1
|
Donda K, Babu S, Rastogi D, Rastogi S. Risk Factors for Pneumothorax and Its Association with Ventilation in Neonates. Am J Perinatol 2024; 41:e1531-e1538. [PMID: 37072012 DOI: 10.1055/s-0043-1768070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVE The mode of ventilation that is implicated in pneumothorax is the one at the time of its diagnosis. Although there is evidence that air leak starts many hours before it is clinically evident, there are no prior studies that have investigated the association of pneumothorax with the mode of ventilation few hours before rather than at the time of its diagnosis. STUDY DESIGN A retrospective case-control study was conducted in the neonatal intensive care unit (NICU) between 2006 and 2016 where cases of neonates with pneumothorax were compared with gestational age-matched control neonates without pneumothorax. Respiratory support associated with pneumothorax was classified as the mode of ventilation 6 hours before the clinical diagnosis of pneumothorax. We investigated the factors that were different between cases and controls, and between cases of pneumothorax on bubble continuous positive airway pressure (bCPAP) and invasive mechanical ventilation (IMV). RESULT Of the 8,029 neonates admitted in the NICU during the study period, 223 (2.8%) developed pneumothorax. Among these, 127 occurred among 2,980 (4.3%) neonates on bCPAP, 38 among 809 (4.7%) neonates on IMV, and the remaining 58 among 4,240 (1.3%) neonates on room air. Those with pneumothorax were more likely to be male, have higher body weight, require respiratory support and surfactant administration, and have bronchopulmonary dysplasia (BPD). Among those who developed pneumothorax, there were differences in the gestational age, gender, and use of antenatal steroids between those who were on bCPAP as compared to those on IMV. IMV was associated with increased odds of pneumothorax as compared to those on bCPAP in a multivariable regression analysis. Cases on IMV had higher incidence of intraventricular hemorrhage, retinopathy of prematurity, BPD, and necrotizing enterocolitis, as well as longer length of stay as compared to those on bCPAP. CONCLUSION Neonates who require any respiratory support have higher incidence of pneumothorax. Among those on respiratory support, those on IMV had higher odds of pneumothorax and worse clinical outcomes as compared to those on bCPAP. KEY POINTS · The process of air leak leading to pneumothorax in majority of neonates starts much before it is clinically diagnosed.. · It is possible to detect the air leak early in the process by subtle changes in the signs, symptoms and changes in lung function.. · True association of the ventilation associated with pneumothorax is not at the time of diagnosis of pneumothorax but few hours before it is diagnosed.. · There is higher incidence of pneumothorax in neonates on any respiratory support.. · There is significantly higher incidence of pneumothorax among neonates on invasive ventilations as compared to noninvasive ventilation after correction for all other clinical factors..
Collapse
Affiliation(s)
- Keyur Donda
- Department of Pediatrics, University of South Florida, Tampa, Florida
| | - Sharmila Babu
- Department of Pediatrics, Maimonides Medical Center, Brooklyn, New York
| | - Deepa Rastogi
- Division of Pulmonary Medicine, Childrens National Hospital George Washington University, Washington, District of Columbia
| | - Shantanu Rastogi
- Division of Neonatology, Childrens National Hospital George Washington University, Washington, District of Columbia
| |
Collapse
|
2
|
Manley BJ, Cripps E, Dargaville PA. Non-invasive versus invasive respiratory support in preterm infants. Semin Perinatol 2024; 48:151885. [PMID: 38570268 DOI: 10.1016/j.semperi.2024.151885] [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: 04/05/2024]
Abstract
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.
Collapse
Affiliation(s)
- Brett J Manley
- Neonatal Services and Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics, Gynecology and Newborn Health, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Emily Cripps
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia
| | - Peter A Dargaville
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| |
Collapse
|
3
|
Ramanathan R, Biniwale M. Noninvasive Ventilation. Crit Care Nurs Clin North Am 2024; 36:51-67. [PMID: 38296376 DOI: 10.1016/j.cnc.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
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.
Collapse
Affiliation(s)
- Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, Keck School of Medicine of USC, Los Angeles General Medical Center, 1200 North State Street, IRD-820, Los Angeles, CA 90033, USA.
| | - Manoj Biniwale
- Division of Neonatology, Department of Pediatrics, Keck School of Medicine of USC, Los Angeles General Medical Center, 1200 North State Street, IRD-820, Los Angeles, CA 90033, USA
| |
Collapse
|
4
|
Mansouri M, Servatyari K, Rahmani K, Sheikhahmadi S, Hemmatpour S, Eskandarifar A, Rahimzadeh M. Surfactant administration methods for premature newborns: LISA vs. INSURE comparative analysis. J Neonatal Perinatal Med 2024; 17:233-239. [PMID: 38759030 DOI: 10.3233/npm-230194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
INTRODUCTION Respiratory Distress Syndrome (RDS) is the most common respiratory disorder among premature infants. The use of surfactant has significantly reduced respiratory complications and mortality. There are two conventional methods for administering surfactant: Intubate-Surfactant-Extubate (INSURE) and Less Invasive Surfactant Administration (LISA). This study aims to compare the effects of surfactant administration using these two methods on the treatment outcomes of premature newborns. MATERIALS AND METHODS In this retrospective cohort study, we included 100 premature newborns with RDS and spontaneous breathing who were admitted to the Neonatal Intensive Care Unit of Besat Hospital in Sanandaj city in 2021. Exclusion criteria comprised congenital anomalies and the needing for intubation for resuscitation at birth. The outcomes of epmericaly trated with two methods were compared: the LISA (50 neonates) and the INSURE (50 neonates). Our interesting outcomes were needing for mechanical ventilation, duration of ventilation, pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia. Finally, we entered the data into STATA-14 statistical software and analyzed it using chi-square and t-tests. RESULTS In this study, 69% of the neonates were boys. The LISA group exhibited significantly lower rates of need for mechanical ventilation (P = 0.003) and ventilation duration (P < 0.001) compared to the INSURE group. Conversely, there were no significant differences between the two groups (P > 0.05) in terms of pneumothorax, pulmonary hemorrhage, severe retinopathy, CPAP duration, and bronchopulmonary dysplasia rates. CONCLUSION The results of this study suggest that the LISA method is a safe and non-invasive approach for surfactant administration. Notably, it resulted in a reduced need for mechanical ventilation and decreased ventilation duration compared to the INSURE method.
Collapse
Affiliation(s)
- M Mansouri
- Department of Pediatrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - K Servatyari
- Student Research Committee, Kurdistan University of Medical Science, Sanandaj, Iran
| | - K Rahmani
- Liver and Digestive Research Center, Research Institute for Health Development, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - S Sheikhahmadi
- Department of Pediatrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - S Hemmatpour
- Department of Pediatrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - A Eskandarifar
- Department of Pediatrics, Faculty of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | - M Rahimzadeh
- Student Research Committee, Kurdistan University of Medical Science, Sanandaj, Iran
| |
Collapse
|
5
|
van Kaam AH, Niemarkt HJ, Onland W. Timing of surfactant treatment in respiratory distress syndrome. Semin Fetal Neonatal Med 2023; 28:101495. [PMID: 38012889 DOI: 10.1016/j.siny.2023.101495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
The introduction of exogenous surfactant in the 1980s has resulted in an improved survival of very preterm infants with respiratory distress syndrome (RDS). Randomized controlled trials conducted before 2000 have shown that the magnitude of this beneficial effect strongly depends on the timing of surfactant treatment, i.e. the earlier surfactant is administered after birth the better. However, the initial mode of respiratory support in infants with RDS has changed dramatically over the last decades, moving from invasive to non-invasive support. Furthermore, new, less invasive techniques to administer surfactant have been introduced to match this non-invasive approach. This review summarizes the evidence on how these practice changes impacted the effect of surfactant timing on mortality and morbidity in preterm infants with RDS.
Collapse
Affiliation(s)
- Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - Hendrik J Niemarkt
- Department of Neonatology, Maxima Medical Center, De Run 4600, 5504 DB, Veldhoven, the Netherlands.
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| |
Collapse
|
6
|
Taha S, Simpson RB, Sharkey D. The critical role of technologies in neonatal care. Early Hum Dev 2023; 187:105898. [PMID: 37944264 DOI: 10.1016/j.earlhumdev.2023.105898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
Neonatal care has made significant advances in the last few decades. As a result, mortality and morbidity in high-risk infants, such as extremely preterm infants or those infants with birth-related brain injury, has reduced significantly. Many of these advances have been facilitated or delivered through development of medical technologies allowing clinical teams to be better supported with the care they deliver or provide new therapies and diagnostics to improve management. The delivery of neonatal intensive care requires the provision of medical technologies that are easy to use, reliable, accurate and ideally developed for the unique needs of the newborn population. Many technologies have been developed and commercialised following adult trials without ever being studied in neonatal patients despite the unique characteristics of this population. Increasingly, funders and industry are recognising this major challenge which has resulted in initiatives to develop new ideas from concept through to clinical care. This review explores some of the key medical technologies used in neonatal care and the evidence to support their adoption to improve outcomes. A number of devices have yet to realise their full potential and will require further development to optimise and find their ideal target population and clinical benefit. Examples of emerging technologies, which may soon become more widely used, are also discussed. As neonatal care relies more on medical technologies, we need to be aware of the impact on care pathways, especially from a human factors approach, the associated costs and subsequent benefits to patients alongside the supporting evidence.
Collapse
Affiliation(s)
- Syed Taha
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Rosalind B Simpson
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Don Sharkey
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom.
| |
Collapse
|
7
|
Glaser K, Bamat NA, Wright CJ. Can we balance early exogenous surfactant therapy and non-invasive respiratory support to optimise outcomes in extremely preterm infants? A nuanced review of the current literature. Arch Dis Child Fetal Neonatal Ed 2023; 108:554-560. [PMID: 36600473 PMCID: PMC10246486 DOI: 10.1136/archdischild-2022-324530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
Therapeutic advances have significantly improved the survival of premature infants. However, a high burden of bronchopulmonary dysplasia (BPD) persists. Aiming at prevention of neonatal lung injury, continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV) strategies have replaced mechanical ventilation for early respiratory support and treatment of respiratory distress syndrome. Multiple randomised controlled trials have demonstrated that broad application of CPAP/NIV decreases exposure to mechanical ventilation and reduces rates of BPD. Here, we explore why this treatment effect is not larger. We discuss that today's neonatal intensive care unit population evolving from the premature to the extremely premature infant demands better targeted therapy, and indicate how early and accurate identification of preterm infants likely to fail CPAP/NIV could increase the treatment effect and minimise the potential harm of delaying exogenous surfactant therapy in these infants. Finally, we argue that less invasive modes of surfactant administration may represent both a pragmatic and beneficial approach in combining CPAP/NIV and early surfactant. Beneficial treatment effects might be higher than reported in the literature when targeting this approach to preterm infants suffering from respiratory failure primarily due to surfactant deficiency. Considering ongoing limitations of current approaches and focusing both on prospects and potential harm of modified strategies, this commentary ultimately addresses the need and the challenge to prove that pushing early CPAP/NIV and strategies of early and less invasive surfactant application prevents lung injury in the long term.
