Nasal high-frequency oscillatory ventilation versus nasal continuous positive airway pressure as primary respiratory support strategies for respiratory distress syndrome in preterm infants: a systematic review and meta-analysis

Noninvasive high-frequency oscillation ventilation as post- extubation respiratory support in neonates: Systematic review and meta-analysis

INTRODUCTION

Noninvasive High-Frequency Oscillatory Ventilation (NHFOV) is increasingly being adopted to reduce the need for invasive ventilation after extubation.

OBJECTIVES

To evaluate the benefits and harms of NHFOV as post-extubation respiratory support in newborns compared to other non-invasive respiratory support modes.

MATERIAL & METHODS

We included randomized controlled trials comparing NHFOV with other non-invasive modes post-extubation in newborns. Data sources were MEDLINE (via Pubmed), Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, WHO international clinical trials registry platform and Clinical Trial Registry, forward and backward citation search. Methodological quality of studies was assessed by Cochrane's Risk of Bias tool 1.0.

RESULTS

This systematic review included 21 studies and 3294 participants, the majority of whom were preterm. NHFOV compared to nasal continuous positive airway pressure (NCPAP) reduced reintubation within seven days (RR 0.34, 95% CI 0.22 to 0.53) after extubation. It also reduced extubation failure (RR 0.39, 95% CI 0.30 to 0.51) and reintubation within 72 hrs (RR 0.40, 95% CI 0.31 to 0.53), bronchopulmonary dysplasia (RR 0.59, 95% CI 0.37 to 0.94) and pulmonary air leak (RR 0.46, 95% CI 0.27 to 0.79) compared to NCPAP. The rate of reintubation within seven days (RR 0.62, 95% CI 0.18 to 2.14) was similar whereas extubation failure (RR 0.65, 95% CI 0.50 to 0.83) and reintubation (RR 0.68, 95% CI 0.52 to 0.89) within 72 hrs were lower in NHFOV group compared to nasal intermittent positive pressure ventilation. There was no effect on other outcomes. Overall quality of the evidence was low to very low in both comparisons.

CONCLUSIONS

NHFOV may reduce the rate of reintubation and extubation failure post-extubation without increasing complications. Majority of the trials were exclusively done in preterm neonates. Further research with high methodological quality is warranted.

Nasal High-Frequency Oscillatory Ventilation Use in Romanian Neonatal Intensive Care Units-The Results of a Recent Survey

BACKGROUND

Nasal high-frequency oscillatory ventilation (nHFOV) has emerged as an effective initial and rescue noninvasive respiratory support mode for preterm infants with respiratory distress syndrome (RDS); however, little is known about nHFOV use in Romanian neonatal intensive care units (NICUs).

OBJECTIVES

We aimed to identify the usage extent and clinical application of nHFOV in Romania.

METHODS

A structured web-based questionnaire was designed to find the rate of nHFOV use and knowledge of this new method of noninvasive respiratory support in Romanian level III NICUs. Using multiple-choice, open-ended, and yes/no questions, we collected information on the NICU's size, noninvasive respiratory support modes used, nHFOV use, indications, settings, nasal interfaces, secondary effects, and equipment used. Descriptive statistics and comparisons were performed using IBM SPSS Statistics 26.0.

RESULTS

A total of 21/23 (91.3%) leaders from level III NICUs (median [IQR] number of beds of 10 [10-17.5]) responded to the survey. The most frequently used noninvasive ventilation modes were CPAP mode on mechanical ventilators (76.2%), followed by NIPPV (76.2%); heated, humidified high-flow nasal cannula (HHHFNC) (61.9%); and nHFOV (11/21 units; 52.4%). A total of 5/11 units reported frequent nHFOV use (in two or more newborns/month) in both term and preterm infants. The main indications reported for nHFOV use were CPAP failure (90.9%), hypercapnia (81.8%), and bronchopulmonary dysplasia (72.7%). Face/nasal masks and short binasal prongs are the most commonly used nasal interfaces (90.9% and 72.7%, respectively). Air leaks at the interface level (90.9%), thick secretions (81.8%), and airway obstruction (63.6%) were the most frequently mentioned adverse effects of nHFOV. Only three of the NICUs had a written protocol for nHFOV use. Most units not yet using nHFOV cited lack of equipment, experience, training, or insufficient information and evidence for the clinical use and outcome of nHFOV use in neonates as the main reasons for not implementing this noninvasive respiratory mode.

