Continuous Positive Pressure Ventilation Research Articles

Comparison of short-term outcomes between Nasal Continuous Positive Airway Pressure and Nasal Intermittent Positive Pressure Ventilation in preterm neonates with respiratory distress syndrome.

Objective: To compare the safety and effectiveness of nasal continuous positive airway pressure (NCPAP) versus nasal intermittent positive pressure ventilation (NIPPV) as initial respiratory therapy among preterm neonates with respiratory distress syndrome (RDS). Study Design: Randomized Controlled Trial. Setting: The Neonatal Intensive Care Unit (NICU) of Indus Hospital and Health Network, Muzaffargarh, Pakistan. Period: January 2024 to June 2024. Methods: A total of 118 preterm neonates with 26-34 weeks gestation and admitted to NICU with RDS were randomly allocated to either NCPAP or NIPPV. Success respiratory support, along with complications, and mortality were noted. Results: In a total of 118 newborns, 64 (54.2%) were girls. The mean gestational age, and birth weight were 30.94±1.43 weeks, and 1479.07±310.69 grams. In NIPPV group, 49 (83.1%) babies showed successful outcome versus 29 (49.2%) in NCPAP group (p<0.001). Necessitation of intubation within 7 days (40.7% vs. 22.0%, p=0.029). Surfactant requirement (37.3% vs. 16.9%, p=0.013), and bronco pulmonary dysplasia (BDP) (11.9% vs. 0%, p=0.006) were significantly more in NCPAP group. Pneumothorax was significantly more prevalent in NIPPV group (18.6% vs. 3.4%, p=0.008). Duration of non-invasive support was significantly more in NCPAP group (10.58±6.07 vs. 8.15±3.58 days, p=0.009). Conclusion: NIPPV significantly outperformed NCPAP in terms of successful outcomes, as measured by reduced rates of intubation, surfactant requirement, and the incidence of BPD.

High-flow nasal cannula for stabilisation of very premature infants: A prospective observational study.

To assess the feasibility, safety and efficacy of using a high-flow nasal cannula (HFNC) for stabilising very preterm infants after birth. A prospective observational study included preterm infants born at 28 + 0 to 31 + 6 weeks' gestation between February 2021 and December 2022 at the General University Hospital in Prague. Following delayed cord clamping, HFNC was administered at a flow rate of 8 L/min through the infants' nostrils. Criteria for switching to continuous positive airway pressure (CPAP) or positive pressure ventilation (PPV) included persistent bradycardia in the first few minutes or low saturation of oxygen (SpO2) after 5 min, respectively. Of the 65 infants enrolled in the study, 56 (86%) were successfully stabilised exclusively using HFNC while 7 (11%) required PPV. Additionally, 52 (80%) infants achieved SpO2 > 80% at 5 min, and 54 (83%) infants were successfully treated with HFNC within the first 3 h of life. The primary use of HFNC seems to be an appropriate alternative to CPAP for the stabilisation of very premature infants after birth and subsequent transfer to the NICU. A randomised trial comparing HFNC and CPAP in the delivery room will enable to answer the questions raised in this study.

Skin-to-skin stabilisation and uninterrupted respiratory support for preterm infants after birth: feasibility of a new and simplified rPAP system

BackgroundThe rPAP respiratory support system, used for delivery room stabilisation with nasal prongs, has been shown to reduce the need for intubation in extremely preterm infants. A simplified version of...

RAM Cannula versus Short Binasal Prongs for Non-invasive Ventilation in Preterm Infants: An Updated Systematic Review and Meta-analysis.