Collapse
Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Nicolas A Bamat
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| |
Collapse
|
8
|
Dey R, Sardar SK, Kumar Saha A, Mukherjee S. Nonsynchronized nasal intermittent positive pressure ventilation versus continuous positive airway pressure as a primary mode of respiratory support in neonates (26-40 weeks) admitted in a tertiary care center: A randomized controlled trial. Pediatr Pulmonol 2023; 58:3063-3070. [PMID: 37530509 DOI: 10.1002/ppul.26624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/08/2023] [Accepted: 07/21/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Continuous positive airway pressure (CPAP) is a standard respiratory care for neonates for last few decades but it too has a high failure rate. Nasal intermittent positive pressure ventilation (NIPPV) is proven to be superior to CPAP in maintaining higher mean airway pressure in neonates with Respiratory Distress Syndrome. The main objective of this study was to compare failure within 72 h of initiation of primary respiratory support between nonsynchronized NIPPV and CPAP in all causes of respiratory distress in newborn infants. Secondarily feed intolerance, Necrotizing enterocolitis (NEC > stage II), hemodynamically significant patent ductus arteriosus, intraventricular hemorrhage (IVH > gradeIII), retinopathy of prematurity (ROP), bronchopulmonary dysplasia (BPD), duration of support and mortality were also compared. METHODS This was a single center randomized controlled trial. Stratified randomization was done for 216 neonates, based on the gestational age in two subgroups 26-33 weeks and 34-40 weeks whopresented with respiratory distress within 5 days of birth, to receive either NIPPV or CPAP. Primary and secondary outcomes were documented. RESULTS Statisticalsignificant difference was noted for primary outcome (RR 0.48 [confidence interval = 0.301-0.786], p = 0.003) but not for other secondary outcomes. NIPPV appeared superior in respect to noninvasiveventilation days, BPD occurrence and hospitalization duration. CONCLUSION As a primary mode, nonsynchronized NIPPV was more efficacious than CPAP in preventing intubation within 72 h of initiation of respiratory support. Further multicenter studies are warranted to explore the benefits of this respiratory support.
Collapse
Affiliation(s)
- Rakesh Dey
- Department of Neonatology, Institute of Post Graduate Medical Education & Research and SSKM Hospital, Kolkata, India
| | - Syamal Kumar Sardar
- Department of Neonatology, Institute of Post Graduate Medical Education & Research and SSKM Hospital, Kolkata, India
| | - Anindya Kumar Saha
- Department of Neonatology, Institute of Post Graduate Medical Education & Research and SSKM Hospital, Kolkata, India
| | - Suchandra Mukherjee
- Department of Neonatology, Institute of Post Graduate Medical Education & Research and SSKM Hospital, Kolkata, India
| |
Collapse
|
9
|
Kribs A, Roberts KD, Trevisanuto D, O'Donnell C, Dargaville PA. Surfactant delivery strategies to prevent bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151813. [PMID: 37805275 DOI: 10.1016/j.semperi.2023.151813] [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: 10/09/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the most devastating morbidities of preterm infants. Antenatal factors like growth restriction and inflammation are risk factors for its development. Use of oxygen and positive pressure ventilation, which are often necessary to treat respiratory distress syndrome (RDS), increase the risk for development of BPD. Continuous positive airway pressure (CPAP) as primary respiratory support allows for avoidance of positive pressure ventilation in many cases but may lead to a delay of surfactant administration which is a proven therapy for RDS. Several alternative surfactant delivery strategies, including nebulization of surfactant, pharyngeal instillation of surfactant, delivery of surfactant via supraglottic airway device or surfactant delivery via a thin endotracheal catheter have been described which allow for the benefit of surfactant therapy while on CPAP. This review reports available data and discusses the existing evidence of their value in preventing BPD as well as further research directions.
Collapse
Affiliation(s)
- Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Faculty of medicine, Cologne, Germany.
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Colm O'Donnell
- School of Medicine, University College Dublin, Dublin, Ireland; Department of Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
| |
Collapse
|
10
|
Lavizzari A, Zannin E, Klotz D, Dassios T, Roehr CC. State of the art on neonatal noninvasive respiratory support: How physiological and technological principles explain the clinical outcomes. Pediatr Pulmonol 2023; 58:2442-2455. [PMID: 37378417 DOI: 10.1002/ppul.26561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/26/2023] [Accepted: 06/10/2023] [Indexed: 06/29/2023]
Abstract
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.
Collapse
Affiliation(s)
- Anna Lavizzari
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neonatal Intensive Care Unit, Milan, Italy
| | - Emanuela Zannin
- Fondazione Monza e Brianza per il Bambino e la sua Mamma, Monza, Italy
| | - Daniel Klotz
- Center for Pediatrics, Division of Neonatology, Faculty of Medicine, Medical Center-University of Freiburg, Freiburg, Germany
| | - Theodore Dassios
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Charles C Roehr
- Faculty of Health Sciences, University of Bristol, Bristol, UK
- National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| |
Collapse
|
11
|
Baldursdottir S, Donaldsson S, Palleri E, Drevhammar T, Jonsson B. Respiratory outcomes after delivery room stabilisation with a new respiratory support system using nasal prongs. Acta Paediatr 2023; 112:719-725. [PMID: 36627506 DOI: 10.1111/apa.16665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
AIM To study if stabilisation using a new respiratory support system with nasal prongs compared to T-piece with a face mask is associated with less need for mechanical ventilation and bronchopulmonary dysplasia. METHODS A single-centre follow-up study of neonates born <28 weeks gestation at Karolinska University Hospital, Stockholm included in the multicentre Comparison of Respiratory Support after Delivery (CORSAD) trial and randomised to initial respiratory support with the new system versus T-piece. Data on respiratory support, neonatal morbidities and mortality were collected up to 36 weeks post-menstrual age. RESULTS Ninety-four infants, 51 female, with a median (range) gestational age of 25 + 2 (23 + 0, 27 + 6) weeks and days, were included. Significantly fewer infants in the new system group received mechanical ventilation during the first 72 h, 24 (52.2%) compared with 35 (72.9%) (p = 0.034) and during the first 7 days, 29 (63.0%) compared with 39 (81.3%) (p = 0.045) in the T-piece group. At 36 weeks post-menstrual age, 13 (28.3%) in the new system and 13 (27.1%) in the T-piece group were diagnosed with bronchopulmonary dysplasia. CONCLUSION Stabilisation with the new system was associated with less need for mechanical ventilation during the first week of life. No significant difference was seen in the outcome of bronchopulmonary dysplasia.
Collapse
Affiliation(s)
- Sonja Baldursdottir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Snorri Donaldsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Elena Palleri
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Drevhammar
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Anaesthesiology, Östersund Hospital, Östersund, Sweden
| | - Baldvin Jonsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
12
|
Escrig-Fernández R, Zeballos-Sarrato G, Gormaz-Moreno M, Avila-Alvarez A, Toledo-Parreño JD, Vento M. The Respiratory Management of the Extreme Preterm in the Delivery Room. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020351. [PMID: 36832480 PMCID: PMC9955623 DOI: 10.3390/children10020351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
The fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization.
Collapse
Affiliation(s)
- Raquel Escrig-Fernández
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
- Correspondence:
| | | | - María Gormaz-Moreno
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Alejandro Avila-Alvarez
- Division of Neonatology, Pediatric Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, 15006 A Coruña, Spain
| | - Juan Diego Toledo-Parreño
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Máximo Vento
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| |
Collapse
|
13
|
Hysinger EB, Ahlfeld SK. Respiratory support strategies in the prevention and treatment of bronchopulmonary dysplasia. Front Pediatr 2023; 11:1087857. [PMID: 36937965 PMCID: PMC10018229 DOI: 10.3389/fped.2023.1087857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/02/2023] [Indexed: 03/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Erik B. Hysinger
- Division of Pulmonary Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
- Correspondence: Erik B. Hysinger
| | - Shawn K. Ahlfeld
- Division of Neonatology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States
| |
Collapse
|
14
|
Boix H, Fernández C, Serrano Martín MDM, Arruza L, Concheiro A, Gimeno A, Sánchez A, Rite S, Jiménez F, Méndez P, Agüera JJ. Failure of early non-invasive ventilation in preterm infants with respiratory distress syndrome in current care practice in Spanish level-III neonatal intensive care units - a prospective observational study. Front Pediatr 2023; 11:1098971. [PMID: 36896404 PMCID: PMC9989254 DOI: 10.3389/fped.2023.1098971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Introduction Despite advances in respiratory distress syndrome (RDS) management over the past decade, non-invasive ventilation (NIV) failure is frequent and associated with adverse outcomes. There are insufficient data on the failure of different NIV strategies currently used in clinical practice in preterm infants. Methods This was a prospective, multicenter, observational study of very preterm infants [gestational age (GA) <32 weeks] admitted to the neonatal intensive care unit for RDS that required NIV from the first 30 min after birth. The primary outcome was the incidence of NIV failure, defined as the need for mechanical ventilation for <72 h of life. Secondary outcomes were risk factors associated with NIV failure and complication rates. Results The study included 173 preterm infants with a median GA of 28 (IQR 27-30) weeks and a median birth weight of 1,100 (IQR 800-1,333) g. The incidence of NIV failure was 15.6%. In the multivariate analysis, lower GA (OR, 0.728; 95% CI, 0.576-0.920) independently increased the risk of NIV failure. Compared to NIV success, NIV failure was associated with higher rates of unfavorable outcomes, including pneumothorax, intraventricular hemorrhage, periventricular leukomalacia, pulmonary hemorrhage, and a combined outcome of moderate-to-severe bronchopulmonary dysplasia or death. Conclusion NIV failure occurred in 15.6% of the preterm neonates and was associated with adverse outcomes. The use of LISA and newer NIV modalities most likely accounts for the reduced failure rate. Gestational age remains the best predictor of NIV failure and is more reliable than the fraction of inspired oxygen during the first hour of life.
