damage in newborn infants with respiratory distress. OBJECTIVES To evaluate the benefits and harms of nasal high-frequency ventilation (nHFV) compared to invasive ventilation via an ET tube or other non-invasive ventilation methods on morbidity and mortality in preterm and term infants with or at risk of respiratory distress. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL and three trial registries in April 2023. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster- or quasi-RCTs of nHFV in newborn infants with respiratory distress compared to invasive or non-invasive ventilation. DATA COLLECTION AND ANALYSIS Two authors independently selected the trials for inclusion, extracted data, assessed the risk of bias, and undertook GRADE assessment. MAIN RESULTS We identified 33 studies, mostly in low- to middle-income settings, that investigated this therapy in 5068 preterm and 46 term infants. nHFV compared to invasive respiratory therapy for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 0.67, 95% CI 0.20 to 2.18; 1 study, 80 infants) or the incidence of CLD (RR 0.38, 95% CI 0.09 to 1.59; 2 studies, 180 infants), both very low-certainty. ET intubation, death or CLD, severe intraventricular haemorrhage (IVH) and neurodevelopmental disability (ND) were not reported. nHFV vs nasal continuous positive airway pressure (nCPAP) used for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 1.00, 95% CI 0.41 to 2.41; 4 studies, 531 infants; very low-certainty). nHFV may reduce ET intubation (RR 0.52, 95% CI 0.33 to 0.82; 5 studies, 571 infants), but there may be little or no difference in CLD (RR 1.35, 95% CI 0.80 to 2.27; 4 studies, 481 infants); death or CLD (RR 2.50, 95% CI 0.52 to 12.01; 1 study, 68 participants); or severe IVH (RR 1.17, 95% CI 0.36 to 3.78; 4 studies, 531 infants), all low-certainty evidence. ND was not reported. nHFV vs nasal intermittent positive-pressure ventilation (nIPPV) used for initial RS nHFV may result in little to no difference in mortality before hospital discharge (RR 1.86, 95% CI 0.90 to 3.83; 2 studies, 84 infants; low-certainty). nHFV may have little or no effect in reducing ET intubation (RR 1.33, 95% CI 0.76 to 2.34; 5 studies, 228 infants; low-certainty). There may be a reduction in CLD (RR 0.63, 95% CI 0.42 to 0.95; 5 studies, 307 infants; low-certainty). A single study (36 infants) reported no events for severe IVH. Death or CLD and ND were not reported. nHFV vs high-flow nasal cannula (HFNC) used for initial RS We are very uncertain whether nHFV reduces ET intubation (RR 2.94, 95% CI 0.65 to 13.27; 1 study, 37 infants) or reduces CLD (RR 1.18, 95% CI 0.46 to 2.98; 1 study, 37 participants), both very low-certainty. There were no mortality events before hospital discharge or severe IVH. Other deaths, CLD and ND, were not reported. nHFV vs nCPAP used for RS following planned extubation nHFV probably results in little or no difference in mortality before hospital discharge (RR 0.92, 95% CI 0.52 to 1.64; 6 studies, 1472 infants; moderate-certainty). nHFV may result in a reduction in ET reintubation (RR 0.42, 95% CI 0.35 to 0.51; 11 studies, 1897 infants) and CLD (RR 0.78, 95% CI 0.67 to 0.91; 10 studies, 1829 infants), both low-certainty. nHFV probably has little or no effect on death or CLD (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 966 infants) and severe IVH (RR 0.80, 95% CI 0.57 to 1.13; 3 studies, 1117 infants), both moderate-certainty. We are very uncertain whether nHFV reduces ND (RR 0.92, 95% CI 0.37 to 2.29; 1 study, 74 infants; very low-certainty). nHFV versus nIPPV used for RS following planned extubation nHFV may have little or no effect on mortality before hospital discharge (RR 1.83, 95% CI 0.70 to 4.79; 2 studies, 984 infants; low-certainty). There is probably a reduction in ET reintubation (RR 0.69, 95% CI 0.54 to 0.89; 6 studies, 1364 infants), but little or no effect on CLD (RR 0.88, 95% CI 0.75 to 1.04; 4 studies, 1236 infants); death or CLD (RR 0.92, 95% CI 0.79 to 1.08; 3 studies, 1070 infants); or severe IVH (RR 0.78, 95% CI 0.55 to 1.10; 4 studies, 1162 infants), all moderate-certainty. One