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Sahni M, Bhandari V. Invasive and non-invasive ventilatory strategies for early and evolving bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151815. [PMID: 37775369 DOI: 10.1016/j.semperi.2023.151815] [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: 10/01/2023]
Abstract
In the age of surfactant and antenatal steroids, neonatal care has improved outcomes of preterm infants dramatically. Since the early 2000's neonatologists have strived to decrease bronchopulmonary dysplasia (BPD) by decreasing ventilator-associated lung injury and utilizing many novel modes of non-invasive respiratory support. After the initial success with nasal continuous positive airway pressure, it was established that discontinuing invasive ventilation early in favor of non-invasive respiratory support is the most effective way to reduce the incidence of BPD. In this review, we discuss the management of the preterm lung from the time of delivery, through the phases of respiratory distress syndrome (early BPD) and then evolving BPD. The goal remains to optimize respiratory support of the preterm lung while minimizing ventilator-associated lung injury and oxygen toxicity. A multidisciplinary approach involving the medical team and family is quintessential in reaching this goal and involves adequate respiratory support, optimizing nutrition and fluid balance as well as preventing infections.
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Affiliation(s)
- Mitali Sahni
- Pediatrix Medical Group, Sunrise Children's Hospital, Las Vegas, NV, United States; University of Nevada, Las Vegas, NV, United States
| | - Vineet Bhandari
- Neonatology Research Laboratory (Room #206), Education and Research Building, Cooper University Hospital, Camden, NJ, United States; The Children's Regional Hospital at Cooper, Cooper Medical School of Rowan University, Camden, NJ, United States.
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2
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Oxygen care and treatment of retinopathy of prematurity in ocular and neurological prognosis. Sci Rep 2022; 12:341. [PMID: 35013470 PMCID: PMC8748614 DOI: 10.1038/s41598-021-04221-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 12/17/2021] [Indexed: 01/01/2023] Open
Abstract
This retrospective cohort study aimed to investigate the effects of neonatal oxygen care and retinopathy of prematurity (ROP) treatment on ROP-related ocular and neurological prognoses. We included premature infants treated for ROP at a tertiary referral center between January 2006 and December 2019. Demographic and clinical data were collected from electronic medical records. Odds ratios (ORs) of oxygen care- and ROP treatment-related factors were calculated for ocular and neurological comorbidities 3 years after ROP treatment, after adjusting for potential confounders. ROP requiring treatment was detected in 171 eyes (88 infants). Laser treatment for ROP (OR = 4.73, 95% confidence interval [CI] 1.64–13.63) and duration of invasive ventilation (OR = 1.02, 95% CI 1.00–1.03) were associated with an increase in ocular comorbidities, along with a history of neonatal seizure (OR = 28.29, 95% CI 5.80–137.95) and chorioamnionitis (OR = 32.13, 95% CI 5.47–188.74). No oxygen care- or ROP treatment-related factors showed significant odds for neurological comorbidities. Shorter duration of invasive oxygen supply during neonatal care (less than 49 days) and anti-vascular endothelial growth factor injection as the primary treatment for ROP are less likely to cause ocular comorbidities. No association was identified between ROP treatment modalities and the risk of neurological comorbidities.
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Tian C, Li D, Fu J. Molecular Mechanism of Caffeine in Preventing Bronchopulmonary Dysplasia in Premature Infants. Front Pediatr 2022; 10:902437. [PMID: 35795332 PMCID: PMC9251307 DOI: 10.3389/fped.2022.902437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/31/2022] [Indexed: 11/24/2022] Open
Abstract
Bronchopulmonary dysplasia (BPD) is a chronic respiratory complication commonly seen in premature infants. Following continuous advances in neonatal intensive care diagnosis and treatment technology, an increasing number of premature babies are being treated successfully. Despite these remarkable improvements, there has been no significant decline in the incidence of BPD; in fact, its incidence has increased as more extremely preterm infants survive. Therefore, in view of the impact of BPD on the physical and mental health of children and the increased familial and social burden on these children, early prevention of BPD is emphasized. In recent decades, the clinical application of caffeine in treating primary apnea in premature infants was shown not only to stimulate the respiratory center but also to confer obvious protection to the nervous and respiratory systems. Numerous clinical cross-sectional and longitudinal studies have shown that caffeine plays a significant role in the prevention and treatment of BPD, but there is a lack of overall understanding of its potential molecular mechanisms. In this review, we summarize the possible molecular mechanisms of caffeine in the prevention or treatment of BPD, aiming to better guide its clinical application.
