Early Nasal Continuous Positive Airway Pressure Research Articles

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

Noninvasive Ventilation and Exogenous Surfactant in Times of Ever Decreasing Gestational Age: How Do We Make the Most of These Tools?

Prophylactic or very early initiation of continuous positive airway pressure (CPAP) for preterm infants.

Prophylactic or very early initiation of continuous positive airway pressure (CPAP) for preterm infants.

Use of early nasal continuous positive airway pressure in preterm neonates with hyaline membrane disease (neonatal respiratory distress syndrome)

Background: In developing countries like ours, there is high burden of prematurity and sub-optimal use of antenatal steroid administration resulting infrequent hyaline membrane disease (HMD).Methods: A total 50 cases of clinically diagnosed HMD with gestational age between 28-34 weeks admitted to neonatal intensive care unit (ICU). 50 babies were treated with early nasal continuous positive airway pressure (CPAP) (within 6 hours of onset of respiratory distress).Results: Incidence of prematurity was 12.42%. Incidence of HMD observed between gestational ages of 28-34 weeks is 3.2%. Out of total 50 babies who were managed with early nasal CPAP, it proved effective in 40 babies (80%), remaining 10 babies (20%) had to be intubated and required ventilation. Out of 10 babies who required ventilation 90% of the babies were less than 32 weeks gestation age; remaining 10% were between 33-34 weeks. Analysis of these results showed that outcome is better with increased gestational age (p<0.005). Out of 10 babies who failed 80% were <1500 g and remaining 20% above 1500 g. We found significant improvement (p<0.005) in SA score after application of nasal CPAP. Babies on CPAP had significant improvement in oxygenation (p<0.05). A success rate of 93.1% observed in moderate grade HMD (p<0.005). Out of 10 babies who failed on nasal CPAP, 80% of them had severe grade HMD and 20% showed moderate HMD. A success rate of 92.86% was found in babies of mothers who had received antenatal steroids and 63.63% of babies whose mothers had not received antenatal steroids improved with early nasal CPAP (p<0.05).Conclusions: Nasal CPAP is found to be effective in babies of mothers who had received antenatal steroids. Nasal CPAP is safe, inexpensive and effective means of respiratory support in HMD. Use of early nasal CPAP which is simple, non-invasive, has low capital outlay and does not require expertise, is the option for us where most places cannot provide invasive ventilation.

Application of two different nasal CPAP levels for the treatment of respiratory distress syndrome in preterm infants\u2014\u201cThe OPTTIMMAL-Trial\u201d\u2014Optimizing PEEP To The IMMAture Lungs: study protocol of a randomized controlled trial

BackgroundNasal continuous positive airway pressure (CPAP) applies positive end-expiratory pressure (PEEP) and has been shown to reduce the need for intubation and invasive mechanical ventilation in very low birth weight infants with respiratory distress syndrome. However, CPAP failure rates of 50% are reported in large randomized controlled trials. A possible explanation for these failure rates is the application of insufficient low levels of PEEP during nasal CPAP treatment to maintain adequate functional residual capacity shortly after birth. The optimum PEEP level to treat symptoms of respiratory distress in very low birth weight infants has not been assessed in clinical studies. The aim of the study is to compare two different PEEP levels during nasal CPAP treatment in preterm infants.MethodsIn this randomized multicenter trial, 216 preterm infants born at 26 + 0–29 + 6 gestational weeks will be allocated to receive a higher (6–8 cmH2O) or a lower (3–5 cmH2O) PEEP during neonatal resuscitation and the first 120 h of life. The PEEP level within each group will be titrated throughout the intervention based on the FiO2 (fraction of inspired oxygen concentration) requirements to keep oxygenation within the target range. The primary outcome is defined as the need for intubation and mechanical ventilation for > 1 h or being not ventilated but reaching one of the two pre-defined CPAP failure criteria (FiO2 > 0.5 for > 1 h or pCO2 ≥ 70 mmHg in two consecutive blood gas analyses at least 2 h apart).DiscussionBased on available data from the literature, the optimum level of PEEP that most effectively treats respiratory distress syndrome in preterm infants is unknown, since the majority of large clinical trials applied a wide range of PEEP levels (4–8 cmH2O). The rationale for our study hypothesis is that the early application of a higher PEEP level will more effectively counteract the collapsing properties of the immature and surfactant-deficient lungs and that the level of inspired oxygen may serve as a surrogate marker to guide PEEP titration. Finding the optimum noninvasive continuous distending pressure during early nasal CPAP is required to improve CPAP efficacy and as a consequence to reduce the exposure to ventilator-induced lung injury and the incidence of chronic lung disease in this vulnerable population of very preterm infants.Trial registrationdrks.de DRKS00019940. Registered on March 13, 2020