Collapse
Affiliation(s)
- Hector Boix
- Division of Neonatology, Hospital Universitario Dexeus, Barcelona, Spain
| | - Cristina Fernández
- Department of Neonatology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | | | - Luis Arruza
- Department of Neonatology, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Ana Concheiro
- Department of Neonatology, Álvaro Cunqueiro University Hospital, Vigo, Spain
| | - Ana Gimeno
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Ana Sánchez
- Department of Neonatology, Hospital Universitario La Paz, Madrid, Spain
| | - Segundo Rite
- Division of Neonatology, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Francisco Jiménez
- Department of Neonatology and Neonatal Intensive Care Unit, Hospital Infantil Universitario Virgen del Rocio, Seville, Spain
| | - Paula Méndez
- Division of Paediatrics, Section of Neonatology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Juan José Agüera
- Department of Paediatrics, Neonatology Section, Virgen de la Arrixaca, University Hospital, Murcia, Spain
| | | |
Collapse
|
15
|
Dani C, Cecchi A, Ciarcià M, Miselli F, Luzzati M, Remaschi G, Bona MD, la Marca G, Boni L. Enteral and Parenteral Treatment with Caffeine for Preterm Infants in the Delivery Room: A Randomised Trial. Paediatr Drugs 2023; 25:79-86. [PMID: 36301511 PMCID: PMC9810558 DOI: 10.1007/s40272-022-00541-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Early treatment with caffeine in the delivery room (DR) has been proposed to decrease the need for mechanical ventilation (MV) by limiting episodes of apnoea and improving respiratory mechanics in preterm infants. Our aim was to verify the hypothesis that intravenous or enteral administration of caffeine can be performed in the preterm infant in the DR. METHODS Infants with 25±0-29±6 weeks of gestational age were enrolled and randomised to receive 20 mg/kg of caffeine citrate intravenously, via the umbilical vein, or enterally, through an orogastric tube, within 10 min of birth. Caffeine blood level was measured at 60 ± 15 min after administration and 60 ± 15 min before the next dose (5 mg/kg). The primary endpoint was evaluation of the success rate of intravenous and enteral administration of caffeine in the DR. RESULTS Nineteen patients were treated with intravenous caffeine and 19 with enteral caffeine. In all patients the procedure was successfully performed. Peak blood level of caffeine 60 ± 15 min after administration in the DR was found to be below the therapeutic range (5 µg/mL) in 25 % of samples and above the therapeutic range in 3%. Blood level of caffeine 60 ± 15 min before administration of the second dose was found to be below the therapeutic range in 18% of samples. CONCLUSIONS Intravenous and enteral administration of caffeine can be performed in the DR without interfering with infants' postnatal assistance. Some patients did not reach the therapeutic range, raising the question of which dose is the most effective to prevent MV. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT04044976; EudraCT number 2018-003626-91.
Collapse
Affiliation(s)
- Carlo Dani
- Division of Neonatology, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Florence, Italy.
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy.
| | - Alessandra Cecchi
- Division of Neonatology, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Martina Ciarcià
- Division of Neonatology, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Francesca Miselli
- Division of Neonatology, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Michele Luzzati
- Division of Neonatology, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Giulia Remaschi
- Division of Neonatology, Careggi University Hospital of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Maria Della Bona
- Laboratory of Clinical Chemistry and Pharmacology of the Meyer Children's Hospital IRCCS, Florence, Italy
| | - Giancarlo la Marca
- Laboratory of Clinical Chemistry and Pharmacology of the Meyer Children's Hospital IRCCS, Florence, Italy
| | - Luca Boni
- SC Epidemiologia Clinica, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Policlinico San Martino of Genova, Genoa, Italy
| |
Collapse
|
16
|
Branagan A, Yu I, Gurusamy K, Miletin J. Thresholds for surfactant use in preterm neonates: a network meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022:archdischild-2022-324184. [PMID: 36600484 DOI: 10.1136/archdischild-2022-324184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To perform a network meta-analysis of randomised controlled trials of different surfactant treatment strategies for respiratory distress syndrome (RDS) to assess if a certain fraction of inspired oxygen (FiO2) is optimal for selective surfactant therapy. DESIGN Systematic review and network meta-analysis using Bayesian analysis of randomised trials of prophylactic versus selective surfactant for RDS. SETTING Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Science Citation Index Expanded. PATIENTS Randomised trials including infants under 32 weeks of gestational age. INTERVENTIONS Intratracheal surfactant, irrespective of type or dose. MAIN OUTCOME MEASURES Our primary outcome was neonatal mortality, compared between groups treated with selective surfactant therapy at different thresholds of FiO2. Secondary outcomes included respiratory morbidity and major complications of prematurity. RESULTS Of 4643 identified references, 14 studies involving 5298 participants were included. We found no statistically significant differences between 30%, 40% and 50% FiO2 thresholds. A sensitivity analysis of infants treated in the era of high antenatal steroid use and nasal continuous positive airway pressure as initial mode of respiratory support showed no difference in mortality, RDS or intraventricular haemorrhage alone but suggested an increase in the combined outcome of major morbidities in the 60% threshold. CONCLUSION Our results do not show a clear benefit of surfactant treatment at any threshold of FiO2. The 60% threshold was suggestive of increased morbidity. There was no advantage seen with prophylactic treatment. Randomised trials of different thresholds for surfactant delivery are urgently needed to guide clinicians and provide robust evidence. PROSPERO REGISTRATION NUMBER CRD42020166620.
Collapse
Affiliation(s)
- Aoife Branagan
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland .,Division of Surgery and Interventional Science, UCL, London, UK
| | - Ivan Yu
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,Division of Surgery and Interventional Science, UCL, London, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, UCL, London, UK.,Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moskva, Russian Federation
| | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic.,2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| |
Collapse
|
17
|
Jensen EA, Laughon MM, DeMauro SB, Cotten CM, Do B, Carlo WA, Watterberg KL. Contributions of the NICHD neonatal research network to the diagnosis, prevention, and treatment of bronchopulmonary dysplasia. Semin Perinatol 2022; 46:151638. [PMID: 36085059 PMCID: PMC11075436 DOI: 10.1016/j.semperi.2022.151638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Despite improvements in the care and outcomes of infants born extremely preterm, bronchopulmonary dysplasia (BPD) remains a common and frustrating complication of prematurity. This review summarizes the BPD-focused research conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network (NRN). To improve disease classification and outcome prediction, the NRN developed new data-driven diagnostic criteria for BPD and web-based tools that allow clinicians and investigators to reliably estimate BPD risk in preterm infants. Randomized trials of intramuscular vitamin A and prophylactic nasal continuous positive airway pressure conducted by the NRN have contributed to our current use of these therapies as evidence-based approaches to reduce BPD risk. A recent large, randomized trial of hydrocortisone administered beginning between the 2nd and 4th postnatal weeks provided strong evidence that this therapy promotes successful extubation but does not lower BPD rates. Ongoing studies within the NRN will address important, unanswered questions on the risks and benefits of intratracheal surfactant/corticosteroid combinations and treatment versus expectant management of the patent ductus arteriosus to prevent BPD.
Collapse
Affiliation(s)
- Erik A Jensen
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Laughon
- Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sara B DeMauro
- Division of Neonatology and Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, United States
| | - C Michael Cotten
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Barbara Do
- Biostatistics and Epidemiology Division, RTI International, Research Triangle Park, NC, United States
| | - Waldemar A Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristi L Watterberg
- University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| |
Collapse
|
18
|
Should less invasive surfactant administration (LISA) become routine practice in US neonatal units? Pediatr Res 2022; 93:1188-1198. [PMID: 35986148 PMCID: PMC9389478 DOI: 10.1038/s41390-022-02265-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
The harmful effects of mechanical ventilation (MV) on the preterm lung are well established. Avoiding MV at birth and stabilization on continuous positive airway pressure (CPAP) decreases the composite outcome of death or bronchopulmonary dysplasia. Although preterm infants are increasingly being admitted to the neonatal intensive care unit on CPAP, centers differ in the ability to manage infants primarily on CPAP. Over the last decade, less invasive surfactant administration (LISA), a method of administering surfactant with a thin catheter, has been devised and has been shown to decrease the need for MV and improve outcomes compared to surfactant administration via an endotracheal tube following intubation. While LISA has been widely adopted in Europe and other countries, its use is not widespread in the United States. This article provides a summary of the existing evidence on LISA, and practical guidance for US units choosing to implement a change of practice incorporating optimization of CPAP and LISA. IMPACT: The accumulated body of evidence for less invasive surfactant administration (LISA), a widespread practice in other countries, justifies its use as an alternative to intubation and surfactant administration in US neonatal units. This article summarizes the current evidence for LISA, identifies gaps in knowledge, and offers practical tips for the implementation of LISA as part of a comprehensive non-invasive respiratory support strategy. This article will help neonatal units in the US develop guidelines for LISA, provide optimal respiratory support for infants with respiratory distress syndrome, improve short- and long-term outcomes of preterm infants, and potentially decrease costs of NICU care.
Collapse
|
19
|
Wright CJ, Glaser K, Speer CP, Härtel C, Roehr CC. Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools? J Pediatr 2022; 247:138-146. [PMID: 35429507 DOI: 10.1016/j.jpeds.2022.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/27/2021] [Accepted: 04/08/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Charles C Roehr
- Southmead Hospital, North Bristol NHS Trust, University of Bristol, Dept. Pediatrics, Faculty of Health Science, Bristol, UK; National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford Oxfordshire, UK.
