Early extubation and nasal continuous positive airway pressure after surfactant treatment for respiratory distress syndrome among preterm infants <30 weeks' gestation

A clinical study evaluating the combination of LISA and SNIPPV for the treatment of respiratory distress syndrome in preterm infants

To compare the therapeutic effect of less invasive surfactant administration (LISA) followed by synchronized nasal intermittent positive pressure ventilation (SNIPPV) and traditional intubate-Surfactant-Extubate (InSurE) strategy for the treatment of neonatal respiratory distress syndrome (NRDS). A single-center, non-randomized and single- blinded study Tertiary neonatal intensive care unit 89 infants enrolled were preterm with gestational age < 366/7 weeks and clinically diagnosed with neonatal RDS (NRDS) Interventions: 32 infants were assigned to the LISA + SNIPPV group and 57 infants to the InSurE + nCPAP group. No statistically significant differences were noted in the baseline characteristics of the enrolled infants. A lower proportion of infants developed BPD in the LISA + SNIPPV group compared to the InSurE + CPAP group [10 (31.25%) vs. 21 (36.84%), P > 0.05]; however, there was no statistically significant difference. The number needed to treat (NNT) with LISA + SNIPPV to prevent BPD development is 18. The mortality rate was not significant between our study arms [1 (3.13%) vs 2 (3.51%), P > 0.05]. There were no statistically significant differences in the durations (days) of MV [(12.18 ± 13.89) vs. (11.35 ± 11.61), P > 0.05], oxygen therapy [(35.03 ± 19.13) vs. (39.75 ± 17.91), P > 0.05] and re-intubation rates [(0.19 ± 0.40) vs. (0.21 ± 0.45), P > 0.05] between the two study groups. In terms of complications, the incidence of patent ductus arteriosus (PDA) [24 (75.00%) vs. 27 (47.37%), P < 0.05] was higher and a lower rate of disturbed liver function [1 (3.23%) vs. 19 (33.33%), P < 0.05] were observed in the LISA + SNIPPV group. Acid-base imbalances were reportedly significantly higher in the InSurE group (P < 0.05). No significant differences in other complications were noted. In the interventional group, FiO2 requirements were significantly lower up until the 3rd week of treatment [FiO2 at day 0, (30.75 ± 4.78) vs. (34.66 ± 9.83), P < 0.05; FiO2 at day 21, (25.32 ± 3.74) vs. (29.11 ± 8.17), P < 0.05], as was RSS on days 2 [(0.77 ± 0.38) vs. (1.94 ± 0.75), P < 0.05] and 3 [(0.66 ± 0.33) vs. (1.89 ± 0.82), P < 0.05] after treatment. Additionally, infants in the standard group had a significantly prolonged hospital stay (days) [(45.97 ± 16.93) vs. (54.40 ± 16.26), P < 0.05]. The combination of LISA and SNIPPV for NRDS can potentially lower the rate of BPD, FiO2 demand and shorten the length of hospitalization.

Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis

Background

The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS.

Methods

The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life.

Findings

58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2) <0.36 (FiO2: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO2 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO2 ≥ 40%. There was insufficient evidence for the comparison of FiO2 thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low.

Interpretation

Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO2 requirement is ≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound.

Funding

None.

Changes in ventilation modes in the last decade and their impact on the prevalence of bronchopulmonary dysplasia in preterm infants

BACKGROUND

Less invasive forms of ventilation have evolved aiming to decrease bronchopulmonary dysplasia (BPD) morbidity. It is unclear whether changes in ventilation practices have been associated with improvements in respiratory outcomes.

OBJECTIVE

To examine the changes in ventilation modes in preterm neonates between two periods during the last decade and their impact on BPD prevalence.

METHODS

A retrospective chart review of very low birth weight infants and those born at less than 32 weeks gestation hospitalized during two periods: the years 2012-2013 and 2018-2019. The primary outcome was the prevalence of BPD. Study variables included the mode and duration of ventilation, duration of oxygen need, and perinatal clinical parameters.

RESULTS

Four hundred eighty-one infants were enrolled. Between the two study periods, a significant increase was observed in invasive (33%-47%, p = 0.002), and noninvasive ventilation rates (44%-72%, p < 0.001). The average duration of noninvasive ventilation increased significantly (from 9.24 to 14.08 days, p = 0.016). The total duration of respiratory support remained unchanged. The overall prevalence of moderate and severe BPD at 36 weeks corrected age remained approximately 40% in preterm infants born at less than 28 weeks gestation.

CONCLUSION

The increasing use of non-invasive ventilation was not accompanied by a reduction in the use of invasive ventilation, nor by a reduced prevalence of BPD. The high prevalence of BPD remains a significant problem in extreme prematurity. Other interventions, in addition to less aggressive ventilation, need to be explored.

Bi-level Nasal Positive Airway Pressure (BiPAP) versus Nasal Continuous Positive Airway Pressure (CPAP) for Preterm Infants with Birth Weight Less Than 1500 g and Respiratory Distress Syndrome Following INSURE Treatment: A Two-center Randomized Controlled Trial

The present study aimed to examine the effectiveness of bi-level positive airway pressure (BiPAP) versus continuous positive airway pressure (CPAP) in preterm infants with birth weight less than 1500 g and respiratory distress syndrome (RDS) following intubation-surfactant-extubation (INSURE) treatment. A two-center randomized control trial was performed. The primary outcome was the reintubation rate of infants within 72 h of age after INSURE. Secondary outcomes included bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP) and incidences of adverse events. Lung function at one year of corrected age was also compared between the two groups. There were 140 cases in the CPAP group and 144 in the BiPAP group. After INSURE, the reintubation rates of infants within 72 h of age were 15% and 11.1% in the CPAP group and the BiPAP group, respectively (P>0.05). Neonates in the BiPAP group was on positive airway pressure (PAP) therapy three days less than in the CPAP group (12.6 d and 15.3 d, respectively, P<0.05), and on oxygen six days less than in the CPAP group (20.6 d and 26.9 d, respectively, P<0.05). Other outcomes such as BPD, NEC, ROP and feeding intolerance were not significantly different between the two groups (P>0.05). There was no difference in lung function at one year of age between the two groups (P>0.05). In conclusion, after INSURE, the reintubation rate of infants within 72 h of age was comparable between the BiPAP group and the CPAP group. BiPAP was superior to CPAP in terms of shorter durations (days) on PAP support and oxygen supplementation. There were no differences in the incidences of BPD and ROP, and lung function at one year of age between the two ventilation methods.

Examining Variations in Surfactant Administration (ENVISION): A Neonatology Insights Pilot Project

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.

HFOV vs CMV for neonates with moderate-to-severe perinatal onset acute respiratory distress syndrome (NARDS): a propensity score analysis

This study aimed to evaluate whether high-frequency oscillatory ventilation (HFOV) could reduce mortality and the incidence of bronchopulmonary dysplasia (BPD) of perinatal-onset neonatal acute respiratory distress syndrome (NARDS) compared with conventional mechanical ventilation (CMV). Medical records were collected and retrospectively analyzed. Among the 700 neonates with NARDS who needed invasive ventilation, 501 (71.6%) received CMV, while 199 (28.4%) received HFOV. One-to-one propensity score matching (127:127) was used to match the baseline characteristics of patients who received CMV and HFOV. The results showed that birth weight and oxygenation index (OI) were independently associated with mortality in the multivariate logistic regression. No significant differences were observed in mortality or the incidence of BPD between the two groups. The incidence of intraventricular hemorrhage (IVH) and ventilation-free days were significantly lower in the HFOV group than in the CMV group (3.9 vs 11.80%, p=0.02; 15.226 vs 20.967 days, p=0.01). There were no significant differences between the two groups regarding other secondary outcomes.Conclusion: HFOV was associated with a decreased incidence of IVH in infants with NARDS compared with CMV. However, there were significantly more VFDs in the CMV group than in the HFOV group, and HFOV did not appear to be superior to CMV in decreasing the mortality and incidence of BPD in infants with NARDS. What is Known: • The diagnostic criteria of neonatal acute respiratory distress syndrome (Montreux criteria) were established in 2017. • To date, studies comparing high-frequency oscillatory ventilation and conventional mechanical ventilation in the treatment of neonatal acute respiratory distress syndrome are insufficient. What is New: • High-frequency oscillatory ventilation did not appear to be superior to conventional mechanical ventilation in decreasing the mortality and incidence of bronchopulmonary dysplasia in infants with moderate-to-severe perinatal-onset neonatal acute respiratory distress syndrome. • High-frequency oscillatory ventilation was associated with a decreased incidence of intraventricular hemorrhage in infants with moderate-to-severe perinatal-onset acute respiratory distress syndrome compared with conventional mechanical ventilation.

