Management of Respiratory Distress in the Newborn

RAM Cannula Versus Bi-Nasal Prongs as Respiratory Device Interfaces in Neonates of Thirty-Two or More Weeks of Gestation With Respiratory Distress: The First "ProRAM" Randomized Trial Report

Background

Using bilateral short nasal prongs as an interface for noninvasive respiratory support is challenging, and it is associated with nasal injury. We aimed to compare RAM cannula with nasal prongs in delivering noninvasive ventilation to newborn infants.

Methods

This is a single-center randomized trial (trial registry: ISRCTN10561691). The setting involves a tertiary neonatal unit with a capacity of 30 beds and more than 13 years of experience in neonatal noninvasive ventilation. We included 50 infants born at ≥ 32 weeks of gestation, who had respiratory distress at birth. We excluded those with major congenital anomalies and those who required intubation in the delivery room. Primary outcomes were intubation rate and use of noninvasive positive-pressure ventilation (NIPPV); other outcomes included air leak and nasal injury rate. The infants were assigned using randomly generated numbers into bi-nasal prong and RAM canula groups in a 1:1 ratio.

Results

Two and four babies in the RAM and prong groups, respectively, were upgraded to NIPPV (P = 0.600). One versus no baby in the RAM vs. prong groups was intubated (P = 1.000). Newborns in the prong group required oxygen support for a longer period (mean duration: 154.6 ± 255.2 h) than those in the RAM group (40.7 ± 72.6 h, P = 0.030). None of the patients in the RAM group had traumatic nasal injury compared to five babies in the prong group (P = 0.050). Four babies in our study developed air leaks, with two in each group.

Conclusions

The use of RAM cannula in delivering noninvasive ventilation to newborns ≥ 32 weeks of age did not affect the noninvasive ventilation failure rate or incidence of air leak. The use was associated with a shorter duration of respiratory support and a reduced risk of nasal septal injury.

Diagnostic utility of lung ultrasound in predicting the need for surfactant therapy in preterm neonates with respiratory distress

Background

Lung ultrasound is an accurate and early predictor for surfactant replacement therapy in respiratory distress syndrome (RDS) as compared to clinical parameters and chest x-ray. However, lung pathologies for respiratory distress at birth have overlapping symptomatology and low middle-income countries have a higher incidence of congenital pneumonia, in addition to RDS, making the immediate diagnosis difficult. Thus, there is a need for assessing a cutoff for lung ultrasound scores in the given setting.

Objectives

The primary objective was to determine the diagnostic accuracy of the lung ultrasound score (LUS) in predicting the need for surfactant therapy in preterm neonates with respiratory distress. Secondary objectives were to correlate LUS with corresponding oxygen saturation to the fraction of inspired oxygen ratio (SpO2/FiO2), arterial/Alveolar oxygen pressure ratio (a/A), and chest x-ray (CXR) findings.

Methodology

A prospective observational study was carried out at a tertiary-level neonatal intensive care unit in India in 2022 enrolling 100 neonates <34 weeks gestational age with respiratory distress at birth. After initial stabilization of the neonate, LUS was performed and baseline parameters were noted. Surfactant was administered as per the 2019 European Consensus guidelines and LUS was repeated after 6 h of therapy.

Results

The mean gestation of enrolled neonates was 31.06 ± 2.12 weeks and the mean birthweight was 1,412 ± 391 g. Approximately 58% were diagnosed with RDS and 30% had congenital pneumonia. Surfactant was administered to 40% of neonates. The cutoff LUS for surfactant therapy was 7 [area under the curve (AUC) 0.977; 95% CI, 0.947-1; P < 0.001; with sensitivity 92.5%, specificity 96.67%, PPV 94.87%, and NPV 95.08%] and the cutoff LUS for the second dose of surfactant was 10 (AUC 0.964; 95% CI, 0.913-1; P < 0.001). The score decreased by 3.24 (2.44-4.05) after 6 h of the first dose and correlated significantly with SpO2/FiO2 ratio (-0.750), a/A ratio (-0.650), and CXR findings (0.801).

Conclusion

The study predicted an optimal LUS cutoff of 7 and 10 for the need for the first dose of surfactant and re-treatment, respectively, in neonates <34 weeks gestational age with respiratory distress.

Two Types of Management for the Noninvasive Treatment of Pectus Excavatum in Neonatal Puppies-Case Reports

Pectus excavatum is a deformity of the thorax characterized by ventrodorsal narrowing of the sternum bone and costal cartilages, which can lead to compression and cardiopulmonary alterations in dogs, presenting a high prevalence in brachycephalic breeds. The aim of this report was to describe two types of management for the noninvasive treatment of pectus excavatum in newborn puppies of the breeds French Bulldog and American Bully. The puppies presented dyspnea, cyanosis and substernal retraction during inspiration. The diagnosis was performed by physical examination and confirmed by chest X-ray. Two types of splints were performed (a circular splint with plastic pipe and a paper box splint on the chest), aiming at thoracic lateral compression and frontal chest remodeling. The management was effective for the conservative treatment of mild-grade pectus excavatum, resulting in the repositioning of the thorax and improvement of the respiratory pattern.