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Affiliation(s)
- Congliang Tian
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China.,Department of Pediatrics, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Danni Li
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jianhua Fu
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
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4
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Cresi F, Chiale F, Maggiora E, Borgione SM, Ferroglio M, Runfola F, Maiocco G, Peila C, Bertino E, Coscia A. Short-term effects of synchronized vs. non-synchronized NIPPV in preterm infants: study protocol for an unmasked randomized crossover trial. Trials 2021; 22:392. [PMID: 34127040 PMCID: PMC8200781 DOI: 10.1186/s13063-021-05351-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Non-invasive ventilation (NIV) has been recommended as the best respiratory support for preterm infants with respiratory distress syndrome (RDS). However, the best NIV technique to be used as first intention in RDS management has not yet been established. Nasal intermittent positive pressure ventilation (NIPPV) may be synchronized (SNIPPV) or non-synchronized to the infant's breathing efforts. The aim of the study is to evaluate the short-term effects of SNIPPV vs. NIPPV on the cardiorespiratory events, trying to identify the best ventilation modality for preterm infants at their first approach to NIV ventilation support. METHODS An unmasked randomized crossover study with three treatment phases was designed. All newborn infants < 32 weeks of gestational age with RDS needing NIV ventilation as first intention or after extubation will be consecutively enrolled in the study and randomized to the NIPPV or SNIPPV arm. After stabilization, enrolled patients will be alternatively ventilated with two different techniques for two time frames of 4 h each. NIPPV and SNIPPV will be administered with the same ventilator and the same interface, maintaining continuous assisted ventilation without patient discomfort. During the whole duration of the study, the patient's cardiorespiratory data and data from the ventilator will be simultaneously recorded using a polygraph connected to a computer. The primary outcome is the frequency of episodes of oxygen desaturation. Secondary outcomes are the number of the cardiorespiratory events, FiO2 necessity, newborn pain score evaluation, synchronization index, and thoracoabdominal asynchrony. The calculated sample size was of 30 patients. DISCUSSION It is known that NIPPV produces a percentage of ineffective acts due to asynchronies between the ventilator and the infant's breaths. On the other hand, an ineffective synchronization could increase work of breathing. Our hypothesis is that an efficient synchronization could reduce the respiratory work and increase the volume per minute exchanged without interfering with the natural respiratory rhythm of the patient with RDS. The results of this study will allow us to evaluate the effectiveness of the synchronization, demonstrating whether SNIPPV is the most effective non-invasive ventilation mode in preterm infants with RDS at their first approach to NIV ventilation. TRIAL REGISTRATION ClinicalTrials.gov NCT03289936 . Registered on September 21, 2017.
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Affiliation(s)
- Francesco Cresi
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Federica Chiale
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy. .,Department of Public Health and Pediatric Sciences, Postgraduate School of Pediatrics, University of Turin, Turin, Italy.