Surfactant lung delivery with LISA and InSurE in adult rabbits with respiratory distress

BACKGROUND

In preterm infants, InSurE (Intubation-Surfactant-Extubation) and LISA (less invasive surfactant administration) techniques allow for exogenous surfactant administration while reducing lung injury associated with mechanical ventilation. We compared the acute pulmonary response and lung deposition of surfactant by LISA and InSurE in surfactant-depleted adult rabbits.

METHODS

Twenty-six spontaneously breathing surfactant-depleted adult rabbits (6-7 weeks old) with moderate RDS and managed with nasal continuous positive airway pressure were randomized to 3 groups: (1) 200 mg/kg of surfactant by InSurE; (2) 200 mg/kg of surfactant by LISA; (3) no surfactant treatment (Control). Gas exchange and lung mechanics were monitored for 180 min. After that, surfactant lung deposition and distribution were evaluated monitoring disaturated-phosphatidylcholine (DSPC) and surfactant protein C (SP-C), respectively.

RESULTS

No signs of recovery were found in the untreated animals. After InSurE, oxygenation improved more rapidly compared to LISA. However, at 180' LISA and InSurE showed comparable outcomes in terms of gas exchange, ventilation parameters, and lung mechanics. Neither DSPC in the alveolar pool nor SP-C signal distributions in a frontal lung section were significantly different between InSurE and LISA groups.

CONCLUSIONS

In an acute setting, LISA demonstrated efficacy and surfactant lung delivery similar to that of InSurE in surfactant-depleted adult rabbits.

IMPACT

Although LISA technique is gaining popularity, there are still several questions to address. This is the first study comparing LISA and InSurE in terms of gas exchange, ventilation parameters, and lung mechanics as well as surfactant deposition and distribution. In our animal study, three hours post-treatment, LISA method seems to be as effective as InSurE and showed similar surfactant lung delivery. Our findings provide some clarifications on a fair comparison between LISA and InSurE techniques, particularly in terms of surfactant delivery. They should reassure some of the concerns raised by the clinical community on LISA adoption in neonatal units.

The Comparison of LISA and INSURE techniques in term of neonatal morbidities and mortality among premature infants

BACKGROUND AND AIM OF THE WORK

Respiratory distress syndrome (RDS) is the most common cause of respiratory failure among premature infants. The most important choice for the treatment of  RDS is still exogenous surfactant replacement therapy and respiratory support. Today, there are some different surfactant applying techniques. In this study, we aimed to evaluate the effects of the surfactant administration techniques in premature infants less than 33 weeks of gestational age.

METHODS

The medical data were collected retrospectively from the medical records of Baskent University, Konya Training and Research Hospital between 2010 and 2016.  The patient divided into two subgroups as Less Invasive Surfactant Administration (LISA) group (n: 35) and Intubation- Surfactant administration and rapid Extubation (INSURE) group (n: 30). Two surfactant administration techniques were evaluated on the neonatal morbidities and mortality among premature infants.

RESULTS

There were no significant differences in maternal and neonatal characteristics between the two groups. Duration on the nasal continues positive airway pressure (nCPAP) is significantly higher in the LISA group as compared with the INSURE group (p<0.001).  And also between two groups, there were no significant differences in term of neonatal mortality and morbidities.

CONCLUSION

The technique of the surfactant administration has no effect on the postnatal morbidities. LISA method is safe and effective as much as INSURE method, which is still a good alternative in centers with lack of experience about LISA. We need to perform studies that have larger sample size and prospective randomized controlled trials.

Microbiological analyses of nasally guided catheters after less invasive surfactant administration - a pilot study

BACKGROUND

Respiratory distress syndrome (RDS) is a frequent complication of premature birth. Treating RDS by continuous positive airway pressure and less invasive surfactant administration (LISA) may reduce bronchopulmonary dysplasia. Surfactant, however, can be inactivated by bacterial infection. Therefore, potential routes of microbe transmission into the airway are of interest. The aim of this study was to evaluate microbiological contamination of catheters used for LISA procedures and its association with postnatal age.

METHODS

Catheter tips used for LISA procedures via the nasal route (LISA-n) in infants with RDS were placed into a sterile eSwab container directly after the procedure, cultured and examined for microbiological contamination.

RESULTS

Interpretable results could be collected from 20 catheter tips. Four showed positive culture results (20%) with microbes potentially associated with the development of early onset neonatal sepsis. Risk of positive microbe detection increased with postnatal age (< 4 h: 10%; 4-18 h: 20%; > 18 h: 40%).

CONCLUSIONS

In this pilot study, the risk of tracheal microbe transmission following the LISA-n procedure increased with postnatal age. Although the clinical relevance of this finding is unclear, earlier surfactant administration might reduce the risk of catheter contamination.

TRIAL REGISTRATION NUMBER

Substudy of the registered Trial: feasibility study - Neofact: NCT04086095, www.ClinicalTrials.gov, September 11, 2019.

Lung deposition of nebulized surfactant in newborn piglets: Nasal CPAP vs Nasal IPPV

BACKGROUND

Nasal continuous positive airway pressure support (nCPAP) is the standard of care for prematurely born infants at risk of neonatal respiratory distress syndrome (nRDS). However, nasal intermittent positive pressure ventilation (NIPPV) may be an alternative to nCPAP in babies requiring surfactant, and in conjunction with surfactant nebulization, it could theoretically reduce the need for invasive mechanical ventilation. We compared lung deposition of nebulized poractant in newborn piglets supported by nCPAP or NIPPV.

METHODS

Twenty-five sedated newborn piglets (1.2-2.2 kg) received either nCPAP (3 cmH2 O, n = 12) or NIPPV (3 cmH2 O positive end expiratory pressure+3 cmH2 O inspiratory pressure, n = 13) via custom-made nasal prongs (FiO2 0.4, Servo-i ventilator). Piglets received 200 mg kg-1 of technetium-99m-surfactant mixture continuously nebulized with a customized eFlow-Neos investigational vibrating-membrane nebulizer system. Blood gases were taken immediately before, during, and after nebulization. The deposition was estimated by gamma scintigraphy.

RESULTS

Mean surfactant deposition in the lungs was 15.9 ± 11.9% [8.3, 23.5] (mean ± SD [95% CI]) in the nCPAP group and 21.6 ± 10% [15.6, 27.6] in the NIPPV group (P = .20). Respiratory rates were similar in both groups. Minute volume was 489 ± 203 [360, 617] in the nCPAP group and 780 ± 239 [636, 924] mL kg-1  min-1 in the NIPPV group (P = .009). Blood gases were comparable in both groups.

CONCLUSION

Irrespective of the noninvasive ventilatory support mode used, relatively high lung deposition rates of surfactant were achieved with nebulization. The amounts of deposited surfactant might suffice to elicit a pulmonary function improvement in the context of nRDS.

Nebulised surfactant to reduce severity of respiratory distress: a blinded, parallel, randomised controlled trial

OBJECTIVE

To evaluate if nebulised surfactant reduces intubation requirement in preterm infants with respiratory distress treated with nasal continuous positive airway pressure (nCPAP).

DESIGN

Double blind, parallel, stratified, randomised control trial.

SETTING

Sole tertiary neonatal unit in West Australia.

PATIENTS

Preterm infants (29⁰-33⁶ weeks' gestational age, GA) less than 4 hours of age requiring 22%-30% supplemental oxygen, with informed parental written consent.