CONCLUSIONS

Our survey showed that nHFOV is already used in more than half of the Romanian level III NICUs to support term and preterm infants with respiratory distress despite a lack of consensus regarding indications and settings during nHFOV.

Non-invasive high-frequency oscillatory ventilation (NHFOV) versus nasal continuous positive airway pressure (NCPAP) for preterm infants: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy and safety of non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) in preterm infants.

DESIGN

The study conducted a comprehensive analysis across three databases, namely EMBASE, MEDLINE and Cochrane Central, to identify randomised controlled trials comparing NHFOV and NCPAP. Statistical analysis was performed using Review Manager V.5.3 software.

MAIN OUTCOMES MEASURES

The primary outcomes of the study were the intubation or reintubation rate in the NHFOV and NCPAP groups. Additionally, secondary outcomes included the partial pressure of carbon dioxide levels and major complications associated with non-invasive respiratory support ventilation.

RESULTS

Ten randomised controlled studies, involving 2031 preterm infants, were included in this meta-analysis. When compared with NCPAP, NHFOV demonstrated a significant reduction in the intubation or reintubation rate (p<0.01, relative risk=0.45, 95% CI 0.37 to 0.55), and there was no statistical difference in related complications.

CONCLUSION

In preterm infants, NHFOV appears to be an effective intervention for decreasing the intubation or reintubation rate compared with NCPAP, with no increase in associated complications.

TRIAL REGISTRATION NUMBER

CRD42023403968.

Blinding Assessments in Neonatal Ventilation Meta-Analyses: A Systematic Meta-Epidemiological Review

INTRODUCTION

Randomization and blinding are generally important in randomized trials. In neonatology, blinding of ventilation strategies is unfeasible if not impossible and we hypothesized that its importance has been overestimated, while the peculiarities of the neonatal patient and the specific outcomes have not been considered.

METHODS

For this meta-epidemiological review, we searched PubMed and Scopus databases in November 2023. We included all meta-analyses focusing on ventilation, published in past 5 years, and reporting either mortality or bronchopulmonary dysplasia (BPD) as an outcome. We extracted the information about how the authors had analyzed risk of bias and evidence certainty.

RESULTS

We screened 494 abstracts and included 40 meta-analyses. Overall, 13 of the 40 reviews assessed blinding properly. Australian and European authors were most likely to perform correct assessment of the blinding (p = 0.03) and the use of RoB 2.0 tool was also associated with proper assessment (p < 0.001). In multivariate regression, the use of RoB 2.0 was the only factor associated with a proper assessment (Beta 0.57 [95% confidence interval: 0.29-0.99]). GRADE ratings were performed in 25 reviews, and the authors downgraded the evidence certainty due to risk of bias in 19 of these and none of these reviews performed the blinding assessment correctly.

CONCLUSION

In past neonatal evidence syntheses, the role of blinding has been mostly overestimated, which has led to downgrading of evidence certainty. Objective outcomes (such as mortality and BPD) do not need to be downgraded due to lack of blinding, as the knowledge of the received intervention does not influence the outcome assessment.

Non-invasive high-frequency ventilation in newborn infants with respiratory distress

BACKGROUND

Respiratory distress occurs in up to 7% of newborns, with respiratory support (RS) provided invasively via an endotracheal (ET) tube or non-invasively via a nasal interface. Invasive ventilation increases the risk of lung injury and chronic lung disease (CLD). Using non-invasive strategies, with or without minimally invasive surfactant, may reduce the need for mechanical ventilation and the risk of lung damage in newborn infants with respiratory distress.

OBJECTIVES

To evaluate the benefits and harms of nasal high-frequency ventilation (nHFV) compared to invasive ventilation via an ET tube or other non-invasive ventilation methods on morbidity and mortality in preterm and term infants with or at risk of respiratory distress.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and three trial registries in April 2023.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster- or quasi-RCTs of nHFV in newborn infants with respiratory distress compared to invasive or non-invasive ventilation.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials for inclusion, extracted data, assessed the risk of bias, and undertook GRADE assessment.