Effect of early nasal continuous positive airway pressure in preterm neonates with mild-to-moderate hyaline membrane disease in a rural area – An analytic prospective observational study

Background: Respiratory distress syndrome (RDS) is the major cause of morbidity and mortality in preterm newborns. Continuous positive airway pressure (CPAP) acts by preventing atelectasis and improves functional residual capacity and arterial oxygenation. Aims: This study aims to evaluate the effectiveness of early nasal bubble CPAP in treating preterm neonates with mild-to-moderate RDS in the rural setting. Materials and Methods: It is a prospective analytic observational study done at a tertiary hospital in the rural area of southern India from December 2018 to December 2019. All babies between 28 and 34 weeks of gestation with mild and moderate RDS were included in the study. Babies with severe RDS requiring surfactant were excluded from the study. Results: Incidence of RDS among babies born between 28 and 34 weeks of gestation was 3.2%. Out of total 50 babies who were managed with early nasal CPAP, it proved effective in 43 babies (86%), while remaining 7 babies (14%) had to be intubated and required ventilation. Babies were studied based on radiological appearance and we found a success rate of 93.1% in moderate grade hyaline membrane disease (HMD) (p<0.005). Conclusion: Bubble CPAP is effective in treating mild and moderate cases of RDS at peripheral center and help decrease the burden at tertiary care center.

Comparing the Efficacy of Nasal Continuous Positive Airway Pressure and Nasal Intermittent Positive Pressure Ventilation in Early Management of Respiratory Distress Syndrome in Preterm Infants.

ObjectivesThere is a tendency to use noninvasive ventilation (NIV) as a substitute for mechanical ventilation in preterm infants who need respiratory support. Two important modes of NIV include nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV). We sought to compare the efficacy of NCPAP and NIPPV as early respiratory support in preterm infants with respiratory distress syndrome in reducing the need for intubation, surfactant administration, and mechanical ventilation.MethodsWe conducted a randomized clinical trial. Sixty-one preterm infants with a gestational age of 28–32 weeks and a birth weight < 1500 g were randomly allocated to early NCPAP (n = 31) or NIPPV (n = 30) groups. The primary outcome was the need for intubation and mechanical ventilation in first 72 hours of life and the secondary outcome was oxygen dependency beyond day 28 post-birth.ResultsSurfactant replacement therapy was done in 15 neonates (50.0%) in the NIPPV group and 19 neonates (61.3%) in the NCPAP group, odds ratio (OR) = 1.58 (95% confidence interval (CI): 0.57–4.37; p = 0.370). Intubation and mechanical ventilation in the first 72 hours of life were needed in five cases (16.7%) in the NIPPV group and two cases (6.5%) in the NCPAP group, OR = 2.90 (95% CI: 0.51–16.27; p = 0.250). The mean duration of hospitalization was 26.2±17.4 days in the NIPPV group and 38.4±19.2 days in the NCPAP group, p = 0.009. Bronchopulmonary dysplasia (BPD) occurred in two (6.7%) neonates in the NIPPV group and eight (25.8%) neonates in the NCPAP group, p = 0.080.ConclusionsNIPPV and NCPAP are similarly effective as initial respiratory support in preterm infants in reducing the need for mechanical ventilation and occurrence of BPD. The duration of hospitalization was significantly reduced using NIPPV in our study.KeywordsNasal Continuous Positive Airway Pressure; Preterm Infants; Mechanical Ventilation; Bronchopulmonary Dysplasia; Respiratory Distress Syndrome, Newborn.