INTERVENTIONS

Infants were randomised within strata (29⁰-31⁶ and 32⁰-33⁶ weeks' GA) to bubble nCPAP or bubble nCPAP and nebulised surfactant (200 mg/kg: poractant alfa) using a customised vibrating membrane nebuliser (eFlow neonatal). Surfactant nebulisation (100 mg/kg) was repeated after 12 hours for persistent supplemental oxygen requirement.

MAIN OUTCOME MEASURES

The primary outcomes were requirement for intubation and duration of mechanical ventilation at 72 hours. Data analysis followed the intention-to-treat principle.

RESULTS

360 of 606 assessed infants were eligible; 64 of 360 infants were enrolled and randomised (n=32/group). Surfactant nebulisation reduced the requirement for intubation within 72 hours: 11 of 32 infants were intubated after continuous positive airway pressure (CPAP) and nebulised surfactant compared with 22 of 32 infants receiving CPAP alone (relative risk (95% CI)=0.526 (0.292 to 0.950)). The reduced requirement for intubation was limited to the 32⁰-33⁶ weeks' GA stratum. The median (range) duration of ventilation in the first 72 hours was not different between the intervention (0 (0-62) hours) and control (9 (0-64) hours; p=0.220) groups. There were no major adverse events.

CONCLUSIONS

Early postnatal nebulised surfactant may reduce the need for intubation in the first 3 days of life compared with nCPAP alone in infants born at 29⁰-33⁶ weeks' GA with mild respiratory distress syndrome. Confirmation requires further adequately powered studies.

TRIAL REGISTRATION NUMBER

ACTRN12610000857000.

The evaluation of the efficacy and safety of non-invasive neurally adjusted ventilatory assist in combination with INtubation-SURfactant-Extubation technique for infants at 28 to 33 weeks of gestation with respiratory distress syndrome

Objectives:

The aim of this study is to evaluate the efficacy and safety of non-invasive neurally adjusted ventilatory assist used after INtubation-SURfactant-Extubation in preterm infants with respiratory distress syndrome.

Methods:

We conducted a prospective observational study that included 15 inborn preterm infants at 28 (0/7) to 33 (6/7) weeks of gestation with respiratory distress syndrome in the period from April 2017 to October 2018. After INtubation-SURfactant-Extubation, infants underwent non-invasive neurally adjusted ventilatory assist. INtubation-SURfactant-Extubation failure was defined as follows: fraction of inspired oxygen requirement >0.4, respiratory acidosis, and severe apnea within 5 days after surfactant administration.

Results:

Two of the 15 (13.3%) infants showed INtubation-SURfactant-Extubation failure and required mechanical ventilation. No infants experienced any major complications such as pneumothorax, patent ductus arteriosus ligation, severe intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, or death.

Conclusion:

The rate of INtubation-SURfactant-Extubation failure when non-invasive neurally adjusted ventilatory assist was used after INtubation-SURfactant-Extubation for preterm infants with respiratory distress syndrome was 13.3%. Non-invasive neurally adjusted ventilatory assist can be safely performed without severe complications for preterm infants soon after birth.

Serum neurotrophins at birth correlate with respiratory and neurodevelopmental outcomes of premature infants

OBJECTIVE

Preterm birth is a significant cause of infant morbidity and mortality, which are primarily the result of respiratory and neurodevelopmental complications. However, no objective biomarker is currently available to predict at birth the risk and severity of such complications. Thus, we sought to determine whether serum neurotrophins concentrations measured at birth correlate with risk for later development of bronchopulmonary dysplasia (BPD) and long-term neurodevelopmental outcomes.

METHODS

This study prospectively included 223 newborns admitted to neonatal intensive care units (NICU) and divided into three groups: (i) preterm infants who developed BPD; (ii) preterm infants who did not develop BPD; (iii) term infants. An exploratory cohort was enrolled in West Virginia, followed by a validation cohort recruited in four NICUs in Ohio. Specimens for serum and tracheal neurotrophins concentrations were collected within 48 h of admission. Infants requiring a fraction of inspired oxygen >0.21 for at least 28 days were diagnosed with BPD. Neurodevelopmental outcomes were extrapolated from Bayley Scales of Infant Development-Third Edition (BSID-III) administered at the 24-month follow-up visit.

RESULTS

Serum brain-derived neurotrophic factor (BDNF) concentration at birth had significant negative correlation with later diagnosis of BPD (P = 0.011) and with duration of invasive ventilation and oxygen supplementation (P = 0.009 and 0.015, respectively). Serum nerve growth factor (NGF) concentration at birth had significant positive correlation with BSID-III cognitive and language composite scores at 24 months (P < 0.001 and 0.010, respectively).

CONCLUSIONS

These data suggest that serum neurotrophins concentrations measured at birth provide prognostic information on subsequent respiratory and neurodevelopmental outcomes.

Novel Surfactant Administration Techniques: Will They Change Outcome?

Traditionally, surfactant has been administered to preterm infants with respiratory distress syndrome via an endotracheal tube and in conjunction with mechanical ventilation. However, negative consequences of mechanical ventilation such as pneumothorax and bronchopulmonary dysplasia are well known. In order to provide the benefits of surfactant administration without the negative effects of mechanical ventilation, several methods of less invasive surfactant administration have been developed. These methods include InSurE (intubate, surfactant, extubate), pharyngeal administration, laryngeal mask administration, aerosolized surfactant administration, and thin catheter administration (TCA). Of these, TCA has been studied most extensively and holds the most promise as a less invasive and effective mode of surfactant administration to preterm infants. Further studies will aid in determining which patients would benefit most from less invasive surfactant administration.

Transient intubation for surfactant administration in the treatment of respiratory distress syndrome in extremely premature infants

Purpose

To investigate the effectiveness of transient intubation for surfactant administration and extubated to nasal continuous positive pressure (INSURE) for treatment of respiratory distress syndrome (RDS) and to identify the factors associated with INSURE failure in extremely premature infants.

Methods

Eighty-four infants with gestational age less than 28 weeks treated with surfactant administration for RDS for 8 years were included. Perinatal and neonatal characteristics were retrospectively reviewed, and major pulmonary outcomes such as duration of mechanical ventilation (MV) and bronchopulmonary dysplasia (BPD) plus death at 36-week postmenstrual age (PMA) were compared between INSURE (n=48) and prolonged MV groups (n=36). The factors associated with INSURE failure were determined.

Results

Duration of MV and the occurrence of BPD at 36-week PMA were significantly lower in INSURE group than in prolonged MV group (P<0.05), but BPD plus death at 36-week PMA was not significantly different between the 2 groups. In a multivariate analysis, a reduced duration of MV was only significantly associated with INSURE (P=0.001). During the study period, duration of MV significantly decreased over time with an increasing rate of INSURE application (P<0.05), and BPD plus death at 36-week PMA also tended to decrease over time. A low arterial-alveolar oxygen tension ratio (a/APO2 ratio) was a significant predictor for INSURE failure (P=0.001).

Conclusion

INSURE was the noninvasive ventilation strategy in the treatment of RDS to reduce MV duration in extremely premature infants with gestational age less than 28 weeks.

Efficacy, Safety, and Usability of Remifentanil as Premedication for INSURE in Preterm Neonates

Background: We previously reported a 67% extubation failure with INSURE (Intubation, Surfactant, Extubation) using morphine as analgosedative premedication. Remifentanil, a rapid- and short-acting narcotic, might be ideal for INSURE, but efficacy and safety data for this indication are limited. Objectives: To assess whether remifentanil premedication increases extubation success rates compared with morphine, and to evaluate remifentanil's safety and usability in a teaching hospital context. Methods: Retrospective review of remifentanil orders for premedication, at a large teaching hospital neonatal intensive care unit (NICU). We compared INSURE failure rates (needing invasive ventilation after INSURE) with prior morphine-associated rates. Additionally, we surveyed NICU staff to identify usability and logistic issues with remifentanil. Results: 73 remifentanil doses were administered to 62 neonates (mean 31.6 ± 3.8 weeks' gestation). Extubation was successful in 88%, vs. 33% with morphine premedication (p < 0.001). Significant adverse events included chest wall rigidity (4%), one case of cardiopulmonary resuscitation (CPR) post-surfactant, naloxone reversal (5%), and notable transient desaturation (34%). Among 137 completed surveys, 57% indicated concerns, including delayed drug availability (median 1.1 h after order), rapid desaturations narrowing intubation timeframes and hindering trainee involvement, and difficulty with bag-mask ventilation after unsuccessful intubation attempts. Accordingly, 33% of ultimate intubators were attending neonatologists, versus 16% trainees. Conclusions: Remifentanil premedication was superior to morphine in allowing successful extubation, despite occasional chest wall rigidity and unfavorable conditions for trainees. We recommend direct supervision and INSURE protocols aimed at ensuring rapid intubation.