A multicenter, randomized controlled, non-inferiority trial, comparing nasal continuous positive airway pressure with nasal intermittent positive pressure ventilation as primary support before minimally invasive surfactant administration for preterm infants with respiratory distress syndrome (the NIV-MISA-RDS trial): Study protocol

BACKGROUND

Non-invasive ventilation (NIV) treatment has been developed to minimize lung damage and to avoid invasive mechanical ventilation (IMV) in preterm infants, especially in those with a gestational age of <30 weeks. Our hypothesis is that for preterm infants <30 weeks with potential to develop respiratory distress syndrome (RDS), nasal continuous positive airway pressure (NCPAP) is non-inferior to the nasal intermittent positive pressure ventilation (NIPPV) as primary respiratory support before minimal invasive surfactant administration (MISA).

METHODS AND DESIGN

The NIV-MISA-RDS trial is planned as an unblinded, multicenter, randomized, non-inferiority trial at 14 tertiary neonatal intensive care units (NICUs) in China. Eligible infants are preterm infants of 24-29⁺⁶ weeks of gestational age who have spontaneous breaths at birth and require primary NIV support for RDS. Infants are randomized 1:1 to treatment with either NCPAP or NIPPV once admitted into NICUs. If an infant presents progressively aggravated respiratory distress and is clinically diagnosed as having RDS, pulmonary surfactant will be supplemented by MISA in the first 2 h of life. The primary outcome is NIV treatment failure within 72 h after birth. With a specified non-inferiority margin of 10%, using a two-sided 95% CI and 80% power, the study requires 480 infants per group (in total 960 infants).

DISCUSSION

Current evidence shows that NIV and MISA may be the most effective strategy for minimizing IMV in preterm infants with RDS. However, there are few large randomized controlled trials to compare the effectiveness of NCPAP and NIPPV as the primary respiratory support after birth and before surfactant administration. We will conduct this trial to test the hypothesis that NCPAP is not inferior to NIPPV as the initial respiratory support in reducing the use of IMV in premature infants who have spontaneous breaths after birth and who do not require intubation in the first 2 h after birth. The study will provide clinical data for the selection of the initial non-invasive ventilation mode in preterm infants with a gestational age of <30 weeks with spontaneous breaths after birth.

CLINICAL TRIAL REGISTRATION

https://register.clinicaltrials.gov, identifier: NCT05137340.

Non-invasive high-frequency oscillatory ventilation in preterm infants after extubation: a randomized, controlled trial

OBJECTIVE

To investigate the effectiveness and safety of non-invasive high-frequency oscillatory ventilation (NHFOV) in post-extubation preterm infants.

METHODS

This was a randomized, controlled trial. A total of 149 preterm infants aged between 25 to 34 weeks' gestational age with a birth weight of <1500 g who required invasive mechanical ventilation on admission were included. After extubation, they were randomized to the NHFOV group (n = 47), nasal intermittent positive pressure ventilation (NIPPV) group (n = 51), or nasal continuous positive airway pressure (NCPAP) group (n = 51). We compared the effectiveness and safety among these three groups.

RESULTS

A total of 139 preterm infants finally completed the study. The reintubation rate was significantly lower in the NHFOV group than in the other groups. The duration of non-invasive ventilation and the length of hospital stay in the NHFOV and NIPPV groups were significantly shorter than those in the NCPAP group. The incidence of bronchopulmonary dysplasia in the NHFOV and NIPPV groups was significantly lower than that in the NCPAP group. The NHFOV group had significantly less nasal injury than the NCPAP group.

CONCLUSION

As post-extubation respiratory support in preterm infants, NHFOV has a lower reintubation rate compared with NCPAP and NIPPV, without increasing the rate of complications.

Barriers and facilitators to implementing bubble CPAP to improve neonatal health in sub-Saharan Africa: a systematic review

BACKGROUND

Bubble continuous positive airway pressure (CPAP) has been shown to be effective in supporting breathing in newborns with respiratory distress. The factors that influence implementation in resource-constrained settings remain unclear. The objective of this review is to evaluate the barriers and facilitators of CPAP implementation for newborn care at sub-Saharan African health facilities and how different facility levels and types of bubble CPAP systems may impact utilization.

METHODS

A systematic search (database inception to July 2019) was performed on MEDLINE Ovid, EMBASE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), the WHO Regional Database for Africa, African Index Medicus (AIM), African Journals Online, grey literature and the references of relevant articles. Studies that met the inclusion criteria (primary research, bubble CPAP implementation with neonates ≤ 28 days old at a health facility in sub-Saharan Africa) were included in the review and assessed with National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) quality assessment tools. The review protocol was published to PROSPERO (CRD42018116082).

