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Kubo Y, Tokuhisa T, Ohashi H. Two Extremely Preterm Infants Discharged with a Home High-Flow Nasal Cannula for Severe Bronchopulmonary Dysplasia. Case Rep Pediatr 2024; 2024:3266928. [PMID: 38741929 PMCID: PMC11090667 DOI: 10.1155/2024/3266928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/26/2024] [Accepted: 04/03/2024] [Indexed: 05/16/2024] Open
Abstract
Home high-flow nasal cannula (HFNC) use in the neonatal field has become prevalent as a noninvasive respiratory support, but its application in home care remains rare. We report two cases in which a home HFNC was effective in managing extremely low-birth-weight infants with severe bronchopulmonary dysplasia (BPD). Case 1 was a male infant born at 22 weeks' gestation weighing 435 g. Case 2 was a female infant born at 23 weeks' gestation weighing 450 g. Both patients had mothers with chronic placental abruption or chorioamnionitis. They transitioned from invasive mechanical ventilation to nasal CPAP (nCPAP) at 45 days (case 1) and 50 days (case 2) old. Subsequently, at 324 days (case 1) and 90 days (case 2) old, they transitioned to a HFNC, demonstrating stable oxygenation and ventilation, but faced difficulty in removal. Considering the drawbacks of prolonged hospitalization, the patients were discharged using a home HFNC at 404 days (case 1) and 391 days (case 2) old. For case 1, the HFNC was set at 4 L/min of room air and 2 L/min of oxygen, whereas for case 2, it was set at 5 L/min of room air and 1 L/min of oxygen. These settings maintained an SpO2 above 90% and a pCO2 below 60 mmHg. An HFNC offers advantages over nCPAP owing to its lower invasiveness and reduced discomfort for long-term use. However, reports on the use of a home HFNC for BPD are scarce. In recent years, while premature infant mortality has decreased worldwide, the incidence of BPD has risen, necessitating preparedness for prolonged ventilation in preterm infants. Home ventilators represent a strategy to prevent extended hospitalization, and based on our cases, home HFNC for BPD appears safe and effective, making it potentially useful for managing preterm infants requiring prolonged respiratory support in the future.
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Affiliation(s)
- Yuichi Kubo
- Department of Neonatology, Imakiire General Hospital, Kagoshima, Japan
| | - Takuya Tokuhisa
- Department of Neonatology, Kagoshima City Hospital, Kagoshima, Japan
| | - Hiroshi Ohashi
- Department of Neonatology, Kagoshima City Hospital, Kagoshima, Japan
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Lei Y, Qiu X, Zhou R. Construction and evaluation of neonatal respiratory failure risk prediction model for neonatal respiratory distress syndrome. BMC Pulm Med 2024; 24:8. [PMID: 38166798 PMCID: PMC10759760 DOI: 10.1186/s12890-023-02819-4] [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: 08/15/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Neonatal respiratory distress syndrome (NRDS) is a common respiratory disease in preterm infants, often accompanied by respiratory failure. The aim of this study was to establish and validate a nomogram model for predicting the probability of respiratory failure in NRDS patients. METHODS Patients diagnosed with NRDS were extracted from the MIMIC-iv database. The patients were randomly assigned to a training and a validation cohort. Univariate and stepwise Cox regression analyses were used to determine the prognostic factors of NRDS. A nomogram containing these factors was established to predict the incidence of respiratory failure in NRDS patients. The area under the receiver operating characteristic curve (AUC), receiver operating characteristic curve (ROC), calibration curves and decision curve analysis were used to determine the effectiveness of this model. RESULTS The study included 2,705 patients with NRDS. Univariate and multivariate stepwise Cox regression analysis showed that the independent risk factors for respiratory failure in NRDS patients were gestational age, pH, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), hemoglobin, blood culture, infection, neonatal intracranial hemorrhage, Pulmonary surfactant (PS), parenteral nutrition and respiratory support. Then, the nomogram was constructed and verified. CONCLUSIONS This study identified the independent risk factors of respiratory failure in NRDS patients and used them to construct and evaluate respiratory failure risk prediction model for NRDS. The present findings provide clinicians with the judgment of patients with respiratory failure in NRDS and help clinicians to identify and intervene in the early stage.
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Affiliation(s)
- Yupeng Lei
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, 610041, China
| | - Xia Qiu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, 610041, China
| | - Ruixi Zhou
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, 610041, China.
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Maki W, Michihata N, Hashimoto Y, Matsui H, Fushimi K, Yasunaga H. Noninvasive Positive Airway Pressure Management for Post-extubation Support in Preterm Infants: Observational Cohort Study with Overlap Weighting Analysis. ANNALS OF CLINICAL EPIDEMIOLOGY 2023; 6:17-23. [PMID: 38605917 PMCID: PMC11006545 DOI: 10.37737/ace.24004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/25/2023] [Indexed: 04/13/2024]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), and high-flow nasal cannula (HFNC) are often used after initial extubation in preterm infants. However, data regarding the choice between NCPAP/NIPPV and HFNC are limited. This study examined which therapy was more effective as post-extubation support. METHODS This is a retrospective, cohort study that used the Diagnosis Procedure Combination database in Japan, 2011-2021. Propensity score overlap weighting analyses were performed to compare the composite outcomes of in-hospital death and reintubation in preterm infants who received NCPAP/NIPPV and HFNC. We identified infants born at gestational age 22-36 weeks who were intubated within 1 day of birth. We included patients who underwent NCPAP/NIPPV or HFNC after initial extubation. Patients with airway obstruction or congenital airway abnormalities were excluded. RESULTS We identified 1,203 preterm infants treated with NCPAP/NIPPV (n = 525) or HFNC (n = 678). The median (interquartile range) gestational age at delivery was 30 (27-33) weeks, and birth weight was 1296 (884-1,802) g. Compared with the HFNC group, the NCPAP/NIPPV group had a significantly lower proportion of the composite outcome after the overlap weighting analysis (risk ratio, 0.62; 95% confidence interval, 0.47 to 0.83; p = 0.001). This significant difference was also observed in infants born at gestational age 22-31 weeks, whereas no significant difference was observed in infants born at gestational age 32-36 weeks. CONCLUSIONS NCPAP/NIPPV may be a superior post-extubation support than HFNC in preterm infants, especially in those born at gestational age of 22-31 weeks.
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Affiliation(s)
- Wakana Maki
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine and Dental Sciences
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
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Lin X, Li X, Qulian G, Bai Y, Liu Q. Efficay of high-flow nasal cannula in the paediatric population: A systematic evidence map. J Pediatr Nurs 2023; 73:e327-e363. [PMID: 37838549 DOI: 10.1016/j.pedn.2023.10.001] [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: 01/27/2023] [Revised: 09/30/2023] [Accepted: 10/01/2023] [Indexed: 10/16/2023]
Abstract
PROBLEM High-flow nasal cannula (HFNC) has been widely used in paediatric medicine as a non-invasive ventilation mode for respiratory support. However, the differences in its efficacy across different diseases and intervention types remain poorly understood. ELIGIBILITY CRITERIA An extensive literature search was performed across multiple academic databases to investigate the systematic reviews and meta-analyses of HFNC. SAMPLE This study included 35 systematic reviews and meta-analyses, which collectively examined 355 randomised controlled trials and assessed 51 outcome indicators. RESULTS The findings suggest that the existing clinical research evidence predominantly supports the therapeutic efficacy of HFNC. Notably, there is a significant focus on treating acute lower respiratory infection, hypoxaemia, bronchiolitis, and respiratory distress syndrome following extubation. However, concerning the respiratory status, the existing clinical research evidence mainly demonstrates the therapeutic benefits in post-extubation respiratory support and primary respiratory support. CONCLUSIONS The research on HFNC has witnessed significant expansion, primarily focusing on respiratory disorders, post-extubation respiratory support, conscious sedation, and related fields. The evidence mapping provides a systematic and comprehensive overview of the available evidence on HFNC therapy in paediatric patients. IMPLICATIONS This study systematically and comprehensively assessed the clinical subjects and populations involved in HFNC therapy. Notably, this study analyzed the trends, current status, and evidence gaps of research, and furnished decision-makers and relevant researchers with a more comprehensive reference basis.
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Affiliation(s)
- Xi Lin
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, PR China; Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan 646000, PR China; Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China
| | - Xiaoqin Li
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, PR China
| | - Guo Qulian
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, PR China; Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan 646000, PR China
| | - Yongqi Bai
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, PR China; Department of Nursing, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, China.
| | - Qin Liu
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, PR China.
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Periasamy U, Salvador A, Janeczko M. Pattern of Inflammatory Markers and Use of Antibiotics in Meconium Aspiration Syndrome: A Retrospective Cohort Study. Cureus 2023; 15:e44921. [PMID: 37814760 PMCID: PMC10560562 DOI: 10.7759/cureus.44921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/11/2023] Open
Abstract
Objectives To study the pattern of inflammatory markers in meconium aspiration syndrome (MAS) and their correlation with illness severity/antibiotic usage. Study design This is a retrospective analysis of neonates who were admitted with MAS and had inflammatory markers done during the first week of life. Results Seventy-six neonates with MAS were identified. White cell count (WCC), absolute neutrophil count (ANC), and immature to total neutrophil count (I/T) ratio peaked at 12 and CRP (43.75 mg/dl) at 48 hours of life (HOL). Neonates needing nasal cannula oxygen had lower CRP at 12 (p=0.035) and 24 HOL (p=0.046). There was no correlation between CRP at 48 HOL and score for neonatal acute physiology and perinatal extension II (SNAPPE-II; R2 0.0004). High CRP at 24 HOL was associated with longer duration of antibiotics (p<0.001) despite no correlation with the blood cultures. Conclusion MAS was associated with inflammatory markers peaking at 12 to 48 HOL; however, antibiotics should not be determined based on them as their correlation for illness severity or blood culture is poor.
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Affiliation(s)
- Uvaraj Periasamy
- Anesthesiology and Critical Care, Boston Children's Hospital, Boston, USA
| | - Agnes Salvador
- Pediatrics and Neonatology, Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Michael Janeczko
- Pediatrics and Neonatology, Einstein Medical Center Philadelphia, Philadelphia, USA
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Dopper A, Steele M, Bogossian F, Hough J. High flow nasal cannula for respiratory support in term infants. Cochrane Database Syst Rev 2023; 8:CD011010. [PMID: 37542728 PMCID: PMC10401649 DOI: 10.1002/14651858.cd011010.pub2] [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: 08/07/2023]
Abstract
BACKGROUND Respiratory failure or respiratory distress in infants is the most common reason for non-elective admission to hospitals and neonatal intensive care units. Non-invasive methods of respiratory support have become the preferred mode of treating respiratory problems as they avoid some of the complications associated with intubation and mechanical ventilation. High flow nasal cannula (HFNC) therapy is increasingly being used as a method of non-invasive respiratory support. However, the evidence pertaining to its use in term infants (defined as infants ≥ 37 weeks gestational age to the end of the neonatal period (up to one month postnatal age)) is limited and there is no consensus of opinion regarding the safety and efficacy HFNC in this population. OBJECTIVES To assess the safety and efficacy of high flow nasal cannula oxygen therapy for respiratory support in term infants when compared with other forms of non-invasive respiratory support. SEARCH METHODS We searched the following databases in December 2022: Cochrane CENTRAL; PubMed; Embase; CINAHL; LILACS; Web of Science; Scopus. We also searched the reference lists of retrieved studies and performed a supplementary search of Google Scholar. SELECTION CRITERIA We included randomised controlled trials (RCTs) that investigated the use of high flow nasal cannula oxygen therapy in infants ≥ 37 weeks gestational age up to one month postnatal age (the end of the neonatal period). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, performed data extraction, and assessed risk of bias in the included studies. Where studies were sufficiently similar, we performed a meta-analysis using mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). For statistically significant RRs, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to evaluate the certainty of the evidence for clinically important outcomes. MAIN RESULTS We included eight studies (654 participants) in this review. Six of these studies (625 participants) contributed data to our primary analyses. Four studies contributed to our comparison of high flow nasal cannula (HFNC) oxygen therapy versus continuous positive airway pressure (CPAP) for respiratory support in term infants. The outcome of death was reported in two studies (439 infants) but there were no events in either group. HFNC may have little to no effect on treatment failure, but the evidence is very uncertain (RR 0.98, 95% CI 0.47 to 2.04; 3 trials, 452 infants; very low-certainty evidence). The outcome of chronic lung disease (need for supplemental oxygen at 28 days of life) was reported in one study (375 participants) but there were no events in either group. HFNC may have little to no effect on the duration of respiratory support (any form of non-invasive respiratory support with or without supplemental oxygen), but the evidence is very uncertain (MD 0.17 days, 95% CI -0.28 to 0.61; 4 trials, 530 infants; very low-certainty evidence). HFNC likely results in little to no difference in the length of stay at the intensive care unit (ICU) (MD 0.90 days, 95% CI -0.31 to 2.12; 3 trials, 452 infants; moderate-certainty evidence). HFNC may reduce the incidence of nasal trauma (RR 0.16, 95% CI 0.04 to 0.66; 1 trial, 78 infants; very low-certainty evidence) and abdominal overdistension (RR 0.22, 95% CI 0.07 to 0.71; 1 trial, 78 infants; very low-certainty evidence), but the evidence is very uncertain. Two studies contributed to our analysis of HFNC versus low flow nasal cannula oxygen therapy (LFNC) (supplemental oxygen up to a maximum flow rate of 2 L/min). The outcome of death was reported in both studies (95 infants) but there were no events in either group. The evidence suggests that HFNC may reduce treatment failure slightly (RR 0.44, 95% CI 0.21 to 0.92; 2 trials, 95 infants; low-certainty evidence). Neither study reported results for the outcome of chronic lung disease (need for supplemental oxygen at 28 days of life). HFNC may have little to no effect on the duration of respiratory support (MD -0.07 days, 95% CI -0.83 to 0.69; 1 trial, 74 infants; very low-certainty evidence), length of stay at the ICU (MD 0.49 days, 95% CI -0.83 to 1.81; 1 trial, 74 infants; very low-certainty evidence), or hospital length of stay (MD -0.60 days, 95% CI -2.07 to 0.86; 2 trials, 95 infants; very low-certainty evidence), but the evidence is very uncertain. Adverse events was an outcome reported in both studies (95 infants) but there were no events in either group. The risk of bias across outcomes was generally low, although there were some concerns of bias. The certainty of evidence across outcomes ranged from moderate to very low, downgraded due to risk of bias, imprecision, indirectness, and inconsistency. AUTHORS' CONCLUSIONS When compared with CPAP, HFNC may result in little to no difference in treatment failure. HFNC may have little to no effect on the duration of respiratory support, but the evidence is very uncertain. HFNC likely results in little to no difference in the length of stay at the intensive care unit. HFNC may reduce the incidence of nasal trauma and abdominal overdistension, but the evidence is very uncertain. When compared with LFNC, HFNC may reduce treatment failure slightly. HFNC may have little to no effect on the duration of respiratory support, length of stay at the ICU, or hospital length of stay, but the evidence is very uncertain. There is insufficient evidence to enable the formulation of evidence-based guidelines on the use of HFNC for respiratory support in term infants. Larger, methodologically robust trials are required to further evaluate the possible health benefits or harms of HFNC in this patient population.