study reported there might be no difference in ND (RR 0.88, 95% CI 0.35 to 2.16; 1 study, 72 infants; low-certainty). nHFV versus nIPPV following initial non-invasive RS failure nHFV may have little or no effect on mortality before hospital discharge (RR 1.44, 95% CI 0.10 to 21.33); or ET intubation (RR 1.23, 95% CI 0.51 to 2.98); or CLD (RR 1.01, 95% CI 0.70 to 1.47); or severe IVH (RR 0.47, 95% CI 0.02 to 10.87); 1 study, 39 participants, all low- or very low-certainty. Other deaths or CLD and ND were not reported. AUTHORS' CONCLUSIONS For initial RS, we are very uncertain if using nHFV compared to invasive respiratory therapy affects clinical outcomes. However, nHFV may reduce intubation when compared to nCPAP. For planned extubation, nHFV may reduce the risk of reintubation compared to nCPAP and nIPPV. nHFV may reduce the risk of CLD when compared to nCPAP. Following initial non-invasive respiratory support failure, nHFV when compared to nIPPV may result in little to no difference in intubation. Large trials, particularly in high-income settings, are needed to determine the role of nHFV in initial RS and following the failure of other non-invasive respiratory support. Also, the optimal settings of nHVF require further investigation.
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Affiliation(s)
- Mohamed E Abdel-Latif
- Discipline of Neonatology, School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, ACT, Australia
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia
- Department of Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Olive Tan
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, ACT, Australia
| | | | - David A Osborn
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
- Department of Neonatology, Royal Prince Alfred Hospital, Camperdown, Australia
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2
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Rallis D, Ben-David D, Woo K, Robinson J, Beadles D, Bernardini L, Abdulhayoglu E, Flanigan E, Christou H. Single center experience with first-intention high-frequency jet vs. volume-targeted ventilation in extremely preterm neonates. Front Pediatr 2024; 11:1326668. [PMID: 38239592 PMCID: PMC10794594 DOI: 10.3389/fped.2023.1326668] [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: 10/23/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
Objectives To examine whether first-intention high-frequency jet ventilation (HFVJ), compared to volume-targeted ventilation (VTV), in extremely preterm infants is associated with lower incidence of bronchopulmonary dysplasia (BPD) and other adverse clinical outcomes. Study design We conducted a retrospective cohort study evaluating neonates with gestational age (GA) ≤28 weeks, who received first-intention HFJV (main exposure) or VTV (comparator), between 11/2020 and 3/2023, with a subgroup analysis including neonates with GA ≤26 weeks and oxygenation index (OI) >5. Results We identified 117 extremely preterm neonates, 24 (GA 25.2 ± 1.6 weeks) on HFJV, and 93 (GA 26.4 ± 1.5 weeks, p = 0.001) on VTV. The neonates in the HFJV group had higher oxygenation indices on admission, higher inotrope use, and remained intubated for a longer period. Despite these differences, there were no statistically significant differences in rates of BPD, survival, or other adverse outcomes between the two groups. In subgroup analysis of 18 neonates on HFJV and 39 neonates on VTV, no differences were recorded in the GA, and duration of mechanical ventilation, while neonates in the HFJV group had significantly lower rates of BPD (50% compared to 83%, p = 0.034), and no significant differences in other adverse outcomes compared to neonates in the VTV group. In neonates ≤26 weeks of GA with OI >5, HFJV was significantly associated with lower rates of BPD (OR 0.21, 95% CI 0.05-0.92), and combined BPD or death (OR 0.18, 95% CI 0.03-0.85), after adjusting for birth weight, and Arterial-alveolar gradient on admission. Conclusions In extremely preterm neonates ≤26 weeks of GA with OI >5, first-intention HFJV, in comparison to VTV, is associated with lower rates of BPD.