| | - Elena Maggiora
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Silvia Maria Borgione
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Mattia Ferroglio
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Federica Runfola
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy.,Department of Public Health and Pediatric Sciences, Postgraduate School of Pediatrics, University of Turin, Turin, Italy
| | - Giulia Maiocco
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Chiara Peila
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Enrico Bertino
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Alessandra Coscia
- Neonatal Intensive Care Unit, Department of Public Health and Pediatrics, University of Turin, Turin, Italy
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5
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Dumpa V, Bhandari V. Non-Invasive Ventilatory Strategies to Decrease Bronchopulmonary Dysplasia-Where Are We in 2021? CHILDREN-BASEL 2021; 8:children8020132. [PMID: 33670260 PMCID: PMC7918044 DOI: 10.3390/children8020132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 11/16/2022]
Abstract
Recent advances in neonatology have led to the increased survival of extremely low-birth weight infants. However, the incidence of bronchopulmonary dysplasia (BPD) has not improved proportionally, partly due to increased survival of extremely premature infants born at the late-canalicular stage of lung development. Due to minimal surfactant production at this stage, these infants are at risk for severe respiratory distress syndrome, needing prolonged ventilation. While the etiology of BPD is multifactorial with antenatal, postnatal, and genetic factors playing a role, ventilator-induced lung injury is a major, potentially modifiable, risk factor implicated in its causation. Infants with BPD are at a higher risk of developing complications including sepsis, pulmonary arterial hypertension, respiratory failure, and death. Long-term problems include increased risk of hospital readmissions, respiratory infections, and asthma-like symptoms during infancy and childhood. Survivors who have BPD are also at increased risk of poor neurodevelopmental outcomes. While the ultimate solution for avoiding BPD lies in the prevention of preterm births, strategies to decrease its incidence are the need of the hour. It is time to focus on gentler modes of ventilation and the use of less invasive surfactant administration techniques to mitigate lung injury, thereby potentially decreasing the burden of BPD. In this article, we discuss the use of non-invasive ventilation in premature infants, with an emphasis on studies showing an effect on BPD with different modes of non-invasive ventilation. Practical considerations in the use of nasal intermittent positive pressure ventilation are also discussed, considering the significant heterogeneity in clinical practices and management strategies in its use.
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Affiliation(s)
- Vikramaditya Dumpa
- Division of Neonatology, Department of Pediatrics, NYU Long Island School of Medicine, NYU Langone Hospital Long Island, Mineola, NY 11501, USA;
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, Cooper Medical School of Rowan University, The Children’s Regional Hospital at Cooper, Camden, NJ 08103, USA
- Correspondence: ; Tel.: +856-342-6156 or +856-342-2000 (ext. 1089752); Fax: +856-342-8007
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6
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Hochwald O, Riskin A, Borenstein-Levin L, Shoris I, Dinur GP, Said W, Jubran H, Littner Y, Haddad J, Mor M, Timstut F, Bader D, Kugelman A. Cannula With Long and Narrow Tubing vs Short Binasal Prongs for Noninvasive Ventilation in Preterm Infants: Noninferiority Randomized Clinical Trial. JAMA Pediatr 2021; 175:36-43. [PMID: 33165539 PMCID: PMC7653541 DOI: 10.1001/jamapediatrics.2020.3579] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Use of cannulas with long and narrow tubing (CLNT) has gained increasing popularity for applying noninvasive respiratory support for newborn infants thanks to ease of use, perceived patient comfort, and reduced nasal trauma. However, there is concern that this interface delivers reduced and suboptimal support. OBJECTIVE To determine whether CLNT is noninferior to short binasal prongs and masks (SPM) when providing nasal intermittent positive pressure ventilation (NIPPV) in preterm infants. DESIGN, SETTING, AND PARTICIPANTS This randomized controlled, unblinded, prospective noninferiority trial was conducted between December 2017 and December 2019 at 2 tertiary neonatal intensive care units. Preterm infants born between 24 weeks' and 33 weeks and 6 days' gestation were eligible if presented with respiratory distress syndrome with the need for noninvasive ventilatory support either as initial treatment after birth or after first extubation. Analysis was performed by intention to treat. INTERVENTIONS Randomization to NIPPV with either CLNT or SPM interface. MAIN OUTCOMES AND MEASURES The primary outcome was the need for intubation within 72 hours after NIPPV treatment began. Noninferiority margin was defined as 15% or less absolute difference. RESULTS Overall, 166 infants were included in this analysis, and infant characteristics and clinical condition (including fraction of inspired oxygen, Pco2, and pH level) were comparable at recruitment in the CLNT group (n = 83) and SPM group (n = 83). The mean (SD) gestational age was 29.3 (2.2) weeks vs 29.2 (2.5) weeks, and the mean (SD) birth weight was 1237 (414) g vs 1254 (448) g in the CLNT and SPM groups, respectively. Intubation within 72 hours occurred in 12 of 83 infants (14%) in the CLNT group and in 15 of 83 infants (18%) in the SPM group (risk difference, -3.6%; 95% CI, -14.8 to 7.6 [within the noninferiority margin], χ2 P = .53). Moderate to severe nasal trauma was significantly less common in the CLNT group compared with the SPM group (4 [5%] vs 14 [17%]; P = .01). There were no differences in other adverse events or in the course during hospitalization. CONCLUSIONS AND RELEVANCE In this study, CLNT was noninferior to SPM in providing NIPPV for preterm infants, while causing significantly less nasal trauma. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03081611.