MAIN RESULTS

We identified 33 studies, mostly in low- to middle-income settings, that investigated this therapy in 5068 preterm and 46 term infants. nHFV compared to invasive respiratory therapy for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 0.67, 95% CI 0.20 to 2.18; 1 study, 80 infants) or the incidence of CLD (RR 0.38, 95% CI 0.09 to 1.59; 2 studies, 180 infants), both very low-certainty. ET intubation, death or CLD, severe intraventricular haemorrhage (IVH) and neurodevelopmental disability (ND) were not reported. nHFV vs nasal continuous positive airway pressure (nCPAP) used for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 1.00, 95% CI 0.41 to 2.41; 4 studies, 531 infants; very low-certainty). nHFV may reduce ET intubation (RR 0.52, 95% CI 0.33 to 0.82; 5 studies, 571 infants), but there may be little or no difference in CLD (RR 1.35, 95% CI 0.80 to 2.27; 4 studies, 481 infants); death or CLD (RR 2.50, 95% CI 0.52 to 12.01; 1 study, 68 participants); or severe IVH (RR 1.17, 95% CI 0.36 to 3.78; 4 studies, 531 infants), all low-certainty evidence. ND was not reported. nHFV vs nasal intermittent positive-pressure ventilation (nIPPV) used for initial RS nHFV may result in little to no difference in mortality before hospital discharge (RR 1.86, 95% CI 0.90 to 3.83; 2 studies, 84 infants; low-certainty). nHFV may have little or no effect in reducing ET intubation (RR 1.33, 95% CI 0.76 to 2.34; 5 studies, 228 infants; low-certainty). There may be a reduction in CLD (RR 0.63, 95% CI 0.42 to 0.95; 5 studies, 307 infants; low-certainty). A single study (36 infants) reported no events for severe IVH. Death or CLD and ND were not reported. nHFV vs high-flow nasal cannula (HFNC) used for initial RS We are very uncertain whether nHFV reduces ET intubation (RR 2.94, 95% CI 0.65 to 13.27; 1 study, 37 infants) or reduces CLD (RR 1.18, 95% CI 0.46 to 2.98; 1 study, 37 participants), both very low-certainty. There were no mortality events before hospital discharge or severe IVH. Other deaths, CLD and ND, were not reported. nHFV vs nCPAP used for RS following planned extubation nHFV probably results in little or no difference in mortality before hospital discharge (RR 0.92, 95% CI 0.52 to 1.64; 6 studies, 1472 infants; moderate-certainty). nHFV may result in a reduction in ET reintubation (RR 0.42, 95% CI 0.35 to 0.51; 11 studies, 1897 infants) and CLD (RR 0.78, 95% CI 0.67 to 0.91; 10 studies, 1829 infants), both low-certainty. nHFV probably has little or no effect on death or CLD (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 966 infants) and severe IVH (RR 0.80, 95% CI 0.57 to 1.13; 3 studies, 1117 infants), both moderate-certainty. We are very uncertain whether nHFV reduces ND (RR 0.92, 95% CI 0.37 to 2.29; 1 study, 74 infants; very low-certainty). nHFV versus nIPPV used for RS following planned extubation nHFV may have little or no effect on mortality before hospital discharge (RR 1.83, 95% CI 0.70 to 4.79; 2 studies, 984 infants; low-certainty). There is probably a reduction in ET reintubation (RR 0.69, 95% CI 0.54 to 0.89; 6 studies, 1364 infants), but little or no effect on CLD (RR 0.88, 95% CI 0.75 to 1.04; 4 studies, 1236 infants); death or CLD (RR 0.92, 95% CI 0.79 to 1.08; 3 studies, 1070 infants); or severe IVH (RR 0.78, 95% CI 0.55 to 1.10; 4 studies, 1162 infants), all moderate-certainty. One study reported there might be no difference in ND (RR 0.88, 95% CI 0.35 to 2.16; 1 study, 72 infants; low-certainty). nHFV versus nIPPV following initial non-invasive RS failure nHFV may have little or no effect on mortality before hospital discharge (RR 1.44, 95% CI 0.10 to 21.33); or ET intubation (RR 1.23, 95% CI 0.51 to 2.98); or CLD (RR 1.01, 95% CI 0.70 to 1.47); or severe IVH (RR 0.47, 95% CI 0.02 to 10.87); 1 study, 39 participants, all low- or very low-certainty. Other deaths or CLD and ND were not reported.