RESULTS

Seventeen studies were included in the review. Reliable availability of equipment, effectively informing and engaging caregivers and staffing shortages were frequently mentioned barriers to the implementation of bubble CPAP. Understaffed neonatal units and high turnover of nurses and doctors compromised effective training. Provider-to-provider clinical mentorship models as well as affordability and cost-effectiveness of innovative bubble CPAP systems were identified as frequently mentioned facilitators of implementation.

CONCLUSIONS

With a strong recommendation by the World Health Organization for its use with premature infants with respiratory distress, it is important to understand the barriers and facilitators that can inform the implementation of bubble CPAP. More research is needed into health system factors that can support or impede the use of this potentially promising intervention.

Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: a randomized controlled trial

Background: Respiratory distress syndrome (RDS) is one of the main causes of mortality in premature neonates. Treatment of these neonates with invasive mechanical ventilation has side effects such as chronic pulmonary diseases. Noninvasive ventilation, such as nasal continuous positive airway pressure (NCPAP) and nasal high-frequency oscillation ventilation (NHFOV), has shown to reduce the burden of chronic lung disease. NHFOV is a promising new mode of noninvasive ventilation and may reduce the need for mechanical ventilation and reduce possible complications. In this study, we hypothesized that early NHFOV would reduce the need for invasive respiratory support in comparison to NCPAP in preterm neonates with RDS.Methods: One hundred twenty-four neonates between 28 to 34 weeks of gestational age (GA) with RDS hospitalized at Imam Khomeini Hospital, Ahvaz in 2016 were included in this randomized controlled study. The primary outcomes were the failure of NHFOV and NCPAP within 72 h after birth. The secondary outcomes were the duration of invasive ventilation and possible side effects.Results: Out of 124 neonates in this study, 63 and 61 neonates were studied in the NHFOV and NCPAP groups, respectively. There were no significant differences between NHFOV (6.5%) and NCPAP (14.1%) groups in terms of rates of primary consequences (p = .13). However, the duration of noninvasive ventilation in NHFOV was significantly less than that of NCPAP group (p = .01).Conclusion: In our study group, preterm infants from 28 to 34 weeks of GA, NHFOV did not reduce the need for mechanical ventilation during the first 72 h after birth compared to NCPAP; however, the duration of noninvasive ventilation in the NHFOV group was significantly shorter.

A randomised cross-over study showed no difference in diaphragm activity during weaning from respiratory support

AIM

We measured electrical activity of the diaphragm (Edi) to compare the breathing effort in preterm infants during weaning from respiratory support with high-flow nasal cannulae (HFNC) or nasal continuous positive airway pressure (nCPAP).

METHODS

This randomised cross-over study was carried out at St Olav's University Hospital, Trondheim, Norway, from December 2013 to June 2015. We gave 21 preterm infants weighing at least 1000 g HFNC 6 L/minute for four hours and nCPAP 3 cmH₂ O for four hours with a one-hour wash-out period. Measurements included diaphragmatic load, Edi, vital signs and a modified Silverman-Andersen Retraction Score.

RESULTS

We found no differences in HFNC and nCPAP in the median Edi peak (8.0 μV versus 7.8 μV, p = 0.095), median Edi min (1.1 μV versus 1.2 μV in, p = 0.958) or mean heart rate (157 versus 159, p = 0.300) in the 21 infants who took part. The mean respiratory rate was significantly lower during HFNC than nCPAP (47 versus 52, p = 0.012). The modified Silverman-Andersen Retraction Score showed no significant differences.

CONCLUSION

This study of preterm infants found no difference in the breathing effort measured by Edi between HFNC 6 L/minute and nCPAP 3 cmH₂ O. HFNC could replace nCPAP when preterm infants are ready for weaning.

Non-invasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: Study protocol for a multi-center prospective randomized controlled trial

BACKGROUND

Invasive mechanical ventilation (IMV) is associated with the development of adverse pulmonary and non-pulmonary outcomes in very premature infants. Various modes of non-invasive respiratory support are increasingly being used to decrease the incidence of bronchopulmonary dysplasia. The aim of this trial is to compare the effect of non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) in preterm infants with respiratory distress syndrome (RDS) as a primary non-invasive ventilation support mode.