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Affiliation(s)
- Alex Dopper
- School of Allied Health, Australian Catholic University, Brisbane, Australia
| | - Michael Steele
- School of Allied Health, Australian Catholic University, Brisbane, Australia
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Fiona Bogossian
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Australia
- Sunshine Coast Health Institute, Birtinya, Australia
- School of Health, University of the Sunshine Coast, Petrie, Australia
| | - Judith Hough
- School of Allied Health, Australian Catholic University, Brisbane, Australia
- Department of Physiotherapy, Mater Health, South Brisbane, Australia
- Centre for Children's Health Research, The University of Queensland, South Brisbane, Australia
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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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Algarni SS, Ali K, Alsaif S, Aljuaid N, Alzahrani R, Albassam M, Alanazi R, Alqueflie D, Almutairi M, Alfrijan H, Alanazi A, Ghazwani A, Alshareedah S, Alotaibi TF, Alqahtani MM, Aljohani H, Ismaeil TT, Alwadeai KS, Siraj RA, Alsaif A, Asiri S, Halabi S, Alanazi AMM. Changes in the patterns of respiratory support and incidence of bronchopulmonary dysplasia; a single center experience. BMC Pediatr 2023; 23:357. [PMID: 37442954 PMCID: PMC10339611 DOI: 10.1186/s12887-023-04176-x] [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: 04/14/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND With the advances in neonatal intensive care, the survival rate of extremely preterm infants is increasing. However, bronchopulmonary dysplasia (BPD) remains a major cause of morbidity among infants in this group. This study examined the changes in respiratory support modalities, specifically heated humidified high-flow nasal cannula (HHHFNC), and their association with BPD incidence among preterm infants born at < 29 weeks of gestation. METHOD This population-based retrospective cohort study included infants born at < 29 weeks of gestation between 2016 and 2020. Data regarding the use and duration of respiratory support modalities were obtained, including mechanical ventilation, continuous positive airway pressure, HHHFNC, and low-flow oxygen therapy. Additionally, the incidence of BPD was determined in the included infants. Trend analysis for each respiratory support modality and BPD incidence rate was performed to define the temporal changes associated with changes in BPD rates. In addition, a logistic regression model was developed to identify the association between BPD and severity grade using HHHFNC. RESULTS Three Hundred and sixteen infants were included in this study. The use and duration of HHHFNC therapy increased during the study period. Throughout the study period, the overall incidence of BPD was 49%, with no significant trends. The BPD rate was significantly higher in the infants who received HHHFNC than in those who did not (52% vs. 39%, P = 0.03). Analysis of BPD severity grades showed that both grade 1 BPD (34% vs. 21%, P = 0.03) and grade 2 BPD (12% vs. 1%, P < 0.01) were significantly more common among infants who received HHHFNC than among those who did not. In contrast, the incidence of grade 3 BPD was lower in infants who received HHFNC (6% vs. 17%, P < 0.01). The duration in days of HHHFNC was found to significantly predict BPD incidence (OR 1.04 [95%CI: 1.01-1.06], P < 0.01) after adjusting for confounding variables. CONCLUSION The use of HHHFNC in extremely preterm infants born at < 29 weeks of gestation is increasing. There was a significant association between the duration of HHHFNC therapy and the development of BPD in extremely preterm infants born at < 29 weeks of gestation.
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Affiliation(s)
- Saleh S Algarni
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Kamal Ali
- Department of Neonatal Intensive Care Unit, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Saif Alsaif
- Department of Neonatal Intensive Care Unit, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Nemer Aljuaid
- Department of Neonatal Intensive Care Unit, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Raghad Alzahrani
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Albassam
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Rawan Alanazi
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Dana Alqueflie
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maather Almutairi
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hessah Alfrijan
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmad Alanazi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abadi Ghazwani
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Saad Alshareedah
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Tareq F Alotaibi
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohammed M Alqahtani
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hassan Aljohani
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Taha T Ismaeil
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khalid S Alwadeai
- Department of Rehabilitation Science, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Rayan A Siraj
- Department of Respiratory Care, College of Applied Medical Sciences, King Faisal University, Al-Ahasa, Saudi Arabia
| | - Abdurahman Alsaif
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Sabreen Asiri
- Department of Neonatal Intensive Care Unit, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Shaimaa Halabi
- Department of Neonatal Intensive Care Unit, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Abdullah M M Alanazi
- Department of Respiratory Therapy, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Respiratory Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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9
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Greene Z, O'Donnell CP, Walshe M. Oral stimulation for promoting oral feeding in preterm infants. Cochrane Database Syst Rev 2023; 6:CD009720. [PMID: 37338236 PMCID: PMC10281084 DOI: 10.1002/14651858.cd009720.pub3] [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: 06/21/2023]
Abstract
BACKGROUND Preterm infants (< 37 weeks' post-menstrual age (PMA)) are often delayed in attaining oral feeding. Normal oral feeding is suggested as an important outcome for the timing of discharge from the hospital and can be an early indicator of neuromotor integrity and developmental outcomes. A range of oral stimulation interventions may help infants to develop sucking and oromotor co-ordination, promoting earlier oral feeding and earlier hospital discharge. This is an update of our 2016 review. OBJECTIVES To determine the effectiveness of oral stimulation interventions for attainment of oral feeding in preterm infants born before 37 weeks' PMA. SEARCH METHODS Searches were run in March 2022 of the following databases: CENTRAL via CRS Web; MEDLINE and Embase via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. Searches were limited by date 2016 (the date of the search for the original review) forward. Note: Due to circumstances beyond our control (COVID and staffing shortages at the editorial base of Cochrane Neonatal), publication of this review, planned for mid 2021, was delayed. Thus, although searches were conducted in 2022 and results screened, potentially relevant studies found after September 2020 have been placed in the section, Awaiting Classification, and not incorporated into our analysis. SELECTION CRITERIA Randomised and quasi-randomised controlled trials comparing a defined oral stimulation intervention with no intervention, standard care, sham treatment or non-oral intervention (e.g. body stroking protocols or gavage adjustment protocols) in preterm infants and reporting at least one of the specified outcomes. DATA COLLECTION AND ANALYSIS Following the updated search, two review authors screened the titles and abstracts of studies and full-text copies when needed to identify trials for inclusion in the review. The primary outcomes of interest were time (days) to exclusive oral feeding, time (days) spent in NICU, total hospital stay (days), and duration (days) of parenteral nutrition. All review and support authors contributed to independent extraction of data and analysed assigned studies for risk of bias across the five domains of bias using the Cochrane Risk of Bias assessment tool. The GRADE system was used to rate the certainty of the evidence. Studies were divided into two groups for comparison: intervention versus standard care and intervention versus other non-oral or sham intervention. We performed meta-analysis using a fixed-effect model. MAIN RESULTS We included 28 RCTs (1831 participants). Most trials had methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel. Oral stimulation compared with standard care Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to oral feeding compared with standard care (mean difference (MD) -4.07 days, 95% confidence interval (CI) -4.81 to -3.32 days, 6 studies, 292 infants; I2 =85%, very low-certainty evidence due to serious risk of bias and inconsistency). Time (days) spent in the neonatal intensive care unit (NICU) was not reported. It is uncertain whether oral stimulation reduces the duration of hospitalisation (MD -4.33, 95% CI -5.97 to -2.68 days, 5 studies, 249 infants; i2 =68%, very low-certainty evidence due to serious risk of bias and inconsistency). Duration (days) of parenteral nutrition was not reported. Oral stimulation compared with non-oral intervention Following meta-analysis, it is uncertain whether oral stimulation reduces the time to transition to exclusive oral feeding compared with a non-oral intervention (MD -7.17, 95% CI -8.04 to -6.29 days, 10 studies, 574 infants; I2 =80%, very low-certainty evidence due to serious risk of bias, inconsistency and precision). Time (days) spent in the NICU was not reported. Oral stimulation may reduce the duration of hospitalisation (MD -6.15, 95% CI -8.63 to -3.66 days, 10 studies, 591 infants; I2 =0%, low-certainty evidence due to serious risk of bias). Oral stimulation may have little or no effect on the duration (days) of parenteral nutrition exposure (MD -2.85, 95% CI -6.13 to 0.42, 3 studies, 268 infants; very low-certainty evidence due to serious risk of bias, inconsistency and imprecision). AUTHORS' CONCLUSIONS There remains uncertainty about the effects of oral stimulation (versus either standard care or a non-oral intervention) on transition times to oral feeding, duration of intensive care stay, hospital stay, or exposure to parenteral nutrition for preterm infants. Although we identified 28 eligible trials in this review, only 18 provided data for meta-analyses. Methodological weaknesses, particularly in relation to allocation concealment and masking of study personnel and caregivers, inconsistency between trials in effect size estimates (heterogeneity), and imprecision of pooled estimates were the main reasons for assessing the evidence as low or very low certainty. More well-designed trials of oral stimulation interventions for preterm infants are warranted. Such trials should attempt to mask caregivers to treatment when possible, paying particular attention to blinding of outcome assessors. There are currently 32 ongoing trials. Outcome measures that reflect improvements in oral motor skill development as well as longer term outcome measures beyond six months of age need to be defined and used by researchers to capture the full impact of these interventions.
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Affiliation(s)
- Zelda Greene
- Neonatology, National Maternity Hospital, Dublin, Ireland
- Adjunct Assistant Professor in Clinical Speech and Language Studies, Trinity College, Dublin, Ireland
| | - Colm Pf O'Donnell
- Department of Neonatology, National Maternity Hospital, Dublin 2, Ireland
- University College Dublin, Dublin, Ireland
| | - Margaret Walshe
- Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
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Zhao J, Wu R, Liu W, Li M, Wang W, Li L. Effect of the change of mechanical ventilation mode on cerebral oxygen saturation level in neonates. BMC Pediatr 2023; 23:231. [PMID: 37165309 PMCID: PMC10170683 DOI: 10.1186/s12887-023-04036-8] [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: 12/13/2022] [Accepted: 04/26/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND This study aimed to apply near-infrared spectroscopy (NIRS) to monitor cerebral oxygen saturation (SrO2) level in neonates before and after the change of mechanical ventilation mode, and thus, the effects of the change of mechanical ventilator mode on SrO2 level in neonates were assessed. METHODS This trial was designed as an observational study .A total of 70 neonates who were admitted to the Department of Neonatology of Beijing Luhe Hospital Affiliated to Capital Medical University (Beijing, China) between September 2019 and October 2021 and required respiratory support were included. The variations of SrO2 level before and after the change of mechanical ventilation mode, including changing from Synchronized intermittent mandatory ventilation (SIMV) to noninvasive ventilation (NIV, group 1), and from NIV to oxygen inhalation (group 2), were monitored by Enginmed EGOS-600 A. The changes of SrO2 level at 30 min before and 1 h after the change of ventilation mode were compared between the two groups. RESULTS The SrO2 level in the group 1 30 min before, as well as 10 min, 30 min, and 1 h after the change of ventilation mode was 62.54 ± 3.36%, 65.43 ± 3.98%, 64.38 ± 4.23%, and 64.63 ± 3.71%, respectively. The SrO2 level at all the points after the change of ventilation mode increased compared with 30 min before the change (P < 0.05). The SrO2 level in the group 2 at each time point was 62.67 ± 4.69%, 64.61 ± 5.00%, 64.04 ± 4.48%, and 64.55 ± 4.32%, respectively. Compared with 30 min before ventilator weaning, the SrO2 level at all the points after ventilator weaning increased (P < 0.05). Peak inspiratory pressure (PIP) excluding Nasal Continuous Positive Airway Pressure (NCPAP)) in group 1 was lower than that before extubation, and the difference was statistically significant (P = 0) (Table 7). CONCLUSIONS SrO2 level showed an increasing trend after the change of ventilation mode, and the increase of SrO2 level at 10 min after the change of ventilation mode was the most prominent. From SIMV to NIV, increased SrO2 levels may be associated with decreased PIP.
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Affiliation(s)
- Jingjing Zhao
- Children's Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Rong Wu
- Yangzhou University Medical College, Neonatal Medical Center, Huai'an Maternity and Child Healthcare Hospital, N.104 South Renmin Road, Huai'an, 223002, China
| | - Wei Liu
- Children's Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Manman Li
- Children's Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Wei Wang
- Children's Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Lihua Li
- Children's Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China.
