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Protain A, Firestone K, Hussain S, Lubarsky D, Stein H. Evaluation of NAVA-PAP in premature neonates with apnea of prematurity: minimal backup ventilation and clinically significant events. Front Pediatr 2023; 11:1234964. [PMID: 37868266 PMCID: PMC10587435 DOI: 10.3389/fped.2023.1234964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Background Neonates with apnea of prematurity (AOP) clinically deteriorate because continuous positive airway pressure (CPAP) provides inadequate support during apnea. Neurally adjusted ventilatory assist (NAVA) provides proportional ventilator support from the electrical activity of the diaphragm. When the NAVA level is 0 cmH2O/mcV (NAVA-PAP), patients receive CPAP when breathing and backup ventilation when apneic. This study evaluates NAVA-PAP and time spent in backup ventilation. Methods This was a prospective, two-center, observational study of preterm neonates on NAVA-PAP for AOP. Ventilator data were downloaded after 24 h. The number of clinically significant events (CSEs) was collected. A paired t-test was used to perform statistical analysis. Results The study was conducted on 28 patients with a gestational age of 25 ± 1.8 weeks and a study age of 28 ± 23 days. The number of CSEs was 4 ± 4.39/24 h. The patients were on NAVA-PAP for approximately 90%/min, switched to backup mode 2.5 ± 1.1 times/min, and spent 10.6 ± 7.2% in backup. Conclusion Preterm neonates on NAVA-PAP had few CSEs with minimal time in backup ventilation.
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Affiliation(s)
- Alison Protain
- Pediatrix Medical Group Akron Ohio, Akron Children’s Hospital, Akron, OH, United States
| | - Kimberly Firestone
- Department of Neonatology, Akron Children’s Hospital, Akron, OH, United States
| | - Saima Hussain
- Department of Pediatrics, ProMedica Russell J. Ebeid Children’s Hospital, Toledo, OH, United States
| | - Daniel Lubarsky
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, United States
| | - Howard Stein
- Northwest Ohio Neonatal Associates, ProMedica Russell J. Ebeid Children’s Hospital, Toledo, OH, United States
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Ultrasonographic assessment of diaphragmatic function in preterm infants on non-invasive neurally adjusted ventilatory assist (NIV-NAVA) compared to nasal intermittent positive-pressure ventilation (NIPPV): a prospective observational study. Eur J Pediatr 2023; 182:731-739. [PMID: 36459227 PMCID: PMC9717554 DOI: 10.1007/s00431-022-04738-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 11/19/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022]
Abstract
NIV-NAVA mode for respiratory support in preterm infants is not well-studied. This study aimed to describe the diaphragmatic function, diaphragmatic excursion (DE), and thickness fraction (DTF), in preterm infants < 30 weeks' gestation supported by NIV-NAVA compared to NIPPV using bedside ultrasonography. In this consecutive prospective study, DE, diaphragmatic thickness at end of expiration (DTexp), end of inspiration (DTins), and DTF were assessed using bedside ultrasound. Lung aeration evaluation using lung ultrasound score (LUS) was performed for the two groups. Diaphragmatic measurements and LUS were compared for the 2 groups (NIV-NAVA group versus NIPPV group). Statistical analyses were conducted using the SPSS software version 22. Out of 70 infants evaluated, 40 were enrolled. Twenty infants were on NIV-NAVA and 20 infants on NIPPV with a mean [SD] study age of 25.7 [0.9] weeks and 25.1 [1.4] weeks respectively (p = 0.15). Baseline characteristics and respiratory parameters at the time of the scan showed no significant difference between groups. DE was significantly higher in NIV-NAVA with a mean SD of 4.7 (1.5) mm versus 3.5 (0.9) mm in NIPPV, p = 0.007. Additionally, the mean (SD) of DTF for the NIV-NAVA group was 81.6 (30) % vs 78.2 (27) % for the NIPPV group [p = 0.71]. Both groups showed relatively high LUS but no significant difference between groups [12.8 (2.6) vs 12.6 (2.6), p = 0.8]. Conclusion: Preterm infants managed with NIV-NAVA showed significantly higher DE compared to those managed on NIPPV. This study raises the hypothesis that NIV-NAVA could potentially improve diaphragmatic function due to its synchronization with patients' own breathing. Longitudinal studies to assess diaphragmatic function over time are needed. Trial registry: Clinicaltrials.gov (NCT05079412). Date of registration September 30, 2021. What is Known: • NIV-NAVA utilizes diaphragmatic electrical activity to provide synchronized breathing support. • Evidence for the effect of NIV-NAVA on diaphragmatic thickness fraction (DTF) and excursion (DE) is limited. What is New: • Ultrasonographic assessment of diaphragmatic function (DTF and DE) is feasible. • In preterm infants, DE was significantly higher in infants supported with NIV-NAVA compared to those supported with NIPPV.
