Evidence Support and Guidelines for Using Heated, Humidified, High-Flow Nasal Cannulae in Neonatology: Oxford Nasal High-Flow Therapy Meeting, 2015

Comparison of the effectiveness of different high-flow devices in neonatal care

OBJECTIVE

To evaluate the success rate of high-flow nasal cannula (HFNC) therapy using an adapted obsolete mechanical ventilator (MV), Optiflow™ and Vapotherm™ in newborns (NBs).

METHOD

This was a retrospective observational study conducted in the neonatal intensive care unit (NICU). The sample comprised NBs who underwent HFNC therapy due to ventilatory dysfunction, for weaning from non-invasive ventilation (NIV), or post-extubation. The three groups, stratified according to gestational age (GA) and birth weight, and corrected GA and weight at the beginning of HFNC use, were as follows: Optiflow ™, Vapotherm ™, and obsolete Mechanical Ventilator (MV) adapted for high flow therapy. Subsequently, the NBs were divided into a success group (SG) and a failure group (FG). HFNC success was defined as a therapy duration exceeding 72 h.

RESULTS

A total of 209 NBs were evaluated, with 31.1 % using HFNC due to ventilatory dysfunction, 2.4 % after extubation, and 66.5 % after NIV weaning. HFNC success rate was observed in 90.9 % of the NBs, with no difference between equipment types (Vapotherm ™, Optiflow ™, and adapted VM).

CONCLUSION

Different types of HFNC equipment are equally effective when used in neonatology for respiratory dysfunction, as a method of weaning from NIV and post-extubation. Adapted obsolete MV can be an alternative for HFCN therapy in resource-constrained settings.

High-flow nasal cannula (HFNC) vs continuous positive airway pressure (CPAP) vs nasal intermittent positive pressure ventilation as primary respiratory support in infants of ≥ 32 weeks gestational age (GA): study protocol for a three-arm multi-center randomized controlled trial

BACKGROUND

Health problems in neonates with gestational age (GA) ≥ 32 weeks remain a major medical concern. Respiratory distress (RD) is one of the common reasons for admission of neonates with GA ≥ 32 weeks. Noninvasive ventilation (NIV) represents a crucial approach to treat RD, and currently, the most used NIV modes in neonatal intensive care unit include high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and nasal intermittent positive pressure ventilation. Although extensive evidence supports the use of NIPPV in neonates with a GA < 32 weeks, limited data exist regarding its effectiveness in neonates with GA ≥ 32 weeks. Therefore, the aim of this study is to compare the clinical efficacy of HFNC, CPAP, and NIPPV as primary NIV in neonates with GA ≥ 32 weeks who experience RD.

METHODS

This trial is designed as an assessor-blinded, three-arm, multi-center, parallel, randomized controlled trial, conducted in neonates ≥ 32 weeks' GA requiring primary NIV in the first 24 h of life. The neonates will be randomly assigned to one of three groups: HFNC, CPAP or NIPPV group. The effectiveness, safety and comfort of NIV will be evaluated. The primary outcome is the occurrence of treatment failure within 72 h after enrollment. Secondary outcomes include death before discharge, surfactant treatment within 72 h after randomization, duration of both noninvasive and invasive mechanical ventilation, duration of oxygen therapy, bronchopulmonary dysplasia, time to achieve full enteral nutrition, necrotizing enterocolitis, duration of admission, cost of admission, air leak syndrome, nasal trauma, and comfort score.

DISCUSSION

Currently, there is a paucity of data regarding the utilization of NIPPV in neonates with GA ≥ 32 weeks. This study will provide clinical evidence for the development of respiratory treatment strategies in neonates at GA ≥ 32 weeks with RD, with the aim of minimizing the incidence of tracheal intubation and reducing the complications associated with NIV.

TRIAL REGISTRATION

Chinese Clinical Trial Registry: ChiCTR2300069192. Registered on March 9, 2023, https://www.chictr.org.cn/showproj.html?proj=171491 .

Guidelines for high-flow nasal cannula oxygen therapy in neonates (2022)

High-flow nasal cannula (HFNC) oxygen therapy, which is important in noninvasive respiratory support, is increasingly being used in critically ill neonates with respiratory failure because it is comfortable, easy to setup, and has a low incidence of nasal trauma. The advantages, indications, and risks of HFNC have been the focus of research in recent years, resulting in the development of the application. Based on current evidence, we developed guidelines for HFNC in neonates using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The guidelines were formulated after extensive consultations with neonatologists, respiratory therapists, nurse specialists, and evidence-based medicine experts. We have proposed 24 recommendations for 9 key questions. The guidelines aim to be a source of evidence and reference of HFNC oxygen therapy in clinical practice, and so that more neonates and their families will benefit from HFNC.