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Hodgson KA, Wilkinson D, De Paoli AG, Manley BJ. Nasal high flow therapy for primary respiratory support in preterm infants. Cochrane Database Syst Rev 2023; 5:CD006405. [PMID: 37144837 PMCID: PMC10161968 DOI: 10.1002/14651858.cd006405.pub4] [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: 05/06/2023]
Abstract
BACKGROUND Nasal high flow (nHF) therapy provides heated, humidified air and oxygen via two small nasal prongs, at gas flows of more than 1 litre/minute (L/min), typically 2 L/min to 8 L/min. nHF is commonly used for non-invasive respiratory support in preterm neonates. It may be used in this population for primary respiratory support (avoiding, or prior to the use of mechanical ventilation via an endotracheal tube) for prophylaxis or treatment of respiratory distress syndrome (RDS). This is an update of a review first published in 2011 and updated in 2016. OBJECTIVES To evaluate the benefits and harms of nHF for primary respiratory support in preterm infants compared to other forms of non-invasive respiratory support. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date March 2022. SELECTION CRITERIA We included randomised or quasi-randomised trials comparing nHF with other forms of non-invasive respiratory support for preterm infants born less than 37 weeks' gestation with respiratory distress soon after birth. DATA COLLECTION AND ANALYSIS We used standard Cochrane Neonatal methods. Our primary outcomes were 1. death (before hospital discharge) or bronchopulmonary dysplasia (BPD), 2. death (before hospital discharge), 3. BPD, 4. treatment failure within 72 hours of trial entry and 5. mechanical ventilation via an endotracheal tube within 72 hours of trial entry. Our secondary outcomes were 6. respiratory support, 7. complications and 8. neurosensory outcomes. We used GRADE to assess the certainty of evidence. MAIN RESULTS We included 13 studies (2540 infants) in this updated review. There are nine studies awaiting classification and 13 ongoing studies. The included studies differed in the comparator treatment (continuous positive airway pressure (CPAP) or nasal intermittent positive pressure ventilation (NIPPV)), the devices for delivering nHF and the gas flows used. Some studies allowed the use of 'rescue' CPAP in the event of nHF treatment failure, prior to any mechanical ventilation, and some allowed surfactant administration via the INSURE (INtubation, SURfactant, Extubation) technique without this being deemed treatment failure. The studies included very few extremely preterm infants less than 28 weeks' gestation. Several studies had unclear or high risk of bias in one or more domains. Nasal high flow compared with continuous positive airway pressure for primary respiratory support in preterm infants Eleven studies compared nHF with CPAP for primary respiratory support in preterm infants. When compared with CPAP, nHF may result in little to no difference in the combined outcome of death or BPD (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.74 to 1.60; risk difference (RD) 0, 95% CI -0.02 to 0.02; 7 studies, 1830 infants; low-certainty evidence). Compared with CPAP, nHF may result in little to no difference in the risk of death (RR 0.78, 95% CI 0.44 to 1.39; 9 studies, 2009 infants; low-certainty evidence), or BPD (RR 1.14, 95% CI 0.74 to 1.76; 8 studies, 1917 infants; low-certainty evidence). nHF likely results in an increase in treatment failure within 72 hours of trial entry (RR 1.70, 95% CI 1.41 to 2.06; RD 0.09, 95% CI 0.06 to 0.12; number needed to treat for an additional harmful outcome (NNTH) 11, 95% CI 8 to 17; 9 studies, 2042 infants; moderate-certainty evidence). However, nHF likely does not increase the rate of mechanical ventilation (RR 1.04, 95% CI 0.82 to 1.31; 9 studies, 2042 infants; moderate-certainty evidence). nHF likely results in a reduction in pneumothorax (RR 0.66, 95% CI 0.40 to 1.08; 10 studies, 2094 infants; moderate-certainty evidence) and nasal trauma (RR 0.49, 95% CI 0.36 to 0.68; RD -0.06, 95% CI -0.09 to -0.04; 7 studies, 1595 infants; moderate-certainty evidence). Nasal high flow compared with nasal intermittent positive pressure ventilation for primary respiratory support in preterm infants Four studies compared nHF with NIPPV for primary respiratory support in preterm infants. When compared with NIPPV, nHF may result in little to no difference in the combined outcome of death or BPD, but the evidence is very uncertain (RR 0.64, 95% CI 0.30 to 1.37; RD -0.05, 95% CI -0.14 to 0.04; 2 studies, 182 infants; very low-certainty evidence). nHF may result in little to no difference in the risk of death (RR 0.78, 95% CI 0.36 to 1.69; RD -0.02, 95% CI -0.10 to 0.05; 3 studies, 254 infants; low-certainty evidence). nHF likely results in little to no difference in the incidence of treatment failure within 72 hours of trial entry compared with NIPPV (RR 1.27, 95% CI 0.90 to 1.79; 4 studies, 343 infants; moderate-certainty evidence), or mechanical ventilation within 72 hours of trial entry (RR 0.91, 95% CI 0.62 to 1.33; 4 studies, 343 infants; moderate-certainty evidence). nHF likely results in a reduction in nasal trauma, compared with NIPPV (RR 0.21, 95% CI 0.09 to 0.47; RD -0.17, 95% CI -0.24 to -0.10; 3 studies, 272 infants; moderate-certainty evidence). nHF likely results in little to no difference in the rate of pneumothorax (RR 0.78, 95% CI 0.40 to 1.53; 4 studies, 344 infants; moderate-certainty evidence). Nasal high flow compared with ambient oxygen We found no studies examining this comparison. Nasal high flow compared with low flow nasal cannulae We found no studies examining this comparison. AUTHORS' CONCLUSIONS The use of nHF for primary respiratory support in preterm infants of 28 weeks' gestation or greater may result in little to no difference in death or BPD, compared with CPAP or NIPPV. nHF likely results in an increase in treatment failure within 72 hours of trial entry compared with CPAP; however, it likely does not increase the rate of mechanical ventilation. Compared with CPAP, nHF use likely results in less nasal trauma and likely a reduction in pneumothorax. As few extremely preterm infants less than 28 weeks' gestation were enrolled in the included trials, evidence is lacking for the use of nHF for primary respiratory support in this population.
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Affiliation(s)
- Kate A Hodgson
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Robinson Research Institute, University of Adelaide, Adelaide, Australia
| | | | - Brett J Manley
- Women's Newborn Research Centre, The Royal Women's Hospital, Parkville, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
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12
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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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13
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Razak A, Alhaidari OI, Ahmed J. Interventions for reducing late-onset sepsis in neonates: an umbrella review. J Perinat Med 2023; 51:403-422. [PMID: 36303465 DOI: 10.1515/jpm-2022-0131] [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: 03/11/2022] [Accepted: 08/17/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Neonatal sepsis is one of the leading causes of neonatal deaths in neonatal intensive care units. Hence, it is essential to review the evidence from systematic reviews on interventions for reducing late-onset sepsis (LOS) in neonates. METHODS PubMed and the Cochrane Central were searched from inception through August 2020 without any language restriction. Cochrane reviews of randomized clinical trials (RCTs) assessing any intervention in the neonatal period and including one or more RCTs reporting LOS. Two authors independently performed screening, data extraction, assessed the quality of evidence using Cochrane Grading of Recommendations Assessment, Development and Evaluation, and assessed the quality of reviews using a measurement tool to assess of multiple systematic reviews 2 tool. RESULTS A total of 101 high-quality Cochrane reviews involving 612 RCTs and 193,713 neonates, evaluating 141 interventions were included. High-quality evidence showed a reduction in any or culture-proven LOS using antibiotic lock therapy for neonates with central venous catheters (CVC). Moderate-quality evidence showed a decrease in any LOS with antibiotic prophylaxis or vancomycin prophylaxis for neonates with CVC, chlorhexidine for skin or cord care, and kangaroo care for low birth weight babies. Similarly, moderate-quality evidence showed reduced culture-proven LOS with intravenous immunoglobulin prophylaxis for preterm infants and probiotic supplementation for very low birth weight (VLBW) infants. Lastly, moderate-quality evidence showed a reduction in fungal LOS with the use of systemic antifungal prophylaxis in VLBW infants. CONCLUSIONS The overview summarizes the evidence from the Cochrane reviews assessing interventions for reducing LOS in neonates, and can be utilized by clinicians, researchers, policymakers, and consumers for decision-making and translating evidence into clinical practice.
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Affiliation(s)
- Abdul Razak
- Monash Newborn, Monash Children's Hospital, Department of Paediatrics, Monash University, Clayton, VIC 3168, Australia
- Division of Neonatology, Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Omar Ibrahim Alhaidari
- Division of Neonatology, Department of Pediatrics, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, ON, Canada
| | - Javed Ahmed
- Department of Pediatrics, McMaster Children's Hospital, McMaster University, ON, Canada
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Machine learning to predict late respiratory support in preterm infants: a retrospective cohort study. Sci Rep 2023; 13:2839. [PMID: 36805643 PMCID: PMC9938227 DOI: 10.1038/s41598-023-29708-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/09/2023] [Indexed: 02/19/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD) has been a critical morbidity in preterm infants. To improve our definition and prediction of BPD is challenging yet indispensable. We aimed to apply machine learning (ML) to investigate effective models by using the recently-proposed and data-driven definition to predict late respiratory support modalities at 36 weeks' post menstrual age (PMA). We collected data on very-low-birth-weight infants born between 2016 and 2019 from the Taiwan Neonatal Network database. Twenty-four attributes associated with their early life and seven ML algorithms were used in our analysis. The target outcomes were overall mortality, death before 36 weeks' PMA, and severity of BPD under the new definition, which served as a proxy for respiratory support modalities. Of the 4103 infants initially considered, 3200 were deemed eligible. The logistic regression algorithm yielded the highest area under the receiver operating characteristic curve (AUROC). After attribute selection, the AUROC of the simplified models remain favorable (e.g., 0.801 when predicting no BPD, 0.850 when predicting grade 3 BPD or death before 36 weeks' PMA, and 0.881 when predicting overall mortality). By using ML, we developed models to predict late respiratory support. Estimators were developed for clinical application after being simplified through attribute selection.
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15
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 74] [Impact Index Per Article: 74.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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Dumpa V, Avulakunta I, Bhandari V. Respiratory management in the premature neonate. Expert Rev Respir Med 2023; 17:155-170. [PMID: 36803028 DOI: 10.1080/17476348.2023.2183843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Advances in neonatal care have made possible the increased survival of extremely preterm infants. Even though there is widespread recognition of the harmful effects of mechanical ventilation on the developing lung, its use has become imperative in the management of micro-/nano-preemies. There is an increased emphasis on the use of less-invasive approaches such as minimally invasive surfactant therapy and non-invasive ventilation that have been proven to result in improved outcomes. AREAS COVERED Here, we review the evidence-based practices surrounding the respiratory management of extremely preterm infants including delivery room interventions, invasive and non-invasive ventilation approaches, and specific ventilator strategies in respiratory distress syndrome and bronchopulmonary dysplasia. Adjuvant relevant respiratory pharmacotherapies used in preterm neonates are also discussed. EXPERT OPINION Early use of non-invasive ventilation and use of less invasive surfactant administration are key strategies in the management of respiratory distress syndrome in preterm infants. Ventilator management in bronchopulmonary dysplasia must be tailored according to the individual phenotype. There is strong evidence to start caffeine early to improve respiratory outcomes, but evidence is lacking on the use of other pharmacological agents in preterm neonates, and an individualized approach has to be considered for their use.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Indirapriya Avulakunta
- Division of Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper Medical School of Rowan University, the Children's Regional Hospital at Cooper, Camden, NJ, USA
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17
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Chen X, Tan C, Jiang H. High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy in intensive care unit patients after extubation. Am J Transl Res 2023; 15:1239-1246. [PMID: 36915743 PMCID: PMC10006799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/29/2022] [Indexed: 03/16/2023]
Abstract
BACKGROUND Optimal oxygen supply is the cornerstone of the management of critically ill patients after extubation. High flow oxygen system is an alternative to standard oxygen therapy. This research explored the efficacy of high-flow nasal cannula (HFNC) oxygen therapy in patients after extubation in the intensive care unit (ICU). METHOD We retrospectively analyzed critically ill patients admitted to the ICU and subjected to HFNC or conventional oxygen therapy from January 2018 to June 2022 at the Suzhou Hospital of Integrated Traditional Chinese and Western Medicine. Blood gas analysis, a cough and sputum assessment, and cardiovascular function examinations were performed to evaluate the effect of HFNC oxygen therapy on patients. Also, the 28-d mortality rate, reintubation rate and incidence of respiratory failure were analyzed to evaluate whether HFNC oxygen therapy could improve patients' outcome. RESULTS In patients who received HFNC oxygen therapy, the partial pressure of oxygen and oxygenation index increased, and the respiratory rate decreased. HFNC oxygen therapy improved the patients' ability to cough up sputum and promoted the expulsion of sputum. In terms of cardiovascular function, patients who received HFNC oxygen therapy had a significant improvement in heart rate, but there was no real effect on patients' arterial pressure. There was no significant difference in the rates of reintubation (P = 0.202), 28-d mortality (P = 0.558) or respiratory failure (P = 0.677) between patients who received different oxygen therapies including HFNC oxygen therapy. CONCLUSION HFNC oxygen therapy improves the respiratory function of patients after extubation in their ICU and improves their coughing ability.
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Affiliation(s)
- Xiaoqi Chen
- Intensive Care Unit, Suzhou Hospital of Integrated Traditional Chinese and Western Medicine Suzhou 215101, Jiangsu, P. R. China
| | - Caiping Tan
- Department of Emergency, Suzhou Hospital of Integrated Traditional Chinese and Western Medicine Suzhou 215101, Jiangsu, P. R. China
| | - Huojun Jiang
- Intensive Care Unit, Suzhou Hospital of Integrated Traditional Chinese and Western Medicine Suzhou 215101, Jiangsu, P. R. China
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18
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Sangsari R, Saeedi M, Maddah M, Mirnia K, Goldsmith JP. Weaning and extubation from neonatal mechanical ventilation: an evidenced-based review. BMC Pulm Med 2022; 22:421. [DOI: 10.1186/s12890-022-02223-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
AbstractMechanical ventilation is a lifesaving treatment used to treat critical neonatal patients. It facilitates gas exchange, oxygenation, and CO2 removal. Despite advances in non-invasive ventilatory support methods in neonates, invasive ventilation (i.e., ventilation via an endotracheal tube) is still a standard treatment in NICUs. This ventilation approach may cause injury despite its advantages, especially in preterm neonates. Therefore, it is recommended that neonatologists consider weaning neonates from invasive mechanical ventilation as soon as possible. This review examines the steps required for the neonate's appropriate weaning and safe extubation from mechanical ventilation.