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Affiliation(s)
- Dimitrios Rallis
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Neonatal Intensive Care Unit, Faculty of Medicine, University of Ioannina, Ioannina, Greece
| | - Danielle Ben-David
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kendra Woo
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jill Robinson
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - David Beadles
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Laura Bernardini
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Elisa Abdulhayoglu
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Elizabeth Flanigan
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Helen Christou
- Department of Pediatrics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
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3
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Kaltsogianni O, Dassios T, Greenough A. Neonatal respiratory support strategies-short and long-term respiratory outcomes. Front Pediatr 2023; 11:1212074. [PMID: 37565243 PMCID: PMC10410156 DOI: 10.3389/fped.2023.1212074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/11/2023] [Indexed: 08/12/2023] Open
Abstract
Mechanical ventilation (MV), although life-saving, is associated with chronic respiratory morbidity in both preterm and term born infants. New ventilation modes have been developed with the aim of minimising lung injury. These include invasive and non-invasive respiratory support strategies, techniques for less invasive surfactant administration (LISA) and closed-loop automated oxygen control (CLAC) systems. Increasingly, newborn infants with signs of respiratory distress are stabilised on continuous positive airway pressure (CPAP) and receive LISA. Early CPAP when compared to mechanical ventilation reduced the incidence of BPD and respiratory morbidity at 18 to 22 months corrected age. Nasal intermittent positive pressure ventilation reduced treatment failure rates compared to CPAP, but not bronchopulmonary dysplasia (BPD). LISA compared with intubation and surfactant delivery reduced BPD, but there is no evidence from randomised trials regarding long-term respiratory and neurodevelopmental outcomes. Synchronisation of positive pressure inflations with the infant's respiratory efforts used with volume targeting should be applied for infants requiring intubation as this strategy reduces BPD. A large RCT with long term follow up data demonstrated that prophylactic high frequency oscillatory ventilation (HFOV) improved respiratory and functional outcomes at school age, but those effects were not maintained after puberty. CLAC systems appear promising, but their effect on long term clinical outcomes has not yet been explored in randomised trials. Further studies are required to determine the role of newer ventilation modes such as neurally adjusted ventilator assist (NAVA). All such respiratory support strategies should be tested in randomised controlled trials powered to assess long-term outcomes.
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Affiliation(s)
- Ourania Kaltsogianni
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Theodore Dassios
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
- Neonatal Intensive Care Centre, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anne Greenough
- Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
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4
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Wheeler CR, Vogel ER, Cusano MA, Friedman KG, Callahan R, Porras D, Ibla JC, Levy PT. Definitive Closure of the Patent Ductus Arteriosus in Preterm Infants and Subsequent Short-Term Respiratory Outcomes. Respir Care 2022; 67:594-606. [PMID: 35473850 PMCID: PMC9994254 DOI: 10.4187/respcare.09489] [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: 03/10/2023]
Abstract
A persistent patent ductus arteriosus (PDA) can have significant clinical consequences in preterm infants, depending on the degree of left-to-right shunting, its impact on cardiac performance, and associated perinatal risk factors that can mitigate or exacerbate the shunt. Although the best management strategy remains contentious, PDAs that have contraindications to, or have failed medical management have historically undergone surgical ligation. Recently smaller occluder devices and delivery systems have allowed for minimally invasive closure in the catheterization laboratory even in extremely premature infants. The present review summarizes the pathophysiologic manifestations, treatment options and management of hemodynamically significant PDA in preterm infants. Additionally, we review the available literature surrounding the respiratory support and outcomes of preterm infants following definitive PDA closure.
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Affiliation(s)
- Craig R Wheeler
- Department of Respiratory Care, Boston Children's Hospital, Boston, Massachusetts.
| | - Elizabeth R Vogel
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael A Cusano
- Department of Respiratory Care, Boston Children's Hospital, Boston, Massachusetts
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philip T Levy
- Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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5
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Miller AG, Bartle RM, Feldman A, Mallory P, Reyes E, Scott B, Rotta AT. A narrative review of advanced ventilator modes in the pediatric intensive care unit. Transl Pediatr 2021; 10:2700-2719. [PMID: 34765495 PMCID: PMC8578787 DOI: 10.21037/tp-20-332] [Citation(s) in RCA: 3] [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: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Renee M Bartle
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandra Feldman
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Palen Mallory
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Edith Reyes
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Briana Scott
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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6
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Miller AG, Bartle RM, Rehder KJ. High-Frequency Jet Ventilation in Neonatal and Pediatric Subjects: A Narrative Review. Respir Care 2021; 66:845-856. [PMID: 33931517 PMCID: PMC9994116 DOI: 10.4187/respcare.08691] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High-frequency ventilation is commonly utilized with neonates and with children with severe respiratory failure. Both high-frequency oscillatory ventilation (HFOV) and high-frequency jet ventilation (HFJV) are used extensively in neonates. HFJV can also be used in older, larger children. The purpose of this narrative review is to discuss the physiologic principles behind HFJV, examine the evidence supporting its use in neonatal and pediatric ICUs, give meaningful guidance for clinical application, and highlight potential areas for future research.