Study of the effects of the use of sustained lung inflation in treatment of preterm infants with respiratory distress in the delivery room

Objective To assess the effect of sustained lung inflation (SLI) on the need for invasive mechanical ventilation (MV) within the first 72 h of age in preterm infants with respiratory distress. Study design In this controlled trial, we randomly assigned preterm infants 33 weeks of gestation or less to receive SLI (25 cmH2O) at birth, to be repeated if needed for a second time (30 cmH2O) followed by continuous positive airway pressure (CPAP), or assistance according to the recommendations of the American Academy of Pediatrics. The primary outcome was the need for invasive MV within the first 72 h of life. The secondary outcomes included development of bronchopulmonary dysplasia or death. The risk ratios (RRs) and 95% confidence intervals of the outcomes were calculated for the SLI group and compared with the control group. Results A total of 145 infants were enrolled: 71 in the SLI group and 74 in the control group. Less preterm infants needed invasive MV in the SLI of preterm group compared with the control group (19.72 vs. 29.73%; RR, 0.6633; 95% confidence interval, 0.2693–1.2517), with a number needed to treat of 10 patients; the difference was statistically significant by multivariate logistic regression (P=0.032). No statistically significant difference was detected between the studied groups regarding the occurrence of bronchopulmonary dysplasia, and also the median cumulative survival for the SLI of preterms group showed no statistically significant difference when compared with the median of the standard group. Conclusion A sustained inflation followed by early nasal CPAP, delivered through a nasopharyngeal tube, is a more efficient strategy than repeated manual inflations with a self-inflating bag and mask followed by nasal CPAP on admission to the neonatal intensive care unit.

Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants.

Nasal continuous positive airway pressure (NCPAP) is a strategy for maintaining positive airway pressure throughout the respiratory cycle through the application of bias flow of respiratory gas to an apparatus attached to the nose. Treatment with NCPAP is associated with decreased risk of mechanical ventilation and might be effective in reducing chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation during which patients are exposed intermittently to higher levels of airway pressure, along with NCPAP through the same nasal device. To examine the risks and benefits of early NIPPV versus early NCPAP alone for preterm infants at risk of or in respiratory distress within the first hours after birth.Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), air leaks, duration of respiratory support, duration of oxygen therapy, intraventricular hemorrhage, and incidence of mortality. We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9), MEDLINE via PubMed (1966 to September 28, 2015), Embase (1980 to September 28, 2015), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to September 28, 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. A member of the Cochrane Neonatal Review Group handsearched abstracts from the European Society of Pediatric Research (ESPR). We contacted the authors of ongoing clinical trials to ask for information. We considered all randomized and quasi-randomized controlled trials. Studies selected compared NIPPV versus NCPAP treatment, starting at birth or shortly thereafter in preterm infants (< 37 weeks' gestational age). We performed data collection and analysis using the recommendations of the Cochrane Neonatal Review Group. Ten trials, enrolling a total of 1061 infants, met criteria for inclusion in this review. Meta-analyses of these studies showed significantly reduced risk of meeting respiratory failure criteria (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; typical risk difference (RD) -0.09, 95% CI -0.13 to -0.04) and needing intubation (typical RR 0.78, 95% CI 0.64 to 0.94; typical RD -0.07, 95% CI -0.12 to -0.02) among infants treated with early NIPPV compared with early NCPAP. The meta-analysis did not demonstrate a reduction in the risk of CLD among infants randomized to NIPPV (typical RR 0.78, 95% CI 0.58 to 1.06). Investigators observed no evidence of harm. Review authors graded the quality of the evidence as moderate (unblinded studies). Early NIPPV does appear to be superior to NCPAP alone for decreasing respiratory failure and the need for intubation and endotracheal tube ventilation among preterm infants with respiratory distress syndrome. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.

Impact and Challenges of Early Continuous Positive Airway Pressure Therapy for Very Low Birth Weight Neonates in a Developing Country