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19
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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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20
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Ismail AQT, Boyle EM, Oddie S, Pillay T. Exploring variation in quality of care and clinical outcomes between neonatal units: a novel use for the UK National Neonatal Audit Programme (NNAP). BMJ Open Qual 2022; 11:bmjoq-2022-002017. [PMID: 36253016 PMCID: PMC9577915 DOI: 10.1136/bmjoq-2022-002017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Neonatology is a relatively new specialty, in which much of the practice remains non-evidence based. Variation in the quality of care delivered is recognised but measuring this is challenging. One possible indicator of this is variation in practice. For more than a decade, the National Neonatal Audit Project (NNAP) has described variation in practice between UK neonatal units in relation to its annually reviewed audit measures. These are based on evidence based national standards or developed by a consensus method and have become de facto measures defining good quality of neonatal healthcare within the UK. In this article we explore the practicality of using the NNAP to look for associations between quality of care and outcomes. This would not be to validate the measures but could help towards a better understanding of the reasons underlying recognised variation in outcomes, even between neonatal units of the same designation.
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Affiliation(s)
| | - Elaine M Boyle
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Sam Oddie
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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21
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Ito Y, Yamashita T, Tachibana K. Anesthetic management using high-flow nasal cannula therapy during cardiac catheter examination of a neonate with hypoplastic left heart syndrome. JA Clin Rep 2022; 8:83. [PMID: 36222838 PMCID: PMC9556681 DOI: 10.1186/s40981-022-00572-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 11/06/2022] Open
Abstract
Background Sedation during cardiac catheter examination in neonates with complex congenital heart disease is challenging, as even the slightest change in the circulatory or respiratory status can lead to hemodynamic collapse. Here, we report a case wherein we achieved adequate sedation with a high-flow nasal cannula (HFNC) for catheter examination in a neonate with a congenital cardiac anomaly. Case presentation An 11-day-old boy with hypoplastic left heart syndrome was scheduled for a cardiac catheter examination prior to the Norwood procedure. He underwent bilateral pulmonary artery banding (PAB) on day 1 and was receiving dobutamine, milrinone, alprostadil, and dexmedetomidine in addition to air and nitrogen insufflation via HFNC, which was applied following extubation on day 3 and nitrogen therapy on day 6 owing to persistent pulmonary overcirculation symptoms (tachypnea and low arterial blood pressure) despite bilateral PAB. A catheter examination was performed on day 11 with careful monitoring of expired carbon dioxide and observation of chest wall motion. Adequate sedation was provided with supplemental midazolam and fentanyl along with HFNC without tracheal intubation. Conclusions The findings from this case suggest that HFNC is a safe and effective tool for oxygenation during cardiac catheter examination under sedation in neonates.
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Affiliation(s)
- Yoshiaki Ito
- grid.410796.d0000 0004 0378 8307Department of Anesthesiology, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka 564-8565 Japan ,grid.416629.e0000 0004 0377 2137Department of Anesthesiology, Osaka Women’s and Children’s Hospital, Izumi, Osaka Japan
| | - Tomonori Yamashita
- grid.416629.e0000 0004 0377 2137Department of Anesthesiology, Osaka Women’s and Children’s Hospital, Izumi, Osaka Japan
| | - Kazuya Tachibana
- grid.416629.e0000 0004 0377 2137Department of Anesthesiology, Osaka Women’s and Children’s Hospital, Izumi, Osaka Japan
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22
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Grover R, Singh P, Shubham S, Priyadarshi M, Chaurasia S, Basu S. Delivery Room Respiratory Stabilization of Preterm Neonates: A Randomized, Controlled Trial. Indian J Pediatr 2022; 89:793-800. [PMID: 35397090 DOI: 10.1007/s12098-022-04124-0] [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: 08/14/2021] [Accepted: 11/12/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To determine whether heated humidified high-flow nasal cannula (HHHFNC) is noninferior to NCPAP to provide DR respiratory support to preterm neonates of gestational age (GA) 28-36 wk. METHODS This randomized, controlled, noninferiority trial included 124 spontaneously breathing preterm neonates who developed respiratory distress soon after birth and/or had a FiO2 requirement > 0.3. Primary outcome measure was treatment failure within 24 h. The absolute risk difference with 95% confidence interval (CI) were calculated with a noninferiority margin of 10%. Secondary outcome variables were temperature at admission, time to treatment failure, treatment failure at 72 h, need for surfactant, intubation, duration of respiratory support, and incidences of adverse events including mortality. Intention-to-treat analysis was done in Stata software. RESULTS Both the groups were similar in baseline characteristics. There was no statistically significant difference between the treatment failure rates with HHHFNC (13.1%, n = 61) and NCPAP (11.1%, n = 63) (risk difference 2.0%, 95% CI - 9.9% to 14.07%, p = 0.73). However, noninferiority of HHHFNC to NCPAP could not be conclusively proved as the 95% CI crossed both 0 and the noninferiority margin of 10%. There were no significant differences in secondary outcomes. CONCLUSIONS HHHFNC showed similar efficacy and safety as NCPAP irrespective of gestational age, though its noninferiority to NCPAP remained inconclusive. TRIAL REGISTRATION Clinical Trial Registry of India, Registration no: CTRI/2019/10/021633, https://ctri.icmr.org.in/.
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Affiliation(s)
- Rajat Grover
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Poonam Singh
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Shantanu Shubham
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Mayank Priyadarshi
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Suman Chaurasia
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India
| | - Sriparna Basu
- Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 249203, India.
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23
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Regin Y, Gie A, Eerdekens A, Toelen J, Debeer A. Ventilation and respiratory outcome in extremely preterm infants: trends in the new millennium. Eur J Pediatr 2022; 181:1899-1907. [PMID: 35034202 DOI: 10.1007/s00431-022-04378-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
Ventilation and respiratory care have substantially changed over the last decades in extremely premature neonates but the impact on respiratory health remains largely unclear. To determine changes in respiratory care and disease frequency in extremely premature infants, a retrospective single-centre cohort study of extremely preterm infants was performed. All infants born alive between 24 + 0 and 27 + 6 weeks of gestation in 2000-2001 (Epoch 1), 2009-2010 (Epoch 2), and 2018-2019 (Epoch 3) were included. The primary outcome of this study was the incidence of bronchopulmonary dysplasia (BPD, diagnosed according to three different criteria) or death. Secondary outcomes included the usage of different ventilation modes, changes in pharmacotherapy, and the incidence of significant extra-pulmonary morbidities. A total of 184 neonates were included of whom 151 survived until 36 weeks of corrected GA (cGA). Oxygen or positive pressure dependence increased over time (26.1%, 41.7%, and 56.1% respectively), with higher adjusted odds in Epoch 3 for the composite outcome "BPD or death" (adjusted odds ratio: 2.55 [95%CI 1.19-5.61]). Severity-based definitions showed increasing trends in survivors only. Time spent on invasive mechanical ventilation was similar throughout the years, but the use of non-invasive ventilation significantly increased in Epoch 3 (32.0 [95%CI 25.0-37.0] vs 27.0 [95%CI 26.0-32.0] vs 53.0 [95%CI 46.0-58.0] days). Moreover, mortality-adjusted rates of severe IVH, NEC, or intestinal perforation and multiple sepsis tended to decrease. Conclusion: In spite of significant clinical advancements and adherence to novel treatment guidelines in our neonatal intensive care unit, the incidence of BPD increased over time. What is Known: • Rates of BPD are stable or increase in population-based studies. • Extremely preterm infants are particularly susceptible to developing BPD. What is New: • Despite increased use of evidence-based corticosteroid administration and early initiation of caffeine, the incidence of BPD has not decreased over the past decade. • Increased usage of non-invasive ventilation is associated with an increase of BPD incidence.
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Affiliation(s)
- Yannick Regin
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
| | - Andre Gie
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium.,Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, 7505, South Africa
| | - An Eerdekens
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium.,Department of Neonatology, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Jaan Toelen
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium.,Department of Paediatrics, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Anne Debeer
- Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium. .,Department of Neonatology, University Hospitals Leuven, 3000, Leuven, Belgium.
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24
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Sand L, Szatkowski L, Kwok TC, Sharkey D, Todd DA, Budge H, Ojha S. Observational cohort study of changing trends in non-invasive ventilation in very preterm infants and associations with clinical outcomes. Arch Dis Child Fetal Neonatal Ed 2022; 107:150-155. [PMID: 34413093 DOI: 10.1136/archdischild-2021-322390] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/05/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the change in non-invasive ventilation (NIV) use over time in infants born at <32 weeks' gestation and the associated clinical outcomes. STUDY DESIGN Retrospective cohort study using routinely recorded data from the National Neonatal Research Database of infants born at <32 weeks admitted to neonatal units in England and Wales from 2010 to 2017. RESULTS In 56 537 infants, NIV use increased significantly between 2010 and 2017 (continuous positive airway pressure (CPAP) from 68.5% to 80.2% in 2017 and high flow nasal cannula (HFNC) from 14% to 68%, respectively) (p<0.001)). Use of NIV as the initial mode of respiratory support also increased (CPAP, 21.5%-28.0%; HFNC, 1%-7% (p<0.001)).HFNC was used earlier, and for longer, in those who received CPAP or mechanical ventilation. HFNC use was associated with decreased odds of death before discharge (adjusted OR (aOR) 0.19, 95% CI 0.17 to 0.22). Infants receiving CPAP but no HFNC died at an earlier median chronological age: CPAP group, 22 (IQR 10-39) days; HFNC group 40 (20-76) days (p<0.001). Among survivors, HFNC use was associated with increased odds of bronchopulmonary dysplasia (BPD) (aOR 2.98, 95% CI 2.81 to 3.15) and other adverse outcomes. CONCLUSIONS NIV use is increasing, particularly as initial respiratory support. HFNC use has increased significantly with a sevenfold increase soon after birth which was associated with higher rates of BPD. As more infants survive with BPD, we need robust clinical evidence, to improve outcomes with the use of NIV as initial and ongoing respiratory support.
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Affiliation(s)
- Laura Sand
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lisa Szatkowski
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - T'ng Chang Kwok
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - David A Todd
- Neonatal Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Helen Budge
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shalini Ojha
- Academic Unit of Population and Lifespan Sciences, 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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25
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Bruschettini M, Hassan KO, Romantsik O, Banzi R, Calevo MG, Moresco L. Interventions for the management of transient tachypnoea of the newborn - an overview of systematic reviews. Cochrane Database Syst Rev 2022; 2:CD013563. [PMID: 35199848 PMCID: PMC8867535 DOI: 10.1002/14651858.cd013563.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Transient tachypnoea of the newborn (TTN) is characterised by tachypnoea and signs of respiratory distress. It is caused by delayed clearance of lung fluid at birth. TTN typically appears within the first two hours of life in term and late preterm newborns. Although it is usually a self-limited condition, admission to a neonatal unit is frequently required for monitoring, the provision of respiratory support, and drugs administration. These interventions might reduce respiratory distress during TTN and enhance the clearance of lung liquid. The goals are reducing the effort required to breathe, improving respiratory distress, and potentially shortening the duration of tachypnoea. However, these interventions might be associated with harm in the infant. OBJECTIVES The aim of this overview was to evaluate the benefits and harms of different interventions used in the management of TTN. METHODS We searched the Cochrane Database of Systematic Reviews on 14 July 2021 for ongoing and published Cochrane Reviews on the management of TTN in term (> 37 weeks' gestation) or late preterm (34 to 36 weeks' gestation) infants. We included all published Cochrane Reviews assessing the following categories of interventions administered within the first 48 hours of life: beta-agonists (e.g. salbutamol and epinephrine), corticosteroids, diuretics, fluid restriction, and non-invasive respiratory support. The reviews compared the above-mentioned interventions to placebo, no treatment, or other interventions for the management of TTN. The primary outcomes of this overview were duration of tachypnoea and the need for mechanical ventilation. Two overview authors independently checked the eligibility of the reviews retrieved by the search and extracted data from the included reviews using a predefined data extraction form. Any disagreements were resolved by discussion with a third overview author. Two overview authors independently assessed the methodological quality of the included reviews using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) tool. We used the GRADE approach to assess the certainty of evidence for effects of interventions for TTN management. As all of the included reviews reported summary of findings tables, we extracted the information already available and re-graded the certainty of evidence of the two primary outcomes to ensure a homogeneous assessment. We provided a narrative summary of the methods and results of each of the included reviews and summarised this information using tables and figures. MAIN RESULTS We included six Cochrane Reviews, corresponding to 1134 infants enrolled in 18 trials, on the management of TTN in term and late preterm infants, assessing salbutamol (seven trials), epinephrine (one trial), budesonide (one trial), diuretics (two trials), fluid restriction (four trials), and non-invasive respiratory support (three trials). The quality of the included reviews was high, with all of them fulfilling the critical domains of the AMSTAR 2. The certainty of the evidence was very low for the primary outcomes, due to the imprecision of the estimates (few, small included studies) and unclear or high risk of bias. Salbutamol may reduce the duration of tachypnoea compared to placebo (mean difference (MD) -16.83 hours, 95% confidence interval (CI) -22.42 to -11.23, 2 studies, 120 infants, low certainty evidence). We did not identify any review that compared epinephrine or corticosteroids to placebo and reported on the duration of tachypnoea. However, one review reported on "trend of normalisation of respiratory rate", a similar outcome, and found no differences between epinephrine and placebo (effect size not reported). The evidence is very uncertain regarding the effect of diuretics compared to placebo (MD -1.28 hours, 95% CI -13.0 to 10.45, 2 studies, 100 infants, very low certainty evidence). We did not identify any review that compared fluid restriction to standard fluid rates and reported on the duration of tachypnoea. The evidence is very uncertain regarding the effect of continuous positive airway pressure (CPAP) compared to free-flow oxygen therapy (MD -21.1 hours, 95% CI -22.9 to -19.3, 1 study, 64 infants, very low certainty evidence); the effect of nasal high-frequency (oscillation) ventilation (NHFV) compared to CPAP (MD -4.53 hours, 95% CI -5.64 to -3.42, 1 study, 40 infants, very low certainty evidence); and the effect of nasal intermittent positive pressure ventilation (NIPPV) compared to CPAP on duration of tachypnoea (MD 4.30 hours, 95% CI -19.14 to 27.74, 1 study, 40 infants, very low certainty evidence). Regarding the need for mechanical ventilation, the evidence is very uncertain for the effect of salbutamol compared to placebo (risk ratio (RR) 0.60, 95% CI 0.13 to 2.86, risk difference (RD) 10 fewer, 95% CI 50 fewer to 30 more per 1000, 3 studies, 254 infants, very low certainty evidence); the effect of epinephrine compared to placebo (RR 0.67, 95% CI 0.08 to 5.88, RD 70 fewer, 95% CI 460 fewer to 320 more per 1000, 1 study, 20 infants, very low certainty evidence); and the effect of corticosteroids compared to placebo (RR 0.52, 95% CI 0.05 to 5.38, RD 40 fewer, 95% CI 170 fewer to 90 more per 1000, 1 study, 49 infants, very low certainty evidence). We did not identify a review that compared diuretics to placebo and reported on the need for mechanical ventilation. The evidence is very uncertain regarding the effect of fluid restriction compared to standard fluid administration (RR 0.73, 95% CI 0.24 to 2.23, RD 20 fewer, 95% CI 70 fewer to 40 more per 1000, 3 studies, 242 infants, very low certainty evidence); the effect of CPAP compared to free-flow oxygen (RR 0.30, 95% CI 0.01 to 6.99, RD 30 fewer, 95% CI 120 fewer to 50 more per 1000, 1 study, 64 infants, very low certainty evidence); the effect of NIPPV compared to CPAP (RR 4.00, 95% CI 0.49 to 32.72, RD 150 more, 95% CI 50 fewer to 350 more per 1000, 1 study, 40 infants, very low certainty evidence); and the effect of NHFV versus CPAP (effect not estimable, 1 study, 40 infants, very low certainty evidence). Regarding our secondary outcomes, duration of hospital stay was the only outcome reported in all of the included reviews. One trial on fluid restriction reported a lower duration of hospitalisation in the restricted-fluids group, but with very low certainty of evidence. The evidence was very uncertain for the effects on secondary outcomes for the other five reviews. Data on potential harms were scarce, as all of the trials were underpowered to detect possible increases in adverse events such as pneumothorax, arrhythmias, and electrolyte imbalances. No adverse effects were reported for salbutamol; however, this medication is known to carry a risk of tachycardia, tremor, and hypokalaemia in other settings. AUTHORS' CONCLUSIONS This overview summarises the evidence from six Cochrane Reviews of randomised trials regarding the effects of postnatal interventions in the management of TTN. Salbutamol may reduce the duration of tachypnoea slightly. We are uncertain as to whether salbutamol reduces the need for mechanical ventilation. We are uncertain whether epinephrine, corticosteroids, diuretics, fluid restriction, or non-invasive respiratory support reduces the duration of tachypnoea and the need for mechanical ventilation, due to the extremely limited evidence available. Data on harms were lacking.