AUTHORS' CONCLUSIONS

For initial RS, we are very uncertain if using nHFV compared to invasive respiratory therapy affects clinical outcomes. However, nHFV may reduce intubation when compared to nCPAP. For planned extubation, nHFV may reduce the risk of reintubation compared to nCPAP and nIPPV. nHFV may reduce the risk of CLD when compared to nCPAP. Following initial non-invasive respiratory support failure, nHFV when compared to nIPPV may result in little to no difference in intubation. Large trials, particularly in high-income settings, are needed to determine the role of nHFV in initial RS and following the failure of other non-invasive respiratory support. Also, the optimal settings of nHVF require further investigation.

LISA Eligibility and LISA Success in Extremely Preterm Infants: A Single-Center Experience

INTRODUCTION

Less invasive surfactant application (LISA) is associated with improved short-term outcomes in preterm infants. Data on LISA eligibility and success for infants <28 weeks of gestation are lacking.

METHODS

Preterm infants <28 weeks of gestation who were born and actively treated in our tertiary care center in 2018 were included in the retrospective study. We assessed baseline characteristics, delivery room (DR) management, LISA success and complications, and short-term outcome.

RESULTS

In total, 57 infants received LISA in the DR. LISA eligibility was 73% at 22 weeks, 88% at 23 weeks, and >90% at gestational ages >24 weeks. LISA was successful in 63% of infants. LISA failure was associated with increased risk for high-grade IVH (OR 17.88), death (OR 10.94), and a reduced chance for survival without complications (OR 8.75).

CONCLUSION

Our report justifies LISA as a mode for surfactant application in preterm infants. It contributes to the call for studies to define risk factors for LISA failure.

Non-invasive versus invasive respiratory support in preterm infants

Respiratory insufficiency is almost ubiquitous in infants born preterm, with its incidence increasing with lower gestational age. A wide range of respiratory support management strategies are available for these infants, separable into non-invasive and invasive forms of respiratory support. Here we review the history and evolution of respiratory care for the preterm infant and then examine evidence that has emerged to support a non-invasive approach to respiratory management where able. Continuous positive airway pressure (CPAP) is the non-invasive respiratory support mode currently with the most evidence for benefit. CPAP can be delivered safely and effectively and can commence in the delivery room. Particularly in early life, time spent on non-invasive respiratory support, avoiding intubation and mechanical ventilation, affords benefit for the preterm infant by virtue of a lessening of lung injury and hence a reduction in incidence of bronchopulmonary dysplasia. In recent years, enthusiasm for application of non-invasive support has been further bolstered by new techniques for administration of exogenous surfactant. Methods of less invasive surfactant delivery, in particular with a thin catheter, have allowed neonatologists to administer surfactant without resort to endotracheal intubation. The benefits of this approach appear to be sustained, even in those infants subsequently requiring mechanical ventilation. This cements the notion that any reduction in exposure to mechanical ventilation leads to alleviation of injury to the vulnerable preterm lung, with a long-lasting effect. Despite the clear advantages of non-invasive respiratory support, there will continue to be a role for intubation and mechanical ventilation in some preterm infants, particularly for those born <25 weeks' gestation. It is currently unclear what role early non-invasive support has in this special population, with more studies required.