Changes in the patterns of respiratory support and incidence of bronchopulmonary dysplasia; a single center experience

BACKGROUND

With the advances in neonatal intensive care, the survival rate of extremely preterm infants is increasing. However, bronchopulmonary dysplasia (BPD) remains a major cause of morbidity among infants in this group. This study examined the changes in respiratory support modalities, specifically heated humidified high-flow nasal cannula (HHHFNC), and their association with BPD incidence among preterm infants born at < 29 weeks of gestation.

METHOD

This population-based retrospective cohort study included infants born at < 29 weeks of gestation between 2016 and 2020. Data regarding the use and duration of respiratory support modalities were obtained, including mechanical ventilation, continuous positive airway pressure, HHHFNC, and low-flow oxygen therapy. Additionally, the incidence of BPD was determined in the included infants. Trend analysis for each respiratory support modality and BPD incidence rate was performed to define the temporal changes associated with changes in BPD rates. In addition, a logistic regression model was developed to identify the association between BPD and severity grade using HHHFNC.

RESULTS

Three Hundred and sixteen infants were included in this study. The use and duration of HHHFNC therapy increased during the study period. Throughout the study period, the overall incidence of BPD was 49%, with no significant trends. The BPD rate was significantly higher in the infants who received HHHFNC than in those who did not (52% vs. 39%, P = 0.03). Analysis of BPD severity grades showed that both grade 1 BPD (34% vs. 21%, P = 0.03) and grade 2 BPD (12% vs. 1%, P < 0.01) were significantly more common among infants who received HHHFNC than among those who did not. In contrast, the incidence of grade 3 BPD was lower in infants who received HHFNC (6% vs. 17%, P < 0.01). The duration in days of HHHFNC was found to significantly predict BPD incidence (OR 1.04 [95%CI: 1.01-1.06], P < 0.01) after adjusting for confounding variables.

CONCLUSION

The use of HHHFNC in extremely preterm infants born at < 29 weeks of gestation is increasing. There was a significant association between the duration of HHHFNC therapy and the development of BPD in extremely preterm infants born at < 29 weeks of gestation.

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).

Diaphragm electrical activity during weaning of nasal high-flow therapy in preterm infants

OBJECTIVE

To determine whether electrical activity of the diaphragm (Edi) changes with weaning nasal high-flow (HF) therapy in preterm infants according to a standardised protocol.

DESIGN

Prospective observational cohort study.

SETTING

Neonatal intensive care unit.

PATIENTS

Preterm infants born at <32 weeks gestation, receiving nasal HF as part of routine clinical care.

INTERVENTIONS

Infants recruited to the study had their HF weaned according to set clinical criteria. Edi was measured using a modified gastric feeding tube serially from baseline (pre-wean) to 24-hours post-wean.

MAIN OUTCOME MEASURES

Change in Edi from baseline was measured at four time points up to 24 hours after weaning. Minimum Edi during expiration, maximum Edi during inspiration and amplitude of the Edi signal (Edi_delta) were measured. Clinical parameters (heart rate, respiratory rate and fraction of inspired oxygen) were also recorded.

RESULTS

Forty preterm infants were recruited at a mean corrected gestational age of 31.6 (±2.7) weeks. Data from 156 weaning steps were analysed, 91% of which were successful. Edi did not change significantly from baseline during flow reduction steps, but a significant increase in diaphragm activity was observed when discontinuing HF (median increase in Edi_delta immediately post-discontinuation 1.7 µV (95% CI: 0.6 to 3.0)) and at 24 hours 1.9 µV (95% CI: 0.7 to 3.8)). No significant difference in diaphragm activity was observed between successful and unsuccessful weaning steps.

CONCLUSIONS

A protocolised approach to weaning has a high probability of success. Edi does not change with reducing HF rate, but significantly increases with discontinuation of HF from 2 L/min.