To compare the efficacy and safety of RAM cannula with short binasal prongs (SBPs) as nasal interfaces in preterm infants requiring nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV). The authors searched electronic databases (Medline, Embase, and Web of Science) and trial registries from inception until March 15, 2024, for randomized controlled trials (RCTs) comparing the RAM cannula with SBP for delivering nCPAP/NIPPV. They performed a random-effects meta-analysis using RevMan 5.4 software. The primary outcome was failure of nCPAP/NIPPV. Secondary outcomes included nasal injury, mechanical ventilation, air leaks, and mortality. Five RCTs (825 participants) were included. There was no significant difference in nCPAP/NIPPV failure (RR: 1.04; 95%CI: 0.58 to 1.87) or the need for invasive mechanical ventilation (RR: 1.23; 95%CI: 0.75 to 2.01) between the RAM cannula and SBP groups (low to very low certainty). Compared with infants in the SBP group, those in the RAM cannula group had a significantly lower incidence of moderate to severe nasal injury [(5 RCTs, 825 participants; RR: 0.34; 95%CI: 0.18 to 0.66); low certainty] and any nasal injury [(RR: 0.44; 95%CI: 0.26 to 0.76; very low certainty)]. There was no significant difference in the other clinical outcomes. In comparison to SBP, the RAM cannula may have little to no effect on nCPAP/NIPPV failure, but the evidence is very uncertain. Low-certainty evidence suggests that the use of RAM cannula possibly results in reduction in moderate to severe nasal trauma in preterm infants receiving nCPAP/NIPPV.

Comparison of “IN-REC-SUR-E” and LISA in preterm neonates with respiratory distress syndrome: a randomized controlled trial (IN-REC-LISA trial)

BackgroundSurfactant is a well-established therapy for preterm neonates affected by respiratory distress syndrome (RDS). The goals of different methods of surfactant administration are to reduce the duration of mechanical ventilation and the severity of bronchopulmonary dysplasia (BPD); however, the optimal administration method remains unknown. This study compares the effectiveness of the INtubate-RECruit-SURfactant-Extubate (IN-REC-SUR-E) technique with the less-invasive surfactant administration (LISA) technique, in increasing BPD-free survival of preterm infants. This is an international unblinded multicenter randomized controlled study in which preterm infants will be randomized into two groups to receive IN-REC-SUR-E or LISA surfactant administration.MethodsIn this study, 382 infants born at 24+0–27+6 weeks’ gestation, not intubated in the delivery room and failing nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV) during the first 24 h of life, will be randomized 1:1 to receive IN-REC-SUR-E or LISA surfactant administration. The primary outcome is a composite outcome of death or BPD at 36 weeks’ postmenstrual age. The secondary outcomes are BPD at 36 weeks’ postmenstrual age; death; pulse oximetry/fraction of inspired oxygen; severe intraventricular hemorrhage; pneumothorax; duration of respiratory support and oxygen therapy; pulmonary hemorrhage; patent ductus arteriosus undergoing treatment; percentage of infants receiving more doses of surfactant; periventricular leukomalacia, severe retinopathy of prematurity, necrotizing enterocolitis, sepsis; total in-hospital stay; systemic postnatal steroids; neurodevelopmental outcomes; and respiratory function testing at 24 months of age. Randomization will be centrally provided using both stratification and permuted blocks with random block sizes and block order. Stratification factors will include center and gestational age (24+0 to 25+6 weeks or 26+0 to 27+6 weeks).Analyses will be conducted in both intention-to-treat and per-protocol populations, utilizing a log-binomial regression model that corrects for stratification factors to estimate the adjusted relative risk (RR).DiscussionThis trial is designed to provide robust data on the best method of surfactant administration in spontaneously breathing preterm infants born at 24+0–27+6 weeks’ gestation affected by RDS and failing nCPAP or NIPPV during the first 24 h of life, comparing IN-REC-SUR-E to LISA technique, in increasing BPD-free survival at 36 weeks’ postmenstrual age of life.Trial registrationClinicalTrials.gov NCT05711966. Registered on February 3, 2023.