Neonatal high frequency ventilation: Current trends and future directions

High frequency ventilation (HFV) in neonates has been in use for over forty years. Some early HFV ventilators are no longer available, but high frequency oscillatory ventilation (HFOV) and jet ventilators (HFJV) continue to be commonly employed. Advanced HFOV models available outside of the United States are much quieter and easier to use, and are available as options on many conventional ventilators, providing important improvements such as tidal volume measurement and targeting. HFJV excels in treating air leak and non-homogenous lung disease and is often used for other diseases as well. High frequency non-invasive ventilation (hfNIV) is a novel application of HFV that remains under investigation. Similar to bubble CPAP, hfNIV has been applied with a variety of high-frequency ventilators. Efficacy and safety of hfNIV with any device have not yet been established. This article describes the current approaches to these HFV therapies and stresses the importance of understanding how each device works and what disease processes may respond best to the technology employed.

Noninvasive Ventilation

Systematic Reviews and Randomized clinical trials have shown that the use of noninvasive ventilation (NIV) compared to invasive mechanical ventilation reduces the risk of bronchopulmonary dysplasia and or mortality. Most commonly used NIV modes include nasal continuous positive airway pressure, bi-phasic modes, such as, bi-level positive airway pressure, nasal intermittent positive pressure ventilation, high flow nasal cannula, noninvasive neurally adjusted ventilatory assist, and nasal high frequency ventilation are discussed in this review.

The effect of non-invasive high-frequency oscillatory ventilation on the duration of non-invasive respiratory support in late preterm and term infants with transient tachypnea of the newborn: a randomized controlled trial

Nasal continuous positive airway pressure (nCPAP) is one of the most commonly used non-invasive respiratory support modes in neonates with transient tachypnea of the newborn (TTN). Non-invasive high-frequency oscillatory ventilation (nHFOV) is a non-invasive respiratory support mode that has been increasingly used in neonatal respiratory disorders. This prospective randomized controlled study compared the efficacy of nHFOV and nCPAP in reducing the duration of non-invasive respiratory support. Late preterm and term infants > 34 weeks' gestation were included in the study. The infants were randomly assigned to receive either nHFOV or nCPAP. Treatment was started with standard settings in both groups. Infants who met treatment failure criteria were switched to nasal intermittent mandatory ventilation for further positive-pressure support. A total of 60 infants were included in the study. Thirty of these infants were included in the nHFOV group and 30 were included in the nCPAP group. The median duration of non-invasive respiratory support was not significantly different between the two groups (21 h [IQR: 16-68] for nHFOV vs 15 h [IQR: 11-33] for nCPAP; p = 0.09). However, after adjusting for potential confounders, nHFOV was associated with a shorter duration of non-invasive respiratory support than nCPAP (adjusted mean difference: 16.3 h; 95% CI: 0.7 to 31.9; p = 0.04). nHFOV was well tolerated and did not increase the risk of complications.    Conclusion: Our findings suggest that nHFOV is an effective and safe ventilation mode for late preterm and term neonates with TTN.   Trial registry: Clinicaltrials.gov (NCT03006354). Date of registration: December 30, 2016. What is Known: • nHFOV is a ventilation model that has been increasingly used for the management of RDS. • TTN is one of the most common causes of neonatal respiratory distress. What is New: • nHFOV is associated with shorter duration of non-invasive respiratory support and duration of oxygen support. • nHFOV may be a safe and effective alternative to nCPAP for neonates with TTN.

State of the art on neonatal noninvasive respiratory support: How physiological and technological principles explain the clinical outcomes

Noninvasive respiratory support has gained significant popularity in neonatal units because of its potential to reduce lung injury associated with invasive mechanical ventilation. To minimize lung injury, clinicians aim to apply for noninvasive respiratory support as early as possible. However, the physiological background and the technology behind such support modes are not always clear, and many open questions remain regarding the indications of use and clinical outcomes. This narrative review discusses the currently available evidence for various noninvasive respiratory support modes applied in Neonatal Medicine in terms of physiological effects and indications. Reviewed modes include nasal continuous positive airway pressure, nasal high-flow therapy, noninvasive high-frequency oscillatory ventilation, nasal intermittent positive pressure ventilation (NIPPV), synchronized NIPPV and noninvasive neurally adjusted ventilatory assist. To enhance clinicians' awareness of each support mode's strengths and limitations, we summarize technical features related to the functioning mechanisms of devices and the physical properties of the interfaces commonly used for providing noninvasive respiratory support to neonates. We finally address areas of current controversy and suggest possible areas of research for implementing noninvasive respiratory support in neonatal intensive care units.

