Non-invasive respiratory support for preterm infants following extubation from mechanical ventilation. A narrative review and guideline suggestion

Breathing Effort in Preterm Infants Comparing NIV NAVA and CPAP-A Randomised Crossover Study

AIM

To compare breathing effort in preterm infants during neurally adjusted ventilatory assist (NIV NAVA) and continuous positive airway pressure (CPAP).

METHODS

In this randomised crossover study, preterm infants were randomised to 4 h on NIV NAVA and 4 h on CPAP during daily activity and care. Breathing effort was measured by the diaphragmatic load (Edi) as Edi peak and Edi minimum, respiratory parameters, modified Silverman Andersen index and COMFORT neo score. The parents provided feedback regarding their child's comfort and breathing.

RESULTS

Twenty preterm infants with gestational age 234-284 beyond the postextubation period were included. We found a statistically significant difference in Edi peak (mean difference -1.4% CI: -2.4 to -0.4, p = 0.010) but no significant difference in Edi minimum (-0.1, 95% CI: -0.2 to 0.1, p = 0.521) comparing NIV NAVA to CPAP. Among the 10 secondary outcomes, the respiratory rate was significantly lower on NIV NAVA (-4, 95% CI: -6 to -1, p = 0.013) and there were slightly larger clinical distress scores on CPAP. While almost all parents reported that their child seemed comfortable, not all found the infant's breathing effortless.

CONCLUSION

Edi peak was significantly lower in preterm infants during NIV NAVA versus CPAP.

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in the neonatal intensive care unit (NICU): an Australian NICU experience

BACKGROUND

Preterm infants often require non-invasive breathing support while their lungs and control of respiration are still developing. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is an emerging technology that allows infants to breathe spontaneously while receiving support breaths proportional to their effort. This study describes the first Australian Neonatal Intensive Care Unit (NICU) experience of NIV-NAVA.

METHODS

Retrospective cohort study of infants admitted to a major tertiary NICU between October 2017 and April 2021 supported with NIV-NAVA. Infants were divided into three groups based on the indication to initiate NIV-NAVA (post-extubation; apnoea; escalation). Successful application of NIV-NAVA was based on the need for re-intubation within 48 h of application.

RESULTS

There were 169 NIV-NAVA episodes in 122 infants (82 post-extubation; 21 apnoea; 66 escalation). The median (range) gestational age at birth was 25 + 5 weeks (23 + 1 to 43 + 3 weeks) and median (range) birthweight was 963 g (365-4320 g). At NIV-NAVA application, mean (SD) age was 17 days (18.2), and median (range) weight was 850 g (501-4310 g). Infants did not require intubation within 48 h in 145/169 (85.2%) episodes [72/82 (87.8%) extubation; 21/21 (100%) apnoea; 52/66 (78.8%) escalation).

CONCLUSION

NIV-NAVA was successfully integrated for the three main indications (escalation; post-extubation; apnoea). Prospective clinical trials are still required to establish its effectiveness versus other modes of non-invasive support.

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.

Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside

Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.

Impressive Nasal Septum Regeneration after Cord Blood Platelet Gel (CBPG) in Extreme Premature Neonate with Non-Invasive Ventilation: A Case Report

BACKGROUND

We evaluated the efficacy of Cord Blood Platelet Gel (CBPG) in the regenerative reconstruction of the nasal septal tissue of a preterm infant undergoing non-invasive ventilation.

METHODS

A CBPC treatment was used to enhance the regeneration of the nasal septum of a premature patient in an experimental way, evaluating the efficacy described in the literature (selective bibliographic search in PubMed) of the use of blood products for non-transfusion purposes.

RESULTS

A partial but satisfactory regeneration of the patient's nasal septum was observed. Using the free NIH Image J online software, we were able to calculate the regenerated surface (about 83% of the destroyed cartilage).

CONCLUSIONS

The use of platelet gel has been a promising alternative to surgical treatment in patients with severe damage to the nasal septum.

Standardized nCPAP Care Bundle to Decrease Days to Wean Off nCPAP: A Quality Improvement Initiative

BACKGROUND

Effective bubble nasal continuous positive airway pressure (bnCPAP) implementation is a means to maintain functional residual capacity (FRC) and avoid pulmonary morbidities in neonates.

PURPOSE

A quality improvement project was introduced to establish a standardized bnCPAP care bundle.

METHODS

A bnCPAP care bundle focusing on shoulder roll use, bnCPAP positioning, assessment for suctioning need, and nasopharynx suctioning was created. The outcome measures collected were percentage of time the infant's pulse saturation was less than 86%, corrected gestational age (CGA) when off bnCPAP, length of time a neonate is on bnCPAP, Downes' score, and compliance to bnCPAP care bundle.

RESULTS

An independent-samples t test found a statistically significant higher mean prior to the initiative in the percentage of time the oxygen saturation was less than 86%, Downes' score, length of time, and CGA to wean off bnCPAP (M = 11.7% ± 10.1%, M = 1.6 ± 1.1, M = 27.7 days ± 29.0 days, and M = 35.0 weeks ± 3.38 weeks, respectively) than after the initiative (M = 4.0% ± 4.8%, M = 1.1 ± 0.8, M = 11.2 days ± 10.2 days, and M = 32.8 weeks ± 1.00 weeks, respectively).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Implementing a standardized bnCPAP care bundle showed improvement in oxygen saturation and increased success of weaning off bnCPAP. Future studies to increase the collected data are needed to compare the outcomes on infants born at each gestational age.