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Affiliation(s)
- Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | - Rita Banzi
- Center for Health Regulatory Policies, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy
| | - Maria Grazia Calevo
- Epidemiology, Biostatistics Unit, IRCCS, Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Moresco
- Pediatric and Neonatology Unit, Ospedale San Paolo, Savona, Italy
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26
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Bruet S, Butin M, Dutheil F. Systematic review of high-flow nasal cannula versus continuous positive airway pressure for primary support in preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 107:56-59. [PMID: 34016651 DOI: 10.1136/archdischild-2020-321094] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/13/2021] [Accepted: 05/01/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION We conducted a meta-analysis of trials that compared efficacy and safety of high-flow nasal cannula (HFNC) with continuous positive airway pressure (CPAP) as primary respiratory support in preterm infants and a study of the impact of clinical relevant parameters. METHODS Databases were searched for randomised controlled trials comparing HFNC with CPAP as primary respiratory support in preterm infants. Treatment failure was considered as primary outcome and adverse events as secondary outcomes. We calculated risk ratios (RRs) in intention-to-treat analysis and random-effects meta-analyses of risks were conducted. RESULTS We included 10 studies for a total of 1830 patients. Meta-analysis demonstrated an RR of treatment failure multiplied by 1.34 using HFNC compared with CPAP (RR=1.34, 95% CI 1.01 to 1.68, I2=16.2%). Secondary outcome meta-analysis showed no difference in intubation rates (RR=0.90, 95% CI 0.66 to 1.15) and a lower rate of nasal trauma using HFNC compared with CPAP (RR=0.48, 95% CI 0.31 to 0.65, I²=0.0%). Meta-regressions did not show any influence of gestational age and weight at birth, HFNC flow rate, type of CPAP generator or use of surfactant. CONCLUSIONS Despite a higher risk of treatment failure, considering no difference in intubation rates and a lower rate of nasal trauma using HFNC compared with CPAP, we suggest that HFNC should be used as primary respiratory support in preterm infants.
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Affiliation(s)
- Shaam Bruet
- Neonatology and NICU, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marine Butin
- Neonatology and NICU, Hospices Civils de Lyon, Lyon, France.,Staphylococcal pathogenesis research group, International Center for Infectiology Research, INSERM U1111, Lyon, France
| | - Frederic Dutheil
- Physiological and Psychosocial Stress, LaPSCo, CNRS, Université Clermont Auvergne, Clermont-Ferrand, France.,Preventive and Occupational Medicine, University Hospital of Clermont-Ferrand, Witty Fit, F-63000, CHU Clermont-Ferrand, Clermont-Ferrand, France
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Luo K, Huang Y, Xiong T, Tang J. High-flow nasal cannula versus continuous positive airway pressure in primary respiratory support for preterm infants: A systematic review and meta-analysis. Front Pediatr 2022; 10:980024. [PMID: 36479290 PMCID: PMC9720183 DOI: 10.3389/fped.2022.980024] [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: 06/28/2022] [Accepted: 11/03/2022] [Indexed: 11/22/2022] Open
Abstract
Respiratory support is crucial for the survival of preterm infants, and High-flow Nasal Cannula Oxygen Therapy (HFNC) and Continuous Positive Airway Pressure (CPAP) are commonly used for neonatal respiratory support. This meta-analysis aimed to compare the effects of HFNC and CPAP in primary respiratory support for preterm infants, to provide evidence-based support for clinical practice. PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CNKI, VIP, WANFANG and SinoMed were searched for eligible studies. The primary outcomes included the incidence of treatment failure and the application of mechanical ventilation. A total of 27 eligible studies with 3,351 participants were included. There was no significant difference in the incidence of respiratory support failure [RR = 1.17, 95%CI (0.88-1.56)] and the application of mechanical ventilation [RR = 1.00, 95%CI (0.84-1.19)] between HFNC group and CPAP group. HFNC resulted in lower rate of air leaks [RR = 0.65, 95%CI (0.46-0.92)], nasal trauma [RR = 0.36, 95%CI (0.29-0.45)] and abdominal distension [RR = 0.39, 95%CI (0.27-0.58)], and later time of mechanical ventilation initiating [SMD = 0.60, 95%CI (0.21-0.99)], less duration of oxygen therapy [SMD = -0.35, 95%CI (-0.68 to -0.02)] and earlier enteral feeding [SMD = -0.54, 95%CI (-0.95 to -0.13)]. Alternative non-invasive respiratory support after initial treatment failure resulted in no difference in the application of mechanical ventilation between the two groups [RR = 0.99, 95%CI (0.52-1.88)]. HFNC might be more effective and safer in primary respiratory support for preterm infants. Using CPAP as a remedy for the treatment failure of HFNC could not avoid intubation. For premature infants with the gestational age <28 weeks, HFNC as primary respiratory support still needs to be further elucidated. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022313479, identifier: CRD42022313479.
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Affiliation(s)
- Keren Luo
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
| | - Yi Huang
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
| | - Tao Xiong
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
| | - Jun Tang
- Department of Neonatology, West China Women's and Children's Hospital, Sichuan University, Chengdu, China
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Mukerji A, Shah PS, Ye XY, Razak A. Non-invasive respiratory support in preterm infants as primary mode: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Amit Mukerji
- Department of Paediatrics; McMaster University; Hamilton, Ontario Canada
| | - Prakeshkumar S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation; University of Toronto Mount Sinai Hospital; Toronto, Ontario Canada
| | - Xiang Y Ye
- Department of Pediatric; Maternal-Infant Research Center; Toronto, Ontario Canada
| | - Abdul Razak
- Division of Neonatalogy, Department of Pediatrics; Princess Nourah Bint Abdulrahman University, King Abdullah bin Abdulaziz University Hospital; Riyadh Saudi Arabia
- Department of Pediatrics; McMaster University; Hamilton, Ontario Canada
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Razak A, Shah PS, Ye XY, Mukerji A. Post-extubation use of non-invasive respiratory support in preterm infants: a network meta-analysis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Abdul Razak
- Division of Neonatalogy, Department of Pediatrics; Princess Nourah Bint Abdulrahman University, King Abdullah bin Abdulaziz University Hospital; Riyadh Saudi Arabia
- Department of Pediatrics; McMaster University; Hamilton, Ontario Canada
| | - Prakeshkumar S Shah
- Department of Paediatrics and Institute of Health Policy, Management and Evaluation; University of Toronto Mount Sinai Hospital; Toronto, Ontario Canada
| | - Xiang Y Ye
- Department of Pediatrics; Maternal-Infant Research Center; Toronto, Ontario Canada
| | - Amit Mukerji
- Department of Paediatrics; McMaster University; Hamilton, Ontario Canada
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Subramaniam P, Ho JJ, Davis PG. Prophylactic or very early initiation of continuous positive airway pressure (CPAP) for preterm infants. Cochrane Database Syst Rev 2021; 10:CD001243. [PMID: 34661278 PMCID: PMC8521644 DOI: 10.1002/14651858.cd001243.pub4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cohort studies have suggested that nasal continuous positive airway pressure (CPAP) starting in the immediate postnatal period before the onset of respiratory disease (prophylactic CPAP) may be beneficial in reducing the need for intubation and intermittent positive pressure ventilation (IPPV), and in preventing bronchopulmonary dysplasia (BPD), in preterm or low birth weight infants. OBJECTIVES To determine if prophylactic nasal CPAP (started within the first 15 minutes) or very early nasal CPAP regardless of respiratory status (started within the first hour of life), reduces the use of mechanical ventilation and the incidence of bronchopulmonary dysplasia without any adverse effects in preterm infants. SEARCH METHODS A comprehensive search was run on 6 November 2020 in the Cochrane Central Register of Controlled Trials (CENTRAL via CRS Web) and MEDLINE via Ovid. We also searched the reference lists of retrieved studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) and quasi-RCTs in preterm infants (under 37 weeks of gestation). We included trials if they compared prophylactic nasal CPAP (started within the first 15 minutes) or very early nasal CPAP (started within the first hour of life) in infants with minimal signs of respiratory distress with 'supportive care', such as supplemental oxygen therapy, standard nasal cannula, or mechanical ventilation. We excluded studies where prophylactic CPAP was compared with CPAP along with co-interventions. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal, including independent study selection, assessment of trial quality, and extraction of data by two review authors. MAIN RESULTS We included eight trials (seven from the previous version of the review and one new study), recruiting 3201 babies, in the meta-analysis. Four trials, involving 765 babies, compared CPAP with supportive care, and three trials (2364 babies) compared CPAP with mechanical ventilation. One trial (72 babies) compared prophylactic CPAP with very early CPAP. Apart from a lack of blinding of the intervention, we judged seven studies to have a low risk of bias. However, one study had a high risk of selection bias. Prophylactic or very early CPAP compared to supportive care There may be a reduction in failed treatment (risk ratio (RR) 0.6, 95% confidence interval (CI) 0.49 to 0.74; risk difference (RD) -0.16, 95% CI -0.34 to 0.02; 4 studies, 765 infants; very low certainty evidence). CPAP possibly reduces BPD at 36 weeks (RR 0.76, 95% CI 0.51 to 1.14; 3 studies, 683 infants, moderate certainty evidence); there may be little or no difference in death (RR 1.04, 95% CI 0.56 to 1.93; 4 studies, 765 infants; moderate certainty evidence). Prophylactic CPAP may reduce the composite outcome of death or BPD (RR 0.69, 95% CI 0.40 to 1.19; 1 study, 256 infants; low certainty evidence). There may be no difference in pulmonary air leak (pneumothorax) (RR 0.75, 95% CI 0.35 to 1.16; 3 studies, 568 infants; low certainty evidence), or intraventricular haemorrhage (IVH) Grade 3 or 4 (RR 0.96, 95% CI 0.39 to 2.37; 2 studies, 486 infants; moderate certainty evidence). Neurodevelopmental impairment was not reported in any of the studies. Prophylactic or very early CPAP compared to mechanical ventilation There was probably a reduction in the incidence of BPD at 36 weeks (RR 0.89, 95% CI 0.8 to 0.99; RD -0.04, 95% CI -0.08 to 0.00; 3 studies, 2150 infants; moderate certainty evidence); and death or BPD (RR 0.89, 95% CI 0.81 to 0.97; RD -0.05, 95% CI -0.09 to 0.01; 3 studies, 2358 infants; moderate certainty evidence). There was also probably a reduction in the need for mechanical ventilation (failed treatment) (RR 0.49, 95% CI 0.45 to 0.54; RD -0.50, 95% CI -0.54 to -0.45; 2 studies, 1042 infants; moderate certainty evidence). There was probably a reduction in the incidence of death (RR 0.82, 95% CI 0.66 to 1.03; 3 studies, 2358 infants; moderate certainty evidence); pulmonary air leak (pneumothorax) (RR 1.24, 95% CI 0.91 to 1.69; 3 studies, 2357 infants; low certainty evidence); and IVH Grade 3 or 4 (RR 1.09, 95% CI 0.86 to 1.39; 3 studies, 2301 infants; moderate certainty evidence). One study in this comparison reported that there was probably little or no difference between the groups in the incidence of neurodevelopmental impairment at 18 to 22 months (RR 0.91, 95% CI 0.62 to 1.32; 976 infants; moderate certainty evidence). Prophylactic CPAP compared with very early CPAP There was one study in this comparison. We are very uncertain whether there is any difference in the incidence of BPD (RR 0.5, 95% CI 0.05 to 5.27; very low certainty evidence). The combined outcome of death and BPD was not reported, and failed treatment was reported but without data. There may have been little to no effect on death (RR 0.75, 95% CI 0.29 to1.94; 1 study, 72 infants; very low certainty evidence). Intraventricular haemorrhage Grade 3 or 4 and neurodevelopmental outcomes were not reported in this study. Pulmonary air leak (pneumothorax) was reported in this study, but there were no events in either group. AUTHORS' CONCLUSIONS For preterm and very preterm infants, there is insufficient evidence to evaluate prophylactic CPAP compared to oxygen therapy and other supportive care. When compared to mechanical ventilation, prophylactic nasal CPAP in very preterm infants reduces the incidence of BPD, the combined outcome of death and BPD, and mechanical ventilation. There is probably no difference in neurodevelopmental impairment at 18 to 22 months of age. When prophylactic CPAP is compared to early CPAP, we are very uncertain about whether there is any difference between prophylactic and very early CPAP. There is no information about the effect of prophylactic or very early CPAP in late preterm infants. There is one study awaiting classification.
