PRACTICE VARIABILITIES DURING PRETERM NEONATAL RESUSCITATION BY THE DEDICATED RESUSCITATION STABILIZATION TEAM

ObjectiveTo measure tidal volumes (VT) and describe the interactions between spontaneous breaths and positive pressure ventilation (PPV) inflations during stabilisation of preterm infants in the delivery room (DR). We used...

Obstructive sleep apnea (OSA) is a common pediatric condition characterized by recurrent partial or complete cessation of airflow during sleep, typically due to inadequate upper airway patency. Continuous positive airway pressure (CPAP) is a therapeutic option that reduces morbidity. Despite efforts to promote use, CPAP adherence is poor in both pediatric and adult populations. We sought to determine whether demographics, insurance status, OSA severity, therapeutic pressure, or comorbid conditions were associated with pediatric CPAP adherence. A retrospective review of adherence download data was performed on all pediatric patients with initiation or adjustment of CPAP treatment over a one-year period with documented in-laboratory CPAP titration. Patients were grouped as CPAP adherent or non-adherent, where adherence was defined as > 70% nightly use and average usage ≥ 4 hours per night. Differences between the groups were analyzed by χ(2) test. Overall, nearly half of participants were CPAP adherent (49%, 69/140). Of the demographic data collected (age, ethnicity, sex, insurance status), only female sex was associated with better adherence (60.9% vs 39.5% of males adherent; odds ratio [OR] = 2.41, 95%CI = 1.20-4.85; p = 0.01). Severity of OSA (diagnostic apnea-hypopnea index [AHI] and degree of hypoxemia), therapeutic pressure, and residual AHI did not impact CPAP adherence (p > 0.05). Patients with developmental delay (DD) were more likely to be adherent with CPAP than those without a DD diagnosis (OR = 2.55, 95%CI = 1.27-5.13; p = 0.007). Female patients with trisomy 21 tended to be more adherent, but this did not reach significance or account for the overall increased adherence associated with female sex. Our study demonstrates that adherence to CPAP therapy is poor but suggests that female sex and developmental delay are associated with better adherence. These findings support efforts to understand the pathophysiology of and to develop adherence-promoting and alternative interventions for pediatric OSA.

Noninvasive ventilation by facemask is commonly used for patients with respiratory failure. We evaluated the pressure exerted by two types of facemask on the faces of 12 healthy volunteers while they were being given different levels of continuous or bi-level positive airway pressure ventilation. The mean (SD) pressure recorded on the bridge of the nose was much higher than that on the cheek (nose: 65.8 (21.2) vs cheek 15.4 (7.2) mmHg, p < 0.0001). Progressive tightening of the harness and increasing of the volume of air in the facemask cushions increased the pressure on the bridge of the nose, and the effect of these two factors was additive. Some commercially available facemasks can produce substantial pressure on the bridge of the nose and this explains why pressure complications on the bridge of the nose are common during noninvasive ventilation.

Oxygen Saturation and Heart Rate Ranges in Very Preterm Infants Requiring Respiratory Support at Birth

ObjectiveTo measure tidal volume, plethysmography changes and gas exchange during respiratory support at birth.DesignThe following parameters were measured: (1) expired tidal volumes (Vte (mL/kg)) using respiratory function monitoring, (2) changes...

ABSTRACTAimIn preterm infants, decreasing head circumference (HC) percentiles have been linked to neurodevelopmental impairment. Devices for administering continuous positive airway pressure (CPAP) may alter skull morphology. We investigated the impact of sequentially administered CPAP and high‐flow nasal cannula on HC percentiles.MethodsIn this retrospective single‐institution study of infants < 1500 g birthweight and < 30 weeks gestational age born 2019–2020 (syndromes and intraventricular haemorrhage ≥ grade 2 excluded), routine HC measurements were translated into HC percentiles. We compared data at birth, after CPAP initiation, after partial and complete discontinuation of CPAP, and at discharge.ResultsThe study included 137 infants (median [interquartile range] gestational age 27+3 [25+5–28+6] weeks, birthweight 890 [715–1120] g). After initiation of CPAP, HC percentiles dropped from 57 [18–77] to 16 [2–26] (p < 0.001), and declined further until CPAP was partially replaced by high‐flow nasal cannula to 7 [3–30] (p < 0.001). HC percentiles increased after total weaning off CPAP to 14 [3–30] (p = 0.004) and continued to rise until discharge to 22 [8–37] (p < 0.001).ConclusionCPAP was associated with a transient decline of HC percentiles, with gradual recovery after CPAP discontinuation.