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Affiliation(s)
- Ori Hochwald
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Arieh Riskin
- Bnai Zion Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | | | - Irit Shoris
- Bnai Zion Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Gil P. Dinur
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Waseem Said
- Bnai Zion Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Huda Jubran
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Yoav Littner
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Julie Haddad
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Malka Mor
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Fanny Timstut
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - David Bader
- Bnai Zion Medical Center & Rapport Faculty of Medicine, Haifa, Israel
| | - Amir Kugelman
- Rambam Medical Center & Rapport Faculty of Medicine, Haifa, Israel
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8
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Gharehbaghi MM, Hosseini MB, Eivazi G, Yasrebinia S. Comparing the Efficacy of Nasal Continuous Positive Airway Pressure and Nasal Intermittent Positive Pressure Ventilation in Early Management of Respiratory Distress Syndrome in Preterm Infants. Oman Med J 2019; 34:99-104. [PMID: 30918602 PMCID: PMC6425044 DOI: 10.5001/omj.2019.20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives There is a tendency to use noninvasive ventilation (NIV) as a substitute for mechanical ventilation in preterm infants who need respiratory support. Two important modes of NIV include nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV). We sought to compare the efficacy of NCPAP and NIPPV as early respiratory support in preterm infants with respiratory distress syndrome in reducing the need for intubation, surfactant administration, and mechanical ventilation. Methods We conducted a randomized clinical trial. Sixty-one preterm infants with a gestational age of 28–32 weeks and a birth weight < 1500 g were randomly allocated to early NCPAP (n = 31) or NIPPV (n = 30) groups. The primary outcome was the need for intubation and mechanical ventilation in first 72 hours of life and the secondary outcome was oxygen dependency beyond day 28 post-birth. Results Surfactant replacement therapy was done in 15 neonates (50.0%) in the NIPPV group and 19 neonates (61.3%) in the NCPAP group, odds ratio (OR) = 1.58 (95% confidence interval (CI): 0.57–4.37; p = 0.370). Intubation and mechanical ventilation in the first 72 hours of life were needed in five cases (16.7%) in the NIPPV group and two cases (6.5%) in the NCPAP group, OR = 2.90 (95% CI: 0.51–16.27; p = 0.250). The mean duration of hospitalization was 26.2±17.4 days in the NIPPV group and 38.4±19.2 days in the NCPAP group, p = 0.009. Bronchopulmonary dysplasia (BPD) occurred in two (6.7%) neonates in the NIPPV group and eight (25.8%) neonates in the NCPAP group, p = 0.080. Conclusions NIPPV and NCPAP are similarly effective as initial respiratory support in preterm infants in reducing the need for mechanical ventilation and occurrence of BPD. The duration of hospitalization was significantly reduced using NIPPV in our study. Keywords Nasal Continuous Positive Airway Pressure; Preterm Infants; Mechanical Ventilation; Bronchopulmonary Dysplasia; Respiratory Distress Syndrome, Newborn.
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Affiliation(s)
| | | | - Ghodratollah Eivazi
- Department of Pediatrics and Neonatology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sanaz Yasrebinia
- Department of Pediatrics and Neonatology, Tabriz University of Medical Sciences, Tabriz, Iran
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9
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Abstract
Over 50 years after its first description, Bronchopulmonary Dysplasia (BPD) remains a devastating pulmonary complication in preterm infants with respiratory failure and develops in 30-50% of infants less than 1000-gram birth weight. It is thought to involve ventilator- and oxygen-induced damage to an immature lung that results in an inflammatory response and ends in aberrant lung development with dysregulated angiogenesis and alveolarization. Significant morbidity and mortality are associated with this most common chronic lung disease of childhood. Thus, any therapies that decrease the incidence or severity of this condition would have significant impact on morbidity, mortality, human costs, and healthcare expenditure. It is clear that an inflammatory response and the elaboration of growth factors and cytokines are associated with the development of BPD. Numerous approaches to control the inflammatory process leading to the development of BPD have been attempted. This review will examine the anti-inflammatory approaches that are established or hold promise for the prevention or treatment of BPD.