Comparison of the Pharmacoeconomics of Calfactant and Poractant Alfa in Surfactant Replacement Therapy

OBJECTIVE To compare the pharmacy costs of calfactant (Infasurf, ONY, Inc.) and poractant alfa (Curosurf, Chiesi USA, Inc., Cary, NC).

METHODS The University of South Alabama Children's and Women's Hospital switched from calfactant to poractant alfa in 2013 and back to calfactant in 2015. Retrospectively, we used deidentified data from pharmacy records that provided type of surfactant administered, gestational age, birth weight, and number of doses on each patient. We examined differences in the number of doses by gestational ages and the differences in costs by birth weight cohorts because cost per dose is based on weight.

RESULTS There were 762 patients who received calfactant and 432 patients who received poractant alfa. The average number of doses required per patient was 1.6 administrations for calfactant-treated patients and 1.7 administrations for poractant alfa-treated patients, p = 0.03. A higher percentage of calfactant patients needed only 1 dose (53%) than poractant alfa patients (47%). The distribution of the number of doses for calfactant-treated patients was significantly lower than for the poractant alfa-patients, p &lt; 0.001. Gestational age had no consistent effect on the number of doses required for either calfactant or poractant alfa. Per patient cost was higher for poractant alfa than for calfactant in all birth weight cohorts. Average per patient cost was $1160.62 for poractant alfa, 38% higher than the average per patient cost for calfactant ($838.34). Using poractant alfa for 22 months is estimated to have cost $202,732.75 more than it would have cost if the hospital had continued using calfactant.

CONCLUSION Our experience showed a strong pharmacoeconomic advantage for the use of calfactant compared to the use of poractant alfa because of similar average dosing and lower per patient drug costs.

Golden hour of neonatal life: Need of the hour

"Golden Hour" of neonatal life is defined as the first hour of post-natal life in both preterm and term neonates. This concept in neonatology has been adopted from adult trauma where the initial first hour of trauma management is considered as golden hour. The "Golden hour" concept includes practicing all the evidence based intervention for term and preterm neonates, in the initial sixty minutes of postnatal life for better long-term outcome. Although the current evidence supports the concept of golden hour in preterm and still there is no evidence seeking the benefit of golden hour approach in term neonates, but neonatologist around the globe feel the importance of golden hour concept equally in both preterm and term neonates. Initial first hour of neonatal life includes neonatal resuscitation, post-resuscitation care, transportation of sick newborn to neonatal intensive care unit, respiratory and cardiovascular support and initial course in nursery. The studies that evaluated the concept of golden hour in preterm neonates showed marked reduction in hypothermia, hypoglycemia, intraventricular hemorrhage (IVH), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). In this review article, we will discuss various components of neonatal care that are included in "Golden hour" of preterm and term neonatal care.

Use of naloxone to minimize extubation failure after premedication for INSURE procedure in preterm neonates

OBJECTIVES

A new guideline for the early respiratory management of preterm infants that included early nCPAP and INSURE was recently introduced in our NICU. This case series describes the clinical courses of a group of preterm infants managed according to this guideline, and reports the rates of successful extubation within 30 minutes of surfactant administration with and without the use of naloxone and adverse events encountered.

STUDY DESIGN

Descriptive case series of all preterm babies admitted to our unit who were candidates for INSURE procedure with premedication from August 2012 to August 2013.

RESULTS

A total of 31 infants were included with a mean birth weight of 1178 grams and a mean gestational age of 28.4 weeks. Twelve out of thirteen (92%) infants in the naloxone group were extubated within 30 minutes of surfactant administration while only 12/18 (67%) in the non-naloxone group were extubated within the same time frame. No adverse reactions were noted with naloxone usage in this context.

CONCLUSION

Naloxone can be effective in reversing the respiratory depressive effect of analgesic premedication and in turn facilitates expeditious extubation in some preterm infants intubated for INSURE procedure.

Diode laser spectroscopy for noninvasive monitoring of oxygen in the lungs of newborn infants

BACKGROUND

Newborn infants may have pulmonary disorders with abnormal gas distribution, e.g., respiratory distress syndrome. Pulmonary radiography is the clinical routine for diagnosis. Our aim was to investigate a novel noninvasive optical technique for rapid nonradiographic bedside detection of oxygen gas in the lungs of full-term newborn infants.

METHODS

Laser spectroscopy was used to measure contents of oxygen gas (at 760 nm) and of water vapor (at 937 nm) in the lungs of 29 healthy newborn full-term infants (birth weight 2,900-3,900 g). The skin above the lungs was illuminated using two low-power diode lasers and diffusely emerging light was detected with a photodiode.

RESULTS

Of the total 390 lung measurements performed, clear detection of oxygen gas was recorded in 60%, defined by a signal-to-noise ratio of >3. In all the 29 infants, oxygen was detected. Probe and detector positions for optimal pulmonary gas detection were determined. There were no differences in signal quality with respect to gender, body side or body weight.

CONCLUSION

The ability to measure pulmonary oxygen content in healthy full-term neonates with this technique suggests that with further development, the method might be implemented in clinical practice for lung monitoring in neonatal intensive care.

Analysis and comparison of the effects of N-BiPAP and Bubble-CPAP in treatment of preterm newborns with the weight of below 1500 grams affiliated with respiratory distress syndrome: A randomised clinical trial

BACKGROUND

Nowadays, establishment of nCPAP and surfactant administration is considered to be the first level of intervention for newborns engaged in the process of Respiratory Distress Syndrome (RDS). In order to decrease the side effects of the nCPAP management placed in noninvasive-non-cycled respiratory support. Noninvasive-cycled respiratory support mechanism have been developed such as N-BiPAP. Therefore, we compared N-BiPAP with Bubble-CPAP in a clinical trial.

MATERIALS AND METHODS

This research was done as an on newborns weighing less than 1500 grams affiliated with RDS. A3 The total number of newborns was 70. Newborns were divided into two groups with the sample size of 35 patients in each, according to odd and even document numbers. One group was treated with N-BiPAP and the other with Bubble-CPAP. Patients were compared according to the length of treatment with noninvasive respiratory support, length of oxygen intake, number of surfactant doses administered, need for invasive mechanical ventilation, apnea, patent ductus arteriosus (PDA), chronic lung disease, intraventricular hemorrhage, pneumothorax, and death. Data was recorded and compared.

RESULTS

The average duration for noninvasive respiratory support and the average time of need to complementary oxygen was not significantly different in both groups (P value > 0.05). Need for invasive ventilation, also chronic lung disease, intraventricular hemorrhage (IVH), pneumothorax, need for the next dose of surfactant, and the death rate did also have no meaningful difference. (P value > 0.05).

CONCLUSION

In this research N-BiPAP did not show any obvious clinical preference over the Bubble-CPAP in treatment of newborns weighing less than 1500 grams and affiliated with RDS.

A Comparison of the Effect of Nasal bi-level Positive Airway Pressure and Sigh-positive Airway Pressure on the Treatment of the Preterm Newborns Weighing Less than 1500 g Affiliated with Respiratory Distress Syndrome

BACKGROUND

Nowadays, administering noninvasive positive airway pressure (PAP) is considered as the building block for the management of respiratory distress syndrome (RDS). Since nasal continuous PAP (n-CPAP) established its roots as an interventional approach to treat RDS, there have always been concerns related to the increased work of breathing in newborns treated with this intervention. Therefore, respiratory support systems such as nasal bi-level PAP (N-BiPAP) and sigh-PAP (SiPAP) have been developed during the last decade. In this study, two respiratory support systems which, unlike n-CPAP, are categorized as cycled noninvasive ventilation, are studied.