Continuous positive airway pressure treatment in obstructive sleep apnea syndrome patients with hypertension

Aims: To assess the prevalence and general characteristics of obstructive sleep apnea syndrome in patients with hypertension, investigate the relationship between obstructive sleep apnea syndrome and blood pressure, and the effectiveness of continuous positive pressure ventilation treatment after 1 month in hypertensive patients with obstructive sleep apnea. Methods: Cross-sectional descriptive study with follow-up after 1 month in hypertensive patients treated at the Hue University of Medicine and Pharmacy Hospital with respiratory polygraphy from January 2021 to June 2023. Patients were given history, clinical examination, anthropometric measurements, Lipid profile test, intravenous glucose, Epworth scale assessment, CPAP treatment and re-evaluated after 1 month. Results: 134 patients were registered for the study from 01/2021 to 06/2023. Hypertensive patients with OSAS were 73.13%. BMI in the OSAS (+) group was 22.84 ± 3.04 kg/m2 and was statistically significantly greater than the OSAS (-) group: 22.79 ± 3.07 kg/m2 (p<0.05). Neck circumference in the OSAS (+) group was 37.45 ± 2.44 cm, which was statistically significantly larger than the OSAS (-) group: 36.36 ± 1.57 cm (p<0.05). The rate of loud snoring during sleep and excessive daytime sleepiness in the OSAS patient group was statistically significantly higher than in the group without this syndrome (p<0.05 and p<0.01). The average systolic blood pressure in the OSAS (+) group was 154.79 ± 13.32 mm Hg and was statistically significantly higher than the OSAS (-) group (p<0.01). AHI has a moderate positive correlation with systolic blood pressure (r = 0.45, p<0.01) and diastolic blood pressure (r = 0.34, p<0.01). CPAP treatment improved systolic and diastolic blood pressure and symptoms of excessive daytime sleepiness. Conclusion: There is a relationship between obstructive sleep apnea syndrome and hypertension. CPAP treatment improves blood pressure and daytime sleepiness.

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) reduces extubation failures in preterm neonates-A systematic review and meta-analysis.

To analyse the evidence of non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm neonates compared to nasal continuous positive airway pressure (nCPAP) or nasal intermittent positive pressure ventilation (NIPPV). We performed a systematic review and meta-analysis of randomised controlled trials and included studies where NIV-NAVA was analysed in preterm (<37 gestational weeks) born neonates. Our main outcomes were the need for endotracheal intubation, the need for surfactant therapy, and reintubation rates. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. A total of five studies were included. The endotracheal intubation rate was 25% in the NIV-NAVA group and 26% in the nCPAP group (RR 0.91, CI: 0.56-1.48). The respective rates for surfactant therapy were 30% and 35% (RR 0.85, CI: 0.56-1.29). The reintubation rate in neonates previously invasively ventilated was 8% in the NIV-NAVA group and 29% in the nCPAP/NIPPV group (RR 0.29, 95%CI: 0.10-0.81). Evidence certainty was rated as low for all outcomes. NIV-NAVA as the primary respiratory support did not reduce the need for endotracheal intubation or surfactant therapy. NIV-NAVA seemed to reduce the reintubation rate after extubation in pre-term neonates.

The Outcomes of Preterm Infants with Neonatal Respiratory Distress Syndrome Treated by Minimally Invasive Surfactant Therapy and Non-Invasive Ventilation.

In recent years, the utilization of minimally invasive surfactant therapy (MIST) and Non-invasive ventilation (NIV) as the primary respiratory assistance has become increasingly prevalent among preterm infants with neonatal respiratory distress syndrome (RDS). This study aims to compare the outcomes between MIST administered with nasal continuous positive airway pressure (NCPAP) versus nasal intermittent positive pressure ventilation (NIPPV), with the objective of exploring the respiratory therapeutic benefits of these two approaches. This retrospective study collected data from the neonatal intensive care unit of Kaohsiung Medical University Hospital spanning from January 2016 to June 2021. Infants were divided into two groups based on the type of NIV utilized. The NCPAP group comprised 32 infants, while the NIPPV group comprised 22 infants. Statistical analysis revealed significant differences: the NIPPV group had a smaller gestational age, lower birth weight, higher proportion of female infants, and earlier initiation of MIST. Additionally, the NIPPV group exhibited higher incidence rates of retinopathy of prematurity, longer respiratory support duration, prolonged hospitalization, and mortality. However, upon adjustment, these differences were not statistically significant. Analysis of venous blood gas and respiratory parameter changes indicated that both the NCPAP and NIPPV groups experienced improvements in oxygenation and ventilation following MIST.

High-flow nasal cannula oxygen versus noninvasive ventilation for the management of acute cardiogenic pulmonary edema: a randomized controlled pilot study.