Post-INSURE Administration of Heated Humidified High-Flow Therapy Versus Nasal Continuous Positive Airway Pressure in Preterm Infants More Than 28 Weeks Gestation with Respiratory Distress Syndrome: A Randomized Non-Inferiority Trial

In preterm infants with respiratory distress syndrome (RDS), non-invasive ventilation (NIV) is usually provided using nasal continuous positive airway pressure (NCPAP) or non-invasive mechanical ventilation after surfactant administration by INtubation-SURfactant-Extubation (INSURE) method. Heated humidified high-flow nasal cannula (HHHFNC) is a mode of NIV with advantages of ease of application, less grades of nasal injury and easy handling. This study was done to compare the effectiveness of HHHFNC therapy administration as post-INSURE respiratory support in preterm infants as compared to NCPAP. The primary outcome was to compare the rate of treatment failure within 7 days of randomization to HHHFNC or NCPAP as a post-INSURE ventilatory modality. It was a pilot trial wherein all preterm infants more than 1 kg and more than 28 weeks gestational age with RDS who required surfactant were randomized to receive NCPAP or HHHFNC. Infants with an urgent need for intubation and mechanical ventilation were considered to have treatment failure. Thirty babies were enrolled-15 in each group. Baseline demographic characteristics were comparable. There was no significant difference in the primary outcome of early failure rate, i.e. mechanical ventilation rate within 7 days of starting treatment. There were no significant differences in other outcomes except nasal injury which was significantly lesser in the HHHFNC group. In conclusion, HHHFNC appears to be non-inferior to NCPAP when used in preterm infants more than 28 weeks gestation with RDS as a post-INSURE ventilatory modality.

Use of high flow nasal cannula in Spanish neonatal units

INTRODUCTION

The use of high-flow cannula therapy (HFNC) in neonatal units has increased in recent years, but there are no consensus guidelines on its indications and application strategies. Our aim was to know the rate of use of HFNC, their indications and the management variability among Spanish neonatal units.

MATERIAL AND METHODS

Twenty-five-question survey for medical and nursing staff. Level II and III units were contacted by phone and sent in Google forms between September 2016 and December 2018.

RESULTS

Ninety-seven responses (63.9% medical, 36.1% nursing), from 69 neonatal units representing 15 autonomous communities (87% level of care III; 13% level II). All units except one have HFNC with a humidified and heated system. Their most frequent indications are: non-invasive ventilation weaning (79.4%), bronchiolitis (69.1%), respiratory distress of the term newborn (58.8%), after extubation (50.5%). Minimum flow (1-5 L/min) and maximum flow (5-15 L/min) are variable between units. 22.7% have experienced some adverse effect from its use (9 air leak, 12 nasal trauma). Less than half have an employment protocol, but all the answers agree on the usefulness of national recommendations.

CONCLUSIONS

HFNC therapy is widely used in Spanish units, but there is great variability in its indications and strategies of use. National recommendations would be applicable in most units and would allow unifying its use.

[Use of high flow nasal cannula in Spanish neonatal units]

INTRODUCTION

The use of high-flow cannula therapy (HFNC) in neonatal units has increased in recent years, but there are no consensus guidelines on its indications and application strategies. Our aim was to know the rate of use of HFNC, their indications and the management variability among Spanish neonatal units.

MATERIAL AND METHODS

Twenty-five-question survey for medical and nursing staff. Level II and III units were contacted by phone and sent in Google forms between September 2016 and December 2018.

RESULTS

Ninety-seven responses (63.9% medical, 36.1% nursing), from 69 neonatal units representing 15 autonomous communities (87% level of care III; 13% level II). All units except one have HFNC with a humidified and heated system. Their most frequent indications are: non-invasive ventilation weaning (79.4%), bronchiolitis (69.1%), respiratory distress of the term newborn (58.8%), after extubation (50.5%). Minimum flow (1-5 L/min) and maximum flow (5-15 L/min) are variable between units. 22.7% have experienced some adverse effect from its use (9 air leak, 12 nasal trauma). Less than half have an employment protocol, but all the answers agree on the usefulness of national recommendations.

CONCLUSIONS

HFNC therapy is widely used in Spanish units, but there is great variability in its indications and strategies of use. National recommendations would be applicable in most units and would allow unifying its use.