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Affiliation(s)
- Andrew G Miller
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Renee M Bartle
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Kyle J Rehder
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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7
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Hsu JF, Yang MC, Chu SM, Yang LY, Chiang MC, Lai MY, Huang HR, Pan YB, Fu RH, Tsai MH. Therapeutic effects and outcomes of rescue high-frequency oscillatory ventilation for premature infants with severe refractory respiratory failure. Sci Rep 2021; 11:8471. [PMID: 33875758 PMCID: PMC8055989 DOI: 10.1038/s41598-021-88231-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/09/2021] [Indexed: 11/23/2022] Open
Abstract
Despite wide application of high frequency oscillatory ventilation (HFOV) in neonates with respiratory distress, little has been reported about its rescue use in preterm infants. We aimed to evaluate the therapeutic effects of HFOV in preterm neonates with refractory respiratory failure and investigate the independent risk factors of in-hospital mortality. We retrospectively analyzed data collected prospectively (January 2011–December 2018) in four neonatal intensive care units of two tertiary-level medical centers in Taiwan. All premature infants (gestational age 24–34 weeks) receiving HFOV as rescue therapy for refractory respiratory failure were included. A total of 668 preterm neonates with refractory respiratory failure were enrolled. The median (IQR) gestational age and birth weight were 27.3 (25.3–31.0) weeks and 915.0 (710.0–1380.0) g, respectively. Pre-HFOV use of cardiac inotropic agents and inhaled nitric oxide were 70.5% and 23.4%, respectively. The oxygenation index (OI), FiO2, and AaDO2 were markedly increased after HFOV initiation (all p < 0.001), and can be decreased within 24–48 h (all p < 0.001) after use of HFOV. 375 (56.1%) patients had a good response to HFOV within 3 days. The final in-hospital mortality rate was 34.7%. No association was found between specific primary pulmonary disease and survival in multivariate analysis. We found preterm neonates with gestational age < 28 weeks, occurrences of sepsis, severe hypotension, multiple organ dysfunctions, initial higher severity of respiratory failure and response to HFOV within the first 72 h were independently associated with final in-hospital mortality. The mortality rate of preterm neonates with severe respiratory failure remains high after rescue HFOV treatment. Aggressive therapeutic interventions to treat sepsis and prevent organ dysfunctions are the suggested strategies to optimize outcomes.
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Affiliation(s)
- Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Mei-Chin Yang
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taipei, Taiwan.,School of Business, Executive MBA Program in Health Care Management, Chang Gung University, Taoyüan, Taiwan
| | - Shih-Ming Chu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Lan-Yan Yang
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Mei-Yin Lai
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Hsuan-Rong Huang
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Yu-Bin Pan
- Biostatistics Unit of Clinical Trial Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ren-Huei Fu
- Division of Neonatology, Department of Pediatrics, Linkou Chang Gung Memorial Hospital, Taoyüan, Taiwan.,College of Medicine, Chang Gung University, Taoyüan, Taiwan
| | - Ming-Horng Tsai
- Division of Neonatology and Pediatric Hematology/Oncology, Department of Pediatrics, Chang Gung Memorial Hospital, No.707, Gongye Rd., Sansheng, Mailiao Township, Yunlin, Taiwan, ROC. .,College of Medicine, Chang Gung University, Taoyüan, Taiwan.