Background: Early nasal continuous positive airway pressure (EnCPAP) therapy after birth for very low birth weight (VLBW; <1,500 g) neonates has been reported to be beneficial in developed countries. Its benefits in developing countries, such as Malaysia, are unknown. Objectives: This study aimed to determine EnCPAP rates in 36 neonatal intensive care units of the Malaysian National Neonatal Registry (MNNR) in 2013, to compare the outcomes of VLBW neonates with and without EnCPAP, and to determine whether the availability of CPAP facilities and unit policies played a significant role in EnCPAP rates. Methods: First, a retrospective cohort study was conducted of VLBW neonates born in the hospitals participating in the study without major congenital abnormalities in the MNNR. This was followed by a questionnaire survey of these hospitals focussed on CPAP facilities and unit policies. Results: Of the 2,823 neonates, 963 (34.1%) received EnCPAP. Amongst EnCPAP neonates significantly fewer deaths were recorded (10.9 vs. 21.7%; p < 0.001), less bronchopulmonary dysplasia was observed (BPD; 8.0 vs. 11.7%; p = 0.002) and fewer mechanical ventilation days were necessary (p < 0.001) than in non-EnCPAP neonates. Logistic regression analysis showed that EnCPAP was significantly associated with a lower mortality (adjusted OR 0.623; 95% CI 0.472, 0.824; p = 0.001) and BPD among survivors (adjusted OR 0.585; 95% CI 0.427, 0.802; p = 0.001). The median EnCPAP rate of the 36 hospitals was 28.4% (IQR 14.3-38.7). Hospitals with CPAP facilities in the delivery suites (p = 0.001) and during transport (p = 0.001) and a policy for EnCPAP (p = 0.036) had significantly higher EnCPAP rates. Conclusion: EnCPAP reduced mortality and BPD in Malaysian VLBW neonates. Resource-strapped developing countries should prioritise the use of this low-cost therapy.

A report on early neurodevelopmental outcomes in extremely low birth weight infants managed on early nasal continuous positive airway pressure

At our institution a policy of early nasal continuous positive airway pressure (ENCPAP) in extremely low birth weight (ELBW) infants has been followed during the past 5 years. Routine intubation and surfactant administration is no longer our practice. The impact of this policy on infant outcomes is under investigation. This is a retrospective review of ELBW infants (

The use of nasal CPAP at the Charlotte Maxeke Johannesburg Academic Hospital

Background . Nasal continuous positive airway pressure (NCPAP) is well established as a treatment for hyaline membrane disease (HMD) and other respiratory diagnoses in neonates. NCPAP is an affordable intervention that reduces the number of neonatal admissions to the intensive care unit (ICU) for ventilation. At the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) we have been using NCPAP since April 2006. Objectives. To review the use of early NCPAP in our hospital setting. Methods. This was a retrospective, descriptive study of all neonates ≥750 g admitted to CMJAH between 1 January 2013 and 31 July 2014, who received NCPAP within 72 hours of birth. The characteristics and the survival of all infants who received NCPAP were described using univariate analysis. Results. The NCPAP group ( n =481) of neonates <1 500 g was significantly associated with surfactant use ( p <0.0005), bronchopulmonary dysplasia ( p <0.0005) and late sepsis ( p <0.0005). The survival to day 7 and to discharge of infants treated with NCPAP was significantly decreased ( p <0.0005). NCPAP alone (without ventilation) improved the survival to discharge ( p =0.001). The survival was 95.4% in the ≥1 500 g infants, compared with 87.6% in the very low birth weight infants and 55.2% in the extremely low birth weight infants. Conclusion. NCPAP is an effective intervention for HMD; it is both cost-effective and easy to use in a resource-limited setting, and reduces the morbidity and mortality associated with ICU admission.

Failure of early nasal continuous positive airway pressure in preterm infants of 26 to 30 weeks gestation

To identify variables associated with early nasal continuous positive airway pressure (ENCPAP) failure in preterm neonates less than 30 weeks gestational age. Multicenter prospective study including 131 preterm newborns, over a period of 2 years. Patients and respiratory variables were assessed using univariate analysis. Variables associated with ENCPAP failure were: the need of resuscitation with a FiO(2)>0.30; a CPAP pressure of 6.4±1.2 cm H(2)O; the need of a FiO(2) of 0.40 in the first 4 h of life; male gender maintaining the need of a FiO(2)>0.25 in the first 4 h of life; and respiratory distress syndrome with criteria for surfactant administration. The need for oxygen in resuscitation and maintained in first hours of life, male gender, a CPAP pressure over 5 cm H(2)O and surfactant need are predictors of ENCPAP failure in preterm neonates 26 to 30 weeks gestational age.