Histogram analysis for bedside respiratory monitoring in not critically ill preterm neonates: a proposal for a new way to look at the monitoring data

Despite robust evidence in favour of maintaining optimal oxygen saturation targets in the preterm infants, the titration of oxygen is largely dependent on manual observations and transcription. Similarly, notwithstanding the gaining popularity of non-invasive modalities like high-flow nasal therapy, the practices of weaning and escalating support are largely individualized and based on point of care observations. These are often erroneous and lack objectivity. Histogram analysis from patient monitors is an easy and objective way of quantifying vital parameters and their trends. We review the technology and evidence available behind this practice.Conclusions: Though there are no randomized controlled trials on this practice solely, we identify several quality improvement studies implementing this into practice with benefit. We also cite studies which have implemented histogram analysis in methodology, thus concluding that this is a useful clinical tool worth incorporating into clinical practice to reduce manual errors and bring more objectivity into decisions. What is Known: • The data from NeOProM (Neonatal Oxygenation Prospective Meta-analysis Collaboration study protocol) indicates that optimal saturation targets for preterm infants born < 28 weeks should be between 91 and 95%. • The most "failsafe" way of maintaining strict compliance to these limits is automated oxygen titration but this is not widely used or available and manual transcription and monitoring are susceptible to error and fatigue. What is New: • Histogram analysis from patient monitors can provide intelligent data on respiratory monitoring and can be incorporated into algorithm to decide on weaning or escalation of respiratory support. • With appropriate training, histogram monitoring by nursing staff can limit fatigue of manual recording of data.

Risk factors for treatment failure of heated humidified high-flow nasal cannula as an initial respiratory support in newborn infants with respiratory distress

BACKGROUND

Humidified high-flow nasal cannula (HHFNC) has gained popularity because it is easier to use, more comfortable for babies, and advantageous for mother-infant bonding. HHFNC is not inferior to other non-invasive ventilators for preventing adverse outcomes, but more studies are needed to ensure the safe use of HHFNC as an initial respiratory support for newborns. The aim of this study was to investigate risk factors for treatment failure of HHFNC as an initial respiratory support in newborns with respiratory distress after birth.

METHODS

We included 97 newborns who required non-invasive respiratory support within 24 h after birth. The success group included 68 infants who were successfully managed only on HHFNC, and 29 infants were the failure group who required other respiratory support because of respiratory acidosis, hypoxia, or apnea.

RESULTS

Compared with the success group, the failure group had lower GA, a higher rate of antenatal steroid use, prolonged rupture of membrane, lower pH, higher pCO₂ on blood-gas analysis after HHFNC application and higher incidence of respiratory distress syndrome of newborn (RDS). After adjusting for GA, higher FiO₂ settings during acidosis, hypercarbia after the application of HHFNC shown on blood-gas analysis and the presence of RDS remained significant. The rate of treatment failure was 16.2% for ≥36 weeks, 19.3% for ≥34 weeks, and 22.1% for ≥33 weeks.

CONCLUSION

Treatment failure of HHFNC should be considered a risk for newborns of less than 34 weeks and infants with respiratory distress from RDS. Higher FiO₂ settings during HHFNC, and acidosis and hypercarbia after the application of HHFNC shown on blood-gas analysis may help identify high-risk newborns for other non-invasive ventilators or intubation.

The effects of nasal continuous positive airway pressure and high flow nasal cannula on heart rate variability in extremely preterm infants after extubation: A randomized crossover trial

BACKGROUND

NCPAP and High flow nasal cannula (HFNC) are common modes of non-invasive respiratory support used after extubation. Heart rate variability (HRV) has been demonstrated as a marker of well-being in neonates and differences in HRV were described in preterm infants receiving respiratory care. The objective was to investigate the effects of NCPAP and HFNC on HRV after extubation.

METHODS

Randomized crossover trial in infants with birth weight (BW) ≤1250 g after undergoing their first elective extubation. ECG recordings were performed during 45 min while on HFNC and nasal continuous positive airway pressure (NCPAP). Time domain, non-linear, and frequency domain parameters were calculated and compared during HFNC and NCPAP using paired nonparametric tests. A secondary analysis was performed in the subgroup of infants that were successfully extubated.

RESULTS

Thirty infants with median [range] gestational age of 27 weeks [24.1-29.3] and BW of 930 g [610-1220] were studied at 5 days [1-39] of age. No differences in HRV parameters were observed between HFNC and NCPAP. In the secondary analysis, infants successfully extubated (n = 27) had a significantly higher HRV during HFNC for some time domain parameters. For instance, the standard deviation of the RR intervals (SDRR) was more likely to be higher during HFNC compared to NCPAP (HFNC: 18/27 vs NCPAP: 9/27, P = 0.017) .