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8
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN-BASEL 2021; 8:children8040298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
Background: Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. Objective: The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. Methods: We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. Results: Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. Discussion: There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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Abstract
Despite important advances in neonatal care, rates of bronchopulmonary dysplasia (BPD) have remained persistently high. Numerous drugs and ventilator strategies are used for the prevention and treatment of BPD. Some, such as exogenous surfactant, volume targeted ventilation, caffeine, and non-invasive respiratory support, are associated with modest but important reductions in rates of BPD and long-term respiratory morbidities. Many other therapies, such as corticosteroids, diuretics, nitric oxide, bronchodilators and anti-reflux medications, are widely used despite conflicting, limited or no evidence of efficacy and safety. This paper examines the range of therapies used for the prevention or treatment of BPD. They are classified into those supported by evidence of effectiveness, and those which are widely used despite limited evidence or unclear risk to benefit ratios. Finally, the paper explores emerging therapies and approaches which aim to prevent or reduce BPD and long-term respiratory morbidity.
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10
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Miller AG, Haynes KE, Gates RM, Kumar KR, Cheifetz IM, Rotta AT. High-Frequency Jet Ventilation in Pediatric Acute Respiratory Failure. Respir Care 2021; 66:191-198. [PMID: 33008841 PMCID: PMC9994232 DOI: 10.4187/respcare.08241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND High-frequency jet ventilation (HFJV) is primarily used in premature neonates; however, its use in pediatric patients with acute respiratory failure has been reported. The objective of this study was to evaluate HFJV use in the pediatric critical care setting. We hypothesized that HFJV would be associated with improvements in oxygenation and ventilation. METHODS Medical records of all patients who received HFJV in the pediatric ICU of a quaternary care center between 2014 and 2018 were retrospectively reviewed. Premature infants who had not been discharged home were excluded, as were those in whom HFJV was started while on extracorporeal membrane oxygenation. Data on demographics, pulmonary mechanics, gas exchange, and outcomes were extracted and analyzed using chi-square testing for categorical variables, nonparametric testing for continuous variables, and a linear effects model to evaluate gas exchange over time. RESULTS A total of 35 subjects (median age = 2.9 months, median weight = 5.2 kg) were included. Prior to HFJV initiation, median (interquartile range) oxygenation index (OI) was 11.3 (7.2-16.9), [Formula: see text] = 133 (91.3-190.0), pH = 7.18 (7.11-7.27), [Formula: see text] = 64 (52-87) mm Hg, and [Formula: see text] = 74 (64-125) mm Hg. For subjects still on HFJV (n = 25), there was no significant change in OI, [Formula: see text], or [Formula: see text] at 4-6 h after initiation, whereas pH increased (P = .001) and [Formula: see text] decreased (P = .001). For those remaining on HFJV for > 72 h (n = 12), the linear effects model revealed no differences over 72 h for OI, [Formula: see text], [Formula: see text], or mean airway pressure, but there was a decrease in [Formula: see text] while pH and [Formula: see text] increased. There were 9 (26%) subjects who did not survive, and nonsurvivors had higher Pediatric Index of Mortality 2 scores (P = .01), were more likely to be immunocompromised (P = .01), were less likely to have a documented infection (P = .02), and had lower airway resistance (P = .02). CONCLUSIONS HFJV was associated with improved ventilation among subjects able to remain on HFJV but had no significant effect on oxygenation.
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Affiliation(s)
- Andrew G Miller
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
| | - Kaitlyn E Haynes
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Rachel M Gates
- Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Karan R Kumar
- Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Durham, North Carolina
| | - Ira M Cheifetz
- Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Durham, North Carolina. He is currently affiliated with Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke Children's Hospital, Durham, North Carolina
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11
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Maxwell AR, Frazier M, Varisco BM. High-Frequency Jet Ventilation Is Making Slow Inroads to the Pediatric ICU. Respir Care 2021; 66:349-350. [PMID: 33514662 PMCID: PMC9994233 DOI: 10.4187/respcare.08797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Andrea R Maxwell
- Department of Pediatrics Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnati, Ohio
| | - Maria Frazier
- Department of Pediatrics Division of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnati, Ohio
| | - Brian M Varisco
- Department of PediatricsDivision of Critical Care MedicineCincinnati Children's Hospital Medical CenterCincinnati, OhioUniversity of Cincinnati College of MedicineCincinnati, Ohio
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12
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Ganguly A, Makkar A, Sekar K. Volume Targeted Ventilation and High Frequency Ventilation as the Primary Modes of Respiratory Support for ELBW Babies: What Does the Evidence Say? Front Pediatr 2020; 8:27. [PMID: 32117833 PMCID: PMC7025474 DOI: 10.3389/fped.2020.00027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 01/20/2020] [Indexed: 12/01/2022] Open
Abstract
Respiratory management of the extremely low birth weight (ELBW) newborn has evolved over time. Although non-invasive ventilation is being increasingly used for respiratory support in these ELBW infants, invasive ventilation still remains the primary mode in this population. Current ventilators are microprocessor driven and have revolutionized the respiratory support for these neonates synchronizing the baby's breath to ventilator breaths. High frequency ventilators with the delivery of tidal volumes less than the dead space have been introduced to minimize barotrauma and chronic lung disease. Despite these advances, the incidence of chronic lung disease has not decreased. There is still controversy regarding which mode is ideal as the primary mode of ventilation in ELBW infants. The most common modes seem to be pressure targeted conventional ventilation, volume targeted conventional ventilation and high frequency ventilation which includes high frequency oscillatory ventilation, high frequency jet ventilation and high frequency flow interrupter. In recent years, several randomized controlled trials and meta-analyses have compared volume vs. pressure targeted ventilation and high frequency ventilation. While volume targeted ventilation and high frequency ventilation does show promise, substantial practice variability among different centers persists. In this review, we weighed the evidence for each mode and evaluated which modes show promise as the primary support of ventilation in ELBW babies.