Whether high-flow nasal oxygen can improve clinical signs of acute respiratory failure in acute heart failure (AHF) is uncertain. To compare the effect of high-flow oxygen with noninvasive ventilation (NIV) on respiratory rate in patients admitted to an emergency department (ED) for AHF-related acute respiratory failure. Multicenter, randomized pilot study in three French EDs. Adult patients with acute respiratory failure due to suspected AHF were included. Key exclusion criteria were urgent need for intubation, Glasgow Coma Scale <13 points or hemodynamic instability. Patients were randomly assigned to receive high-flow oxygen (minimum 50 l/min) or noninvasive bilevel positive pressure ventilation. The primary outcome was change in respiratory rate within the first hour of treatment and was analyzed with a linear mixed model. Secondary outcomes included changes in pulse oximetry, heart rate, blood pressure, blood gas samples, comfort, treatment failure and mortality. Among the 145 eligible patients in the three participating centers, 60 patients were included in the analysis [median age 86 (interquartile range (IQR), 90; 92) years]. There was a median respiratory rate of 30.5 (IQR, 28; 33) and 29.5 (IQR, 27; 35) breaths/min in the high-flow oxygen and NIV groups respectively, with a median change of -10 (IQR, -12; -8) with high-flow nasal oxygen and -7 (IQR, -11; -5) breaths/min with NIV [estimated difference -2.6 breaths/min (95% confidence interval (CI), -0.5-5.7), P = 0.052] at 60 min. There was a median SpO 2 of 95 (IQR, 92; 97) and 96 (IQR, 93; 97) in the high-flow oxygen and NIV groups respectively, with a median change at 60 min of 2 (IQR, 0; 5) with high-flow nasal oxygen and 2 (IQR, -1; 5) % with NIV [estimated difference 0.8% (95% CI, -1.1-2.8), P = 0.60]. PaO 2 , PaCO 2 and pH did not differ at 1 h between groups, nor did treatment failure, intubation and mortality rates. In this pilot study, we did not observe a statistically significant difference in changes in respiratory rate among patients with acute respiratory failure due to AHF and managed with high-flow oxygen or NIV. However, the point estimate and its large confidence interval may suggest a benefit of high-flow oxygen. NCT04971213 ( https://clinicaltrials.gov ).

Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures Were Equivalent?

Respiratory support for preterm neonates in modern neonatal intensive care units is predominantly with the use of noninvasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of noninvasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application versus the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing noninvasive respiratory support modes at equal mean airway pressures. KEY POINTS: · Most current literature on CPAP vs. NIPPV in preterm neonates is confounded by use of higher mean airway pressures during NIPPV.. · In this review, we summarize existing evidence on CPAP vs. NIPPV at equivalent mean airway pressures.. · We call for future research on noninvasive support modes to account for mean airway pressures..

Proposition of a tool to calculate the oxygen and air flow for high-flow nasal oxygenation in obese patients

Blood desaturation after surgery in obese patients in not uncommon. Oxygen therapy is almost always necessary in these cases and we have to use low-flow catheters, Venturi masks or non-rebreathing systems, but maybe the most efficacious are the non-invasive ventilation (NIV), continuous positive pressure ventilation (CPAP) and the new high-flow oxygen therapy which offers a warm and humid high-flow mixture of O2 and air (up to 70l/min). We decided to use this device in a very obese patient scheduled for a gastroplasty but one question arose: how to calculate FiO2 without tables or mathematic calculations? We used a tool available in a website since 2020 to resolve this problem precisely. Patient’s SpO2 remained all the time between 99 and 100% and 4h after the surgery he was transferred to the ward.

Noninvasive Neurally Adjusted Ventilation versus Nasal Continuous or Intermittent Positive Airway Pressure for Preterm Infants: A Systematic Review and Meta-Analysis.