CONCLUSION

During the first hours after extubation, no differences in HRV were detected between HFNC and NCPAP in the overall cohort. However, a significantly higher HRV was noted during HFNC in the subgroup of infants successfully extubated.

National surveys of UK and Italian neonatal units highlighted significant differences in the use of non-invasive respiratory support

AIM

This study compared how non-invasive respiratory support (NRS) was provided in neonatal units in Italy and the UK.

METHODS

An NRS questionnaire was sent to tertiary neonatal centres, identified by national societies, from November 2015 to May 2016.

RESULTS

Responses were received from 49/57 (86%) UK units and 103/115 (90%) Italian units. NRS was started in the delivery room by 61% of UK units and 85% of Italian units. In neonatal intensive care units, 33% of UK units used nasal high-flow therapy (HFT) as primary support, compared to 3% in Italy. Nasal continuous positive airway pressure (CPAP) was used in 57% of UK units and 90% of Italian units. The commonest starting flow rate on nasal HFT for term and preterm infants was 6 L/min in the UK, while Italian units mainly used this flow for term infants. In the UK, 67% of units decreased nasal HFT by 1 L/min per day. In Italy, infants on nasal CPAP were weaned by 1 cm H₂ O per day in 39% of units.

CONCLUSION

The way that NRS was managed for very preterm infants differed between the UK and Italy, reflecting a lack of evidence on optimal NRS and the use of local protocols.

Nasal high flow therapy for neonates: Current evidence and future directions

Nasal high flow (nHF) therapy is a commonly used method of providing non-invasive respiratory support for neonates. It has several potential mechanisms of action: continuous distending pressure, nasopharyngeal dead space washout, provision of heated and humidified gases and reduction of work of breathing. nHF is used in a number of clinical scenarios for preterm and term infants, including primary respiratory and post-extubation support. In recent years, large trials have generated evidence pertinent to these indications. Novel applications for nHF in neonates warrant further research: during endotracheal intubation, for initial delivery room stabilisation of preterm infants and in conjunction with minimally invasive surfactant therapy.

Enteral Nutrition Tolerance And REspiratory Support (ENTARES) Study in preterm infants: study protocol for a randomized controlled trial

Background

Respiratory distress syndrome (RDS) and feeding intolerance are common conditions in preterm infants and among the major causes of neonatal mortality and morbidity.

For many years, preterm infants with RDS have been treated with mechanical ventilation, increasing risks of acute lung injury and bronchopulmonary dysplasia.

In recent years non-invasive ventilation techniques have been developed. Showing similar efficacy and risk of bronchopulmonary dysplasia, nasal continuous positive airway pressure (NCPAP) and heated humidified high-flow nasal cannula (HHHFNC) have become the most widespread techniques in neonatal intensive care units. However, their impact on nutrition, particularly on feeding tolerance and risk of complications, is still unknown in preterm infants.

The aim of the study is to evaluate the impact of NCPAP vs HHHFNC on enteral feeding and to identify the most suitable technique for preterm infants with RDS.

Methods

A multicenter randomized single-blind controlled trial was designed. All preterm infants with a gestational age of 25–29 weeks treated with NCPAP or HHHFNC for RDS and demonstrating stability for at least 48 h along with the compliance with inclusion criteria (age less than 7 days, need for non-invasive respiratory support, suitability to start enteral feeding) will be enrolled in the study and randomized to the NCPAP or HHHFNC arm. All patients will be monitored until discharge, and data will be analyzed according to an intention-to-treat model.

The primary outcome is the time to reach full enteral feeding, while parameters of respiratory support, feeding tolerance, and overall health status will be evaluated as secondary outcomes. The sample size was calculated at 141 patients per arm.

Discussion

The identification of the most suitable technique (NCPAP vs HHHFNC) for preterm infants with feeding intolerance could reduce gastrointestinal complications, improve growth, and reduce hospital length of stay, thus improving clinical outcomes and reducing health costs. The evaluation of the timing of oral feeding could be useful in understanding the influence that these techniques could have on the development of sucking-swallow coordination. Moreover, the evaluation of the response to NCPAP and HHHFNC could clarify their efficacy as a treatment for RDS in extremely preterm infants.

Trial registration

ClinicalTrials.gov, NCT03548324. Registered on 7 June 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3119-0) contains supplementary material, which is available to authorized users.