Early Treatment of Obstructive Apnea and Stroke Outcome

747 Letter to the Editor—Parra and Arboix We have read with attention and great interest the article by Bravata et al.1 recently published in this journal, about the feasibility of using early nasal CPAP (continuous positive airway pressure) treatment in patients with ischemic stroke, and its beneficial effects on their neurological recovery after a 1-month follow-up. We have also recently published similar results from a randomized controlled trial with early nasal CPAP treatment in patients with ischemic first-ever stroke. We included 141 selected patients with AHI ≥ 20 events/h: 71 patients (with only 14 refusing nasal CPAP treatment) in the intervention group and 69 patients in the control group. The percentage of patients with neurological improvement 1 month after stroke was significantly higher in the nasal CPAP group (Rankin scale 90.9 of versus 56.3% [P < 0.01]; Canadian scale 88.2 of versus 72.7% [P < 0.05]).2 Our study differed in that nasal CPAP treatment was initiated slightly later, although still in the acute period after stroke onset (between 3-6 days), since our design included a diagnostic sleep study prior to randomization. Considering the high prevalence of sleep breathing disorders (SBD) in stroke patients3 and the potential deleterious effects of apnea consequences, which could be corrected by nasal CPAP,4 we think the methodological approach of Bravata et al. is practical, daring and clever. This is even more so, if we bear in mind the effect of a better potential recovery of the penumbra area.5 We agree with the authors that nasal CPAP is worthy of considerations in such cases and that the earlier the treatment is introduced, the more the beneficial options gained. Nevertheless, the decision to apply it can be a more comfortable one for physicians if they have the prior opportunity to perform a respiratory polygraphy. If this is not possible, however, we think starting with nasal CPAP could be a good option in selected patients with a high probability of having SDB and also a high probability of good compliance, since this treatment does not have any deleterious effects, in our experience. However, the presence of central apneas in some of these patients could be a problem for nasal CPAP use and compliance. LETTER TO THE EDITOR

Respiratory management of the preterm newborn in the delivery room

Respiratory management of the preterm newborn in the delivery room Hesham Abdel-Hady, Nehad NasefNeonatal Intensive Care Unit, Mansoura University Children's Hospital, Mansoura, EgyptAbstract: The survival of preterm infants has improved significantly during the past several decades. However, bronchopulmonary dysplasia remains a major morbidity. Preterm infants have both structural and functional lung immaturity compared with term infants, making them more likely to require resuscitation and more vulnerable to developing bronchopulmonary dysplasia. Interventions in the delivery room may affect short-term and long-term outcomes for preterm infants. The paradigm of resuscitation of preterm infants has been changing over the past decade from being interventional and invasive to be observational and gentle. Recent developments in respiratory management of preterm infants in the delivery room include oxygen supplementation and monitoring, alveolar recruitment techniques, noninvasive ventilation, new surfactant preparations, and new techniques for administration of surfactant. Providing nasal continuous positive airway pressure (CPAP) rather than intubating has been identified as a potentially better practice. Experimental studies have demonstrated that early application of nasal CPAP is protective for the preterm lung and brain compared with mechanical ventilation. Several observational studies have suggested that early nasal CPAP and avoiding intubation leads to reduced oxygen requirements, intubation rates, duration of mechanical ventilation, and may decrease rates of bronchopulmonary dysplasia. Multicenter, randomized controlled trials support the use of nasal CPAP as a primary strategy in preterm babies with respiratory distress syndrome. This approach leads to a reduction in the number of infants who are intubated and given surfactant without an impact on bronchopulmonary dysplasia rates. On the other hand, half of the infants enrolled in these studies failed nasal CPAP treatment. New techniques for surfactant administration include INSURE ("intubate give surfactant and extubate"), administration through a laryngeal mask airway, nebulized surfactant administration, and minimally invasive surfactant therapy.Keywords: continuous positive airway pressure, lung injury, oxygen, resuscitation, surfactants

Impact of Changes in Perinatal Care on Neonatal Respiratory Outcome and Survival of Preterm Newborns: An Overview of 15 Years

Survival and outcomes for preterm infants with respiratory distress syndrome (RDS) have improved over the past 30 years. We conducted a study to assess the changes in perinatal care and delivery room management and their impact on respiratory outcome of very low birth weight newborns, over the last 15 years. A comparison between two epochs was performed, the periods before and after 2005, when early nasal continuous positive airway pressure (NCPAP) and Intubation-SURfactant-Extubation (INSURE) were introduced in our center. Three hundred ninety-five clinical records were assessed, 198 (50.1%) females, gestational age 29.1 weeks (22–36), and birth weight 1130 g (360–1498). RDS was diagnosed in 247 (62.5%) newborns and exogenous surfactant was administered to 217 (54.9%). Thirty-three (8.4%) developed bronchopulmonary dysplasia (BPD), and 92 (23%) were deceased. With the introduction of early NCPAP and INSURE, there was a decrease on the endotracheal intubation need and invasive ventilation (P < 0.0001), oxygen therapy (P = 0.002), and mortality (P < 0.0001). The multivariate model revealed a nonsignificant reduction in BPD between the two epochs (OR = 0.86; 95% CI 0.074–9.95; P = 0.9). The changes in perinatal care over the last 15 years were associated to an improvement of respiratory outcome and survival, despite a nonsignificant decrease in BPD rate.