The noninvasive neurally adjusted ventilatory assist (NIV-NAVA) is a newly developed noninvasive ventilation technique with promising clinical and ventilatory outcomes for preterm infants. This systematic review and meta-analysis aimed to investigate whether NIV-NAVA has better clinical and ventilatory outcomes than nasal continuous airway pressure (NCPAP) or noninvasive positive pressure ventilation (NIPP) on premature infants. MEDLINE, Embase, and CENTRAL were searched, and randomized controlled trials (RCTs) that compared NIV-NAVA with NCPAP or NIPP for preterm infants (gestational age: <37 weeks) were included. We evaluated the following outcomes in the neonatal intensive care unit: the desaturation rate, failure of noninvasive modality requiring intubation when received as the primary mode or the need for re-intubation after extubation from mechanical ventilation in the secondary mode (weaning), length of stay, and fraction of inspired oxygen. The mean difference and risk ratio were used to represent continuous and dichotomous outcomes, respectively. We included nine RCTs involving 339 preterm infants overall. NIV-NAVA showed similar clinical and ventilatory outcomes to NCPAP or NIPP, except for the maximum diaphragmatic electrical activity. The rate of failure of the noninvasive modality was not statistically different between NIV-NAVA and NCPAP. The pooled estimates for the maximum electrical activity were significantly reduced in NIV-NAVA compared with those in NIPP. The findings suggest that NIV-NAVA may be as safe and effective as NCPAP and NIPP for preterm neonates, particularly those who may not tolerate these alternative noninvasive methods. However, further trials are recommended for greater evidence.

Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines

Airway management is required during general anaesthesia and is essential for life-threatening conditions such as cardiopulmonary resuscitation. Evidence from recent trials indicates a high incidence of critical events during airway management, especially in neonates or infants. It is important to define the optimal techniques and strategies for airway management in these groups. In this joint European Society of Anaesthesiology and Intensive Care (ESAIC) and British Journal of Anaesthesia (BJA) guideline on airway management in neonates and infants, we present aggregated and evidence-based recommendations to assist clinicians in providing safe and effective medical care. We identified seven main areas of interest for airway management: i) preoperative assessment and preparation; ii) medications; iii) techniques and algorithms; iv) identification and treatment of difficult airways; v) confirmation of tracheal intubation; vi) tracheal extubation, and vii) human factors. Based on these areas, Population, Intervention, Comparison, Outcomes (PICO) questions were derived that guided a structured literature search. GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to formulate the recommendations based on those studies included with consideration of their methodological quality (strong '1' or weak '2' recommendation with high 'A', medium 'B' or low 'C' quality of evidence). In summary, we recommend: 1. Use medical history and physical examination to predict difficult airway management (1C). 2. Ensure adequate level of sedation or general anaesthesia during airway management (1B). 3. Administer neuromuscular blocker before tracheal intubation when spontaneous breathing is not necessary (1C). 4. Use a videolaryngoscope with an age-adapted standard blade as first choice for tracheal intubation (1B). 5. Apply apnoeic oxygenation during tracheal intubation in neonates (1B). 6. Consider a supraglottic airway for rescue oxygenation and ventilation when tracheal intubation fails (1B). 7. Limit the number of tracheal intubation attempts (1C). 8. Use a stylet to reinforce and preshape tracheal tubes when hyperangulated videolaryngoscope blades are used and when the larynx is anatomically anterior (1C). 9. Verify intubation is successful with clinical assessment and end-tidal CO2 waveform (1C). 10. Apply high-flow nasal oxygenation, continuous positive airway pressure or nasal intermittent positive pressure ventilation for postextubation respiratory support, when appropriate (1B).

Using the Elixhauser risk adjustment model to predict outcomes among patients hospitalized in internal medicine at a large, tertiary-care hospital in Israel