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Boel L, Hixson T, Brown L, Sage J, Kotecha S, Chakraborty M. Non-invasive respiratory support in preterm infants. Paediatr Respir Rev 2022; 43:53-59. [PMID: 35562288 DOI: 10.1016/j.prrv.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 04/12/2022] [Indexed: 12/25/2022]
Abstract
Survival of preterm infants has increased steadily over recent decades, primarily due to improved outcomes for those born before 28 weeks of gestation. However, this has not been matched by similar improvements in longer-term morbidity. One of the key long-term sequelae of preterm birth remains bronchopulmonary dysplasia (also called chronic lung disease of prematurity), contributed primarily by the effect of early pulmonary inflammation superimposed on immature lungs. Non-invasive modes of respiratory support have been rapidly introduced providing modest success in reducing the incidence of bronchopulmonary dysplasia when compared with invasive mechanical ventilation, and improved clinical practice has been reported from population-based studies. We present a comprehensive review of the key modes of non-invasive respiratory support currently used in preterm infants, including their mechanisms of action and evidence of benefit from clinical trials.
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Affiliation(s)
- Lieve Boel
- Neonatal Intensive Care Unit, Queen Alexandra Hospital, Portsmouth, UK
| | - Thomas Hixson
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Lisa Brown
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Jayne Sage
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK
| | - Sailesh Kotecha
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Mallinath Chakraborty
- Regional Neonatal Intensive Care Unit, University Hospital of Wales, Cardiff, UK; Centre for Medical Education, School of Medicine, Cardiff University, Cardiff, UK.
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NIV-NAVA versus NCPAP immediately after birth in premature infants: A randomized controlled trial. Respir Physiol Neurobiol 2022; 302:103916. [PMID: 35500883 DOI: 10.1016/j.resp.2022.103916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/04/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate whether noninvasive-neurally adjusted ventilatory assist (NIV-NAVA) decrease respiratory efforts compared to nasal continuous positive airway pressure (NCPAP) during the first hours of life. METHODS Twenty infants born between 28+0 and 31+6 weeks were randomized to NIV-NAVA or NCPAP. Positive end-expiratory pressure was constantly kept at 6 cmH2O for both groups and the NAVA level was 1.0 cmH2O/µV for NIV-NAVA group. The electrical activity of diaphragm (Edi) were recorded for the first two hours. RESULTS Peak and minimum Edi decreased similarly in both groups (P = 0.98 and P = 0.59, respectively). Leakages were higher in the NIV-NAVA group than in the NCPAP group (P < 0.001). The neural apnea defined as a flat Edi for ≥ 5 s were less frequent in NIV-NAVA group than in NCPAP group (P = 0.046). CONCLUSIONS Immediately applied NIV-NAVA in premature infants did not reduce breathing effort, measured as peak Edi. However, NIV-NAVA decreased neural apneic episodes compared to NCPAP.
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Chen IL, Chen HL. New developments in neonatal respiratory management. Pediatr Neonatol 2022; 63:341-347. [PMID: 35382987 DOI: 10.1016/j.pedneo.2022.02.002] [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: 09/26/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/19/2022] Open
Abstract
Respiratory distress syndrome (RDS) is the major cause of respiratory failure in preterm infants due to immature lung development and surfactant deficiency. Although the concepts and methods of managing respiratory problems in neonates have changed continuously, determining appropriate respiratory treatment with minimal ventilation-induced lung injury and complications is crucially important. This review summarizes neonatal respiratory therapy's advances and available strategies (i.e., exogenous surfactant therapy, noninvasive ventilation, and different ventilation modes), focusing on RDS management.
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Affiliation(s)
- I-Ling Chen
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, San Ming District, Kaohsiung, Taiwan
| | - Hsiu-Lin Chen
- Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, San Ming District, Kaohsiung, Taiwan; Department of Pediatrics, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, San Ming District, Kaohsiung, Taiwan.