METHODS

This study was a randomized clinical trial done on 74 newborns weighing 1500 g or less affiliated with RDS hospitalized in NICU at Al-Zahra Hospital from October 2012 to March 2014. Patients were randomly assigned to two respiratory support groups of N-BiPAP and SiPAP. Each group contained 37 newborns who were compared, according to their demographic characteristics, duration of noninvasive ventilation, the need to administer surfactant, apnea incidence, the need for mechanical ventilation, pneumothorax, intraventricular hemorrhage (IVH), patent ductus arteriosus (PDA), the duration of oxygen supplement administration, and chronic lung disease (CLD).

RESULTS

The average duration of noninvasive respiratory support, and the average duration of the need for oxygen supplement had no significant difference between the groups. Moreover, apnea incidence, the need for mechanical ventilation, pneumothorax, IVH, PDA, CLD, the need for the second dose of surfactant, and the death rate showed no significant difference in two groups.

CONCLUSIONS

In this study, SiPAP showed no significant clinical preference over N-BiPAP in the treatment of the newborns with RDS weighing <1500 g.

Is it feasible to identify preterm infants with respiratory distress syndrome for early extubation to continuous positive airway pressure post-surfactant treatment during retrieval?

AIM

Preterm infants with respiratory distress syndrome (RDS) requiring surfactant treatment are often retrieved mechanically ventilated to the receiving hospital. INSURE (INtubate, SURfactant, Extubate) technique is not routinely performed by Newborn and Pediatric Emergency Transport Services NSW (NETS) during retrieval. This study aims to evaluate the likelihood of using INSURE technique during retrieval. We attempted to study the clinical characteristics of preterm infants with RDS who were favourably extubated (FE) shortly after admission to the receiving hospital.

METHODS

Retrospective study of preterm infants, gestational age (GA) > 28 weeks with RDS requiring retrieval by NETS.

RESULTS

Two hundred twenty-three infants, median GA of 33 weeks (range 29-36), median birthweight 2200 g (1000-4080) were examined. A percentage of 49.7 received CPAP, and 50.3% required MV. Eighteen (16%) infants were FE (<6 h) at receiving hospital. FiO2 on stabilisation (FiO2 (st)) by NETS correlated with FiO2 on admission to receiving hospital (r = 0.863). A percentage of 81 of ventilated infants received premedications including morphine. No significant differences were noted for GA, stabilisation ventilator settings, surfactant dose (mean 155 mg/kg) and mode of transport between FE and non-FE groups. FiO2 (st) post-surfactant treatment was significantly lower in FE compared with non-FE group (mean 0.28 vs. 0.41 respectively). The area under the curve from receiver operating characteristic based on FiO2 (st) was 0.646 (P = 0.050), the sensitivity and specificity of FiO2 (st) cut-off points (between 0.25 and 0.30) was low.

CONCLUSION

FiO2 on stabilisation post-surfactant treatment has a weak predictive value and may not be adequate to be used as sole criteria to extubate to CPAP prior to transport. FiO2 at stabilisation should be included as an eligibility criteria for a randomised trial of INSURE during retrieval, but other clinical assessments are needed.

Comparison between noninvasive mechanical ventilation and standard oxygen therapy in children up to 3 years old with respiratory failure after extubation: a pilot prospective randomized clinical study

OBJECTIVES

The effectiveness of noninvasive positive-pressure ventilation in preventing reintubation due to respiratory failure in children remains uncertain. A pilot study was designed to evaluate the frequency of extubation failure, develop a randomization approach, and analyze the feasibility of a powered randomized trial to compare noninvasive positive-pressure ventilation and standard oxygen therapy post extubation for preventing reintubation within 48 hours in children with respiratory failure.

DESIGN

Prospective pilot study.

SETTING

PICU at a university-affiliated hospital.

PATIENTS

Children aged between 28 days and 3 years undergoing invasive mechanical ventilation for greater than or equal to 48 hours with respiratory failure after programmed extubation.

INTERVENTIONS

Patients were prospectively enrolled and randomly assigned into noninvasive positive-pressure ventilation group and inhaled oxygen group after programmed extubation from May 2012 to May 2013.

MEASUREMENTS AND MAIN RESULTS

Length of stay in PICU and hospital, oxygenation index, blood gas before and after tracheal extubation, failure and reason for tracheal extubation, complications, mechanical ventilation variables before tracheal extubation, arterial blood gas, and respiratory and heart rates before and 1 hour after tracheal extubation were analyzed. One hundred eight patients were included (noninvasive positive-pressure ventilation group, n = 55 and inhaled oxygen group, n = 53), with 66 exclusions. Groups did not significantly differ for gender, age, disease severity, Pediatric Risk of Mortality at admission, tracheal intubation, and mechanical ventilation indications. There was no statistically significant difference in reintubation rate (noninvasive positive-pressure ventilation group, 9.1%; inhaled oxygen group, 11.3%; p > 0.05) and length of stay (days) in PICU (noninvasive positive-pressure ventilation group, 3 [1-16]; inhaled oxygen group, 2 [1-25]; p > 0.05) or hospital (noninvasive positive-pressure ventilation group, 19 [7-141]; inhaled oxygen group, 17 [8-80]).

CONCLUSIONS

The study indicates that a larger randomized trial comparing noninvasive positive-pressure ventilation and standard oxygen therapy in children with respiratory failure is feasible, providing a basis for a future trial in this setting. No differences were seen between groups. The number of excluded patients was high.

Surfactant and noninvasive ventilation

There is mounting evidence that early continuous positive airway pressure (CPAP) from birth is feasible and safe even in very preterm infants. However, many infants will develop respiratory distress syndrome (RDS) and require surfactant treatment. Combining a noninvasive ventilation approach with a strategy for surfactant administration is important to ensure optimal outcome, but questions remain about the optimal timing, mode of delivery and value of predictive tests for surfactant deficiency. Key findings in this review include the following: (1) a noninvasive ventilation strategy with CPAP from birth has a similar outcome to routine intubation in the delivery room; (2) prophylactic surfactant treatment has no advantage over early CPAP with selective surfactant administration; (3) surfactant during CPAP can be safely administered by rapid intubation-extubation (the INSURE method or via tracheal placement of a thin catheter), and (4) predictive tests for surfactant deficiency are being developed and might in future aid in directing surfactant treatment to infants at risk of developing severe RDS. A strategy for surfactant administration should be part of a noninvasive ventilation approach for preterm infants at risk of developing significant RDS. The different methods for surfactant administration during CPAP are reviewed here.

The importance of administration of early surfactant and nasal continuous positive airway pressure in newborns with respiratory distress syndrome

AIM

Mechanical ventilation is an invasive method and causes to important problems in the respiratory tract and lung parenchyma. The objective of our study was to investigate if administration of early surfactant and nasal continuous positive airway pressure (nCPAP) was superior to delayed surfactant administration and mechanical ventilation.

MATERIAL AND METHODS

The study was conducted in the Van 100th Year University, Medical Faculty Hospital, Neonatal Intensive Care Unit. One hundred and nine infants with respiratory distrss syndrome (RDS) with a gestational age of 32 weeks and/or below were included in the study. Surfactant was given to 61 infants in the delivery room or intensive care unit and subsequently nCPAP was administered. Surfactant was administered in 48 infants in the control group and mechanical ventilation was inititated subsequently. Informed consent was obtained from the relatives of all patients and ethics committee approval was also obtained (Approval number: 03.02.2011/15).

RESULTS

There was no statistically significant difference between the two groups in terms of gestational age, birth weight, gender, height and head circumference measurements (p>0.05). The mean hospitalization time in the patients in the study group was 24.4±17.8 days, whereas the mean time of nCPAP was 28.4 (4-120) hours. In the study group, intracranial hemorrhage was found with a rate of 27.85%, bronchopulmonary dysplasia was found with a rate of 4.91%, pneumothorax was found with a rate of 3.27%, necrotizing enterocolitis was found with a rate of 3.27%, patent ductus arteriosus was found with a rate of 16.39, sepsis was found with a rate of 22.95% and retinopathy of prematurity was found with a rate of 1.63%. No statistically significant difference was found between the study and control groups in terms of the rates of complications. During the follow-up period, 17 (27.86%) patients were lost. The length of stay on mechanical ventilation in the study group was found to be statistically significantly shorter compared to the control group (p<0.05).