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10
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Chavez TA, Lakshmanan A, Figueroa L, Iyer N, Stavroudis TA, Garingo A, Friedlich PS, Ramanathan R. Resource utilization patterns using non-invasive ventilation in neonates with respiratory distress syndrome. J Perinatol 2018; 38:850-856. [PMID: 29795324 PMCID: PMC8362839 DOI: 10.1038/s41372-018-0122-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 02/21/2018] [Accepted: 03/30/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To describe the frequency of non-invasive ventilation (NIV) and endotracheal intubation use in neonates diagnosed with respiratory distress syndrome (RDS); to describe resources utilization (length of stay (LOS), charges, costs) among NIV and intubated RDS groups. STUDY DESIGN Retrospective study from the national Kid's Inpatient Database of the Healthcare Cost and Utilization Project, for the years 1997-2012. Propensity scoring and multivariate regression analysis used to describe differences. RESULTS A total of 595,254 out of 42,912,090 cases were identified with RDS. There was an increase in NIV use from 6% in 1997 to 17% in 2012. After matching, patients receiving NIV only were associated with shorter LOS: (95%CI) 25 (25.3,25.7) vs. 35 (34.2,34.9) days, decreased costs: ($/1k) 46.1 (45.5,46.8) vs. 65.0 (64.1,66.0), decreased charges: 130.3 (128.6,132.1) vs. 192.1 (189.5,194.6) compared to intubated neonates. CONCLUSION There was a three-fold increase in NIV use within the 15-year study period. NIV use was associated with decreased LOS, charges and costs compared to intubated patients.
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Affiliation(s)
- Thomas A. Chavez
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ashwini Lakshmanan
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. .,Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States. .,Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, United States.
| | - Lizzette Figueroa
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Narayan Iyer
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Theodora A. Stavroudis
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Arlene Garingo
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Philippe S. Friedlich
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Fetal and Neonatal Institute, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA,Division of Neonatology, Department of Pediatrics, LAC USC Medical Center, University of Southern California, Los Angeles, CA, USA
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11
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Fleeman N, Mahon J, Bates V, Dickson R, Dundar Y, Dwan K, Ellis L, Kotas E, Richardson M, Shah P, Shaw BN. The clinical effectiveness and cost-effectiveness of heated humidified high-flow nasal cannula compared with usual care for preterm infants: systematic review and economic evaluation. Health Technol Assess 2018; 20:1-68. [PMID: 27109425 DOI: 10.3310/hta20300] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Respiratory problems are one of the most common causes of morbidity in preterm infants and may be treated with several modalities for respiratory support such as nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive-pressure ventilation. The heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity in clinical practice. OBJECTIVES To address the clinical effectiveness of HHHFNC compared with usual care for preterm infants we systematically reviewed the evidence of HHHFNC with usual care following ventilation (the primary analysis) and with no prior ventilation (the secondary analysis). The primary outcome was treatment failure defined as the need for reintubation (primary analysis) or intubation (secondary analysis). We also aimed to assess the cost-effectiveness of HHHFNC compared with usual care if evidence permitted. DATA SOURCES The following databases were searched: MEDLINE (2000 to 12 January 2015), EMBASE (2000 to 12 January 2015), The Cochrane Library (issue 1, 2015), ISI Web of Science (2000 to 12 January 2015), PubMed (1 March 2014 to 12 January 2015) and seven trial and research registers. Bibliographies of retrieved citations were also examined. REVIEW METHODS Two reviewers independently screened all titles and abstracts to identify potentially relevant studies for inclusion in the review. Full-text copies were assessed independently. Data were extracted and assessed for risk of bias. Summary statistics were extracted for each outcome and, when possible, data were pooled. A meta-analysis was only conducted for the primary analysis, using fixed-effects models. An economic evaluation was planned. RESULTS Clinical evidence was derived from seven randomised controlled trials (RCTs): four RCTs for the primary analysis and three RCTs for the secondary analysis. Meta-analysis found that only for nasal