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Piątek K, Lehtonen L, Parikka V, Setänen S, Soukka H. Implementation of neurally adjusted ventilatory assist and high flow nasal cannula in very preterm infants in a tertiary level NICU. Pediatr Pulmonol 2022; 57:1293-1302. [PMID: 35243818 PMCID: PMC9314087 DOI: 10.1002/ppul.25879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 01/26/2022] [Accepted: 02/27/2022] [Indexed: 11/11/2022]
Abstract
Preterm infants treated with invasive ventilation are often affected by bronchopulmonary dysplasia, brain structure alterations, and later neurodevelopmental impairment. We studied the implementation of neurally adjusted ventilatory assist (NAVA) and high flow nasal cannula (HFNC) in a level III neonatal unit, and its effects on pulmonary and central nervous system outcomes. This retrospective cohort study included 193 surviving infants born below 32 weeks of gestation in preimplementation (2007-2008) and postimplementation (2016-2017) periods in a single study center in Finland. The proportion of infants requiring invasive ventilation decreased from 67% in the pre- to 48% in the postimplementation period (p = 0.009). Among infants treated with invasive ventilation, 68% were treated with NAVA after its implementation. At the same time, the duration of invasive ventilation of infants born at or below 28 weeks increased threefold compared with the preimplementation period (p = 0.042). The postimplementation period was characterized by a gradual replacement of nasal continuous positive airway pressure (nCPAP) with HFNC, earlier discontinuation of nCPAP, but a longer duration of positive pressure support. The proportion of normal magnetic resonance imaging (MRI) findings at term corrected age increased from 62% to 84% (p = 0.018). Cognitive outcome improved by one standard score between the study periods (p = 0.019). NAVA was used as the primary mode of ventilation in the postimplementation period. During this period, invasive ventilation time was significantly prolonged. HFNC led to a decrease in the use of nCPAP. The change in the respiratory support might have contributed to the improvement in brain MRI findings and cognitive outcomes.
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Affiliation(s)
- Katarzyna Piątek
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Liisa Lehtonen
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Vilhelmiina Parikka
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Sirkku Setänen
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
- Department of Pediatric NeurologyTurku University HospitalTurkuFinland
| | - Hanna Soukka
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
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Abstract
Patient-ventilator asynchrony is very common in newborns. Achieving synchrony is quite challenging because of small tidal volumes, high respiratory rates, and the presence of leaks. Leaks also cause unreliable monitoring of respiratory metrics. In addition, ventilator adjustment must take into account that infants have strong vagal reflexes and demonstrate central apnea and periodic breathing, with a high variability in breathing pattern. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation whereby the timing and amount of ventilatory assist is controlled by the patient's own neural respiratory drive. As NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized assist, both invasively and noninvasively (NIV-NAVA), to follow the variability in breathing pattern, and to monitor patient respiratory drive, independent of leaks. This article provides an updated review of the physiology and the scientific literature pertaining to the use of NAVA in children (neonatal and pediatric age groups). Both the invasive NAVA and NIV-NAVA publications since 2016 are summarized, as well as the use of Edi monitoring. Overall, the use of NAVA and Edi monitoring is feasible and safe. Compared with conventional ventilation, NAVA improves patient-ventilator interaction, provides lower peak inspiratory pressure, and lowers oxygen requirements. Evidence from several studies suggests improved comfort, less sedation requirements, less apnea, and some trends toward reduced length of stay and more successful extubation.
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Affiliation(s)
- Jennifer Beck
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Christer Sinderby
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Abstract
Avoiding MV is a critical goal in neonatal respiratory care. Different modes of noninvasive respiratory support beyond nasal CPAP, such as nasal intermittent positive pressure ventilation (NIPPV) and synchronized NIPPV (SNIPPV), may further reduce intubation rates. SNIPPV offers consistent benefits over nonsynchronized techniques such as a more efficient positive pressure transmission to the lung, an effective increase in transpulmonary pressure during ventilation, and a better stabilization of the chest wall during inspiration. This review discusses mechanisms of action, benefits and limitations of synchronized noninvasive ventilation, describes the different modes of synchronization, and analyzes properties and clinical results.
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Affiliation(s)
- Corrado Moretti
- Department of Paediatrics, Policlinico Umberto I, Sapienza University of Rome, Viale Regina Elena 324, Rome 00185, Italy
| | - Camilla Gizzi
- Paediatric and Neonatology Unit, "Sandro Pertini" Hospital, Via Monti Tiburtini 385, Rome 00157, Italy.