Impact of providing vitamin A to the routine pulmonary care of extremely low birth weight infants

Objective. The objective of this study was to determine if the continued use of vitamin A in a nursery utilizing early surfactant and nasal continuous positive airway pressure (CPAP) was warranted.Study design. A retrospective, cohort study of appropriately sized, preterm neonates weighing ≤1000 g at birth was conducted. Two time periods were compared: Pre-Vitamin A was composed of extremely low birth weight who were routinely cared for with early nasal CPAP (n = 76); and Post-Vitamin A (n = 102) consisted of ELBWs who were cared for similar to Pre-Vitamin A, but with the addition of vitamin A. Outcome variables included the incidence of BPD and other pulmonary and major neonatal morbidities.Results. Between Pre-Vitamin A and Post-Vitamin A the incidence of moderate to severe BPD decreased by 11%, from 33% to 22% (p = 0.2). No difference was found in the number of ventilator days or in the incidence of any other neonatal morbidity or mortality, including intraventricular hemorrhage, necrotizing enterocolitis, or patent ductus arteriosus requiring surgical ligation.Conclusion. In a neonatal unit utilizing early surfactant followed by nasal CPAP at delivery, supplementing extremely premature neonates with vitamin A demonstrated a trend towards a decrease in the incidence of moderate to severe BPD; however, this change requires a larger sample to verify in the future.

Is mechanical ventilation associated with intraventricular hemorrhage in preterm infants?

BackgroundThe impact of mechanical ventilation on the incidence of intraventricular hemorrhage (IVH) in very low birth weight (VLBW) infants is unknown, simply because the vast majority of these infants have been routinely intubated and mechanically ventilated. There is a growing interest in the use of early nasal continuous positive airway pressure (ENCPAP) and avoiding mechanical ventilation. ObjectivesTo examine the role of mechanical ventilation since delivery room in determining severe IVH in VLBW infants in two neonatal units that follow the same strategy of respiratory management using ENCPAP. MethodsWe collected data on delivery room intubation and mechanical ventilation during the first 3days of life in VLBW infants. Logistic regression model was constructed to test the relationship between early mechanical ventilation and the diagnosis of severe IVH after controlling for significant confounding variables, such as BW, gender, duration of mechanical ventilation, and partial pressure of CO2 (PCO2). ResultsOf the studied 340 VLBW, 35 infants had severe IVH; most of them received mechanical ventilation that started either in the delivery room (n=12) or during the first (n=10) and second (n=3) days of life. Severe IVH was independently associated with lower BW, mechanical ventilation in the delivery room, and the cumulative duration of mechanical ventilation during the first 3days. The adjusted odds ratio for severe IVH in infants intubated in delivery room was (OR=2.7, CI: 1.1–6.6, P=0.03). Severe IVH was not associated with gender, prenatal steroids, early sepsis, or patent ductus arteriosus. ConclusionsMechanical ventilation plays a role in predicting severe IVH. Both the time at which ventilation was initiated and the duration of ventilation are important determinants of severe IVH. Risk for severe IVH in infants who were never intubated in delivery room or during the first 3days of life is miniscule.