BackgroundIn Israel, internal medicine admissions are currently reimbursed without accounting for patient complexity. This is at odds with most other developed countries and has the potential to lead to market distortions such as avoiding sicker patients. Our objective was to apply a well-known, freely available risk adjustment model, the Elixhauser model, to predict relevant outcomes among patients hospitalized on the internal medicine service of a large, Israeli tertiary-care hospital.MethodsWe used data from the Shaare Zedek Medical Center, a large tertiary referral hospital in Jerusalem. The study included 55,946 hospitalizations between 01.01.2016 and 31.12.2019. We modeled four patient outcomes: in-hospital mortality, escalation of care (intensive care unit (ICU) transfer, mechanical ventilation, daytime bi-level positive pressure ventilation, or vasopressors), 30-day readmission, and length of stay (LOS). We log-transformed LOS to address right skew. As is usual with the Elixhauser model, we identified 29 comorbid conditions using international classification of diseases codes, clinical modification, version 9. We derived and validated the coefficients for these 29 variables using split-sample derivation and validation. We checked model fit using c-statistics and R2, and model calibration using a Hosmer–Lemeshow test.ResultsThe Elixhauser model achieved acceptable prediction of the three binary outcomes, with c-statistics of 0.712, 0.681, and 0.605 to predict in-hospital mortality, escalation of care, and 30-day readmission respectively. The c-statistic did not decrease in the validation set (0.707, 0.687, and 0.603, respectively), suggesting that the models are not overfitted. The model to predict log length of stay achieved an R2 of 0.102 in the derivation set and 0.101 in the validation set. The Hosmer–Lemeshow test did not suggest issues with model calibration.ConclusionWe demonstrated that a freely-available risk adjustment model can achieve acceptable prediction of important clinical outcomes in a dataset of patients admitted to a large, Israeli tertiary-care hospital. This model could potentially be used as a basis for differential payment by patient complexity.

High-flow nasal cannula (HFNC) vs continuous positive airway pressure (CPAP) vs nasal intermittent positive pressure ventilation as primary respiratory support in infants of ≥ 32 weeks gestational age (GA): study protocol for a three-arm multi-center randomized controlled trial

BackgroundHealth problems in neonates with gestational age (GA) ≥ 32 weeks remain a major medical concern. Respiratory distress (RD) is one of the common reasons for admission of neonates with GA ≥ 32 weeks. Noninvasive ventilation (NIV) represents a crucial approach to treat RD, and currently, the most used NIV modes in neonatal intensive care unit include high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and nasal intermittent positive pressure ventilation. Although extensive evidence supports the use of NIPPV in neonates with a GA < 32 weeks, limited data exist regarding its effectiveness in neonates with GA ≥ 32 weeks. Therefore, the aim of this study is to compare the clinical efficacy of HFNC, CPAP, and NIPPV as primary NIV in neonates with GA ≥ 32 weeks who experience RD.MethodsThis trial is designed as an assessor-blinded, three-arm, multi-center, parallel, randomized controlled trial, conducted in neonates ≥ 32 weeks’ GA requiring primary NIV in the first 24 h of life. The neonates will be randomly assigned to one of three groups: HFNC, CPAP or NIPPV group. The effectiveness, safety and comfort of NIV will be evaluated. The primary outcome is the occurrence of treatment failure within 72 h after enrollment. Secondary outcomes include death before discharge, surfactant treatment within 72 h after randomization, duration of both noninvasive and invasive mechanical ventilation, duration of oxygen therapy, bronchopulmonary dysplasia, time to achieve full enteral nutrition, necrotizing enterocolitis, duration of admission, cost of admission, air leak syndrome, nasal trauma, and comfort score.DiscussionCurrently, there is a paucity of data regarding the utilization of NIPPV in neonates with GA ≥ 32 weeks. This study will provide clinical evidence for the development of respiratory treatment strategies in neonates at GA ≥ 32 weeks with RD, with the aim of minimizing the incidence of tracheal intubation and reducing the complications associated with NIV.Trial registrationChinese Clinical Trial Registry: ChiCTR2300069192. Registered on March 9, 2023, https://www.chictr.org.cn/showproj.html?proj=171491.