METHODS/DESIGN

In this multi-center randomized controlled trial, 300 preterm infants born at a gestational age of 266/7 to 336/7 weeks with a diagnosis of RDS will be randomized to NHFOV or NCPAP as a primary mode of non-invasive respiratory support. The study will be conducted in 18 tertiary neonatal intensive care units in China. The primary outcome is the need for IMV during the first 7 days after enrollment in preterm infants randomized to the two groups. The prespecified secondary outcomes include days of hospitalization, days on non-invasive respiratory support, days on IMV, days on supplemental oxygen, mortality, need for a surfactant, severe retinopathy of prematurity requiring laser treatment or surgery, patent ductus arteriosus needing ligation, bronchopulmonary dysplasia, abdominal distention, air leak syndromes, intraventricular hemorrhage (≥ grade 3), spontaneous intestinal perforation, necrotizing enterocolitis (≥II stage), and nasal trauma. Other secondary outcomes include Bayley Scales of Infant Development at 18-24 months of corrected age.

DISCUSSION

In recent decades, several observational studies have compared the effects of NHFOV and NCPAP in neonates as a rescue mode or during weaning from IMV. To our knowledge, this will be the first multi-center prospective, randomized controlled trial to evaluate NHFOV as a primary mode in preterm infants with RDS in China or any other part of the world. Our trial may help to establish guidelines for NHFOV in preterm infants with RDS to minimize the need for IMV, and to decrease the significant pulmonary and non-pulmonary morbidities associated with IMV.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03099694 . Registered on 4 April 2017.

Performance of the Silverman Andersen Respiratory Severity Score in predicting PCO2 and respiratory support in newborns: a prospective cohort study

OBJECTIVE

To determine if the Silverman Andersen respiratory severity score, which is assessed by physical exam, within 1 h of birth is associated with elevated carbon dioxide level and/or the need for increased respiratory support.

STUDY DESIGN

Prospective cohort study including 140 neonates scored within 1 h of birth. We report respiratory scores and their association with carbon dioxide and respiratory support within 24 h.

RESULTS

Carbon dioxide level correlated with respiratory score (n = 33, r = 0.35, p = 0.045). However, mean carbon dioxide for patients with score <5 vs. ≥5 did not differ significantly (56 vs. 67, p = 0.095). Patients with respiratory scores ≥5 had respiratory support increased within 24 h more often than those with scores <5 (79% vs. 28%, p < 0.001).

CONCLUSION

The Silverman Andersen respiratory severity score may be valuable for predicting need for escalation of respiratory support and facilitate decision making for transfer in low-resource settings.

Kangaroo position: Immediate effects on the physiological variables of preterm and low birth weight newborns

Abstract Introduction: The Kangaroo Mother Care (KMC) method is a significant neonatal alternative that ensures better quality humanized care for preterm and low birth weight newborns. Objective: To analyze the immediate physiological effects of the kangaroo position in critically ill newborns. Methods: Open clinical trial with parallel interventions, involving preterm (up to 28 days old) low or very low birth weight newborns (minimum weight of 1,250 grams) of both sexes, that were clinically stable and undergoing enteral nutrition. The degree of respiratory distress was assessed and quantified using the Silverman-Anderson scoring system. Heart rate and peripheral oxygen saturation were collected using a pulse oximeter. Respiratory rate was determined by auscultation for one minute. The newborns were submitted to the kangaroo position once only, for 90 minutes. Results: Participants were 30 newborns, 56.7% of which were girls. Comparison of the variables before and after application of the kangaroo position using the Wilcoxon test showed a statistically significant reduction in respiratory rate (p = 0.02) and Silverman-Anderson score (p < 0.01). The remaining variables showed no significant differences: heart rate (p = 0.21), peripheral oxygen saturation (p = 0.26) and axillary temperature (p = 0.12). Conclusion: There was a decline in the respiratory rate and Silverman-Anderson score after application of the kangaroo position, while peripheral oxygen saturation, axillary temperature and heart rate remained stable.

Current Issues and Challenges in the Use of Aerosolized Surfactant for Respiratory Distress Syndrome in the Newborns

BACKGROUND: Surfactant replacement therapy is a recognized treatment for respiratory distress syndrome (RDS) in the newborns. Over the past 30 years, human and animal trials have been performed regarding administration of aerosolized surfactant to the injured lung, however the result has been unsatisfactory when compared with instilled surfactant delivery via endotracheal tube (ETT). This review aims to investigate the current issues, challenges and future recommendation of aerosolized surfactant therapy.CONTENT: Five randomized clinical trials in humans and 13 animal trials met the inclusion criteria and were reviewed. Most animal trials agree that this method of treatment is feasible. However, human trials presented conflicting results, and generally showed it to be ineffective. When compared with surfactant delivery via ETT, aerosolized surfactant is less effective in improving respiratory function.SUMMARY: The current data from human trials does not support the implementation of aerosolized surfactant therapy to treat newborns with RDS. Further research is necessary to improve nebulization, delivery, distribution and deposition in the lung, to investigate aerosolized surfactant delivery via ETT and to determine the appropriate dose.KEYWORDS: surfactant, aerosol, prematurity, respiratory distress syndrome