CONCLUSIONS

In our study, it was observed that administration of early surfactant and nCPAP in treatment of preterm newborns with a diagnosis of RDS markedly decreased the lenght of stay on mechanical ventilation, but had no significant impact on morbidity and mortality.

A comparison of two interventions for HHHFNC in preterm infants weighing 1,000 to 1,500 g in the recovery period of newborn RDS

BACKGROUND

Nasal cannula, beside administering low-flow therapy, showed the capability for the administration of continuous positive airway pressure (CPAP) through high-flow nasal cannula (HFNC). Meeting specific physical criteria of 100% relative humidity (RH) and temperature of 37(°)C are the basic interventional requirements to administer oxygen for the newborns through a nasal cannula. Recently, two systems, MR850 and PMH7000, received the Food and Drug Administration (FDA) approval to administer heated, humidified HFNC (HHHFNC). These systems are evaluated in this study based on their humidifying and heating capabilities.

MATERIALS AND METHODS

This study was done as an RCT on newborns weighing 1,000 to 1,500 g recovering from respiratory distress syndrome (RDS) while nCPAP was administered at CDP = 4 cmH2O, Fio2 <30%. Patients were randomized to two groups of 35 receiving HHHFNC after treatment with nCPAP, with one group using MR850 humidifier and the other PMH7000. The patients were compared according to the duration of HHHFNC administration, repeated need for nCPAP respiratory support, the need for invasive ventilation, apnea, chronic lung disease (CLD), nasal trauma, RH, and temperature of the gases.

RESULTS

The average time of support with HHHNFC did not show any significant difference in the two groups. There was no significant difference between the groups in the need for nCPAP, invasive ventilation, apnea, nasal trauma, and CLD. The difference in the levels of average temperature and humidity was significant (P value <0.001).

CONCLUSION

Although the records of temperature and RH in the PMH7000 system was lower than the records from the MR850 system, no clinical priority was observed for respiratory support with HHHNFC in the two systems.

Transitional hemodynamics in preterm infants with a respiratory management strategy directed at avoidance of mechanical ventilation

BACKGROUND

Early respiratory management of very low birth weight infants has changed over recent years to a practice of early use of CPAP with early selective surfactant administration, and decreased use of mechanical ventilation. One strategy is to use the combination of surfactant and prompt extubation to nasal continuous positive airway pressure (INtubate, SURfactant, Extubate, or INSURE). The aim of this study is to describe blood flow and ductal flow in a prospective cohort during the transitional period when this respiratory management strategy is used.

METHODS

Inborn infants <29week gestation underwent INSURE within 30min of birth using 200mg/kg Curosurf. Blood pressure and blood flow parameters (RVO, LVO, SVC flow, ductus arteriosus) were measured at 6, 24 and 72h of age and information on morbidity was collected.

RESULTS

Sixty-eight infants with a median (range) weight of 940 (450-1380) g were studied. 13 (19%) patients needed mechanical ventilation within 72h of life (INSURE failure). Blood flows and blood pressure were within reported ranges. Eleven (16%) patients had a blood pressure <gestational age and 9 (13%) patients had low blood flow.

CONCLUSION

These data show a low prevalence of low blood pressure and low blood flow in the first 3days after INSURE as compared to cohorts where mechanical ventilation was preferred during transition. We speculate that altered ventilation strategies have helped decrease the incidence of low blood flow and low blood pressure.

Early surfactant therapy with nasal continuous positive airway pressure or continued mechanical ventilation in very low birth weight neonates with respiratory distress syndrome

Background:

Various strategies have been suggested for the treatment of respiratory distress syndrome (RDS).

Objectives:

The aim of this study was to compare the efficacies of two common methods of RDS management among neonates with low birth weight.

Patients and Methods:

A cohort study was conducted on 98 neonates with definite diagnosis of RDS during 2008-2009. The neonates were divided into two groups by a blinded supervisor using simple randomization (odd and even numbers). Forty-five cases in the first group were treated with intubation, surfactant therapy, extubation (INSURE method) followed by nasal continuous positive airway pressure (N.CPAP) and 53 cases in the second group underwent intubation, surfactant therapy followed by mechanical ventilation (MV).

Results:

Five (11.1%) cases in the first group and 23 (43%) cases in the second group expired during the study. The rates of MV dependency among cases with INSURE failure and cases in the MV group were 37% and 83%, respectively (P < 0.001). Birth weight (BW) (P = 0.017), presence of retinopathy of prematurity (P = 0.022), C/S delivery (P = 0.029) and presence of lung bleeding (P = 0.010) could significantly predict mortality in the second group, although only BW (P = 0.029) had a significant impact on the mortality rate in the first group. Moreover, BW was significantly related to the success rate in the first group (P = 0.001).

Conclusions:

Our findings demonstrated that INSURE plus NCPAP was more effective than the routine method (permanent intubation after surfactant prescription). In addition, the lower rates of mortality, MV dependency, duration of hospitalization, and complications were observed in cases treated with the INSURE method compared to the routine one.

Resuscitation intensity at birth is associated with changes in brain metabolic development in preterm neonates

INTRODUCTION

Intensive resuscitation at birth has been linked to intraventricular haemorrhage (IVH) in the preterm neonate. However, the impact of less intensive resuscitation on more subtle alterations in brain metabolic development is largely unknown. Our objective was to determine the relationship between the intensity of neonatal resuscitation following preterm birth on brain metabolic development.

METHODS

One hundred thirty-three very preterm-born neonates (median gestational age [GA] 27 ± 2 weeks) underwent MR spectroscopic imaging early in life (median postmenstrual age 32 weeks) and again at term-equivalent age (median 40 weeks). Severity of white matter injury, IVH and cerebellar haemorrhage on magnetic resonance imaging were scored. Ratios of N-acetylaspartate (NAA) and lactate to choline (Cho) were calculated in eight regions of interest and were assessed in relation to intensiveness of resuscitation strategy (bag and mask, continuous positive airway pressure [CPAP], intubation, cardiopulmonary resuscitation [CPR]).

RESULTS

Within the first hour of life, 14 newborns had no intervention, 3 received bag and mask, 30 had CPAP, 79 were intubated and 7 had CPR. Resuscitated infants were more likely to have IVH (p = 0.02). More intensive resuscitation was associated with decreased NAA/Cho maturation (p < 0.001, adjusting for birth GA). Metabolic development was similar in neonates requiring CPAP in comparison to those receiving no intervention. The change in lactate/Cho did not differ across resuscitation categories (p = 0.8).

CONCLUSIONS

Intensity of resuscitation at birth is related to changes in metabolic brain development from early in life to term-equivalent age. Results suggest that preventing the need for intensive neonatal resuscitation may provide an opportunity to improve brain development in preterm neonates.

Delivery and performance of surfactant replacement therapies to treat pulmonary disorders

Lung surfactant is crucial for optimal pulmonary function throughout life. An absence or deficiency of surfactant can affect the surfactant pool leading to respiratory distress. Even if the coupling between surfactant dysfunction and the underlying disease is not always well understood, using exogenous surfactants as replacement is usually a standard therapeutic option in respiratory distress. Exogenous surfactants have been extensively studied in animal models and clinical trials. The present article provides an update on the evolution of surfactant therapy, types of surfactant treatment, and development of newer-generation surfactants. The differences in the performance between various surfactants are highlighted and advanced research that has been conducted so far in developing the optimal delivery of surfactant is discussed.

A pharmacoeconomic analysis of in-hospital costs resulting from reintubation in preterm infants treated with lucinactant, beractant, or poractant alfa

OBJECTIVES

Reintubation and subsequent mechanical ventilation (MV) in preterm infants after surfactant replacement therapy are associated with excess morbidity and mortality and likely increase in-hospital costs. Specific surfactant therapy selection for prevention of respiratory distress syndrome (RDS) in preterm infants receiving conventional MV may impact not only clinical outcomes but also pharmacoeconomic outcomes.