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Williamson M, Poorun R, Hartley C. Apnoea of Prematurity and Neurodevelopmental Outcomes: Current Understanding and Future Prospects for Research. Front Pediatr 2021; 9:755677. [PMID: 34760852 PMCID: PMC8573333 DOI: 10.3389/fped.2021.755677] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/27/2021] [Indexed: 11/13/2022] Open
Abstract
Infants who are born prematurely are at significant risk of apnoea. In addition to the short-term consequences such as hypoxia, apnoea of prematurity has been associated with long-term morbidity, including poor neurodevelopmental outcomes. Clinical trials have illustrated the importance of methylxanthine drugs, in particular caffeine, in reducing the risk of long term adverse neurodevelopmental outcomes. However, the extent to which apnoea is causative of this secondary neurodevelopmental delay or is just associated in a background of other sequelae of prematurity remains unclear. In this review, we first discuss the pathophysiology of apnoea of prematurity, previous studies investigating the relationship between apnoea and neurodevelopmental delay, and treatment of apnoea with caffeine therapy. We propose a need for better methods of measuring apnoea, along with improved understanding of the neonatal brain's response to consequent hypoxia. Only then can we start to disentangle the effects of apnoea on neurodevelopment in preterm infants. Moreover, by better identifying those infants who are at risk of apnoea, and neurodevelopmental delay, we can work toward a risk stratification system for these infants that is clinically actionable, for example, with doses of caffeine tailored to the individual. Optimising treatment of apnoea for individual infants will improve neonatal care and long-term outcomes for this population.
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Affiliation(s)
- Max Williamson
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Ravi Poorun
- Department of Paediatrics, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Caroline Hartley
- Department of Paediatrics, University of Oxford, Oxford, United Kingdom
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Immature control of breathing and apnea of prematurity: the known and unknown. J Perinatol 2021; 41:2111-2123. [PMID: 33712716 PMCID: PMC7952819 DOI: 10.1038/s41372-021-01010-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 02/05/2021] [Accepted: 02/16/2021] [Indexed: 02/05/2023]
Abstract
This narrative review provides a broad perspective on immature control of breathing, which is universal in infants born premature. The degree of immaturity and severity of clinical symptoms are inversely correlated with gestational age. This immaturity presents as prolonged apneas with associated bradycardia or desaturation, or brief respiratory pauses, periodic breathing, and intermittent hypoxia. These manifestations are encompassed within the clinical diagnosis of apnea of prematurity, but there is no consensus on minimum criteria required for diagnosis. Common treatment strategies include caffeine and noninvasive respiratory support, but other therapies have also been advocated with varying effectiveness. There is considerable variability in when and how to initiate and discontinue treatment. There are significant knowledge gaps regarding effective strategies to quantify the severity of clinical manifestations of immature breathing, which prevent us from better understanding the long-term potential adverse outcomes, including neurodevelopment and sudden unexpected infant death.
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Auten RL. Pediatric Pulmonology 2019 year in review: Neonatal pulmonology. Pediatr Pulmonol 2020; 55:1563-1566. [PMID: 32353217 DOI: 10.1002/ppul.24803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/23/2020] [Accepted: 04/23/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Richard L Auten
- Women's and Children's Center Moses H. Cone Hospital, Greensboro, North Carolina
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Firestone K, Horany BA, de Leon-Belden L, Stein H. Nasal continuous positive airway pressure versus noninvasive NAVA in preterm neonates with apnea of prematurity: a pilot study with a novel approach. J Perinatol 2020; 40:1211-1215. [PMID: 32218494 PMCID: PMC7223609 DOI: 10.1038/s41372-020-0661-x] [Citation(s) in RCA: 8] [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: 01/04/2020] [Revised: 03/02/2020] [Accepted: 03/11/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Neonates with apnea of prematurity often fail CPAP because it does not provide adequate support during apnea. NAVA provides proportional ventilator support based on electrical activity of the diaphragm. When the NAVA level is 0 cmH20/mcV, the patient receives minimal support above PEEP when breathing and backup ventilation when apneic. This study compares number of clinically significant events on CPAP versus noninvasive NAVA level 0. METHODS Retrospective study of preterm neonates having apnea of prematurity on nasal CPAP. Patients were then placed on NAVA level 0. The number of events on each mode was collected. Statistics were paired t-test. RESULTS Seventeen subjects with gestational age 26.1 ± 1.7 weeks, study age 19.5 ± 12.5 days. Events decreased from 17.9 ± 7.8 on CPAP to 10.2 ± 8.1 events on NAVA level 0 (p = 0.00047). CONCLUSIONS NAVA level 0 reduced the number of clinically significant events compared with CPAP in premature neonates with apnea of prematurity.
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Affiliation(s)
- Kimberly Firestone
- 0000 0000 9013 1194grid.413473.6Akron Children’s Hospital, Akron, OH USA
| | - Bassel Al Horany
- 0000 0004 0430 081Xgrid.414129.bValley Children’s Hospital, Madera, CA USA
| | | | - Howard Stein
- ProMedica Russell J. Ebeid Children's Hospital, Toledo, OH, USA. .,College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA.
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