Nasal High-Flow Therapy as Primary Respiratory Support for Preterm Infants without the Need for Rescue with Nasal Continuous Positive Airway Pressure

AIM

To evaluate the effectiveness of nasal high-flow therapy (nHFT) as primary respiratory support for preterm infants with respiratory distress syndrome (RDS) in two tertiary neonatal units.

METHODS

A retrospective outcome analysis of initial respiratory support strategies was performed in two tertiary neonatal units in the UK: John Radcliffe Hospital (JRH), Oxford and St Peter's Hospital (SPH), Chertsey. Infants born between 28+0 and 36+6 weeks gestational age (GA) between May 2013 and June 2015 were included.

RESULTS

A total of 381 infants, 191 from JRH and 190 from SPH, were analysed. Infants were stabilised in the delivery room using mask continuous positive airway pressure followed by nHFT. Endotracheal intubation was performed according to local protocols, depending on the severity of RDS. There were significant differences in initial intubation rates according to GA (26% JRH vs. 16.9% SPH, p < 0.001 for babies < 32 weeks GA, and 8.2% JRH vs. 6.5% SPH, p < 0.001 for babies > 32 weeks GA); however, most infants were successfully transitioned to nHFT. Intubation rates during the first 72 h were comparable between centres (14.7% JRH vs. 11.1% SPH, p = 0.29). There were no differences in neonatal morbidities, including air leak, duration of oxygen supplementation, bronchopulmonary dysplasia, sepsis, retinopathy of prematurity, intraventricular haemorrhage, necrotising enterocolitis, or median time to full-suck feeds.

CONCLUSION

Use of nHFT for primary respiratory support, without use of nasal continuous positive airway pressure as "rescue" treatment, resulted in intubation rates lower or comparable to published data from randomised controlled trials.

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update

As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and 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 using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.

Sustained inflations and avoiding mechanical ventilation to prevent death or bronchopulmonary dysplasia: a meta-analysis

Sustained inflations and avoidance of endotracheal mechanical ventilation (eMV) are delivery room interventions aimed at preventing bronchopulmonary dysplasia (BPD). Their effectiveness is the subject of the present meta-analysis.The databases MEDLINE, EMBASE and CENTRAL were searched for randomised controlled trials (RCTs) of preterm infants that compared: 1) sustained inflations with intermittent positive-pressure ventilation; and 2) a non-intubated strategy of respiratory support with one that prescribed eMV at an earlier stage. Data extraction and analysis followed the standard methods of the Cochrane Collaboration. The primary outcome was death or BPD, defined as need for oxygen or positive pressure treatment at 36 weeks' postmenstrual age.Avoiding eMV (nine RCTs, 3486 infants) reduced the risk of death or BPD, with a risk ratio of 0.90 (95% CI 0.84-0.97) and a number needed to treat of 35. After sustained inflations (six RCTs, 854 infants), the risk ratio was 0.85 (95% CI 0.65-1.12). A current multicentre RCT of sustained inflations in very preterm infants was halted for increased early mortality in the sustained inflations arm.While strategies aimed at avoiding eMV had a small but significant impact on preventing BPD, sustained inflations had no effect and may even increase mortality in very preterm infants.

Differential impact of flow and mouth leak on oropharyngeal humidification during high-flow nasal cannula: a neonatal bench study

BACKGROUND

Heated humidification is paramount during neonatal high-flow nasal cannula (HFNC) therapy. However, there is little knowledge about the influence of flow rate and mouth leak on oropharyngeal humidification and temperature.

METHODS

The effect of the Optiflow HFNC on oropharyngeal gas conditioning was investigated at flow rates of 4, 6 and 8 L min^-1 with and without mouth leak in a bench model simulating physiological oropharyngeal air conditions during spontaneous breathing. Temperature and absolute humidity (AH) were measured using a digital thermo-hygrosensor.

RESULTS

Without mouth leak, oropharyngeal temperature and AH increased significantly with increasing flow (P < 0.001). Mouth leak did not affect this increase up to 6 L min^-1, but at 8 L min^-1, temperature and AH plateaued, and the effect of mouth leak became statistically significant (P < 0.001).

CONCLUSIONS

Mouth leak during HFNC had a negative impact on oropharyngeal gas conditioning when high flows were applied. However, temperature and AH always remained clinically acceptable.