[Interpretation of the key updates in the 2022 European guideline on the management of neonatal respiratory distress syndrome]

With the deepening of clinical research, the management of neonatal respiratory distress syndrome (RDS) needs to be optimized and improved. This article aims to introduce the 2022 European guideline on the management of neonatal RDS, focusing on its key updates. The guide has optimized the management of risk prediction for preterm birth, maternal referral, application of prenatal corticosteroids, application of lung protective ventilation strategies, and general care for infants with RDS. The guideline is mainly applicable to the management of RDS in neonates with gestational age greater than 24 weeks.

Fluctuations in Oxygen Saturation during Synchronized Nasal Intermittent Positive Pressure Ventilation and Nasal High-Frequency Oscillatory Ventilation in Very Low Birth Weight Infants: A Randomized Crossover Trial

BACKGROUND

Very low birth weight (VLBW) infants on noninvasive ventilation (NIV) experience frequent fluctuations in oxygen saturation (SpO2) that are associated with an increased risk for mortality and severe morbidities.

METHODS

In this randomized crossover trial, VLBW infants (n = 22) born 22+3 to 28+0 weeks on NIV with supplemental oxygen were allocated on two consecutive days in random order to synchronized nasal intermittent positive pressure ventilation (sNIPPV) and nasal high-frequency oscillatory ventilation (nHFOV) for 8 h. nHFOV and sNIPPV were set to equivalent mean airway pressure and transcutaneous pCO2. Primary outcome was the time spent within the SpO2 target (88-95%).

RESULTS

During sNIPPV, VLBW infants spent significantly more time within the SpO2 target (59.9%) than during nHFOV (54.6%). The proportion of time spent in hypoxemia (22.3% vs. 27.1%) and the mean fraction of supplemental oxygen (FiO2) (29.4% vs. 32.8%) were significantly reduced during sNIPPV, while the respiratory rate (50.1 vs. 42.6) was significantly higher. Mean SpO2, SpO2 above the target, number of prolonged (>1 min) and severe (SpO2 <80%) hypoxemic episodes, parameters of cerebral tissue oxygenation using NIRS, number of FiO2 adjustments, heart rate, number of bradycardias, abdominal distension and transcutaneous pCO2 did not differ between both interventions.

CONCLUSIONS

In VLBW infants with frequent fluctuations in SpO2, sNIPPV is more efficient than nHFOV to retain the SpO2 target and to reduce FiO2 exposure. These results demand more detailed investigations into cumulative oxygen toxicities during different modes of NIV over the weaning period, particularly with regard to consequences for long-term outcomes.

A Nomogram for Predicting Extubation Failure in Preterm Infants with Gestational Age Less than 29 Weeks

INTRODUCTION

How to avoid reintubations in prematurity remains a hard nut. This study aimed to develop and validate a nomogram for predicting extubation failure in preterm infants who received different modes of noninvasive ventilation as post-extubation support.

METHODS

This was a secondary analysis of pre-existing data from a large multicenter RCT combined with a multicenter retrospective investigation in three tertiary referral NICUs in China. The training cohort consisted of extubated infants from the RCT and the validation cohort included neonates admitted to the three NICUs in the last 5 years. The nomogram was developed through univariate and multivariate logistic regression analyses of peri-extubation clinical variables.

RESULTS

A total of 432 and 183 preterm infants (25 weeks ≤ gestational age [GA] <29 weeks) were, respectively, included in the training cohort and the validation cohort. Lower birth weight, lower Apgar 5-min score, lower postmenstrual age at extubation, lower PO2 and higher PCO2 before extubation, and continuous positive airway pressure rather than nasal intermittent positive pressure ventilation or noninvasive high-frequency oscillatory ventilation after extubation were associated with higher risks of extubation failure (p < 0.05), on which the nomogram was established. In both the training cohort and the validation cohort, the nomogram demonstrated good predictive accuracy (area under the receiver operating characteristic curve = 0.744 and 0.826); the Hosmer-Lemeshow test (p = 0.192 and 0.401) and the calibration curve (R2 = 0.195 and 0.307) proved a good fitness and conformity; and the decision curve analysis showed significant net benefit at the best threshold (p = 0.201).