Noninvasive Ventilation for Respiratory Distress Syndrome: A Randomized Controlled Trial

Strategies for reducing exposure to endotracheal ventilation through the use of early noninvasive ventilation has proven to be safe and effective, but the option with the greatest benefits needs to be determined. To determine, in infants with respiratory distress syndrome, if early nasal intermittent positive-pressure ventilation (NIPPV) compared with nasal continuous positive airway pressure (NCPAP) decreases the need for mechanical ventilation. In this single-center, randomized controlled trial, infants (gestational ages 26 to 33/7 weeks) with respiratory distress syndrome were randomly assigned to receive early NIPPV or NCPAP. Surfactant was administered as rescue therapy. The primary outcome was the need for mechanical ventilation within the first 72 hours of life. A total of 200 infants, 100 in each arm, were randomly assigned. Rates of the primary outcome did not differ significantly between the NIPPV (25%) and NCPAP (34%) groups (relative risk [RR]: 0.71 [95% confidence interval (CI): 0.48–1.14]). In posthoc analysis, from 24 to 72 hours of life, significantly more infants in the NIPPV group remained extubated compared with those in the NCPAP groups (10 vs 22%; RR: 0.45 [95% CI: 0.22–0.91]). This difference was also noted in the group of infants who received surfactant therapy, NIPPV (10.9%), and NCPAP (27.1%) (RR: 0.40 [95% CI: 0.18–0.86]). Early NIPPV did not decrease the need for mechanical ventilation compared with NCPAP, overall, in the first 72 hours of life. However, further studies to assess the potential benefits of noninvasive ventilation are warranted, especially for the most vulnerable or preterm infants.

Pulmonary air leaks and NCPAP failure in late preterm infants with respiratory distress

Aims: To study incidence and type of pulmonary air leak in preterm infants with respiratory distress treated with early nasal continuous positive airway pressure (NCPAP) and to assess risk factors for NCPAP-failure. Methods: A prospective, observational, single center study from August 2007 to November 2008. Early NCPAP using Infant Flow CPAP system was started in patients with a median (range) postnatal age of 1.47 (0.5-11) hours. A written NCPAP protocol including chest x-ray was applied to detect early signs of air leak. Babies were intubated when their FiO2 requirements were > 0.35. Results: 54 neonates, 45 with respiratory distress syndrome and 9 with transient tachypnea of the newborn, were studied with a gestational age of 33.6 ± 1.1 weeks and a birthweight of 2026± 303 gm (mean± SD). A total of five infants had air leak (9.3%), one of them developed pneumothorax (1.8%) and four infants had transient pulmonary interstitial emphysema (7.4%). NCPAP- failure rate was 48.1%. The single case with pneumothorax was discovered only after being intubated and surfactant was administered. Conclusion: Early NCPAP/low threshold rescue surfactant policy in preterm infants > 32 weeks of gestation with respiratory distress was associated with a 9.3% incidence of air leak, mainly in the form of pulmonary interstitial emphysema. Clinical variables significantly associated with NCPAP- failure wer e RDS and early onset sepsis.

Estratégias de suporte ventilatório no recém-nascido pré-termo – Inquérito nacional (2008)

Background: Respiratory support strategies for the preterm newborn have been the subject of intense research.Aim: To survey neonatal respiratory support practices in Portugal and to determine whether they reflect evidence from randomised trials.Methods: Questionnaires were given out to 31 Portuguese neonatal units to determine the types of ventilators, modes of ventilation, lung function monitoring, use of exogenous surfactant, oxygen saturation levels used and the prevalence of chronic lung disease in the preterm newborn.Results: There was a 94% response rate. Draeger babylog was the most frequently used ventilator in neonates. Twelve (41%) units prefer to use early nasal continuous positive airway pressure (NCPAP) whenever possible. Triggered ventilation is the choice of invasive ventilation in 24 (83%) units (SIMV, SIPPV, PSV); four (14%) units have high frequency oscillation ventilation. SIMV is the most frequent (n=13, 45%) weaning mode. Exogenous surfactant is used as prophylactic in 12 (41%) units. All units use lung function measurements to aid choice of ventilator settings and five (17%) units monitor PaCO2 (transcutaneous=3; capnometry=2). Seventeen (59%) units allow oxygen saturation levels from 90% to 95% in infants with respiratory distress syndrome and 15 (52%) levels from 85% to 90% in infants with chronic lung disease. Prevalence of chronic lung disease of prematurity ranged from 0% to 75% (median: 10).Conclusions: Many respiratory strategies for extremely low birth weight infants reflect the result of large randomised trials. More effective methods may be required to encourage the use of early NCPAP preferably with binasal prongs, the use of SIPPV as the main weaning mode, the use of volume targeted ventilation and a more judicious use of exogenous surfactant in order to ensure evidence–based practice.Rev Port Pneumol 2009; XV (6): 1043-1071