Perinatal outcomes in critically ill pregnant women with coronavirus disease 2019

To evaluate the effect of high-frequency jet ventilation (HFJV) and continuous positive airway pressure (CPAP) on oxygenation and the shunt fraction (Qs/Qt) during one-lung ventilation (OLV). Twenty-five patients who were undergoing resection of a descending aortic aneurysm were studied. Arterial oxygenation, Qs/Qt, and hemodynamics were evaluated just before the initiation of OLV (T1), 15 min after OLV (T2), and 15 min (T3) and 30 min (T4) after the application of HFJV or CPAP to the nondependent lung. There were no significant changes in the mean arterial blood pressure (MAP), heart rate (HR), central venous pressure (CVP), or mixed venous partial pressure of oxygen throughout this study. The arterial partial pressure of oxygen (Pa(O2)) values after the application of HFJV or CPAP increased significantly, from 173.8 +/- 39.6 mmHg (T2) to 344.1 +/- 87.9 mmHg (T3) and 359.9 +/- 82.4 mmHg (T4) in the HFJV group (P < 0.05), and from 153 +/- 38.5 mmHg (T2) to 243 +/- 48.5 mmHg (T3) and 249.7 +/- 55.0 mmHg (T4) in the CPAP group (P < 0.05). The shunt fraction decreased significantly after the initiation of HFJV or CPAP, from 38.7% +/- 8.9% (T2) to 27.0% +/- 8.0% (T3) and 25.9% +/- 8.7% (T4) in the HFJV group (P < 0.05), and from 44.6% +/- 8.6% (T2) to 34.3% +/- 10.2% (T3) and 32.6% +/- 8.5% (T4) in the CPAP group (P < 0.05). The arterial saturation of oxygen (Sa(O) (2)) increased significantly after the application of either HFJV or CPAP (P < 0.05). Both HFJV and CPAP can improve oxygenation during OLV.

ObjectivesTo determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation.Design, setting and patientsA prospective observational study in an unselected population at Stavanger...

Selective or routine face mask application for breathing support of preterm infants at birth: a randomised trial.

BackgroundIf infants fail to initiate spontaneous breathing, resuscitation guidelines recommend respiratory support with positive pressure ventilation (PPV). The purpose of PPV is to establish functional residual capacity and deliver an adequate tidal volume (VT) to achieve gas exchange.ObjectiveThe aim of our pilot study was to measure changes in exhaled carbon dioxide (ECO2), VT, and rate of carbon dioxide elimination (VCO2) to assess lung aeration in preterm infants requiring respiratory support immediately after birth.MethodA prospective observational study was performed between March and July 2013. Infants born at <37 weeks gestational age who received continuous positive airway pressure (CPAP) or PPV immediately after birth had VT delivery and ECO2 continuously recorded using a sensor attached to the facemask.ResultsFifty-one preterm infants (mean (SD) gestational age 29 (3) weeks and birth weight 1425 (592 g)) receiving respiratory support in the delivery room were included. Infants in the CPAP group (n = 31) had higher ECO2 values during the first 10 min after birth compared to infants receiving PPV (n = 20) (ranging between 18–30 vs. 13–18 mmHg, p<0.05, respectively). At 10 min no significant difference in ECO2 values was observed. VT was lower in the CPAP group compared to the PPV group over the first 10 min ranging between 5.2–6.6 vs. and 7.2–11.3 mL/kg (p<0.05), respectively.ConclusionsImmediately after birth, spontaneously breathing preterm infants supported via CPAP achieved better lung aeration compared to infants requiring PPV. PPV guided by VT and ECO2 potentially optimize lung aeration without excessive VT administered.

Background Respiratory distress is a frequent complication in preterm infants, often requiring respiratory support. Respiratory distress syndrome (RDS), caused by surfactant deficiency in the immature lung, is the predominant etiology in this population. Continuous positive airway pressure (CPAP) is a common intervention, but the optimal timing of CPAP initiation remains less clearly defined in the late preterm population (33–36 weeks gestation). This study aimed to determine the outcomes of preterm newborns with respiratory distress in relation to the timing of CPAP initiation. Methods This prospective observational study was conducted at a tertiary NICU in central India and enrolled 170 preterm newborns (gestational age 28–36 weeks, birth weight &lt;1800 g) with respiratory distress over 18 months. Infants were categorized as Early CPAP (initiated within 30 min of birth, n = 121) or Late CPAP (after 30 min, n = 49). Primary outcome was need for mechanical ventilation; secondary outcomes included mortality, CPAP duration, surfactant use, and length of hospital stay. Results The mortality rate was lower in the early CPAP group compared to the late CPAP group (13.2% vs 24.5%), though this difference did not reach statistical significance on unadjusted analysis (χ 2 = 3.218, p = 0.073). After adjustment for gestational age and disease severity, early CPAP initiation was independently associated with lower odds of mortality (aOR = 0.34, 95% CI: 0.13–0.89, p = 0.027). Median CPAP duration was significantly longer in the early CPAP group (48.0 vs 24.0 h; p = 0.027). Length of hospital stay was also significantly longer (14 vs 8 days; p = 0.014), while mechanical ventilation duration did not differ significantly (p = 0.140). Conclusion Early CPAP initiation in preterm newborns with respiratory distress was associated with lower mortality after adjustment for gestational age and disease severity, although the unadjusted analysis was not statistically significant. These findings suggest a potential benefit of early CPAP initiation in resource-limited settings.