| |
Collapse
|
20
|
Härtel C, Herting E, Humberg A, Hanke K, Mehler K, Keller T, Mauer I, Frieauff E, Meyer S, Thome UH, Wieg C, Schmidtke S, Kribs A, Göpel W. Association of Administration of Surfactant Using Less Invasive Methods With Outcomes in Extremely Preterm Infants Less Than 27 Weeks of Gestation. JAMA Netw Open 2022; 5:e2225810. [PMID: 35943742 PMCID: PMC9364126 DOI: 10.1001/jamanetworkopen.2022.25810] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE The inclusion of less invasive surfactant administration (LISA) in the care of preterm infants has been found to be beneficial for respiratory outcomes. Recently, the OPTIMIST trial found higher mortality rates in the subgroup of infants born at 25 to 26 weeks' gestational age (GA) who received surfactant treatment while spontaneously breathing. OBJECTIVE To analyze outcomes among LISA-exposed, highly vulnerable babies born at less than 27 weeks' GA within the large-scale observational cohort of the German Neonatal Network. DESIGN, SETTING, AND PARTICIPANTS In this cohort study of data from 68 tertiary level neonatal intensive care units in Germany of infants born between 22 weeks 0 days to 26 weeks 6 days of gestation between April 1, 2009, and December 31, 2020, short-term outcomes among infants receiving LISA vs infants not receiving LISA were compared. EXPOSURE Use of LISA within the first 72 hours of life. MAIN OUTCOMES AND MEASURES The main outcomes were rates of LISA use, use of mechanical ventilation within the first 72 hours (considered failure of LISA), and association of LISA with outcomes, including death from all causes, bronchopulmonary dysplasia (BPD), death and BPD combined, pneumothorax, retinopathy of prematurity, intracerebral hemorrhage, and periventricular leukomalacia. To address potential confounding factors, multivariate logistic regression models were used. RESULTS A total of 6542 infants (3030 [46.3%] female and 3512 [53.7%] male; mean [SD] GA, 25.3 (1.1) weeks; mean [SD] birth weight, 715 [180] g) were analyzed; 2534 infants (38.7%) received LISA, which was most frequently given quasi-prophylactically during delivery room management. Among the infants who received LISA, 1357 (53.6%) did not require mechanical ventilation in the first 72 hours compared with 331 infants (8.3%) of 4008 who did not receive LISA. In a multivariate logistic regression model that adjusted for GA, small-for-GA status, sex, multiple birth, inborn status, antenatal steroid use, and maximum fraction of inspired oxygen in the first 12 hours of life, LISA was associated with reduced risks of all-cause death (odds ratio [OR], 0.74; 95% CI, 0.61-0.90; P = .002), BPD (OR, 0.69; 95% CI, 0.62-0.78; P < .001), and BPD or death (OR, 0.64; 95% CI, 0.57-0.72; P < .001) compared with infants without LISA exposure. CONCLUSIONS AND RELEVANCE The results of this long-term multicenter cohort study suggest that LISA may be associated with reduced risks of adverse outcomes in extremely preterm infants.
Collapse
Affiliation(s)
- Christoph Härtel
- Department of Paediatrics, University of Würzburg, Würzburg, Germany
| | - Egbert Herting
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Alexander Humberg
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Kathrin Hanke
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| | - Katrin Mehler
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Titus Keller
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Isabell Mauer
- Department of Paediatrics, University of Würzburg, Würzburg, Germany
| | - Eric Frieauff
- Department of Paediatrics, University of Würzburg, Würzburg, Germany
| | - Sascha Meyer
- Department of General Pediatrics and Neonatology, University Children’s Hospital of Saarland, Homburg, Germany
| | - Ulrich H. Thome
- Division of Neonatology, Department of Women’s and Children’s Health, University Children’s Hospital Leipzig, Leipzig, Germany
| | - Christian Wieg
- Neonatology and Pediatric Intensive Care, Children’s Hospital Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Susanne Schmidtke
- Division of Neonatology, Asklepios Hospital Hamburg-Barmbek, Hamburg, Germany
| | - Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Cologne, Germany
| | - Wolfgang Göpel
- Department of Paediatrics, University Hospital Schleswig-Holstein/Campus Lübeck, Lübeck, Germany
| |
Collapse
|
21
|
Javaudin F, Zayat N, Bagou G, Mitha A, Chapoutot AG. Prise en charge périnatale du nouveau-né lors d’une naissance en milieu extrahospitalier. ANNALES FRANCAISES DE MEDECINE D URGENCE 2022. [DOI: 10.3166/afmu-2022-0396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Les accouchements inopinés extrahospitaliers représentent environ 0,3 % des accouchements en France. La prise en charge du nouveau-né en préhospitalier par une équipe Smur fait partie de l’activité courante. L’évaluation initiale du nouveau-né comprend systématiquement la mesure de sa fréquence cardiaque (FC) et respiratoire (FR), l’appréciation de son tonus ainsi que la mesure de sa température axillaire. En cas de doute ou de transition incomplète un monitoring cardiorespiratoire sera immédiatement mis en place (FC, FR, SpO2). Nous faisons ici une mise au point sur les données connues et avons adapté les pratiques, si besoin, au contexte extrahospitalier, car la majeure partie des données rapportées dans la littérature concernent les prises en charge en maternité ou en milieu hospitalier. Nous abordons les points essentiels de la prise en charge des nouveau-nés, à savoir la réanimation cardiopulmonaire, le clampage tardif du cordon ombilical, la lutte contre l’hypothermie et l’hypoglycémie; ainsi que des situations particulières comme la prématurité, la conduite à tenir en cas de liquide méconial ou de certaines malformations congénitales. Nous proposons aussi quels peuvent être : le matériel nécessaire à la prise en charge des nouveau-nés en extrahospitalier, les critères d’engagement d’un renfort pédiatrique à la régulation ainsi que les méthodes de ventilation et d’abord vasculaire que l’urgentiste doit maîtriser. L’objectif de cette mise au point est de proposer des prises en charge les plus adaptées au contexte préhospitalier.
Collapse
|
22
|
Poractant alfa versus bovine lipid extract surfactant: prospective comparative effectiveness study. J Perinatol 2022; 42:468-475. [PMID: 35177795 DOI: 10.1038/s41372-022-01346-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare short term respiratory outcomes in preterm infants treated with bovine lipid extract surfactant or poractant alfa. STUDY DESIGN Prospective comparative effectiveness cohort study of infants <32 weeks' gestational age requiring surfactant in thirteen centers. Each center provided bovine lipid extract surfactant for a set period of time in the year 2019 and then changed to poractant alfa for the remainder of the year. The primary outcome was total duration of respiratory support. RESULT 968 infants were included. 494 received bovine lipid extract surfactant and 474 received poractant alfa. No difference was observed in the total duration of respiratory support (mechanical ventilation or non-invasive) (median 38 vs 40.5 days), need to re-dose surfactant, bronchopulmonary dysplasia, survival to discharge, or length of admission. CONCLUSION In this pragmatic study, we did not identify any difference in short term outcomes between the groups based on the type of surfactant received.
Collapse
|
23
|
Usuda H, Carter S, Takahashi T, Newnham JP, Fee EL, Jobe AH, Kemp MW. Perinatal care for the extremely preterm infant. Semin Fetal Neonatal Med 2022; 27:101334. [PMID: 35577715 DOI: 10.1016/j.siny.2022.101334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Being born preterm (prior to 37 weeks of completed gestation) is a leading cause of childhood death up to five years of age, and is responsible for the demise of around one million preterm infants each year. Rates of prematurity, which range from approximately 5 to 18% of births, are increasing in most countries. Babies born extremely preterm (less than 28 weeks' gestation) and in particular, in the periviable (200/7-256/7 weeks) period, are at the highest risk of death, or the development of long-term disabilities. The perinatal care of extremely preterm infants and their mothers raises a number of clinical, technical, and ethical challenges. Focusing on 'micropremmies', or those born in the periviable period, this paper provides an update regarding the aetiology and impacts of periviable preterm birth, advances in the antenatal, intrapartum, and acute post-natal management of these infants, and a review of counselling/support approaches for engaging with the infant's family. It concludes with an overview of emerging technology that may assist in improving outcomes for this at-risk population.
Collapse
Affiliation(s)
- Haruo Usuda
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - Sean Carter
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore
| | - Tsukasa Takahashi
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan
| | - John P Newnham
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Erin L Fee
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia
| | - Alan H Jobe
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Perinatal Research, Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, University of Cincinnati, Cincinnati, OH, 45229, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynaecology, The University of Western Australia, Perth, Western Australia, 6009, Australia; Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, 119228, Singapore; School of Veterinary and Life Sciences, Murdoch University, Perth, Western Australia, 6150, Australia; Centre for Perinatal and Neonatal Medicine, Tohoku University Hospital, Sendai, 980-8574, Japan.
| |
Collapse
|
24
|
Sindelar R, Nakanishi H, Stanford AH, Colaizy TT, Klein JM. Respiratory management for extremely premature infants born at 22 to 23 weeks of gestation in proactive centers in Sweden, Japan, and USA. Semin Perinatol 2022; 46:151540. [PMID: 34872750 DOI: 10.1016/j.semperi.2021.151540] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Survival of preterm newborn infants have increased steadily since the introduction of surfactant treatment and antenatal steroids. In the absence of randomized controlled trials on ventilatory strategies in extremely preterm infants, we present ventilatory strategies applied during the initial phase and the continued ventilatory care as applied in three centers with proactive prenatal and postnatal management and well documented good outcomes in terms of mortality and morbidity in this cohort of infants.
Collapse
Affiliation(s)
- Richard Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Hidehiko Nakanishi
- Research and Development Center for New Medical Frontiers, Division of Neonatal Intensive Care Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Amy H Stanford
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Tarah T Colaizy
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Jonathan M Klein
- Division of Neonatology, Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
25
|
Impact of a Care Bundle on Cost Saving for Noninvasive Respiratory Support for Neonates. Adv Neonatal Care 2022; 22:22-27. [PMID: 33783385 DOI: 10.1097/anc.0000000000000856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neonates often receive noninvasive respiratory support via continuous positive airway pressure (CPAP) or high-flow nasal cannula oxygen (HHFNC). The decision to change from one mode to the other, however, is not evidence based, hence not standardized and does not consider cost implications. PURPOSE To assess the introduction of a care bundle for the medical and nursing staff in a tertiary medical and surgical neonatal center with regard to any financial savings or adverse outcomes. METHODS An education package and written guidelines were used to increase the awareness of the durations for which CPAP and HHFNC Vapotherm (VT) circuits could be used and the costs of the circuits. RESULTS This resulted in a cost saving of £17,000 ($22,254) for the year without adverse outcomes. IMPLICATIONS FOR PRACTICE Introduction of a care bundle involving an education package and written guidelines to increase the awareness of the durations that circuits could be used and the costs of CPAP and HHFNC circuits among the medical and nursing staff can lead to cost savings when incorporated into clinical practice. IMPLICATIONS FOR RESEARCH Strategies, particularly during weaning, which involve changing from one form of noninvasive respiratory support to another, need a greater evidence base. Future research should include awareness of the duration different circuits could be used and the cost implications of changes between modes and hence circuits.
Collapse
|
26
|
Kalikkot Thekkeveedu R, El-Saie A, Prakash V, Katakam L, Shivanna B. Ventilation-Induced Lung Injury (VILI) in Neonates: Evidence-Based Concepts and Lung-Protective Strategies. J Clin Med 2022; 11:jcm11030557. [PMID: 35160009 PMCID: PMC8836835 DOI: 10.3390/jcm11030557] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/05/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
Supportive care with mechanical ventilation continues to be an essential strategy for managing severe neonatal respiratory failure; however, it is well known to cause and accentuate neonatal lung injury. The pathogenesis of ventilator-induced lung injury (VILI) is multifactorial and complex, resulting predominantly from interactions between ventilator-related factors and patient-related factors. Importantly, VILI is a significant risk factor for developing bronchopulmonary dysplasia (BPD), the most common chronic respiratory morbidity of preterm infants that lacks specific therapies, causes life-long morbidities, and imposes psychosocial and economic burdens. Studies of older children and adults suggest that understanding how and why VILI occurs is essential to developing strategies for mitigating VILI and its consequences. This article reviews the preclinical and clinical evidence on the pathogenesis and pathophysiology of VILI in neonates. We also highlight the evidence behind various lung-protective strategies to guide clinicians in preventing and attenuating VILI and, by extension, BPD in neonates. Further, we provide a snapshot of future directions that may help minimize neonatal VILI.