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Affiliation(s)
- Prema Subramaniam
- Paediatric Department, Mount Isa Base Hospital, Mount Isa, Australia
| | - Jacqueline J Ho
- Department of Paediatrics, RCSI & UCD Malaysia Campus (formerly Penang Medical College), George Town, Malaysia
| | - 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
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Sarafidis K, Chotas W, Agakidou E, Karagianni P, Drossou V. The Intertemporal Role of Respiratory Support in Improving Neonatal Outcomes: A Narrative Review. CHILDREN (BASEL, SWITZERLAND) 2021; 8:883. [PMID: 34682148 PMCID: PMC8535019 DOI: 10.3390/children8100883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/17/2021] [Accepted: 09/27/2021] [Indexed: 11/18/2022]
Abstract
Defining improvements in healthcare can be challenging due to the need to assess multiple outcomes and measures. In neonates, although progress in respiratory support has been a key factor in improving survival, the same degree of improvement has not been documented in certain outcomes, such as bronchopulmonary dysplasia. By exploring the evolution of neonatal respiratory care over the last 60 years, this review highlights not only the scientific advances that occurred with the application of invasive mechanical ventilation but also the weakness of the existing knowledge. The contributing role of non-invasive ventilation and less-invasive surfactant administration methods as well as of certain pharmacological therapies is also discussed. Moreover, we analyze the cost-benefit of neonatal care-respiratory support and present future challenges and perspectives.
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Affiliation(s)
- Kosmas Sarafidis
- 1st Department of Neonatology and Neonatal Intensive Care, School of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (P.K.); (V.D.)
| | - William Chotas
- Department of Neonatology, University of Vermont, Burlington, VT 05405, USA;
| | - Eleni Agakidou
- 1st Department of Neonatology and Neonatal Intensive Care, School of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (P.K.); (V.D.)
| | - Paraskevi Karagianni
- 1st Department of Neonatology and Neonatal Intensive Care, School of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (P.K.); (V.D.)
| | - Vasiliki Drossou
- 1st Department of Neonatology and Neonatal Intensive Care, School of Medicine, Aristotle University of Thessaloniki, Ippokrateion General Hospital, 54642 Thessaloniki, Greece; (E.A.); (P.K.); (V.D.)
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32
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Pierantoni L, Dondi A, Biagi C, Scozzarella A, Camela F, Lanari MA. Subcutaneous emphysema of the neck as a complication of high flow nasal cannula therapy in children: a case report. EMERGENCY CARE JOURNAL 2021. [DOI: 10.4081/ecj.2021.9615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
High Flow Nasal Cannula (HFNC) is a noninvasive technique for respiratory support increasingly used in the pediatric wards for the management of respiratory failure. Few data are reported about the safety of HFNC. We describe the case of a 3-months-old infant admitted for acute bronchiolitis Respiratory Syncyctial Virus-related and treated with HFNC for severe respiratory distress. 12 hours after the beginning of HFNC a subcutaneous swelling of the neck, attributable to subcutaneous emphysema, became clinically evident. Radiological imaging showed pneumomediastinum with air leaking up to the neck. Patient was moved to PICU where he further worsened due to a mediastinal shift requiring drainage and mechanical ventilation. He was then progressively weaned from ventilation and was discharged from the hospital. Pneumomediastinum may occur during HFNC, particularly in moderate-severe cases of acute bronchiolitis. Patients undergoing HFNC should be strictly monitored in order to promptly recognize this complication and treat the child appropriately.
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Sett A, Noble EJ, Forster DE, Collins CL. Cerebral oxygenation is stable in preterm infants transitioning to heated humidified high-flow nasal cannula therapy. Acta Paediatr 2021; 110:2059-2064. [PMID: 33595862 DOI: 10.1111/apa.15811] [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: 12/19/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/28/2022]
Abstract
AIM To assess cerebral oxygenation in premature infants who are transitioning from nasal continuous positive airway pressure (nCPAP) to heated humidified high-flow nasal cannula therapy (HFNC). METHODS A prospective observational study done in a single-centre neonatal intensive care unit (NICU). Regional cerebral oxygen saturations (RcSO2 ) were measured using frequency-domain near-infrared spectroscopy (FD-NIRS) in very low birthweight (VLBW) premature infants born at <32 weeks transitioning from nCPAP to HFNC. RESULTS Median gestational age was 27 weeks and median birthweight was 924 g. Recordings were performed at a median gestational age of 30 weeks and a median postnatal age of 10 days. Median weight at study entry was 1111 g. Cerebral oxygenation was not significantly different in infants transitioning from nCPAP to HFNC (66% vs 66%). CONCLUSION No difference in cerebral oxygenation in premature infants transitioning from nCPAP to HFNC was observed. This finding is reassuring and further supports the use of HFNC in preterm infants.
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Affiliation(s)
- Arun Sett
- Department of Paediatrics Mercy Hospital for Women Heidelberg Vic Australia
- Joan Kirner Women’s and Children’s HospitalWestern Health St Alban’s Vic. Australia
| | - Elizabeth J. Noble
- Department of Paediatrics Mercy Hospital for Women Heidelberg Vic Australia
| | | | - Clare L. Collins
- Joan Kirner Women’s and Children’s HospitalWestern Health St Alban’s Vic. Australia
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Kovatis KZ, Locke RG, Mackley AB, Subedi K, Shaffer TH. Adjustment of high flow nasal cannula rates using real-time work of breathing indices in premature infants with respiratory insufficiency. J Perinatol 2021; 41:1711-1717. [PMID: 33664469 PMCID: PMC8867510 DOI: 10.1038/s41372-021-00977-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/03/2020] [Accepted: 01/28/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the feasibility of real-time monitoring of work of breathing (WOB) indices and the impact of adjusting HFNC flow on breathing synchrony and oxygen stability in premature infants. STUDY DESIGN A prospective, observational study of infants stable on HFNC. The flow adjusted per predetermined algorithm. Respiratory inductive plethysmography (RIP) noninvasively measured WOB. A high-resolution pulse oximeter collected oxygen saturation and heart rate data. Summary statistics and mixed linear models were used. RESULTS Baseline data for 32 infants, final analysis of 21 infants. Eighty-one percent with abnormal WOB. Sixty-two percent demonstrated 20% improvement in WOB. For infants with gestational age <28 weeks, an incremental increase in HFNC flow rate decreased WOB (p < 0.001) and improved oxygen saturation and stability (p < 0.01). CONCLUSIONS Premature infants do not receive optimal support on HFNC. The use of a real-time feedback system to adjust HFNC is feasible and improves WOB, oxygen saturation, and oxygen stability. This technology may improve the utility of HFNC in premature infants.
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Affiliation(s)
- Kelley Z. Kovatis
- Department of Neonatology, ChristianaCare, Newark, DE, United States,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Robert G. Locke
- Department of Neonatology, ChristianaCare, Newark, DE, United States,Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Amy B. Mackley
- Department of Neonatology, ChristianaCare, Newark, DE, United States
| | - Keshab Subedi
- Value Institute, ChristianaCare, Newark, DE, United States
| | - Thomas H. Shaffer
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States,Nemours Biomedical Research, Alfred I. DuPont Hospital for Children, Wilmington, DE, United States,Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
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Lewis SR, Baker PE, Parker R, Smith AF. High-flow nasal cannulae for respiratory support in adult intensive care patients. Cochrane Database Syst Rev 2021; 3:CD010172. [PMID: 33661521 PMCID: PMC8094160 DOI: 10.1002/14651858.cd010172.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review. OBJECTIVES To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches. SELECTION CRITERIA We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO2/FiO2 may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma. AUTHORS' CONCLUSIONS HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.
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Affiliation(s)
- Sharon R Lewis
- Lancaster Patient Safety Research Unit, Royal Lancaster Infirmary, Lancaster, UK
| | - Philip E Baker
- Academic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Roses Parker
- Cochrane MOSS Network, c/o Cochrane Pain Palliative and Supportive Care Group, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Payne CD, Owen LS, Hodgson KA, Morley CJ, Davis PG, Manley BJ. Gas flow in preterm infants treated with bubble CPAP: an observational study. Arch Dis Child Fetal Neonatal Ed 2021; 106:156-161. [PMID: 32847830 DOI: 10.1136/archdischild-2020-319337] [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: 04/08/2020] [Revised: 06/26/2020] [Accepted: 07/17/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To measure the nasal gas flow in infants treated with bubble continuous positive airway pressure (CPAP) and compare it with commonly used flows during nasal high flow (nHF) treatment. DESIGN This is a prospective, single-centre study. Bubble CPAP pressure was measured at the nasal prongs. Set gas flow was reduced until bubbling in the water chamber just ceased. Set gas flow without bubbling then approximated flow entering the infant's nose ('delivered flow'). SETTING Neonatal intensive care at The Royal Women's Hospital, Melbourne, Australia. PATIENTS Clinically stable preterm infants receiving bubble CPAP therapy. MAIN OUTCOME MEASURE Delivered flow (L/min) when bubbling stopped at a range of clinically set CPAP pressures (cm H2O). RESULTS Forty-four infants were studied, with a mean (SD) gestational age at birth of 28.4 (2.2) weeks and birth weight of 1154 (419) g. At the time of the study, infants had a median (IQR) age of 4.5 (2-12) days and a mean (SD) weight of 1205 (407) g. Delivered flow ranged from 0.5 to 9.0 L/min, and increased with higher set CPAP pressures (median 3.5 L/min at CPAP 5 cm H2O vs 6.3 L/min at CPAP 8 cm H2O) and heavier weights (median 3.5 L/min in infants <1000 g vs 6.5 L/min for infants >1500 g). CONCLUSIONS Nasal gas flows during bubble CPAP in preterm infants are similar to flows used during nHF and increase with higher set bubble CPAP pressures and in larger infants. Trial registration number ACTRN12619000197134.
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Affiliation(s)
- Cameron D Payne
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Louise S Owen
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kate Alison Hodgson
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
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Canning A, Clarke S, Thorning S, Chauhan M, Weir KA. Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review. BMC Pediatr 2021; 21:83. [PMID: 33596866 PMCID: PMC7887825 DOI: 10.1186/s12887-021-02531-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this systematic review was to determine whether introduction of oral feeding for infants and children receiving nasal continuous positive airway pressure (nCPAP) or high flow nasal cannula (HFNC) respiratory support facilitates achievement of full oral feeding without adverse effects, compared to no oral feeding (NPO; nil per oral) on CPAP or HFNC. METHODS A protocol was lodged with the PROSPERO International Prospective Register of Systematic Reviews. We searched Medline, Embase, CINAHL, CENTRAL and AustHealth from database inception to 10th June 2020. Study population included children (preterm to < 18 years) on nCPAP or HFNC who were orally feeding. Primary outcomes included full or partial oral feeding and oropharyngeal aspiration. Secondary outcomes examined adverse events including clinical signs of aspiration, aspiration pneumonia and deterioration in respiratory status. RESULTS The search retrieved 1684 studies following duplicate removal. Title and abstract screening identified 70 studies for full text screening and of these, 16 were included in the review for data extraction. Methods of non-invasive ventilation (NIV) included nCPAP (n = 6), nCPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Eleven studies reported on adverse events. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status. CONCLUSIONS Findings are insufficient to conclude whether commencing oral feeding whilst on nCPAP or HFNC facilitates transition to full oral feeding without adverse effects, including oropharyngeal aspiration. Further research is required to determine the safety and efficacy of oral feeding on CPAP and HFNC for infants and children. TRIAL REGISTRATION PROSPERO registration number: CRD42016039325 .