METHODS

We conducted a pharmacoeconomic analysis of the impact of surfactant selection and reintubation and subsequent MV of preterm infants on health care resource utilization. Rates of reintubation and duration of MV after reintubation were determined from 1546 preterm infants enrolled in two surfactant trials comparing lucinactant to beractant and poractant alfa. Hospital costs were obtained from a 2010 US database from 1564 preterm infants with RDS, with a direct cost of $2637 per day for MV in the neonatal intensive care unit. Cost of reintubation by study and treatment was estimated as the incidence of reintubation multiplied by days on MV therapy after reintubation multiplied by cost per day for direct MV costs, standardized per 100 surfactant-treated infants.

RESULTS

There were no differences between studies or treatment groups in the overall extubation rate. Average MV duration following reintubation was similar between groups in both trials; however, reintubation rates were significantly lower (p<0 05) for infants treated with lucinactant than for those receiving beractant or poractant alfa. The observed differences in reintubation rates resulted in a projected cost saving of $160,013 to $252,203 per 100 infants treated with lucinactant versus animal-derived surfactants.

CONCLUSIONS

In this analysis, higher reintubation rates following successful extubation in preterm infants receiving animal-derived surfactant preparations significantly increased estimated in-hospital costs, primarily due to excess costs associated with MV. This analysis suggests that surfactant selection may have a significant pharmacoeconomic impact on cost of patient care. Additional cost assessment of potential reduction in reintubation-associated morbidity is warranted.

Flow-synchronized nasal intermittent positive pressure ventilation for infants <32 weeks' gestation with respiratory distress syndrome

Aim. To evaluate whether synchronized-NIPPV (SNIPPV) used after the INSURE procedure can reduce mechanical ventilation (MV) need in preterm infants with RDS more effectively than NCPAP and to compare the clinical course and the incidence of short-term outcomes of infants managed with SNIPPV or NCPAP. Methods. Chart data of inborn infants <32 weeks undergoing INSURE approach in the period January 2009–December 2010 were reviewed. After INSURE, newborns born January –December 2009 received NCPAP, whereas those born January–December 2010 received SNIPPV. INSURE failure was defined as FiO₂ need >0.4, respiratory acidosis, or intractable apnoea that occurred within 72 hours of surfactant administration. Results. Eleven out of 31 (35.5%) infants in the NCPAP group and 2 out of 33 (6.1%) infants in the SNIPPV group failed the INSURE approach and underwent MV (P < 0.004). Fewer infants in the INSURE/SNIPPV group needed a second dose of surfactant, a high caffeine maintenance dose, and pharmacological treatment for PDA. Differences in O₂ dependency at 28 days and 36 weeks of postmenstrual age were at the limit of significance in favor of SNIPPV treated infants. Conclusions. SNIPPV use after INSURE technique in our NICU reduced MV need and favorably affected short-term morbidities of our premature infants.

CPAP review

Continuous positive airway pressure (CPAP) is widely used in neonatal units both as a primary mode of respiratory support and following extubation from mechanical ventilation. In this review, the evidence for CPAP use particularly in prematurely born infants is considered. Studies comparing methods of CPAP generation have yielded conflicting results, but meta-analysis of randomised trials has demonstrated that delivering CPAP via short nasal prongs is most effective in preventing re-intubation. At present, there is insufficient evidence to establish the safety or efficacy of high flow nasal cannulae for prematurely born infants. Observational studies highlighted that early CPAP use rather than intubation and ventilation was associated with a lower incidence of bronchopulmonary dysplasia (BPD), but this has not been confirmed in three large randomised trials. Meta-analysis of the results of randomised trials has demonstrated that use of CPAP reduces extubation failure, particularly if a CPAP level of 5 cm H2O or more is used. Nasal injury can occur and is related to the length of time CPAP is used; weaning CPAP by pressure rather than by "time-cycling" reduces the weaning time and may reduce BPD. In conclusion, further studies are required to identify the optimum mode of CPAP generation and it is important that prematurely born infants are weaned from CPAP as soon as possible.

Initial respiratory support of preterm infants: the role of CPAP, the INSURE method, and noninvasive ventilation

This article explores the potential benefits and risks for the various approaches to the initial respiratory management of preterm infants. The authors focus on the evidence for the increasingly used strategies of initial respiratory support of preterm infants with continuous positive airway pressure (CPAP) beginning in the delivery room or very early in the hospital course and blended strategies involving the early administration of surfactant replacement followed by immediate extubation and stabilization on CPAP. Where possible, the evidence referenced in this review comes from individual randomized controlled trials or meta-analyses of those trials.

Brain injury in chronically ventilated preterm neonates: collateral damage related to ventilation strategy

Brain injury is a frequent comorbidity in chronically ventilated preterm infants. However, the molecular basis of the brain injury remains incompletely understood. This article discusses the subtle (diffuse) form of brain injury that has white matter and gray matter lesions without germinal matrix hemorrhage-intraventricular hemorrhage, posthemorrhagic hydrocephalus, or cystic periventricular leukomalacia. This article synthesizes data that suggest that diffuse lesions to white matter and gray matter are collateral damage related to ventilator strategy. Evidence is introduced from the 2 large-animal, physiologic models of evolving neonatal chronic lung disease that suggest that an epigenetic mechanism may underlie the collateral damage.

The role of surfactant in respiratory distress syndrome

The key feature of respiratory distress syndrome (RDS) is the insufficient production of surfactant in the lungs of preterm infants. As a result, researchers have looked into the possibility of surfactant replacement therapy as a means of preventing and treating RDS. We sought to identify the role of surfactant in the prevention and management of RDS, comparing the various types, doses, and modes of administration, and the recent development. A PubMed search was carried out up to March 2012 using phrases: surfactant, respiratory distress syndrome, protein-containing surfactant, protein-free surfactant, natural surfactant, animal-derived surfactant, synthetic surfactant, lucinactant, surfaxin, surfactant protein-B, surfactant protein-C.Natural, or animal-derived, surfactant is currently the surfactant of choice in comparison to protein-free synthetic surfactant. However, it is hoped that the development of protein-containing synthetic surfactant, such as lucinactant, will rival the efficacy of natural surfactants, but without the risks of their possible side effects. Administration techniques have also been developed with nasal continuous positive airway pressure (nCPAP) and selective surfactant administration now recommended; multiple surfactant doses have also reported better outcomes. An aerosolised form of surfactant is being trialled in the hope that surfactant can be administered in a non-invasive way. Overall, the advancement, concerning the structure of surfactant and its mode of administration, offers an encouraging future in the management of RDS.

Trends in survival among extremely-low-birth-weight infants (less than 1000 g) without significant bronchopulmonary dysplasia

Objective

The aim of this study was to analyze the evolution from 1997 to 2009 of survival without significant (moderate and severe) bronchopulmonary dysplasia (SWsBPD) in extremely-low-birth-weight (ELBW) infants and to determine the influence of changes in resuscitation, nutrition and mechanical ventilation on the survival rate.

Study design

In this study, 415 premature infants with birth weights below 1000 g (ELBW) were divided into three chronological subgroups: 1997 to 2000 (n = 65), 2001 to 2005 (n = 178) and 2006 to 2009 (n = 172).

Between 1997 and 2000, respiratory resuscitation in the delivery room was performed via a bag and mask (Ambu®, Ballerup, Sweden) with 40-50% oxygen. If this procedure was not effective, oral endotracheal intubation was always performed. Pulse oximetry was never used. Starting on January 1, 2001, a change in the delivery room respiratory policy was established for ELBW infants. Oxygenation and heart rate were monitored using a pulse oximeter (Nellcor®) attached to the newborn’s right hand. If resuscitation was required, ventilation was performed using a face mask, and intermittent positive pressure was controlled via a ventilator (Babylog2, Drägger). In 2001, a policy of aggressive nutrition was also initiated with the early provision of parenteral amino acids. We used standardized parenteral nutrition to feed ELBW infants during the first 12–24 hours of life. Lipids were given on the first day. The glucose concentration administered was increased by 1 mg/kg/minute each day until levels reached 8 mg/kg/minute. Enteral nutrition was started with trophic feeding of milk. In 2006, volume guarantee treatment was instituted and administered together with synchronized intermittent mandatory ventilation (SIMV + VG). The complications of prematurity were treated similarly throughout the study period. Patent ductus arteriosus was only treated when hemodynamically significant. Surgical closure of the patent ductus arteriosus was performed when two courses of indomethacin or ibuprofen were not sufficient to close it.