Collapse
Affiliation(s)
| | - Ahmed El-Saie
- Section of Neonatology, Department of Pediatrics, Children’s Mercy Hospital, Kansas City, MO 64106, USA;
- Department of Pediatrics, Cairo University, Cairo 11956, Egypt
| | - Varsha Prakash
- Department of Pathology, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Lakshmi Katakam
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Binoy Shivanna
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA;
- Correspondence: ; Tel.: +832-824-6474; Fax: +832-825-3204
| |
Collapse
|
27
|
Ugowe O, Adejuyigbe EA, Anyabolu C, Babalola T. Clinical outcome of preterm babies managed for respiratory distress syndrome using nasal continuous positive airway pressure and surfactant: An experience from Ile-Ife, South-Western Nigeria. J Clin Neonatol 2022. [DOI: 10.4103/jcn.jcn_27_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
28
|
Dargaville PA, Kamlin COF, Orsini F, Wang X, De Paoli AG, Kanmaz Kutman HG, Cetinkaya M, Kornhauser-Cerar L, Derrick M, Özkan H, Hulzebos CV, Schmölzer GM, Aiyappan A, Lemyre B, Kuo S, Rajadurai VS, O’Shea J, Biniwale M, Ramanathan R, Kushnir A, Bader D, Thomas MR, Chakraborty M, Buksh MJ, Bhatia R, Sullivan CL, Shinwell ES, Dyson A, Barker DP, Kugelman A, Donovan TJ, Tauscher MK, Murthy V, Ali SKM, Yossuck P, Clark HW, Soll RF, Carlin JB, Davis PG. Effect of Minimally Invasive Surfactant Therapy vs Sham Treatment on Death or Bronchopulmonary Dysplasia in Preterm Infants With Respiratory Distress Syndrome: The OPTIMIST-A Randomized Clinical Trial. JAMA 2021; 326:2478-2487. [PMID: 34902013 PMCID: PMC8715350 DOI: 10.1001/jama.2021.21892] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE The benefits of surfactant administration via a thin catheter (minimally invasive surfactant therapy [MIST]) in preterm infants with respiratory distress syndrome are uncertain. OBJECTIVE To examine the effect of selective application of MIST at a low fraction of inspired oxygen threshold on survival without bronchopulmonary dysplasia (BPD). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial including 485 preterm infants with a gestational age of 25 to 28 weeks who were supported with continuous positive airway pressure (CPAP) and required a fraction of inspired oxygen of 0.30 or greater within 6 hours of birth. The trial was conducted at 33 tertiary-level neonatal intensive care units around the world, with blinding of the clinicians and outcome assessors. Enrollment took place between December 16, 2011, and March 26, 2020; follow-up was completed on December 2, 2020. INTERVENTIONS Infants were randomized to the MIST group (n = 241) and received exogenous surfactant (200 mg/kg of poractant alfa) via a thin catheter or to the control group (n = 244) and received a sham (control) treatment; CPAP was continued thereafter in both groups unless specified intubation criteria were met. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of death or physiological BPD assessed at 36 weeks' postmenstrual age. The components of the primary outcome (death prior to 36 weeks' postmenstrual age and BPD at 36 weeks' postmenstrual age) also were considered separately. RESULTS Among the 485 infants randomized (median gestational age, 27.3 weeks; 241 [49.7%] female), all completed follow-up. Death or BPD occurred in 105 infants (43.6%) in the MIST group and 121 (49.6%) in the control group (risk difference [RD], -6.3% [95% CI, -14.2% to 1.6%]; relative risk [RR], 0.87 [95% CI, 0.74 to 1.03]; P = .10). Incidence of death before 36 weeks' postmenstrual age did not differ significantly between groups (24 [10.0%] in MIST vs 19 [7.8%] in control; RD, 2.1% [95% CI, -3.6% to 7.8%]; RR, 1.27 [95% CI, 0.63 to 2.57]; P = .51), but incidence of BPD in survivors to 36 weeks' postmenstrual age was lower in the MIST group (81/217 [37.3%] vs 102/225 [45.3%] in the control group; RD, -7.8% [95% CI, -14.9% to -0.7%]; RR, 0.83 [95% CI, 0.70 to 0.98]; P = .03). Serious adverse events occurred in 10.3% of infants in the MIST group and 11.1% in the control group. CONCLUSIONS AND RELEVANCE Among preterm infants with respiratory distress syndrome supported with CPAP, minimally invasive surfactant therapy compared with sham (control) treatment did not significantly reduce the incidence of the composite outcome of death or bronchopulmonary dysplasia at 36 weeks' postmenstrual age. However, given the statistical uncertainty reflected in the 95% CI, a clinically important effect cannot be excluded. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611000916943.
Collapse
Affiliation(s)
- Peter A. Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
| | - C. Omar F. Kamlin
- Neonatal Services, Royal Women’s Hospital, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Francesca Orsini
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Xiaofang Wang
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
| | | | - H. Gozde Kanmaz Kutman
- Department of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, Ankara, Turkey
| | - Merih Cetinkaya
- Division of Neonatology, Department of Pediatrics, Istanbul Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Lilijana Kornhauser-Cerar
- Department of Perinatology, Division of Gynaecology and Obstetrics, University Medical Centre, Ljubljana, Slovenia
| | - Matthew Derrick
- Division of Neonatology, NorthShore University Health System, Evanston, Illinois
| | - Hilal Özkan
- Department of Pediatrics, Division of Neonatology, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Christian V. Hulzebos
- Division of Neonatology, Beatrix Children’s Hospital, University Medical Center Groningen, Groningen, the Netherlands
| | - Georg M. Schmölzer
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Ajit Aiyappan
- Neonatal Services, Mercy Hospital for Women, Heidelberg, Australia
| | - Brigitte Lemyre
- Department of Obstetrics, Gynecology, and Newborn Care, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Sheree Kuo
- Department of Pediatrics, Kapi’olani Medical Center for Women and Children, Honolulu, Hawaii
| | - Victor S. Rajadurai
- Department of Neonatology, KK Women’s and Children’s Hospital, Duke-NUS Medical School, Singapore
| | - Joyce O’Shea
- Neonatal Unit, Royal Hospital for Children, Glasgow, Scotland
| | - Manoj Biniwale
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center and Good Samaritan Hospital, Keck School of Medicine of USC, Los Angeles, California
| | - Rangasamy Ramanathan
- Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center and Good Samaritan Hospital, Keck School of Medicine of USC, Los Angeles, California
| | - Alla Kushnir
- Department of Pediatrics, Children’s Regional Hospital, Cooper University Health Care, Camden, New Jersey
| | - David Bader
- Department of Neonatology, Bnai Zion Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Mark R. Thomas
- Department of Neonatal Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, England
| | | | - Mariam J. Buksh
- Newborn Service, Starship Child Health, Auckland Hospital, Auckland, New Zealand
| | - Risha Bhatia
- Monash Newborn, Monash Children’s Hospital, Clayton, Australia
| | | | - Eric S. Shinwell
- Department of Neonatology, Ziv Medical Center, Faculty of Medicine, Bar-Ilan University, Tsfat, Israel
| | - Amanda Dyson
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Woden, Australia
| | - David P. Barker
- Neonatal Intensive Care Unit, Dunedin Hospital, Dunedin, New Zealand
| | - Amir Kugelman
- Department of Neonatology, Rambam Medical Center, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Tim J. Donovan
- Division of Neonatology, Royal Brisbane and Women’s Hospital, Brisbane, Australia
| | - Markus K. Tauscher
- Division of Neonatology, Peyton Manning Children’s Hospital, Ascension St Vincent, Indianapolis, Indiana
| | - Vadivelam Murthy
- Neonatal Intensive Care Centre, Royal London Hospital-Barts Health NHS Foundation Trust, London, England
| | | | - Pete Yossuck
- Department of Pediatrics, WVU Medicine Children’s Hospital, Morgantown, West Virginia
| | - Howard W. Clark
- Neonatal Intensive Care Unit, Princess Anne Hospital, Southampton, England
- Department of Neonatology, EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, England
| | - Roger F. Soll
- Division of Neonatal-Perinatal Medicine, Larner College of Medicine, University of Vermont, Burlington
| | - John B. Carlin
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Peter G. Davis
- Neonatal Services, Royal Women’s Hospital, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| |
Collapse
|
29
|
Dell'Orto V, Nobile S, Correani A, Marchionni P, Giretti I, Rondina C, Burattini I, Palazzi ML, Carnielli VP. Early nasal continuous positive airway pressure failure prediction in preterm infants less than 32 weeks gestational age suffering from respiratory distress syndrome. Pediatr Pulmonol 2021; 56:3879-3886. [PMID: 34610212 DOI: 10.1002/ppul.25678] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 09/11/2021] [Accepted: 09/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early continuous positive airway pressure (CPAP) and surfactant replacement are effective treatments for neonatal respiratory distress syndrome (RDS). CPAP is the first line in preterm infants needing respiratory support, with surfactant replacement in case of CPAP failure (CPAP-F). OBJECTIVES To analyze incidence and factors associated with CPAP-F in preterm infants with RDS. DESIGN, SETTING AND PATIENTS Single-center retrospective database analysis (2004-2017) of inborn infants, gestational age (GA) 24 + 0/7-31 + 6/7 weeks, not intubated on admission to the neonatal intensive care unit, managed with CPAP. CPAP-F was defined as intubation and surfactant administration in the first 72 h of life; CPAP success (CPAP-S) was CPAP alone without need for additional RDS treatments. Demographic, respiratory, and clinical data associated with CPAP-F were studied using logistic regression analysis. RESULTS A total of 562 infants met the inclusion criteria: 252 (44.8%) were CPAP-F and 310 (55.2%) were CPAP-S. The CPAP-F, compared to CPAP-S group, had lower GA and birth weight, and were less likely to receive antenatal steroids or to be vaginal births. Logistic regression showed that the fraction of inspired oxygen (FiO2 ) ≥ 0.23 between 180 and 240 min of life (FiO2 180-240 min) was the strongest factor associated with CPAP-F (odds ratio: 16.01 [95% confidence interval: 10.34-24.81]). CONCLUSION FiO2 180-240 min was highly predictive of CPAP-F in preterm infants. With this model for surfactant administration/CPAP-F, 11.2% of infants would have unnecessarily received treatment, but importantly, 27.7% would have been treated much earlier, with a potential reduction in air leaks and duration of mechanical ventilation.