Effectiveness of Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation vs Noninvasive High-Frequency Oscillatory Ventilation as Support After Extubation of Neonates Born Extremely Preterm or With More Severe Respiratory Failure

The NASONE (Nasal Oscillation Post-Extubation) trial showed that noninvasive high-frequency oscillatory ventilation (NHFOV) slightly reduces the duration of invasive mechanical ventilation (IMV) in preterm infants, whereas NHFOV and noninvasive intermittent positive pressure ventilation (NIPPV) result in fewer reintubations than nasal continuous positive airway pressure (NCPAP). It is unknown whether NHFOV is similarly effective in extremely preterm neonates or in those with more severe respiratory failure (based on the duration of previous ventilation and CO2 levels). To clarify whether NHFOV is better than NIPPV and NCPAP in reducing the duration of IMV in extremely preterm neonates or those with severe respiratory failure. This study is a predefined secondary analyses of a multicenter randomized clinical trial that was performed at tertiary academic neonatal intensive care units (NICUs) in China. Participants included neonates enrolled in the NASONE trial between December 2017 and May 2021 and belonging to 3 predefined subgroups: (1) born at less than or equal to 28 weeks' (plus 6 days) gestation, (2) invasively ventilated for more than 1 week from birth, and (3) with CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Data analysis was performed in August 2022. NCPAP, NIPPV, or NHFOV since the first extubation and until NICU discharge, with airway pressure higher in NHFOV than in NIPPV and than in NCPAP. The co-primary outcomes were total duration of IMV during the NICU stay, need for reintubation, and ventilator-free days calculated as per the original trial protocol. Outcomes were analyzed on an intention-to-treat basis as for the whole trial, and subgroup analyses followed the original statistical plan. Among 1137 preterm infants, 455 (279 boys [61.3%]) were born at 28 weeks' gestation or less, 375 (218 boys [58.1%]) underwent IMV for more than 1 week from birth, and 307 (183 boys [59.6%]) had CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Both NIPPV and NHFOV were associated with significantly fewer reintubations (risk difference range, -28% [95% CI, -39% to -17%] to -15% [95% CI, -25% to -4%]; number needed to treat, 3-7 infants) and early reintubations (risk difference range, -24% [95% CI, -35% to -14%] to -20% [95% CI, -30% to -10%]) than NCPAP, and these reintubations were less frequently due to refractory hypoxemia. IMV was shorter in the NIPPV and NHFOV groups (mean difference range, -5.0 days [95% CI, -6.8 to -3.1 days] to -2.3 days [95% CI, -4.1 to -0.4 days]) than in the NCPAP group. Co-primary outcomes were not different between NIPPV and NHFOV; there was no significant interaction effect. Infants in the NHFOV group showed significantly less moderate-to-severe bronchopulmonary dysplasia than infants in the NCPAP group (range, -12% to -10%; number needed to treat, 8-9 infants) and better postextubation gas exchange in all subgroups. The 3 interventions were provided at different mean airway pressure and were equally safe. The subgroup analyses of extremely preterm or more ill infants confirm the results obtained in the whole population: NIPPV and NHFOV appeared equally effective in reducing duration of IMV compared with NCPAP. ClinicalTrials.gov Identifier: NCT03181958.

Effect of obstructive sleep apnea on semen quality.

Obstructive sleep apnea (OSA) has several notable complications such as hypertension and diabetes. Studies have also shown that OSA is associated with erectile dysfunction and reduced androgen levels. However, the effect of OSA on semen quality remains poorly studied. Men attending a tertiary reproductive center for semen analysis were tested with a portable sleep breathing monitor. Patients were divided into four groups based on their apnea hypopnea index: none, mild, moderate, and severe obstructive sleep apnea. Differences between groups were assessed using χ2, and associations were tested with multiple regression analysis. We included a total of 175 male subjects with a mean age of 32.2 ± 3.6years. There were significant differences between groups in progressive sperm motility (%) (43 ± 16, 42 ± 17, 36 ± 18, 29 ± 18, respectively; p = 0.002), total motility (%) (59 ± 19, 59 ± 20, 49 ± 21, 42 ± 20, respectively; p = 0.010), and vitality (%) (80 ± 10, 81 ± 11, 79 ± 8, 72 ± 19, respectively; p = 0.039). Asthenospermia (progressive motility < 35%) was significantly more common in subjects with OSA (χ2 = 5.195, p = 0.023). In multiple regression models, after adjusting for age and body mass index, apnea hypopnea index remained negatively and significantly associated with progressive motility, total motility, and vitality. OSA is an independent risk factor for sperm motility and vitality, and further investigation is now needed to determine if continuous positive pressure ventilation or other therapies can improve semen quality in these patients.