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Affiliation(s)
- Abhrajit Ganguly
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Abhishek Makkar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Krishnamurthy Sekar
- Section of Neonatal-Perinatal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
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13
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Reiterer F, Schwaberger B, Freidl T, Schmölzer G, Pichler G, Urlesberger B. Lung-protective ventilatory strategies in intubated preterm neonates with RDS. Paediatr Respir Rev 2017; 23:89-96. [PMID: 27876355 DOI: 10.1016/j.prrv.2016.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 11/16/2022]
Abstract
This article provides a narrative review of lung-protective ventilatory strategies (LPVS) in intubated preterm infants with RDS. A description of strategies is followed by results on short-and long-term respiratory and neurodevelopmental outcomes. Strategies will include patient-triggered or synchronized ventilation, volume targeted ventilation, the technique of intubation, surfactant administration and rapid extubation to NCPAP (INSURE), the open lung concept, strategies of high-frequency ventilation, and permissive hypercapnia. Based on this review single recommendations on optimal LPVS cannot be made. Combinations of several strategies, individually applied, most probably minimize or avoid potential serious respiratory and cerebral complications like bronchopulmonary dysplasia and cerebral palsy.
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Affiliation(s)
- F Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria.
| | - B Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - T Freidl
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - G Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - G Pichler
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - B Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
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14
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Owen LS, Manley BJ, Davis PG, Doyle LW. The evolution of modern respiratory care for preterm infants. Lancet 2017; 389:1649-1659. [PMID: 28443559 DOI: 10.1016/s0140-6736(17)30312-4] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/27/2016] [Accepted: 12/19/2016] [Indexed: 10/19/2022]
Abstract
Preterm birth rates are rising, and many preterm infants have breathing difficulty after birth. Treatments for infants with prolonged breathing difficulty include oxygen therapy, exogenous surfactant, various modes of respiratory support, and postnatal corticosteroids. In this Series paper, we review the history of neonatal respiratory care and its effect on long-term outcomes, and we outline the future direction of the research field. The delivery and monitoring of oxygen therapy remains controversial, despite being in use for more than 50 years. Exogenous surfactant replacement has been used for 25 years and has dramatically reduced mortality and morbidity, but more research on when and how it is administered is needed. Methods and techniques of neonatal respiratory support are evolving. Clinicians are moving away from routine intubation and ventilation, and new modes of non-invasive support are being investigated. Postnatal corticosteroids have a limited role in infants with evolving bronchopulmonary dysplasia, but more research is needed to identify the best timing, type, dose, and method of administration. Despite advances in neonatal care in the past 50 years, bronchopulmonary dysplasia, with all its adverse short-term and long-term consequences, is still a serious problem in neonatal care. The challenge remains to support breathing in preterm infants, with special attention to risk factors in the subpopulation of infants that are at highest risk of bronchopulmonary dysplasia, without damaging their lungs or adversely affecting their long-term health.
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Affiliation(s)
- Louise S Owen
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia.
| | - Brett J Manley
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Peter G Davis
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Lex W Doyle
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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