Collapse
Affiliation(s)
- Valentina Dell'Orto
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Stefano Nobile
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy.,Department of Mother, Child and Public Health, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Alessio Correani
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Paolo Marchionni
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Ilaria Giretti
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Clementina Rondina
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Ilaria Burattini
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Maria L Palazzi
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy
| | - Virgilio P Carnielli
- Division of Neonatology, Mother and Child Department, G. Salesi University Hospital, Ospedali Riuniti, Ancona, Italy.,Department of Odontostomatologic and Specialized Clinical Sciences, Polytechnic University of Marche, Ancona, Italy
| |
Collapse
|
30
|
Owen LS, Manley BJ, Hodgson KA, Roberts CT. Impact of early respiratory care for extremely preterm infants. Semin Perinatol 2021; 45:151478. [PMID: 34474939 DOI: 10.1016/j.semperi.2021.151478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite advances in neonatal intensive care, more than half of surviving infants born extremely preterm (EP; < 28 weeks' gestation) develop bronchopulmonary dysplasia (BPD). Prevention of BPD is critical because of its associated mortality and morbidity, including adverse neurodevelopmental outcomes and respiratory health in later childhood and beyond. The respiratory care of EP infants begins before birth, then continues in the delivery room and throughout the primary hospitalization. This chapter will review the evidence for interventions after birth that might improve outcomes for infants born EP, including the timing of umbilical cord clamping, strategies to avoid or minimize exposure to mechanical ventilation, modes of mechanical ventilation and non-invasive respiratory support, oxygen saturation targets, postnatal corticosteroids and other adjunct therapies.
Collapse
Affiliation(s)
- Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kate A Hodgson
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
| |
Collapse
|
31
|
Rüegger CM, Owen LS, Davis PG. Nasal Intermittent Positive Pressure Ventilation for Neonatal Respiratory Distress Syndrome. Clin Perinatol 2021; 48:725-744. [PMID: 34774206 DOI: 10.1016/j.clp.2021.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Nasal or noninvaisve intermittent positive pressure ventilation (NIPPV) refers to well-established noninvasive respiratory support strategies combining a continuous distending pressure with intermittent pressure increases. Uncertainty remains regarding the benefits provided by the various devices and techniques used to generate NIPPV. Our included meta-analyses of trials comparing NIPPV with continuous positive airway pressure (CPAP) in preterm infants demonstrate that both primary and postextubation NIPPV are superior to CPAP to prevent respiratory failure leading to additional ventilatory support. This short-term benefit is associated with a reduction in bronchopulmonary dysplasia, but not with mortality. Benefits are greatest when ventilator-generated, synchronized NIPPV is used.
Collapse
Affiliation(s)
- Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital Zurich, University of Zurich, Frauenklinikstrasse 10, Zurich 8091, Switzerland.
| | - Louise S Owen
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| |
Collapse
|
32
|
Altamimi T, Read B, da Silva O, Bhattacharya S. Airway injury and pneumomediastinum associated with less invasive surfactant administration in a premature neonate: a case report. BMC Pediatr 2021; 21:500. [PMID: 34758781 PMCID: PMC8579620 DOI: 10.1186/s12887-021-02981-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 10/29/2021] [Indexed: 11/22/2022] Open
Abstract
Background The use of less invasive surfactant administration (LISA)/minimally invasive surfactant therapy (MIST) has increased due to its potential advantage over traditional surfactant delivery methods through an endotracheal tube. Known complications for this procedure include failure of the first attempt at insertion, desaturation, and bradycardia. To the best of our knowledge, this is the first reported case of pneumomediastinum and subcutaneous emphysema following LISA. Case presentation A preterm newborn born at 27 weeks of gestation presented with respiratory distress syndrome requiring surfactant replacement. LISA using the Hobart method was completed. There was a report of procedural difficulty related to increased resistance to insertion of the 16G angiocath. The newborn was subsequently noted to have subcutaneous emphysema over the anterior aspect of the neck and substantial pneumomediastinum on radiological assessment. Associated complications included hypotension requiring inotropic support. The newborn was successfully managed conservatively, with complete resolution of the air leak. Conclusions Upper airway injury leading to air leak syndrome is a rare complication of the Hobart method for LISA. Awareness of such procedural complications is important as the use of the LISA method increases.
Collapse
Affiliation(s)
- Talal Altamimi
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada.
| | - Brooke Read
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| | - Orlando da Silva
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| | - Soume Bhattacharya
- Neonatal - Perinatal Medicine, University of Western, 800 Commissioners Rd E, D4-200, London, Ontario, N6A 5W9, Canada
| |
Collapse
|
33
|
Ramaswamy VV, Abiramalatha T, Bandyopadhyay T, Shaik NB, Pullattayil S AK, Cavallin F, Roehr CC, Trevisanuto D. Delivery room CPAP in improving outcomes of preterm neonates in low-and middle-income countries: A systematic review and network meta-analysis. Resuscitation 2021; 170:250-263. [PMID: 34757058 DOI: 10.1016/j.resuscitation.2021.10.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
AIM To study the impact of delivery room continuous positive airway pressure (DRCPAP) on outcomes of preterm neonates in low- and middle- income countries (LMICs) by comparing with interventions: oxygen supplementation, late DRCPAP, DRCPAP with sustained inflation, DRCPAP with surfactant and invasive mechanical ventilation (IMV). METHODS Medline, Embase, CENTRAL, WOS and CINAHL searched. Observational studies and randomized controlled trials (RCTs) were included. Pair-wise meta-analysis and Bayesian network meta-analysis (NMA) were utilized. Primary outcome was receipt of IMV. RESULTS Data from 11 of the 18 included studies (4 observational studies, 7 RCTs) enrolling 4210 preterm infants was synthesized. Moderate certainty of evidence (CoE) from NMA of RCTs comparing DRCPAP with surfactant administration versus DRCPAP alone suggested no decrease in subsequent receipt of IMV [Risk ratio (RR); 95% Credible Interval (CrI): 0.73; (0.34, 1.40)]. Very low CoE from observational studies comparing use of DRCPAP versus oxygen supplementation indicated a trend towards decreased IMV [RR; 95% Confidence Interval (CI): 0.75; (0.56-1.00)]. Although moderate CoE from NMA evaluating DRCPAP versus oxygen supplementation showed a trend towards decreased receipt of surfactant, it did not reach statistical significance [RR; 95% CrI: 0.69; (0.44, 1.06)]. Moderate CoE from NMA indicated that none of the interventions, when compared with use of supplemental oxygen alone or with each other decreased mortality or bronchopulmonary dysplasia. LIMITATIONS CoE was very low for primary outcome. CONCLUSIONS Present evidence is not sufficient for use of DRCPAP, but also did not show harm. Since it seems unlikely that there are marked variations in patient physiology to explain the difference in efficacy between high income countries and LMICs, we suggest future research evaluating other barriers in improving the effectiveness of DRCPAP in LMICs.
Collapse
Affiliation(s)
| | - Thangaraj Abiramalatha
- Department of Neonatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | - Nasreen Banu Shaik
- Department of Neonatology, Ankura Hospital for Women and Children, Hyderabad, India
| | | | | | - Charles Christoph Roehr
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences, Division, University of Oxford, Oxford, United Kingdom; Newborn Services, Southmead Hospital, North Bristol Trust, Bristol, United Kingdom; University of Bristol, Women's and Children Division, Bristol, United Kingdom
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
| |
Collapse
|
34
|
Stimulating and maintaining spontaneous breathing during transition of preterm infants. Pediatr Res 2021; 90:722-730. [PMID: 31216570 DOI: 10.1038/s41390-019-0468-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/25/2019] [Accepted: 06/03/2019] [Indexed: 01/30/2023]
Abstract
Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.
Collapse
|
35
|
Kakkilaya VB, Weydig HM, Smithhart WE, Renfro SD, Garcia KM, Brown CM, He H, Wagner SA, Metoyer GC, Brown LS, Kapadia VS, Savani RC, Jaleel MA. Decreasing Continuous Positive Airway Pressure Failure in Preterm Infants. Pediatrics 2021; 148:peds.2020-014191. [PMID: 34552000 DOI: 10.1542/peds.2020-014191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks' gestational age (GA). METHODS A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks' GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre-OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). RESULTS Of the 216 infants ≤29 weeks' GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks' GA (46% vs 3%; P < .01). CONCLUSIONS Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.
Collapse
Affiliation(s)
- Venkatakrishna B Kakkilaya
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heather M Weydig
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - William E Smithhart
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Cari M Brown
- Parkland Hospital and Health System, Dallas, Texas
| | - Henry He
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Vishal S Kapadia
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rashmin C Savani
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
36
|
Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, Bell EF, Rysavy MA, Conroy S, Backes CH. Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review. J Pediatr 2021; 235:63-74.e12. [PMID: 33894262 PMCID: PMC9348995 DOI: 10.1016/j.jpeds.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation). STUDY DESIGN PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale. RESULTS Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation. CONCLUSIONS The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.
Collapse
Affiliation(s)
- Leeann R. Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital
| | - Charles V. Smith
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - Joanie Randle
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Cory Hanlon
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Kristi Small
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Matthew A. Rysavy
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sara Conroy
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University,Biostatistics Resource at Nationwide Children’s Hospital
| | - Carl H. Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH,Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH,Obstetrics and Gynecology, The Ohio State University Wexner Medical Center,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
| |
Collapse
|
37
|
Biswas A, Ho SKY, Yip WY, Kader KBA, Kong JY, Ee KTT, Baral VR, Chinnadurai A, Quek BH, Yeo CL. Singapore Neonatal Resuscitation Guidelines 2021. Singapore Med J 2021; 62:404-414. [PMID: 35001116 PMCID: PMC8804489 DOI: 10.11622/smedj.2021110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
Neonatal resuscitation is a coordinated, team-based series of timed sequential steps that focuses on a transitional physiology to improve perinatal and neonatal outcomes. The practice of neonatal resuscitation has evolved over time and continues to be shaped by emerging evidence as well as key opinions. We present the revised Neonatal Resuscitation Guidelines for Singapore 2021. The recommendations from the International Liaison Committee on Resuscitation Neonatal Task Force Consensus on Science and Treatment Recommendations (2020) and guidelines from the American Heart Association and European Resuscitation Council were compared with existing guidelines. The recommendations of the Neonatal Subgroup of the Singapore Resuscitation and First Aid Council were derived after the work group discussed and appraised the current available evidence and their applicability to local clinical practice.