trauma leading to a change of treatment was there a statistically significant difference, favouring HHHFNC over NCPAP [risk ratio (RR) 0.21, 95% confidence interval (CI) 0.10 to 0.42]. For the following outcomes, there were no statistically significant differences between arms: treatment failure (reintubation < 7 days; RR 0.76, 95% CI 0.54 to 1.09), bronchopulmonary dysplasia (RR 0.92, 95% CI 0.72 to 1.17), death (RR 0.56, 95% CI 0.22 to 1.44), pneumothorax (RR 0.33, 95% CI 0.03 to 3.12), intraventricular haemorrhage (grade ≥ 3; RR 0.41, 95% CI 0.15 to 1.15), necrotising enterocolitis (RR 0.41, 95% CI 0.15 to 1.14), apnoea (RR 1.08, 95% CI 0.74 to 1.57) and acidosis (RR 1.16, 95% CI 0.38 to 3.58). With no evidence to support the superiority of HHHFNC over NCPAP, a cost-minimisation analysis was undertaken, the results suggesting HHHFNC to be less costly than NCPAP. However, this finding is sensitive to the lifespan of equipment and the cost differential of consumables. LIMITATIONS There is a lack of published RCTs of relatively large-sized populations comparing HHHFNC with usual care; this is particularly true for preterm infants who had received no prior ventilation. CONCLUSIONS There is a lack of convincing evidence suggesting that HHHFNC is superior or inferior to usual care, in particular NCPAP. There is also uncertainty regarding whether or not HHHFNC can be considered cost-effective. Further evidence comparing HHHFNC with usual care is required. STUDY REGISTRATION This review is registered as PROSPERO CRD42015015978. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Nigel Fleeman
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - James Mahon
- Coldingham Analytical Services, Berwickshire, UK
| | - Vickie Bates
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Rumona Dickson
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Yenal Dundar
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Kerry Dwan
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK.,Cochrane Editorial Unit, Cochrane Collaboration, London, UK
| | - Laura Ellis
- Patient representative (parent of premature infants)
| | - Eleanor Kotas
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Marty Richardson
- Liverpool Reviews and Implementation Group, University of Liverpool, Liverpool, UK
| | - Prakesh Shah
- Departments of Paediatrics and Institute of Health Policy, Management and Evaluation, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | - Ben Nj Shaw
- Neonatal Unit, Liverpool Women's NHS Foundation Trust, Liverpool, UK
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12
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Sadeghnia A, Foroshani MZ, Badiei Z. A Comparative Study of the Effect of Nasal Intermittent Positive Pressure Ventilation and Nasal Continuous Positive Airway Pressure on the Regional Brain Tissue Oximetry in Premature Newborns Weighing <1500 g. Int J Prev Med 2017; 8:41. [PMID: 28656097 PMCID: PMC5474904 DOI: 10.4103/ijpvm.ijpvm_233_16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 02/08/2017] [Indexed: 11/04/2022] Open
Abstract
Background: Near-infrared spectroscopy (NIRS) provides the capability of monitoring oxygenation levels in cerebral microscopic vessels, enabling the operator to observe the spontaneous changes in the levels of hemoglobin concentration in tissue and interpret the resulting fluctuations. The current study tried to investigate whether brain's autoregulatory mechanisms in premature newborns have the potential to prevent the adverse effects caused by asynchronous changes of pressure in the rib cage. Therefore, NIRS method was applied to newborns that were alternatively shifted from nasal continuous positive airway pressure (nCPAP) to nasal intermittent positive pressure ventilation (NIPPV) and vice versa. Methods: This study was done as a crossover randomized clinical trial on 30 very low-weight newborns under nCPAP, who had received surfactant as a result of respiratory distress syndrome diagnosis, from April 2015 to April 2016, in Isfahan Shahid Beheshti Educational Hospital. The newborns were 72 h old, experiencing continuous distending pressure (CDP) = 4–6 cmH2O with FiO2 = 30%–40%. The respiratory support would alternate from nCPAP to NIPPV and vice versa (with indicators of expiratory PAP (EPAP) = CDP and inspiratory PAP = EPAP + 4 cmH2O), and the cerebral regional oxygen saturation (CrSO2) was monitored using NIRS. Results: The study results indicated that newborns significantly showed higher levels of CrSO2(84.93, P = 0.005) and oxygenation (94.63, P = 0.007) under nCPAP rather than NIPPV (82.43 and 93.43, respectively). The respiratory rate was also meaningfully slower when newborns were under nCPAP (P = 0.013). Conclusions: This study revealed that applying NIPPV may have an unfavorable effect on the premature newborn's brain tissue perfusion. However, more studies are needed to ensure solid outcomes.