Mild BPD were defined by a supplemental oxygen requirement at 28 days of life and moderate BPD if breathing room air or a need for <30% oxygen at 36 weeks postmenstrual age or discharge from the NICU, whichever came first. Severe BPD was defined by a supplemental oxygen requirement at 28 days of life and a need for greater than or equal to 30% oxygen use and/or positive pressure support (IPPV or nCPAP) at 36 weeks postmenstrual age or discharge, whichever came first. Moderate and severe BPD have been considered together as “significant BPD”. The goal of pulse oximetry was to maintain a hemoglobin saturation of between 88% and 93%. Patients were considered to not need oxygen supplementation when it could be permanently withdrawn. The distribution of the variables was not normal based on a Kolmogorov-Smirnov test (p < 0.05 in all cases). Therefore, quantitative variables were expressed as the median and interquartile range (IQR; 25^th-75^th percentile). Statistical analysis of the data was performed using nonparametric techniques (Kruskal-Wallis test and Mann–Whitney U test). A chi-square analysis was used to analyze qualitative variables. Potential confounding variables were those possibly related to BPD in survivors (p between 0.05 and 0.3 in univariate analysis). Logistic regression analysis was performed with variables related to BPD in survivors (p < 0.05) and potential confounding variables. The forward stepwise method adjusted for confounding factors was used to select the variables, and the enter method using selected variables was used to obtain the odds ratios.

Results and conclusion

There was an increase in the rate of SWsBPD (1997 to 2000: 58.5%; 2001 to 2005: 74.2%; and 2006 to 2009: 75.0%; p = 0.032). In survivors, the occurrence of significant BPD decreased after 2001 (9.5% vs. 2.3%; p = 0.013). The factors associated with improved SWsBPD were delivery by caesarean section, a reduced endotracheal intubation rate and a reduced duration of mechanical ventilation.While the mortality of ELBW infants has not changed since 2001, the frequency of SWsBPD has significantly increased (75.0%) in association with increased caesarean sections and reductions in the endotracheal intubation rate, as well as the duration of mechanical ventilation.

Nasal intermittent positive pressure ventilation after surfactant treatment for respiratory distress syndrome in preterm infants <30 weeks' gestation: a randomized, controlled trial

OBJECTIVE

To compare the effect of early extubation to nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) on the need for mechanical ventilation via endotracheal tube (MVET) at 7 days of age in preterm infants <30 weeks' gestation requiring intubation and surfactant for respiratory distress syndrome (RDS) within 60  min of delivery.

STUDY DESIGN

Multicenter, randomized, controlled trial. A total of 57 infants were randomized within 120  min of birth to NCPAP (BW 1099 g and GA 27.8 weeks) and 53 infants to NIPPV (BW 1052  g, and GA 27.8 weeks). Infants were stabilized on NCPAP at birth and were given poractant alfa combined with MVET within 60  min of age. When stabilized on MVET, they were extubated within the next hours or days to NCPAP or NIPPV.

RESULT

A total of 42% [corrected] of infants needed MVET at 7 days of age in the NCPAP group compared with 17% in the NIPPV group (OR: 3.6; 95% CI: 1.5, 8.7). Days on MVET were 12 ± 11 days in NCPAP group compared with 7.5 ± 12 days in the NIPPV group (median 1 vs 7 days; P=0.006). Clinical bronchopulmonary dysplasia (BPD) was 39% in the NCPAP group compared to 21% in the NIPPV group (OR: 2.4; 95% CI: 1.02, 5.6). Physiological BPD was 46% in the NCPAP group compared with 11% in the NIPPV group (OR: 6.6, 95% CI: 2.4, 17.8; P=0.001). There were no differences in any other outcomes between the two groups.

CONCLUSION

NIPPV compared with NCPAP reduced the need for MVET in the first week, duration of MVET, and clinical as well as physiological BPD in preterm infants receiving early surfactant for RDS.

RDS--CPAP or surfactant or both

There is mounting evidence that early continuous positive airway pressure (CPAP) from birth is feasible and safe even in very preterm infants. However, many infants will develop respiratory distress syndrome (RDS) and require surfactant treatment. Combining a non-invasive ventilation approach with a strategy for surfactant administration is important, but questions remain about the optimal timing, mode of delivery and the value of predictive tests for surfactant deficiency.

CONCLUSION

Early CPAP in very preterm infants is as safe as routine intubation in the delivery room. However, a strategy for surfactant administration should be part of a non-invasive ventilation approach for those infants at risk of developing significant RDS.

Risk factors for intubation-surfactant-extubation (INSURE) failure and multiple INSURE strategy in preterm infants

The INSURE method, which consists of an intubation-surfactant-extubation sequence, is effective in reducing the need for mechanical ventilation (MV), the duration of respiratory support, and the need for surfactant replacement in preterm infants with respiratory distress syndrome. Although beneficial, the INSURE method fails to avoid MV in selected patients. We demonstrated that body weight <750 g, pO(2)/FiO(2) <218, and a/ApO(2) <0.44 at the first blood gas analysis are independent risk factors for INSURE failure in infants with gestational age <30 weeks. Moreover, we demonstrated that the INSURE treatment can be safely repeated with the aim to avoid MV, since the respiratory outcome did not differ between infants treated with single or multiple INSURE procedures.

First intention high-frequency oscillatory and conventional mechanical ventilation in premature infants without antenatal glucocorticoid prophylaxis

OBJECTIVE

Data comparing the effectiveness of high-frequency oscillatory ventilation and of conventional mechanical ventilation in the treatment of respiratory distress syndrome of very low birth weight infants are, to date, still matter of debate. We investigated the effects of first intention high-frequency oscillatory ventilation or conventional mechanical ventilation support on selected primary and secondary outcomes in very low birth weight infants complicated by respiratory distress syndrome in which antenatal glucocorticoid prophylaxis was not performed.

DESIGN

Multicenter randomized control trial.

SETTING

Three tertiary centers of neonatal intensive care units from December 2004 to December 2007.

POPULATION

Eighty-eight very low birth weight infants complicated by respiratory distress syndrome, without antenatal glucocorticoids, supported by first intention high-frequency oscillatory ventilation (n = 44) or conventional mechanical ventilation (n = 44).

INTERVENTIONS

All newborns were monitored by standard monitoring procedure, including routine laboratory variables, neurologic patterns, and ultrasound imaging. Primary outcomes were: the length of ventilatory support, the need of reintubation, and the length of nasal continuous positive airway pressure support in the postextubation period. Secondary outcomes were: the length of stay in neonatal intensive care unit and in hospital, death before discharge, adverse short- and long-term pulmonary and neonatal outcomes, and the need for a second dose of surfactant and of postnatal glucocorticoid treatment.

RESULTS

High-frequency oscillatory ventilation infants showed a significant lower duration (p < .001 for all) of ventilator dependency, lower need of reintubation and of duration of nasal continuous positive airway pressure support in the postextubation period. Among secondary outcomes in the high-frequency oscillatory ventilation infants, the need of a second dose of surfactant administration, and the length of stay in the neonatal intensive care unit and in hospital were significantly lower (p < .05 for all).

CONCLUSIONS

We found that high-frequency oscillatory ventilation in very low birth weight infants without antenatal glucocorticoid prophylaxis reduced the need of ventilatory support, surfactant therapy, and reintubation, and shortened neonatal intensive care unit and hospital stay, thus reducing unit and hospital costs. These data would support the usefulness of first intention high-frequency oscillatory ventilation strategy in managing in a selected population, such as very low birth weight newborns complicated by severe respiratory distress syndrome not antenatally treated with glucocorticoids.