Collapse
Affiliation(s)
- Agnihotri Biswas
- Department of Neonatology, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
| | - Selina Kah Ying Ho
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Wai Yan Yip
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Khadijah Binti Abdul Kader
- Department of Neonatology, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
| | - Juin Yee Kong
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Kenny Teong Tai Ee
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
- Kinder Clinic Pte Ltd, Singapore
| | - Vijayendra Ranjan Baral
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Amutha Chinnadurai
- Department of Neonatology, Khoo Teck Puat-National University Children’s Medical Institute, National University Health System, Singapore
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Bin Huey Quek
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Cheo Lian Yeo
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Neonatal Group, Paediatric Subcommittee, Singapore Resuscitation and First Aid Council, Singapore
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| |
Collapse
|
38
|
Patel P, Houck A, Fuentes D. Examining Variations in Surfactant Administration (ENVISION): A Neonatology Insights Pilot Project. CHILDREN-BASEL 2021; 8:children8040261. [PMID: 33800603 PMCID: PMC8065748 DOI: 10.3390/children8040261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/01/2022]
Abstract
Variability in neonatal clinical practice is well recognized. Respiratory management involves interdisciplinary care and often is protocol driven. The most recent published guidelines for management of respiratory distress syndrome and surfactant administration were published in 2014 and may not reflect current clinical practice in the United States. The goal of this project was to better understand variability in surfactant administration through conduct of health care provider (HCP) interviews. Questions focused on known practice variations included: use of premedication, decisions to treat, technique of surfactant administration and use of guidelines. Data were analyzed for trends and results were communicated with participants. A total of 54 HCPs participated from June to September 2020. In almost all settings, neonatologists or nurse practitioners intubated the infant and respiratory therapists administered surfactant. The INSURE (INtubation-SURrfactant-Extubation) technique was practiced by 83% of participants. Premedication prior to intubation was used by 76% of HCPs. An FiO2 ≥ 30% was the most common threshold for surfactant administration (48%). In conclusion, clinical practice variations exist in respiratory management and surfactant administration and do not seem to be specific to NICU level or institution type. It is unknown what effects the variability in clinical practice might have on clinical outcomes.
Collapse
|
39
|
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.
Collapse
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
| |
Collapse
|
40
|
Gahlawat V, Chellani H, Saini I, Gupta S. Predictors of mortality in premature babies with respiratory distress syndrome treated by early rescue surfactant therapy. J Neonatal Perinatal Med 2021; 14:547-552. [PMID: 34120918 DOI: 10.3233/npm-190244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To determine the predictors of mortality following early rescue surfactant therapy in preterm babies with respiratory distress syndrome. STUDY DESIGN Prospective cohort study enrolling babies between 28 weeks to 34 weeks with respiratory distress syndrome requiring early rescue surfactant therapy. For statistical analysis babies were further divided into two subgroups: survivors and non-survivors. Maternal and neonatal variables were compared between the two groups to find out the predictors of mortality. RESULTS Out of total 110 babies, 72 (65.45%) survived. The mean birth weight and mean gestational age of the study population was 1614.36 (±487.86) g and 31.40 (±2.0)1 weeks, respectively. Birth weight < 1500 g, gestational age < 32 weeks, primiparity, vaginal delivery, prolonged rupture of membranes, lack of antenatal steroid cover, bag and mask ventilation at birth, sepsis, apneic episodes and mechanical ventilation were significantly associated with death on univariate analysis. On multivariate analysis, very low birth weight, vaginal delivery, lack of antenatal steroid cover, bag and mask ventilation at birth and mechanical ventilation were found to be independent predictors of mortality. CONCLUSIONS Some of the identified predictors of mortality are modifiable and can be used to draw up a screening tool to predict the clinical severity and mortality among these babies.
Collapse
Affiliation(s)
- Vivek Gahlawat
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Harish Chellani
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Isha Saini
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shobhna Gupta
- Department of Pediatrics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| |
Collapse
|
41
|
Glaser K, Wright CJ. Indications for and Risks of Noninvasive Respiratory Support. Neonatology 2021; 118:235-243. [PMID: 33902052 PMCID: PMC8178193 DOI: 10.1159/000515818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/10/2021] [Indexed: 01/20/2023]
Abstract
Within the last decades, therapeutic advances have significantly improved the survival of extremely preterm infants. In contrast, the incidence of major neonatal morbidities, including bronchopulmonary dysplasia, has not declined. Given the well-established relationship between exposure to invasive mechanical ventilation and neonatal lung injury, neonatologists have sought for effective strategies of noninvasive respiratory support in high-risk infants. Continuous positive airway pressure has replaced invasive mechanical ventilation for the initial stabilization and the treatment of respiratory distress syndrome. Today, noninvasive respiratory support has been adopted even in the tiniest babies with the highest risk of lung injury. Moreover, different modes of noninvasive respiratory support supplemented by a number of adjunctive measures and rescue strategies have entered clinical practice with the goal of preventing intubation or reintubation. However, does this unquestionably important paradigm shift to strategies focused on noninvasive support lull us into a false sense of security? Can we do better in (i) identifying those very immature preterm infants best equipped for noninvasive stabilization, can we improve (ii) determinants of failure of noninvasive respiratory support in the individual infant and underlying etiology, and can we enhance (iii) success of noninvasive respiratory support and (iv) better prevent ultimate harm to the developing lung? With increased survival of infants at the highest risk of developing lung injury and an unchanging burden of bronchopulmonary dysplasia, we should question indiscriminate use of noninvasive respiratory support and address the above issues.
Collapse
Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| |
Collapse
|
42
|
Wyckoff MH, Weiner CGM. 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Pediatrics 2021; 147:peds.2020-038505C. [PMID: 33087553 DOI: 10.1542/peds.2020-038505c] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid.Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed.All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published.Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
Collapse
|
43
|
Dani C, Cecchi A, Remaschi G, Mercadante D, la Marca G, Boni L, Mosca F. Study protocol: treatment with caffeine of the very preterm infant in the delivery room: a feasibility study. BMJ Open 2020; 10:e040105. [PMID: 33277284 PMCID: PMC7722383 DOI: 10.1136/bmjopen-2020-040105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Early treatment with caffeine in the delivery room has been proposed to decrease the need for mechanical ventilation (MV) by limiting episodes of apnoea and improving respiratory mechanics in preterm infants. Thus, the purpose of this feasibility study is to verify the hypothesis that intravenous or enteral administration of caffeine can be performed in the preterm infant in the delivery room. METHODS AND ANALYSIS In this multicentre prospective study, infants with 25+0-29+6 weeks of gestational age will be enrolled and randomised to receive 20 mg/kg of caffeine citrate intravenously, via the umbilical vein, or enterally, through an orogastric tube, within 10 min of birth. Caffeine plasma level will be measured at 60±15 min after administration and 60±15 min before the next dose (5 mg/kg). The primary endpoint will be evaluation of the success rate of intravenous and enteral administration of caffeine in the delivery room. Secondary endpoints will be the comparison of success rate of intravenous versus oral administration and the evaluation of the need for MV in treated infants. In the absence of previous references, we arbitrarily decided to study 20 infants treated with intravenous caffeine and 20 infants treated with enteral caffeine. Primary endpoint will be evaluated measuring the success rate of intravenous and enteral caffeine administration which will be considered a success when it is followed by the achievement of the caffeine therapeutic level (8-25 µg/mL) 60±15 min before administration of the second dose. ETHICS AND DISSEMINATION The study has been approved by the Italian Medicines Agency (AIFA: AIFA/RSC/P/32755) and by Comitato Etico Pediatrico Regione Toscana. The results will be published in peer-reviewed academic journals. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier NCT04044976; EudraCT number 2018-003626-91.
Collapse
Affiliation(s)
- Carlo Dani
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Firenze, Italy
| | - Alessandra Cecchi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Giulia Remaschi
- Division of Neonatology, Careggi University Hospital of Florence, Florence, Italy
| | - Domenica Mercadante
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico of Milan, University of Milan, Florence, Italy
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giancarlo la Marca
- Laboratory of Clinical Chemistry and Pharmacology of the A Meyer Pediatric Hospital of Florence, University of Florence, Florence, Italy
| | - Luca Boni
- Department of Human Pathology and Oncology, University of Florence, Florence, Italy
| | - Fabio Mosca
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
44
|
Murki S, Kandraju H, Oleti T, Saikiran, Gaddam P. Predictors of CPAP Failure - 10 years' Data of Multiple Trials from a Single Center: A Retrospective Observational Study. Indian J Pediatr 2020; 87:891-896. [PMID: 32632570 DOI: 10.1007/s12098-020-03399-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 06/09/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To identify risk factors and outcomes associated with early failure of nasal continuous positive airway pressure (CPAP) in premature infants with respiratory distress (RD). METHODS This is a retrospective observational study of all the preterm infants with RD primarily supported on nasal CPAP and included in CPAP trials conducted at the study site. Data was collected from the raw excel sheets of the previous trials but limited to eligible patients from study site. Early CPAP failure was defined as the need for mechanical ventilation in the first 72 h after birth. Predictor variables for CPAP failure included baseline maternal and infant characteristics, CPAP care practices, morbidities and adjuvant therapies. The morbidities and outcomes were compared among infants with CPAP failure and CPAP success. RESULTS Six hundred and fifty-two infants were enrolled in the study. Early CPAP failure was seen in 96 infants (14.7%, 95% CI: 12%-17.5%). On logistic regression, adjusting for gestation and year of study, time of starting CPAP in hours (OR 1.01, 95% CI: 1.003-1.013), time of surfactant administration in hours (OR 1.12, 95% CI: 1.05-1.19), InSurE (Intubate Surfactant Extubate) (OR 2.7, 95% CI: 1.43-5.06) and higher starting FiO2 (OR 1.03, 95% CI: 1.01-1.05) predicted early CPAP failure. Neonatal morbidities and hospital duration were significantly higher in infants who failed CPAP. CONCLUSIONS Early starting of CPAP, InSurE, early surfactant administration, lower CPAP pressures and lower FiO2 at starting of CPAP were the important determinants of success.