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Affiliation(s)
- Alireza Sadeghnia
- Department of Pediatrics, School of Medicine, Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Marzieh Zamani Foroshani
- Department of Pediatrics, School of Medicine, Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zohreh Badiei
- Department of Pediatrics, School of Medicine, Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Millar D, Lemyre B, Kirpalani H, Chiu A, Yoder BA, Roberts RS. A comparison of bilevel and ventilator-delivered non-invasive respiratory support. Arch Dis Child Fetal Neonatal Ed 2016; 101:F21-5. [PMID: 26162889 DOI: 10.1136/archdischild-2014-308123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 06/17/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the rates of death or bronchopulmonary dysplasia (BPD) in infants who received nasal intermittent positive pressure ventilation (NIPPV) delivered by a conventional mechanical ventilator (CMV) or a bilevel device. DESIGN A preplanned non-randomised comparison of infants randomised to the NIPPV arm of the NIPPV trial. SETTING Thirty-six tertiary neonatal units in three continents. PATIENTS Infants <1000 g and <30 weeks gestational age at birth. INTERVENTIONS Infants received treatment with CMV NIPPV or bilevel NIPPV, as a primary mode of respiratory support or following first extubation. RESULTS 241 received mainly bilevel NIPPV and 215 mainly CMV NIPPV. No difference was found in death or BPD at 36 weeks corrected age (adjusted OR 0.88 (95% CI 0.57 to 1.35)). More deaths occurred in infants receiving bilevel NIPPV (9.4%) than in CMV NIPPV (2.3%) (adjusted OR 5.01: 95% CI 1.74 to 14.4). There was a corresponding but not statistically significant decrease in BPD in the bilevel NIPPV group (30% vs 37%) (adjusted OR 0.64 (95% CI 0.41 to 1.02)). No difference was observed in extubation failure or age at last extubation. A post hoc test of interaction between device type and synchronisation was not statistically significant. CONCLUSIONS We did not observe a statistically significant difference in the composite outcome of death or BPD between infants who received mostly bilevel NIPPV compared with mostly CMV NIPPV. Differences in component outcomes of morbidity and BPD may be due to the competing nature of these outcomes or differences in baseline characteristics of infants. TRIAL REGISTRATION NUMBER NCT00433212.
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Affiliation(s)
- David Millar
- Department of Neonatology, Royal Maternity Hospital, Belfast, UK
| | - Brigitte Lemyre
- Department of Pediatrics, University of Ottawa, Ottawa, Canada
| | - Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, USA Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
| | - Aaron Chiu
- Department of Pediatrics, University of Manitoba, Winnipeg, Canada
| | - Bradley A Yoder
- Departments of Neonatology and Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Robin S Roberts
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
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Abstract
Mechanical ventilation is associated with increased survival of preterm infants but is also associated with an increased incidence of chronic lung disease (bronchopulmonary dysplasia) in survivors. Nasal continuous positive airway pressure (nCPAP) is a form of noninvasive ventilation that reduces the need for mechanical ventilation and decreases the combined outcome of death or bronchopulmonary dysplasia. Other modes of noninvasive ventilation, including nasal intermittent positive pressure ventilation, biphasic positive airway pressure, and high-flow nasal cannula, have recently been introduced into the NICU setting as potential alternatives to mechanical ventilation or nCPAP. Randomized controlled trials suggest that these newer modalities may be effective alternatives to nCPAP and may offer some advantages over nCPAP, but efficacy and safety data are limited.