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Affiliation(s)
- Angie Canning
- Speech Pathology, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Australia.
| | - Sally Clarke
- Queensland Children's Hospital, Children's Health Queensland, Brisbane, Australia
| | - Sarah Thorning
- Library Services, Gold Coast University Hospital, Gold Coast Health, Gold Cost, Australia
| | - Manbir Chauhan
- Newborn Care Unit, Gold Coast University Hospital, Gold Coast Health, Gold Coast, Australia
| | - Kelly A Weir
- Allied Health Sciences & Menzies Health Institute Queensland Griffith University, Gold Coast, Australia.,Allied Health Research Gold Coast Health, Gold Coast, Australia
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Glaser K, Wright CJ. Indications for and Risks of Noninvasive Respiratory Support. Neonatology 2021; 118:235-243. [PMID: 33902052 PMCID: PMC8178193 DOI: 10.1159/000515818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 01/20/2023]
Abstract
Within the last decades, therapeutic advances have significantly improved the survival of extremely preterm infants. In contrast, the incidence of major neonatal morbidities, including bronchopulmonary dysplasia, has not declined. Given the well-established relationship between exposure to invasive mechanical ventilation and neonatal lung injury, neonatologists have sought for effective strategies of noninvasive respiratory support in high-risk infants. Continuous positive airway pressure has replaced invasive mechanical ventilation for the initial stabilization and the treatment of respiratory distress syndrome. Today, noninvasive respiratory support has been adopted even in the tiniest babies with the highest risk of lung injury. Moreover, different modes of noninvasive respiratory support supplemented by a number of adjunctive measures and rescue strategies have entered clinical practice with the goal of preventing intubation or reintubation. However, does this unquestionably important paradigm shift to strategies focused on noninvasive support lull us into a false sense of security? Can we do better in (i) identifying those very immature preterm infants best equipped for noninvasive stabilization, can we improve (ii) determinants of failure of noninvasive respiratory support in the individual infant and underlying etiology, and can we enhance (iii) success of noninvasive respiratory support and (iv) better prevent ultimate harm to the developing lung? With increased survival of infants at the highest risk of developing lung injury and an unchanging burden of bronchopulmonary dysplasia, we should question indiscriminate use of noninvasive respiratory support and address the above issues.
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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
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
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Hodgson KA, Owen LS, Kamlin CO, Roberts CT, Donath SM, Davis PG, Manley BJ. A multicentre, randomised trial of stabilisation with nasal high flow during neonatal endotracheal intubation (the SHINE trial): a study protocol. BMJ Open 2020; 10:e039230. [PMID: 33020105 PMCID: PMC7537449 DOI: 10.1136/bmjopen-2020-039230] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Neonatal endotracheal intubation is an essential but potentially destabilising procedure. With an increased focus on avoiding mechanical ventilation, particularly in preterm infants, there are fewer opportunities for clinicians to gain proficiency in this important emergency skill. Rates of successful intubation at the first attempt are relatively low, and adverse event rates are high, when compared with intubations in paediatric and adult populations. Interventions to improve operator success and patient stability during neonatal endotracheal intubations are needed. Using nasal high flow therapy extends the safe apnoea time of adults undergoing upper airway surgery and during endotracheal intubation. This technique is untested in neonates. METHODS AND ANALYSIS The Stabilisation with nasal High flow during Intubation of NEonates (SHINE) trial is a multicentre, randomised controlled trial comparing the use of nasal high flow during neonatal intubation with standard care (no nasal high flow). Intubations are randomised individually, and stratified by site, use of premedications, and postmenstrual age (<28 weeks' gestation; ≥28 weeks' gestation). The primary outcome is the incidence of successful intubation on the first attempt without physiological instability of the infant. Physiological instability is defined as an absolute decrease in peripheral oxygen saturation >20% from preintubation baseline and/or bradycardia (<100 beats per minute). ETHICS AND DISSEMINATION The SHINE trial received ethical approval from the Human Research Ethics Committees of The Royal Women's Hospital, Melbourne, Australia and Monash Health, Melbourne, Australia. The trial is currently recruiting in these two sites. The findings of this study will be disseminated via peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12618001498280.
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Affiliation(s)
- Kate A Hodgson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Louise S Owen
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Camille Omar Kamlin
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University, Clayton, Victoria, Australia
| | - Susan M Donath
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Brett James Manley
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Allen K, Galek K. The Influence of Airflow Via High-Flow Nasal Cannula on Duration of Laryngeal Vestibule Closure. Dysphagia 2020; 36:729-735. [PMID: 33006075 PMCID: PMC7529319 DOI: 10.1007/s00455-020-10193-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/21/2020] [Indexed: 11/29/2022]
Abstract
The purpose of this experimental study was to investigate the influence of airflow via high-flow nasal cannula (HFNC) on the duration of laryngeal vestibule closure (dLVC) and Penetration-Aspiration Scale (PAS) scores. Twenty-nine healthy adults participated in a repeated-measures design. Each participant completed a videofluoroscopic swallow study while receiving airflow via HFNC across a control condition of zero flow and conditions of 10, 20, 30, 40, 50, and 60 L/min. Five raters rated dLVC and PAS scores. Laryngeal vestibule closure was complete on all swallows. Linear regression revealed that the amount of airflow via HFNC significantly influenced dLVC, F(1, 810) = 19.056, p < .001. The mode of airway invasion for each airflow condition was PAS 2, with > 80% frequency compared to other PAS scores. Aspiration (PAS 7 or 8) did not occur. A Fisher's Exact test determined there was no association between normal/abnormal PAS score and no airflow/HFNC (p = .610). Findings indicate that for healthy adults, airflow via HFNC influenced dLVC in a dose-dependent manner with no change in airway invasion. The influence of HFNC on dLVC was a positive relationship, meaning when airflow increased, dLVC increased, and when airflow decreased, dLVC decreased. Modulation of dLVC in response to the amount of airflow highlights the ability of healthy adults to adapt to swallow conditions as needed to protect the airway.
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Affiliation(s)
- Katie Allen
- University of Nevada, 1664 North Virginia Street, Mailstop 0152, Reno, NV, 89557, USA.
| | - Kristine Galek
- University of Nevada, 1664 North Virginia Street, Mailstop 0152, Reno, NV, 89557, USA
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Sammour I, Karnati S. Non-invasive Respiratory Support of the Premature Neonate: From Physics to Bench to Practice. Front Pediatr 2020; 8:214. [PMID: 32457860 PMCID: PMC7227410 DOI: 10.3389/fped.2020.00214] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/09/2020] [Indexed: 12/04/2022] Open
Abstract
Premature births continue to rise globally with a corresponding increase in various morbidities among this population. Rates of respiratory distress syndrome and the consequent development of Bronchopulmonary Dysplasia (BPD) are highest among the extremely preterm infants. The majority of extremely low birth weight premature neonates need some form of respiratory support during their early days of life. Invasive modes of respiratory assistance have been popular amongst care providers for many years. However, the practice of prolonged invasive mechanical ventilation is associated with an increased likelihood of developing BPD along with other comorbidities. Due to the improved understanding of the pathophysiology of BPD, and technological advances, non-invasive respiratory support is gaining popularity; whether as an initial mode of support, or for post-extubation of extremely preterm infants with respiratory insufficiency. Due to availability of a wide range of modalities, wide variations in practice exist among care providers. This review article aims to address the physical and biological basis for providing non-invasive respiratory support, the current clinical evidence, and the most recent developments in this field of Neonatology.
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Affiliation(s)
- Ibrahim Sammour
- Department of Neonatology, Lerner College of Medicine, Pediatric Institute, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, OH, United States
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Moresco L, Romantsik O, Calevo MG, Bruschettini M. Non-invasive respiratory support for the management of transient tachypnea of the newborn. Cochrane Database Syst Rev 2020; 4:CD013231. [PMID: 32302428 PMCID: PMC7164572 DOI: 10.1002/14651858.cd013231.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Transient tachypnea of the newborn (TTN) is characterized by tachypnea and signs of respiratory distress. Transient tachypnea typically appears within the first two hours of life in term and late preterm newborns. Supportive management might be sufficient. Non-invasive (i.e. without endotracheal intubation) respiratory support may, however, be administered to reduce respiratory distress during TTN. In addition, non-invasive respiratory support might improve clearance of lung liquid thus reducing the effort required to breathe, improving respiratory distress and potentially reducing the duration of tachypnea. OBJECTIVES To assess benefits and harms of non-invasive respiratory support for the management of transient tachypnea of the newborn. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 2), MEDLINE (1996 to 19 February 2019), Embase (1980 to 19 February 2019) and CINAHL (1982 to 19 February 2019). We applied no language restrictions. We searched clinical trial registries for ongoing studies. SELECTION CRITERIA Randomized controlled trials, quasi-randomized controlled trials and cluster trials on non-invasive respiratory support provided to infants born at 34 weeks' gestational age or more and less than three days of age with transient tachypnea of the newborn. DATA COLLECTION AND ANALYSIS For each of the included trials, two review authors independently extracted data (e.g. number of participants, birth weight, gestational age, duration of oxygen therapy, need for continuous positive airway pressure [CPAP] and need for mechanical ventilation, duration of mechanical ventilation, etc.) and assessed the risk of bias (e.g. adequacy of randomization, blinding, completeness of follow-up). The primary outcomes considered in this review were need for mechanical ventilation and pneumothorax. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included three trials (150 infants) comparing either CPAP to free-flow oxygen, nasal intermittent mandatory ventilation to nasal CPAP, or nasal high-frequency percussive ventilation versus nasal CPAP. Due to these different comparisons and to high clinical heterogeneity in the baseline clinical characteristics, we did not pool the three studies. The use of CPAP versus free oxygen did not improve the primary outcomes of this review: need for mechanical ventilation (risk ratio [RR] 0.30, 95% confidence interval [CI] 0.01 to 6.99; 1 study, 64 participants); and pneumothorax (not estimable, no cases occurred). Among secondary outcomes, CPAP reduced the duration of tachypnea as compared to free oxygen (mean difference [MD] -21.10 hours, 95% CI -22.92 to -19.28; 1 study, 64 participants). Nasal intermittent ventilation did not reduce the need for mechanical ventilation as compared with CPAP (RR 4.00, 95% CI 0.49 to 32.72; 1 study, 40 participants) or the incidence of pneumothorax (RR 1.00, 95% CI 0.07 to 14.90; 1 study, 40 participants); duration of tachypnea did not differ (MD 4.30, 95% CI -19.14 to 27.74; 1 study, 40 participants). In the study comparing nasal high-frequency ventilation to CPAP, no cases of mechanical ventilation of pneumothorax occurred (not estimable; 1 study, 46 participants); duration of tachypnea was reduced in the nasal high-frequency ventilation group (MD -4.53, 95% CI -5.64 to -3.42; 1 study, 46 participants). The quality of the evidence was very low due to the imprecision of the estimates and unclear risk of bias for detection bias and high risk of bias for reporting bias. Tests for heterogeneity were not applicable for any of the analyses as no studies were pooled. Two trials are ongoing. AUTHORS' CONCLUSIONS There is insufficient evidence to establish the benefit and harms of non-invasive respiratory support in the management of transient tachypnea of the newborn. Though two of the included trials showed a shorter duration of tachypnea, clinically relevant outcomes did not differ amongst the groups. Given the limited and low quality of the evidence available, it was impossible to determine whether non-invasive respiratory support was safe or effective for the treatment of transient tachypnea of the newborn.
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Affiliation(s)
- Luca Moresco
- Ospedale San PaoloPediatric and Neonatology UnitSavonaItaly
| | - Olga Romantsik
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics Unit, IRCCSGenoaItaly16147
| | - Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
- Skåne University HospitalCochrane SwedenWigerthuset, Remissgatan 4, First FloorRoom 11‐221LundSweden22185
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Behnke J, Lemyre B, Czernik C, Zimmer KP, Ehrhardt H, Waitz M. Non-Invasive Ventilation in Neonatology. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:177-183. [PMID: 31014448 DOI: 10.3238/arztebl.2019.0177] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 05/29/2018] [Accepted: 01/21/2019] [Indexed: 01/02/2023]
Abstract
BACKGROUND Invasive mechanical ventilation (IMV) has been replaced by early continuous positive airway pressure (CPAP) in the treatment of respiratory distress syndrome (RDS) in preterm infants aiming to reduce the rate of bronchopulmonary dysplasia (BPD). Subsequently, modern non-invasive ventilation strategies (NIV) were introduced into clinical practice with limited evidence of effects on pulmonary and neurodevelopmental outcomes. METHODS We performed a selective literature search in PubMed including randomized controlled trials (RCT) (n ≥ 200) and meta-analyses published in the field of NIV in neonatology and follow-up studies focusing on long term pulmonary and neurodevelopmental outcomes. RESULTS Individual studies do not show a significant risk reduction for the combined endpoint death or BPD in preterm infants caused by early CPAP in RDS when compared to primary intubation. One meta-analysis comparing four studies found CPAP significantly reduces the risk of BPD or death (relative risk: 0.91; 95% confidence interval [0.84;0.99]). Nasal intermittent positive pressure ventilation (NIPPV) as a primary ventilation strategy reduces the rate of intubations in infants with RDS (RR: 0.78 [0.64;0.94]) when compared to CPAP but does not affect the rate of BPD (RR: 0.78 [0.58;1.06]). CONCLUSION Early CPAP reduces the need for IMV and the risk of BPD or death in preterm infants with RDS. NIPPV may offer advantages over CPAP regarding intubation rates. Networking-based follow-up programs are required to assess the effect of NIV on long term pulmonary and neurodevelopmental outcomes.