Collapse
Affiliation(s)
- Srinivas Murki
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India.
| | - Hemasree Kandraju
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
| | - Tejopratap Oleti
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
| | - Saikiran
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
| | - Pramod Gaddam
- Department of Neonatology, Fernandez Hospital, Hyderabad, Telangana, 500029, India
| |
Collapse
|
45
|
Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Resuscitation 2020; 156:A156-A187. [DOI: 10.1016/j.resuscitation.2020.09.015] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
46
|
Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, Kim HS, Liley HG, McKinlay CJD, Mildenhall L, Perlman JM, Rabi Y, Roehr CC, Schmölzer GM, Szyld E, Trevisanuto D, Velaphi S, Weiner GM. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S185-S221. [PMID: 33084392 DOI: 10.1161/cir.0000000000000895] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
Collapse
|
47
|
Aziz K, Lee HC, Escobedo MB, Hoover AV, Kamath-Rayne BD, Kapadia VS, Magid DJ, Niermeyer S, Schmölzer GM, Szyld E, Weiner GM, Wyckoff MH, Yamada NK, Zaichkin J. Part 5: Neonatal Resuscitation: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S524-S550. [DOI: 10.1161/cir.0000000000000902] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
|
48
|
Ho JJ, Subramaniam P, Sivakaanthan A, Davis PG. Early versus delayed continuous positive airway pressure (CPAP) for respiratory distress in preterm infants. Cochrane Database Syst Rev 2020; 10:CD002975. [PMID: 33058139 PMCID: PMC8094884 DOI: 10.1002/14651858.cd002975.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The application of continuous positive airway pressure (CPAP) has been shown to have some benefits in the treatment of preterm infants with respiratory distress. CPAP has the potential to reduce lung damage, particularly if applied early before atelectasis has occurred. Early application may better conserve an infant's own surfactant stores and consequently may be more effective than later application. OBJECTIVES • To determine if early compared with delayed initiation of CPAP results in lower mortality and reduced need for intermittent positive-pressure ventilation in preterm infants in respiratory distress ○ Subgroup analyses were planned a priori on the basis of weight (with subdivisions at 1000 grams and 1500 grams), gestation (with subdivisions at 28 and 32 weeks), and according to whether surfactant was used ▫ Sensitivity analyses based on trial quality were also planned ○ For this update, we have excluded trials using continuous negative pressure SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 6), in the Cochrane Library; Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations Daily and Versions(R); and the Cumulative Index to Nursing and Allied Health Literatue (CINAHL), on 30 June 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA We included trials that used random or quasi-random allocation to either early or delayed CPAP for spontaneously breathing preterm infants in respiratory distress. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane and Cochrane Neonatal, including independent assessment of trial quality and extraction of data by two review authors. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We found four studies that recruited a total of 119 infants. Two were quasi-randomised, and the other two did not provide details on the method of randomisation or allocation used. None of these studies used blinding of the intervention or the outcome assessor. Evidence showed uncertainty about whether early CPAP has an effect on subsequent use of intermittent positive-pressure ventilation (IPPV) (typical risk ratio (RR) 0.77, 95% confidence interval (CI) 0.43 to 1.38; typical risk difference (RD) -0.08, 95% CI -0.23 to 0.08; I² = 0%, 4 studies, 119 infants; very low-certainty evidence) or mortality (typical RR 0.93, 95% CI 0.43 to 2.03; typical RD -0.02, 95% CI -0.15 to 0.12; I² = 33%, 4 studies, 119 infants; very low-certainty evidence). The outcome 'failed treatment' was not reported in any of these studies. There was an uncertain effect on air leak (pneumothorax) (typical RR 1.09, 95% CI 0.39 to 3.04, I² = 0%, 3 studies, 98 infants; very low-certainty evidence). No trials reported intraventricular haemorrhage or necrotising enterocolitis. No cases of retinopathy of prematurity were reported in one study (21 infants). One case of bronchopulmonary dysplasia was reported in each group in one study involving 29 infants. Long-term outcomes were not reported. AUTHORS' CONCLUSIONS All four small trials included in this review were performed in the 1970s or the early 1980s, and we are very uncertain whether early application of CPAP confers clinical benefit in the treatment of respiratory distress, or whether it is associated with any adverse effects. Further trials should be directed towards establishing the appropriate level of CPAP and the timing and method of administration of surfactant when used along with CPAP.
Collapse
Affiliation(s)
- Jacqueline J Ho
- Department of Paediatrics, RCSI & UCD Malaysia Campus (formerly Penang Medical College), George Town, Malaysia
| | - Prema Subramaniam
- Paediatric Department, Mount Isa Base Hospital, Mount Isa, Australia
| | | | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
| |
Collapse
|
49
|
Ho JJ, Subramaniam P, Davis PG. Continuous positive airway pressure (CPAP) for respiratory distress in preterm infants. Cochrane Database Syst Rev 2020; 10:CD002271. [PMID: 33058208 PMCID: PMC8094155 DOI: 10.1002/14651858.cd002271.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Respiratory distress, particularly respiratory distress syndrome (RDS), is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant has been the usual treatment, but it is invasive, potentially resulting in airway and lung injury. Continuous positive airway pressure (CPAP) has been used for the prevention and treatment of respiratory distress, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae. OBJECTIVES To determine the effect of continuous distending pressure in the form of CPAP on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress. SEARCH METHODS We used the standard strategy of Cochrane Neonatal to search CENTRAL (2020, Issue 6); Ovid MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions; and CINAHL on 30 June 2020. We also searched clinical trials databases and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA All randomised or quasi-randomised trials of preterm infants with respiratory distress were eligible. Interventions were CPAP by mask, nasal prong, nasopharyngeal tube or endotracheal tube, compared with spontaneous breathing with supplemental oxygen as necessary. DATA COLLECTION AND ANALYSIS We used standard methods of Cochrane and its Neonatal Review Group, including independent assessment of risk of bias and extraction of data by two review authors. We used the GRADE approach to assess the certainty of evidence. Subgroup analyses were planned on the basis of birth weight (greater than or less than 1000 g or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), timing of application (early versus late in the course of respiratory distress), pressure applied (high versus low) and trial setting (tertiary compared with non-tertiary hospitals; high income compared with low income) MAIN RESULTS: We included five studies involving 322 infants; two studies used face mask CPAP, two studies used nasal CPAP and one study used endotracheal CPAP and continuing negative pressure for a small number of less ill babies. For this update, we included one new trial. CPAP was associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.64, 95% confidence interval (CI) 0.50 to 0.82; typical risk difference (RD) -0.19, 95% CI -0.28 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 4 to 11; I2 = 50%; 5 studies, 322 infants; very low-certainty evidence), lower use of ventilatory assistance (typical RR 0.72, 95% CI 0.54 to 0.96; typical RD -0.13, 95% CI -0.25 to -0.02; NNTB 8, 95% CI 4 to 50; I2 = 55%; very low-certainty evidence) and lower overall mortality (typical RR 0.53, 95% CI 0.34 to 0.83; typical RD -0.11, 95% CI -0.18 to -0.04; NNTB 9, 95% CI 2 to 13; I2 = 0%; 5 studies, 322 infants; moderate-certainty evidence). CPAP was associated with increased risk of pneumothorax (typical RR 2.48, 95% CI 1.16 to 5.30; typical RD 0.09, 95% CI 0.02 to 0.16; number needed to treat for an additional harmful outcome (NNTH) 11, 95% CI 7 to 50; I2 = 0%; 4 studies, 274 infants; low-certainty evidence). There was no evidence of a difference in bronchopulmonary dysplasia, defined as oxygen dependency at 28 days (RR 1.04, 95% CI 0.35 to 3.13; I2 = 0%; 2 studies, 209 infants; very low-certainty evidence). The trials did not report use of surfactant, intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis and neurodevelopment outcomes in childhood. AUTHORS' CONCLUSIONS In preterm infants with respiratory distress, the application of CPAP is associated with reduced respiratory failure, use of mechanical ventilation and mortality and an increased rate of pneumothorax compared to spontaneous breathing with supplemental oxygen as necessary. Three out of five of these trials were conducted in the 1970s. Therefore, the applicability of these results to current practice is unclear. Further studies in resource-poor settings should be considered and research to determine the most appropriate pressure level needs to be considered.
Collapse
Affiliation(s)
- Jacqueline J Ho
- Department of Paediatrics, RCSI & UCD Malaysia Campus (formerly Penang Medical College), George Town, Malaysia
| | - Prema Subramaniam
- Paediatric Department, Mount Isa Base Hospital, Mount Isa, Australia
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
- Murdoch Children's Research Institute, Melbourne, Australia
- Department of Obstetrics and Gynecology, University of Melbourne, Melbourne, Australia
| |
Collapse
|
50
|
Abstract
BACKGROUND Hyaline membrane disease contributes majorly to preterm mortality, particularly in the developing world. There are two animal-derived surfactants available in South Africa: poractant-alfa (120 mg/1.5 ml) and beractant (100 mg/4 ml). At equivalent doses, studies have shown no difference in mortality or morbidity, although there are limited data from the developing world. Both surfactants have been available for use at Groote Schuur Hospital in Cape Town but due to policy change, poractant-alfa was no longer available from November 2014. Due to weight-based dosing charts, infants who were given poractant-alfa received 20% higher dosages of phospholipid. METHODS A before-and-after policy change non-experimental study was performed including infants from 2013 to 2015. Infants weighing <1500 g were recruited by identifying them from the surfactant register and further data were obtained from patient records. Data fields included infant weight, gestation, respiratory support and outcomes. RESULTS Two hundred and eight infants were included. One hundred and eight received beractant and 100 received poractant-alfa. The mean birth weight was 1031 g and gestational age 28.8 weeks. Seventy-nine percent of the infants received surfactant via the INSURE (intubation, surfactant and extubation) method. The combined outcome for death or bronchopulmonary dysplasia was 35.3% in the beractant group and 36% in the poractant-alfa group (p = 0.902). All secondary outcomes including neonatal morbidities, oxygen at 28 days or length of ventilation were not statistically significant. CONCLUSION There were no significant differences in outcomes between the two groups of infants who received different surfactants at the dosages used in our unit. This is one of the few studies of this type performed in a low- and middle-income countries.
Collapse
Affiliation(s)
- Lize Boshoff Coyles
- Division of Neonatal Medicine, Department of Paediatrics, University of Cape Town, Groote Schuur Hospital, Cape Town, 7925, South Africa
| | - Yaseen Joolay
- Division of Neonatal Medicine, Department of Paediatrics, University of Cape Town, Groote Schuur Hospital, Cape Town, 7925, South Africa
| | - Lloyd Tooke
- Division of Neonatal Medicine, Department of Paediatrics, University of Cape Town, Groote Schuur Hospital, Cape Town, 7925, South Africa
| |
Collapse
|