CONCLUSION

This nomogram could serve as a good decision-support tool when predicting extubation failure in preterm infants with GA less than 29 weeks.

Noninvasive high-frequency oscillatory ventilation versus nasal intermittent positive pressure ventilation for preterm infants as an extubation support: A systematic review and meta-analysis

OBJECTIVE

We aimed to explore whether noninvasive high-frequency oscillatory ventilation (NHFOV) could reduce the incidence of reintubation compared with nasal intermittent positive pressure ventilation (NIPPV) in the postextubation phase of preterm infants.

METHODS

Randomized controlled trials of NHFOV versus NIPPV were searched in PubMed, EMBASE, Cochrane Central, and MEDLINE. Meta-analysis was performed using Review Manager 5.3.

RESULTS

Four randomized controlled trials including 1138 preterm infants were included in this study. Compared with NIPPV, NHFOV reduced the incidence of reintubation in the post-extubation phase of preterm infants (p = 0.01, RR = 0.72, 95% confidence interval (CI): 0.56∼0.94), and no heterogeneity was found in the four studies (p = 0.55, I²  = 0%). In the sensitivity analysis, the result showed that there was no significant difference in the incidence of reintubation between NHFOV and NIPPV after excluding one study (p = 0. 05, RR = 0.76 95% CI: 0.58∼1.00), and no heterogeneity was found in the other three studies (p = 0.95, I²  = 0%). There was no statistical difference between NHFOV and NIPPV in BPD, air leak, IVH (≥Grade III) and mortality.

CONCLUSION

Among mechanically ventilated preterm infants, compared with NIPPV, NHFOV was potentially beneficial to reduce the incidence of reintubation after extubation and did not increase the risk of complications.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update

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).

Respiratory management in the premature neonate

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.

Respiratory support strategies in the prevention and treatment of bronchopulmonary dysplasia

Neonates who are born preterm frequently have inadequate lung development to support independent breathing and will need respiratory support. The underdeveloped lung is also particularly susceptible to lung injury, especially during the first weeks of life. Consequently, respiratory support strategies in the early stages of premature lung disease focus on minimizing alveolar damage. As infants grow and lung disease progresses, it becomes necessary to shift respiratory support to a strategy targeting the often severe pulmonary heterogeneity and obstructive respiratory physiology. With appropriate management, time, and growth, even those children with the most extreme prematurity and severe lung disease can be expected to wean from respiratory support.

Noninvasive High-Frequency Oscillatory Ventilation vs Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation as Postextubation Support for Preterm Neonates in China: A Randomized Clinical Trial

Importance

Several respiratory support techniques are available to minimize the use of invasive mechanical ventilation (IMV) in preterm neonates. It is unknown whether noninvasive high-frequency oscillatory ventilation (NHFOV) is more efficacious than nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) in preterm neonates after their first extubation.

Objective

To test the hypothesis that NHFOV is more efficacious than NCPAP or NIPPV in reducing IMV after extubation and until neonatal intensive care unit discharge among preterm neonates.

Design, Setting, and Participants

This multicenter, pathophysiology-based, assessor-blinded, 3-group, randomized clinical trial was conducted in 69 tertiary referral neonatal intensive care units in China, recruiting participants from December 1, 2017, to May 31, 2021. Preterm neonates who were between the gestational age of 25 weeks plus 0 days and 32 weeks plus 6 days and were ready to be extubated were randomized to receive NCPAP, NIPPV or NHFOV. Data were analyzed on an intention-to-treat basis.

Interventions

The NCPAP, NIPPV, or NHFOV treatment was initiated after the first extubation and lasted until discharge.

Main Outcomes and Measures

Primary outcomes were total duration of IMV, need for reintubation, and ventilator-free days. These outcomes were chosen to describe the effect of noninvasive ventilation strategy on the general need for IMV.