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Affiliation(s)
- Judith Behnke
- Department of General Pediatrics & Neonatology, Center for Pediatrics and Youth Medicine, Justus Liebig University of Giessen; Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada; Department of Neonatology, Charité-Universitätsmedizin Berlin, Berlin; Member of the German Lung Research Center (DZL), Giessen
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Bruschettini M, Hassan KO, Romantsik O, Banzi R, Calevo MG, Moresco L. Interventions for the management of transient tachypnoea of the newborn - an overview of systematic reviews. Hippokratia 2020. [DOI: 10.1002/14651858.cd013563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Matteo Bruschettini
- Lund University, Skåne University Hospital; Department of Clinical Sciences Lund, Paediatrics; Lund Sweden
- Skåne University Hospital; Cochrane Sweden; Wigerthuset, Remissgatan 4, first floor room 11-221 Lund Sweden 22185
| | | | - Olga Romantsik
- Lund University, Skåne University Hospital; Department of Clinical Sciences Lund, Paediatrics; Lund Sweden
| | - Rita Banzi
- IRCCS - Mario Negri Institute for Pharmacological Research; Laboratory of Regulatory Policies; via G La Masa 19 Milan Italy 20156
| | - Maria Grazia Calevo
- Istituto Giannina Gaslini; Epidemiology, Biostatistics Unit, IRCCS; Genoa Italy 16147
| | - Luca Moresco
- Ospedale San Paolo; Pediatric and Neonatology Unit; Savona Italy
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Goel D, Oei JL, Smyth J, Schindler T. Diaphragm-triggered non-invasive respiratory support in preterm infants. Cochrane Database Syst Rev 2020; 3:CD012935. [PMID: 32176939 PMCID: PMC7075711 DOI: 10.1002/14651858.cd012935.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Diaphragm-triggered non-invasive respiratory support, commonly referred to as NIV-NAVA (non-invasive neurally adjusted ventilatory assist), uses the electrical activity of the crural diaphragm to trigger the start and end of a breath. It provides variable inspiratory pressure that is proportional to an infant's changing inspiratory effort. NIV-NAVA has the potential to provide effective, non-invasive, synchronised, multilevel support and may reduce the need for invasive ventilation; however, its effects on short- and long-term outcomes, especially in the preterm infant, are unclear. OBJECTIVES To assess the effectiveness and safety of diaphragm-triggered non-invasive respiratory support in preterm infants (< 37 weeks' gestation) when compared to other non-invasive modes of respiratory support (nasal intermittent positive pressure ventilation (NIPPV); nasal continuous positive airway pressure (nCPAP); high-flow nasal cannulae (HFNC)), and to assess preterm infants with birth weight less than 1000 grams or less than 28 weeks' corrected gestation at the time of intervention as a sub-group. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 5), MEDLINE via PubMed (1946 to 10 May 2019), Embase (1947 to 10 May 2019), and CINAHL (1982 to 10 May 2019). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that compared diaphragm-triggered non-invasive versus other non-invasive respiratory support in preterm infants. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed trial quality and extracted data from included studies. We performed fixed-effect analyses and expressed treatment effects as mean difference (MD), risk ratio (RR), and risk difference (RD) with 95% confidence intervals (CIs). We used the generic inverse variance method to analyse specific outcomes for cross-over trials. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS There were two small randomised controlled trials including a total of 23 infants eligible for inclusion in the review. Only one trial involving 16 infants included in the analysis reported on either of the primary outcomes of the review. This found no difference in failure of modality between NIV-NAVA and NIPPV (RR 0.33, 95% CI 0.02 to 7.14; RD -0.13, 95% CI -0.41 to 0.16; 1 study, 16 infants; heterogeneity not applicable). Both trials reported on secondary outcomes of the review, specific for cross-over trials (total 22 infants; 1 excluded due to failure of initial modality). One study involving seven infants reported a significant reduction in maximum FiO₂ with NIV-NAVA compared to NIPPV (MD -4.29, 95% CI -5.47 to -3.11; heterogeneity not applicable). There was no difference in maximum electric activity of the diaphragm (Edi) signal between modalities (MD -1.75, 95% CI -3.75 to 0.26; I² = 0%) and a significant increase in respiratory rate with NIV-NAVA compared to NIPPV (MD 7.22, 95% CI 0.21 to 14.22; I² = 72%) on a meta-analysis of two studies involving a total of 22 infants. The included studies did not report on other outcomes of interest. AUTHORS' CONCLUSIONS Due to limited data and very low certainty evidence, we were unable to determine if diaphragm-triggered non-invasive respiratory support is effective or safe in preventing respiratory failure in preterm infants. Large, adequately powered randomised controlled trials are needed to determine if diaphragm-triggered non-invasive respiratory support in preterm infants is effective or safe.
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Affiliation(s)
- Dimple Goel
- Westmead HospitalNeonatal Intensive CareHawkesbury Rd & Darcy RoadWestmeadNSWAustralia2145
| | - Ju Lee Oei
- Royal Hospital for WomenNewborn CareBarker StreetRandwickNSWAustralia2031
| | - John Smyth
- Royal Hospital for WomenNewborn CareBarker StreetRandwickNSWAustralia2031
| | - Tim Schindler
- Royal Hospital for WomenNewborn CareBarker StreetRandwickNSWAustralia2031
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Nasef N, Rashed HM, Aly H. Practical aspects on the use of non-invasive respiratory support in preterm infants. Int J Pediatr Adolesc Med 2020; 7:19-25. [PMID: 32373698 PMCID: PMC7193067 DOI: 10.1016/j.ijpam.2020.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Preterm infants frequently present with respiratory insufficiency requiring respiratory assistance. Invasive mechanical ventilation has been associated with several short and long term complications. Therefore, the practice of early use of non-invasive ventilation has been adopted. Nasal CPAP proved efficacy as an initial therapy for preterm infants. Non-invasive positive pressure ventilation is an alternative used to mitigate CPAP failure in infants with apnea or increased work of breathing. High flow nasal cannula gained popularity primarily due to the ease of its use, despite multiple prominent trials that demonstrated its inferiority. Bi-level positive airway pressure and neurally adjusted non-invasive ventilatory are used in infants with apnea and increased work of breathing. The effectiveness of non invasive ventilation tools can be augmented by having a proper protocol for initiation, weaning, skin care, positioning, and developmental care during their application.
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Affiliation(s)
- Nehad Nasef
- Neonatal Intensive Care Unit, Mansora University Children's Hospital, Mansoura, Egypt.,Department of Pediatrics, Faculty of Medicine, University of Mansoura, Egypt
| | - Hend Me Rashed
- School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
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Kanbar LJ, Shalish W, Latremouille S, Rao S, Brown KA, Kearney RE, Sant’Anna GM. Cardiorespiratory behavior of preterm infants receiving continuous positive airway pressure and high flow nasal cannula post extubation: randomized crossover study. Pediatr Res 2020; 87:62-68. [PMID: 31277077 PMCID: PMC7222114 DOI: 10.1038/s41390-019-0494-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/24/2019] [Accepted: 06/20/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) and high flow nasal cannula (HFNC) are modes of non-invasive respiratory support commonly used after extubation in extremely preterm infants. However, the cardiorespiratory physiology of these infants on each mode is unknown. METHODS Prospective, randomized crossover study in infants with birth weight ≤1250 g undergoing their first extubation attempt. NCPAP and HFNC were applied randomly for 45 min each, while ribcage and abdominal movements, electrocardiogram, oxygen saturation, and fraction of inspired oxygen (FiO2) were recorded. Respiratory signals were analyzed using an automated method, and differences between NCPAP and HFNC features and changes in FiO2 were analyzed. RESULTS A total of 30 infants with median [interquartile range] gestational age of 27 weeks [25.7, 27.9] and birth weight of 930 g [780, 1090] were studied. Infants were extubated at 5 days [2, 13] of life with 973 g [880, 1170] and three failed (10%). No differences in cardiorespiratory behavior were noted, except for longer respiratory pauses (9.2 s [5.0, 11.5] vs. 7.3 s [4.6, 9.3]; p = 0.04) and higher FiO2 levels (p = 0.02) during HFNC compared to NCPAP. CONCLUSIONS In extremely preterm infants studied shortly after extubation, the use of HFNC was associated with longer respiratory pauses and higher FiO2 requirements.
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Affiliation(s)
- Lara J. Kanbar
- Department of Biomedical Engineering, Montreal, QC Canada
| | - Wissam Shalish
- Department of Pediatrics, Neonatal Division, Montreal, QC Canada
| | | | - Smita Rao
- Department of Pediatrics, Neonatal Division, Montreal, QC Canada
| | - Karen A. Brown
- 0000 0004 1936 8649grid.14709.3bDepartment of Anesthesia, McGill University, Montreal, QC Canada
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Gibbons JTD, Wilson AC, Simpson SJ. Predicting Lung Health Trajectories for Survivors of Preterm Birth. Front Pediatr 2020; 8:318. [PMID: 32637389 PMCID: PMC7316963 DOI: 10.3389/fped.2020.00318] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/18/2020] [Indexed: 11/13/2022] Open
Abstract
Rates of preterm birth (<37 weeks of gestation) are increasing worldwide. Improved perinatal care has markedly increased survival of very (<32 weeks gestation) and extremely (<28 weeks gestation) preterm infants, however, long term respiratory sequalae are common among survivors. Importantly, individual's lung function trajectories are determined early in life and tend to track over the life course. Preterm infants are impacted by antenatal, postnatal and early life perturbations to normal lung growth and development, potentially resulting in significant shifts from the "normal" lung function trajectory. This review summarizes what is currently known about the long-term lung function trajectories in survivors of preterm birth. Further, this review highlights how antenatal, perinatal and early life factors are likely to contribute to individual lung health trajectories across the life course.
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Affiliation(s)
- James T D Gibbons
- Telethon Kids Institute, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia.,Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia
| | - Andrew C Wilson
- Telethon Kids Institute, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia.,Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, WA, Australia
| | - Shannon J Simpson
- Telethon Kids Institute, Perth, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, WA, Australia
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Liew Z, Fenton AC, Harigopal S, Gopalakaje S, Brodlie M, O’Brien CJ. Physiological effects of high-flow nasal cannula therapy in preterm infants. Arch Dis Child Fetal Neonatal Ed 2020; 105:87-93. [PMID: 31123057 PMCID: PMC6951230 DOI: 10.1136/archdischild-2018-316773] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 04/27/2019] [Accepted: 05/03/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE High-flow nasal cannula (HFNC) therapy is increasingly used in preterm infants despite a paucity of physiological studies. We aimed to investigate the effects of HFNC on respiratory physiology. STUDY DESIGN A prospective randomised crossover study was performed enrolling clinically stable preterm infants receiving either HFNC or nasal continuous positive airway pressure (nCPAP). Infants in three current weight groups were studied: <1000 g, 1000-1500 g and >1500 g. Infants were randomised to either first receive HFNC flows 8-2 L/min and then nCPAP 6 cm H2O or nCPAP first and then HFNC flows 8-2 L/min. Nasopharyngeal end-expiratory airway pressure (pEEP), tidal volume, dead space washout by nasopharyngeal end-expiratory CO2 (pEECO2), oxygen saturation and vital signs were measured. RESULTS A total of 44 preterm infants, birth weights 500-1900 g, were studied. Increasing flows from 2 to 8 L/min significantly increased pEEP (mean 2.3-6.1 cm H2O) and reduced pEECO2 (mean 2.3%-0.9%). Tidal volume and transcutaneous CO2 were unchanged. Significant differences were seen between pEEP generated in open and closed mouth states across all HFNC flows (difference 0.6-2.3 cm H2O). Infants weighing <1000 g received higher pEEP at the same HFNC flow than infants weighing >1000 g. Variability of pEEP generated at HFNC flows of 6-8 L/min was greater than nCPAP (2.4-13.5 vs 3.5-9.9 cm H2O). CONCLUSIONS HFNC therapy produces clinically significant pEEP with large variability at higher flow rates. Highest pressures were observed in infants weighing <1000 g. Flow, weight and mouth position are all important determinants of pressures generated. Reductions in pEECO2 support HFNC's role in dead space washout.
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Affiliation(s)
- Zheyi Liew
- Paediatric Respiratory Medicine, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Alan C Fenton
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK,Newcastle University, Newcastle upon Tyne, UK
| | - Sundeep Harigopal
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK,Newcastle University, Newcastle upon Tyne, UK
| | - Saikiran Gopalakaje
- Paediatric Respiratory Medicine, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Malcolm Brodlie
- Paediatric Respiratory Medicine, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher J O’Brien
- Paediatric Respiratory Medicine, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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50
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Shi Y, Muniraman H, Biniwale M, Ramanathan R. A Review on Non-invasive Respiratory Support for Management of Respiratory Distress in Extremely Preterm Infants. Front Pediatr 2020; 8:270. [PMID: 32548084 PMCID: PMC7270199 DOI: 10.3389/fped.2020.00270] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Abstract
Majority of extremely preterm infants require positive pressure ventilatory support at the time of delivery or during the transitional period. Most of these infants present with respiratory distress (RD) and continue to require significant respiratory support in the neonatal intensive care unit (NICU). Bronchopulmonary dysplasia (BPD) remains as one of the major morbidities among survivors of the extremely preterm infants. BPD is associated with long-term adverse pulmonary and neurological outcomes. Invasive mechanical ventilation (IMV) and supplemental oxygen are two major risk factors for the development of BPD. Non-invasive ventilation (NIV) has been shown to decrease the need for IMV and reduce the risk of BPD when compared to IMV. This article reviews respiratory management with current NIV support strategies in extremely preterm infants both in delivery room as well as in the NICU and discusses the evidence to support commonly used NIV modes including nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), bi-level positive pressure (BI-PAP), high flow nasal cannula (HFNC), and newer NIV strategies currently being studied including, nasal high frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Randomized, clinical trials have shown that early NIPPV is superior to NCPAP to decrease the need for intubation and IMV in preterm infants with RD. It is also important to understand that selection of the device used to deliver NIPPV has a significant impact on its success. Ventilator generated NIPPV results in significantly lower rates of extubation failures when compared to Bi-PAP. Future studies should address synchronized NIPPV including NIV-NAVA and early rescue use of NHFV in the respiratory management of extremely preterm infants.
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Affiliation(s)
- Yuan Shi
- Ministry of Education Key Laboratory of Child Development and Disorders, Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hemananda Muniraman
- Department of Pediatrics, Creighton School of Medicine, Omaha, NE, United States
| | - Manoj Biniwale
- Neonatology Association Limited, Obstetrix Medical Group of Phoenix, Mednax, Arizona, AZ, United States
| | - Rangasamy Ramanathan
- Division of Neonatology, LAC+USC Medical Center, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
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