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Mukerji A, Belik J. Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission. J Perinatol 2015; 35:716-9. [PMID: 26043417 DOI: 10.1038/jp.2015.61] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 04/24/2015] [Accepted: 04/29/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate carbon dioxide (CO2) clearance, delivered pressures and tidal volume (VT) during neonatal nasal intermittent positive pressure ventilation (NIPPV) with two commonly used interfaces. STUDY DESIGN A neonatal lung model, with either short binasal prongs (SBP) or a small caliber nasal cannula (RAM) interface, was tested over a range of clinically relevant settings. A fixed amount of CO2 was infused and the fraction remaining in the lung 100 s postinfusion was measured. Pressure transmission to the lung and VT was measured at the level of the trachea. RESULT CO2 elimination was directly proportional to the inspiratory pressure during NIPPV. At peak pressures of 22 to 34 cm H2O, CO2 clearance was greater (P<0.001) with SBP as compared with RAM. Relative to the set ventilator parameters, a substantial pressure dampening effect was documented at the lung level, which was significantly lower with RAM when compared with SBP (2.8% (0.2) versus 11.9% (1.5), P<0.0001). CO2 elimination was dependent on VT and effective despite only a small fraction of physiological VT (maximum delivered VT%: SBP 15.5 (0.7) versus RAM 6.1 (1.4), P<0.0001). CONCLUSION NIPPV promotes CO2 elimination even at low transmitted airway pressures, but less effective with RAM as compared with SBP. CO2 elimination despite small VT suggests that NIPPV may depend on a non-conventional gas-exchange mechanism.
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Affiliation(s)
- A Mukerji
- Division of Neonatology, Department of Paediatrics, McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - J Belik
- Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Wald M. „Nasal continuous positive airway pressure“ und noninvasive Beatmung bei Frühgeborenen. Monatsschr Kinderheilkd 2014. [DOI: 10.1007/s00112-014-3109-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Nzegwu NI, Mack T, DellaVentura R, Dunphy L, Koval N, Levit O, Bhandari V. Systematic use of the RAM nasal cannula in the Yale–New Haven Children’s Hospital Neonatal Intensive Care Unit: a quality improvement project. J Matern Fetal Neonatal Med 2014; 28:718-21. [DOI: 10.3109/14767058.2014.929659] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
PURPOSE OF THE REVIEW Noninvasive respiratory support for neonates is growing in popularity as clinicians increasingly recognize the dangers of prolonged invasive ventilation. The purpose of this review is to critically evaluate the existing evidence for safety and efficacy of these modes of respiratory support in neonates. RECENT FINDINGS In recent years, multiple randomized controlled trials (RCTs) have evaluated several modes of noninvasive support, most importantly nasal intermittent positive pressure ventilation and high flow nasal cannulae, in comparison to the standard therapy of continuous positive airway pressure (CPAP). The three largest RCTs were recently published in 2013. One demonstrated no difference in death or survival with bronchopulmonary dysplasia between nasal intermittent positive pressure ventilation and CPAP, both when used as primary support and as postextubation support. Two others demonstrated that high flow nasal cannulae are noninferior to or no better than CPAP when used to support preterm infants after extubation. These trials showed no serious safety concerns with current modalities. SUMMARY The optimal forms of noninvasive respiratory support for neonates remain to be determined. Continued evaluation of these technologies with large, well-designed RCTs is warranted.
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Abstract
Bronchopulmonary dysplasia (BPD), the most common chronic lung disease in infancy, has serious long-term pulmonary and neurodevelopmental consequences right up to adulthood, and is associated with significant healthcare costs. BPD is a multifactorial disease, with genetic and environmental factors interacting to culminate in the characteristic clinical and pathological phenotype. Among the environmental factors, invasive endotracheal tube ventilation is considered a critical contributing factor to the pathogenesis of BPD. Since BPD currently has no specific preventive or effective therapy, considerable interest has focused on the use of non-invasive ventilation as a means to potentially decrease the incidence of BPD. This article reviews the progress made in the last 5 years in the use of nasal continuous positive airways pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV) as it pertains to impacting on BPD rates. Research efforts are summarized, and some guidelines are suggested for clinical use of these techniques in neonates.
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Affiliation(s)
- Vineet Bhandari
- Division of Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
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