Results

A total of 1440 neonates (mean [SD] age at birth, 29.4 [1.8] weeks; 860 boys [59.7%]) were included in the trial. Duration of IMV was longer in NIPPV (mean difference, 1.2; 95% CI, 0.01-2.3 days; P = .04) and NCPAP (mean difference, 1.5 days; 95% CI, 0.3-2.7 days; P = .01) compared with NHFOV. Neonates who were treated with NCPAP needed reintubations more often than those who were treated with NIPPV (risk difference: 8.1%; 95% CI, 2.9%-13.3%; P = .003) and NHFOV (risk difference, 12.5%; 95% CI, 7.5%-17.4%; P < .001). There were fewer ventilator-free days in neonates treated with NCPAP than in those treated with NIPPV (median [25th-75th percentile] difference, -3 [-6 to -1] days; P = .01). There were no differences between secondary efficacy or safety outcomes, except for the use of postnatal corticosteroids (lower in NHFOV than in NCPAP group; risk difference, 7.3%; 95% CI, 2.6%-12%; P = .002), weekly weight gain (higher in NHFOV than in NCPAP group; mean difference, -0.9 g/d; 95% CI, -1.8 to 0 g/d; P = .04), and duration of study intervention (shorter in NHFOV than in NIPPV group; median [25th-75th percentile] difference, -1 [-3 to 0] days; P = .01).

Conclusions and Relevance

Results of this trial indicated that NHFOV, if used after extubation and until discharge, slightly reduced the duration of IMV in preterm neonates, and both NHFOV and NIPPV resulted in a lower risk of reintubation than NCPAP. All 3 respiratory support techniques were equally safe for this patient population.

Trial Registration

ClinicalTrials.gov Identifier: NCT03181958.

Moving bronchopulmonary dysplasia research from the bedside to the bench

Although advances in the respiratory management of extremely preterm infants have led to improvements in survival, this progress has not yet extended to a reduction in the incidence of bronchopulmonary dysplasia (BPD). BPD is a complex multifactorial condition that primarily occurs due to disturbances in the regulation of normal pulmonary airspace and vascular development. Preterm birth and exposure to invasive mechanical ventilation also compromises large airway development, leading to significant morbidity and mortality. Although both predisposing and protective genetic and environmental factors have been frequently described in the clinical literature, these findings have had limited impact on the development of effective therapeutic strategies. This gap is likely because the molecular pathways that underlie these observations are yet not fully understood, limiting the ability of researchers to identify novel treatments that can preserve normal lung development and/or enhance cellular repair mechanisms. In this review article, we will outline various well-established clinical observations while identifying key knowledge gaps that need to be filled with carefully designed preclinical experiments. We will address these issues by discussing controversial topics in the pathophysiology, the pathology, and the treatment of BPD, including an evaluation of existing animal models that have been used to answer important questions.

Use of NHFOV vs. NIPPV for the respiratory support of preterm newborns after extubation: A meta-analysis

OBJECTIVES

This meta-analysis evaluated and compared the efficacy and safety of noninvasive high-frequency oscillatory ventilation (NHFOV) and nasal intermittent positive-pressure ventilation (NIPPV) for preterm newborns after extubation.

METHODS

We searched the PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, Wanfang and VIP databases from inception to August 28, 2022. Randomized controlled trials (RCTs) that evaluated and compared the efficacy and safety of NHFOV and NIPPV in newborns were included in the review and meta-analysis, which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines.

RESULTS

Eight studies involving 1,603 patients were included. Compared with NIPPV, NHFOV could reduce the reintubation rates (RR = 0.68, 95% CI 0.53, 0.86, P = 0.002). Subgroup analysis showed that the significant difference was found in reintubation rates within 72 h (RR = 0.48, 95% CI 0.32, 0.73, P = 0.0005). NHFOV also could decrease the duration of non-invasive ventilation (standard mean difference (SMD) = -1.52, 95% CI -2.58, -0.45, P = 0.005). However, all included studies had a high risk of bias, and the overall quality of the evidence of the outcomes was low or very low.

CONCLUSION

In our study, compared with NIPPV, NHFOV seems to reduce the reintubation rates without increasing adverse outcomes. Nevertheless, definite recommendations cannot be made based on the quality of the published evidence.