The Feasibility and Impact of a Postresuscitation Care Protocol in the Well Baby Nursery.

The objective of this study is to determine if a postresuscitation care (PRC) protocol in the well baby nursery (WBN) would improve identification of infants requiring neonatal intensive care unit (NICU) admission. This is a retrospective and prospective cohort study of a PRC protocol in 765 WBN admissions after delivery room (DR) resuscitation with continuous positive airway pressure and/or positive pressure ventilation. After protocol initiation, NICU transfers during the birth hospitalization increased significantly (11.17 vs. 16.08%, p < 0.05). There was no difference in incidence of NICU transfer (5.99 vs. 7.29%, pre-PRC vs. PRC, p = 0.47) during the first 4 hours of life during protocol administration. Respiratory distress was the most common indication for NICU transfer in both cohorts (7.90 vs. 11.81%, p = 0.09, pre-PRC vs. PRC). Noninvasive positive pressure and/or high-flow nasal cannula (5.72 vs. 9.55%, p = 0.06, pre-PRC vs. PRC) were routinely administered in the NICU to transferred infants. After apparent recovery from DR resuscitation, WBN admissions experience significant risk of complications requiring NICU transfer, supporting Neonatal Resuscitation Program recommendation for enhanced monitoring. In our study, we demonstrated the feasibility of standardized PRC protocol in the WBN. NICU transfers increased after initiation of a PRC protocol; however, further studies are needed to confirm possible benefits of this PRC protocol in improving identification of infants requiring a higher level of care. · A PRC protocol in WBN is feasible and associated with increased NICU transfer.. · Despite initial apparent recovery, delayed presentation of respiratory distress is a frequent morbidity.. · Increased surveillance as recommended by Neonatal Resuscitation Program is indicated in this population..

Effect of continuous positive pressure ventilation on left ventricular diastolic function E/A ratio in patients with obstructive sleep apnea: a meta-analysis.

Many studies have shown that obstructive sleep apnea (OSA) is related to reduced left ventricular diastolic function. Continuous positive airway pressure (CPAP) is generally recognized as the preferred therapy for OSA. Yet, the effect of CPAP on left ventricular diastolic function in patients with OSA is inconclusive. In order to assess the influence of CPAP on left ventricular diastolic function in patients with OSA, we performed this meta-analysis of clinical experiments. PubMed, Web of Science, OVID, Embase, and Cochrane Library from the establishment of the database to July 6, 2022, were searched for clinical trial data. Inclusion criteria for this meta-analysis were: (1) Patients in the experimental group were diagnosed with OSA by polysomnography; (2) CPAP treatment course ≥ 4weeks; (3) baseline and follow-up data of the diastolic function parameter E/A ratio were reported in the literature. Exclusion criteria were: (1) Central sleep apnea (CSA); (2) comorbid organic heart diseases such as coronary heart disease; (3) age < 18years old; (4) conference abstracts or duplicate publications. After exclusions, 7 studies (2 RCTs and 5 prospective studies) with 473 subjects (225 in the treatment group and 248 in the matchedcontrol group) were included in the meta-analysis. Subgroup analysis indicated that after CPAP therapy, the left ventricular (LV) E/A ratio was significantly increased in patients with OSA(weighted mean difference (WMD) = 0.22, 95% CI = - 0.06-0.38; P = 0.007). Sensitivity analyses showed that the combined results were not influenced by single studies. Publication bias was not significant (Egger's test, P = 0.813). The results of this meta-analysis suggest that CPAP may improve the E/A ratio in patients withOSA patients. However, the small number of studies (n = 7) decreases confidence in the findings. Thus, carefully designed randomized controlled trials are needed to confirm the findings.

High continuous positive airway pressures versus non-invasive positive pressure ventilation in preterm neonates: protocol for a multicentre pilot randomised controlled trial

IntroductionLow pressure nasal continuous positive airway pressure (nCPAP) has long been the mainstay of non-invasive respiratory support for preterm neonates, at a constant distending pressure of 5–8 cmH2O. When traditional...