To predict continuous positive airway pressure (CPAP) adherence at 1 year. We followed consecutive OSA patients scheduled for CPAP initiation for 1 year. Patients completed a self-efficacy questionnaire (5 = low, 25 = high score) before CPAP initiation. After CPAP initiation, we enquired about patients' satisfaction in CPAP trial and their eagerness and willingness to continue CPAP therapy (0 = unsatisfied, uneager, or refused CPAP; 100 = satisfied, eager, or willing to continue CPAP treatment). Of the 580 patients we followed, 377 continued CPAP therapy beyond 1 year. A low willingness score (<50) was expressed by 77 patients but only 7 of them used CPAP >4 h daily at 1 year, yielding a specificity of 97 % in predicting CPAP failure. At 1 year, patients with a self-efficacy score >20, expressed prior to CPAP initiation, used CPAP more often than the patients with a score <20 (average use 4.4 ± 2.2 h vs. 3.7 ± 2.3 h, p<0.001). A low score of willingness to continue CPAP therapy after a short trial predicts CPAP failure and poor CPAP adherence at 1 year.

Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBDs), including obstructive sleep apnea (OSA). After a patient is diagnosed with OSA, the current standard of practice involves performing attended polysomnography (PSG), during which positive airway pressure is adjusted throughout the recording period to determine the optimal pressure for maintaining upper airway patency. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) represent the two forms of PAP that are manually titrated during PSG to determine the single fixed pressure of CPAP or the fixed inspiratory and expiratory positive airway pressures (IPAP and EPAP, respectively) of BPAP for subsequent nightly usage. A PAP Titration Task Force of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Task Force developed these recommendations for conducting CPAP and BPAP titrations. Major recommendations are as follows: (1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. (2) CPAP (IPAP and/or EPAP for patients on BPAP) should be increased until the following obstructive respiratory events are eliminated (no specific order) or the recommended maximum CPAP (IPAP for patients on BPAP) is reached: apneas, hypopneas, respiratory effort-related arousals (RERAs), and snoring. (3) The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BPAP. (4) The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients or = 12 years. (5) The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (6) CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events. (7) CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients or = 12 years. (8) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients or = 12 years. (9) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients or = 12 years. (10) CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients or = 12 years. (11) The titration algorithm for split-night CPAP or BPAP titration studies should be identical to that of full-night CPAP or BPAP titration studies, respectively. (12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP. (13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably 3 hr).

Background: Poor adherence (30-60%) to CPAP is a recognized limiting factor in treating OSAHS, leaving patients at risk for co-morbid conditions and impaired quality of life. Aims and Objectives: To study patient9s compliance to CPAP in OSAHS, evaluate effect of regular follow-up on compliance and establish causes for noncompliance. Method: 42 patients with OSAHS on polysomnography and symptoms of excessive daytime sleepiness were randomised in 2 equal groups. All were counseled on CPAP initiation. Follow up was at regular intervals over six months in group 1 and directly at end of 6 months in group 2. The groups were compared for a co-relation between frequency of follow up and CPAP compliance. Effect of age, sex, AHI, Epworth Sleepiness Scale (ESS) Score, hours of first night use of CPAP and type of CPAP machine was also studied. Results: Good compliance to CPAP was seen in 52% and poor compliance in 48%. Regular follow up had no statistically significant change in compliance amongst the group 1 patients. Epworth Sleepiness Scale (ESS) Score >12 [p 4 hours [p=0.003] and usage of auto CPAP unit [p=0.007] were statistically significant predictors of compliance. No significance was established with factors like age, gender and AHI. Causes of poor compliance were, mask related (60%), patient related (25%) and machine related (15%). Conclusion: Counseling at CPAP initiation is important in improving long term CPAP compliance. Addressing factors like mask size, fitting or type of machine on CPAP initiation itself will increase adherence to CPAP therapy and may obviate the need for frequent follow up.