Early nCPAP Research Articles

Early nasal continuous positive airway pressure in preterm neonates with Respiratory Distress Syndrome.

Objective: To assess the effectiveness of early nasal Continuous Positive Airway Pressure (nCPAP) in preterm neonates with respiratory distress syndrome (RDS). Study Design: Cohort study. Setting: Department of Neonatology, The Children’s Hospital and Institute of Child Health, Multan. Period: September 2018 to June 2020. Material & Methods: A total of 172 neonates admitted to neonatal intensive care unit (NICU), having RDS with gestational age as 28 to 34 weeks were enrolled. All study participants were administered early nCPAP (within 6 hours of onset of RDS). All babies with RDS were evaluated using Silverman–Anderson (SA) score, blood gas analysis and pulse oximetry. Results: Out of a total of 172 neonates, most, 91 (52.9%) were mal, nourished 89 (51.7%) had gestational age between 31 to 32 weeks and 97 (56.4%) with birth-weight between 1000 to 1500 grams. Majority of the neonates, 97 (56.4%) were found to have radiological grading of RDS as moderate. Successful outcome of early nCPAP was observed in 143 (83.1%) neonates. There was no statistical difference in terms of nCPAP outcome among study participants with respect to gender (p=0.4990). Gestational age, birth weight and severity of radiological grading of RDS were significantly associated with outcome of nCPAP (p <0.00001). Arterial blood gas parameters as PO2, PCO2 and HCO3 were also significantly associated with nCPAP outcome among study participants (p<0.0001). Conclusion: Early Nasal CPAP is safe, inexpensive and effective means of respiratory support in neonates with RDS. Early nasal CPAP is useful especially in mild to moderate grade RDS.

Very preterm neonates receiving \u201caggressive\u201d nutrition and early nCPAP had similar long-term respiratory outcomes as term neonates

BackroundThe impact of the consistent implementation of “aggressive” nutrition by means of intensive early neonatal nutritional support up to 40–44 weeks postmenstrual age and the use of nasal continuous positive airway pressure (nCPAP) within the first hour of life on the respiratory function of very premature neonates (VPN) at school age is unclear.MethodRespiratory function was evaluated in 108 VPN and 70 term controls. Growth, frequency of lower respiratory tract infections, re-hospitalization, and spirometry were recorded up to 8–10 years of age. Comparison was carried out between the two study groups.ResultsThere was no significant difference in forced expiratory volume in 1 s and forced vital capacity at 8 years of age, and also in lower respiratory tract infections and re-hospitalization due to them, up to 8 years of age between preterm and term neonates. No significant difference was found in spirometry measurements neither between premature neonates with and without BPD nor between the two subgroups of preterms and term neonates.Conclusion“Aggressive” nutrition, persistent nCPAP use, and their impact on early postnatal growth probably positively affect the respiratory function of our study population. These very encouraging results need to be confirmed by larger studies.

A comparison of the effects of invasive mechanic ventilation/surfactant therapy and non-invasive nasal-continuous positive airway pressure in preterm newborns

Aims: This study compared the early-term outcomes of mechanical ventilation (MV)/surfactant treatment with nasal-continuous positive airway pressure (nCPAP) in preterm infants with respiratory distress syndrome (RDS).Materials and methods: Data from newborns born between ≥24 and ≤32 weeks of gestation, hospitalized at our newborn intensive care unit, and diagnosed with RDS between January 2009 and February 2012 were analyzed.Results: Of 193 newborns with RDS who were enrolled in the study, 113 were treated with nCPAP and 80 with MV at a level of 57.5% of nCPAP. Within the study group, 46.3% of the infants were female. The mean gestation of the continuous positive airway pressure (CPAP) group was 29.07 ± 1.99 weeks; that of the MV group was 28.61 ± 2.01 weeks. The birth weight was 1321.1 ± 325.4 g and 1240.3 ± 366.1 g; however, the difference between the two groups was not significant. MV was not required in 54.9% of the patients with nCPAP treatment. Bronchopulmonary dysplasia (BPD) developed in 20 (18.7%) patients in the nCPAP group and 18 (24.4%) patients in the MV group; the difference was not significant (p = .351). Between 2009 and 2012, nCPAP was used at a rate of 33.9, 70.8, 68.4, and 69%. The risk factors for developing BPD were low gestation week, duration of intubation, and proven sepsis (p = .0001, p = .004, and p = .011, respectively).Conclusions: Early nCPAP treatment in preterm infants (≤32 weeks of gestation) decreases both the need for MV and the use of surfactant, but without a significant effect on BPD development. (No. 2016/324)

Surfactant Need by Gestation for Very Preterm Babies Initiated on Early Nasal CPAP: A Danish Observational Multicentre Study of 6,628 Infants Born 2000-2013

Background: In recent years, early nasal continuous positive airway pressure (nCPAP) as respiratory support for preterm infants is being advocated as an alternative to prophylactic surfactant and treatment with mechanical ventilation. A number of infants treated with early nCPAP do not need treatment with surfactant, but few studies provide data on this. Since the 1990s, the first approach to respiratory support to preterm infants in Denmark has been early nCPAP combined with surfactant administration by the INSURE method by which the infant is intubated and surfactant administration is followed by rapid extubation to nCPAP if possible. Objectives: To investigate how often surfactant was administered in preterm infants with a gestational age below 34 weeks treated with early nCPAP as a first approach to respiratory support. Methods: An observational multicentre study including all inborn infants with a gestational age below 34 weeks admitted to 1 of the 4 level 3 neonatal intensive care units in Denmark in the period from 2000 to 2013. Results: A total of 6,628 infants were included in this study. We found that surfactant was administered in 1,056 of 1,799 (59%; 95% CI: 57-61%), in 821 of 2,864 (29%; 95% CI: 27-31%), and in 132 of 1,796 (7%; 95% CI: 6-8%) of the infants with a gestational age from 24 to 27, 28 to 31, and 32 to 33 weeks and 6 days, respectively. Conclusions: A large proportion of preterm infants treated with early nCPAP as the first approach to respiratory support was never treated with surfactant.

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

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. 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. 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. 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.

Plasma cytokine levels fall in preterm newborn infants on nasal CPAP with early respiratory distress.

IntroductionEarly nCPAP seems to prevent ventilator-induced lung injury in humans, although the pathophysiological mechanisms underlying this beneficial effect have not been clarified yet.ObjectiveTo evaluate plasma levels IL-1β, IL-6, IL-8, IL-10, and TNF-α immediately before the start of nCPAP and 2 hours later in preterm infants.MethodsProspective cohort including preterm infants with 28 to 35 weeks gestational age with moderate respiratory distress requiring nCPAP. Extreme preemies, newborns with malformations, congenital infections, sepsis, surfactant treatment, and receiving ventilatory support in the delivery room were excluded. Blood samples were collected right before and 2 hours after the start of nCPAP.Results23 preterm infants (birth weight 1851±403 grams; GA 32.3±1.7 weeks) were treated with nCPAP. IL-1β, IL-10, TNF-α levels were similar, IL-8 levels were reduced in 18/23 preterm infants and a significant decrease in IL-6 levels was observed after 2 hours of nCPAP. All newborns whose mothers received antenatal steroids had lower cytokine levels at the onset of nCPAP than those whose mothers didn’t receive it; this effect was not sustained after 2 hours of nCPAP.ConclusionEarly use nCPAP is not associated with rising of plasma pro-inflammatory cytokines and it seems to be a less harmful respiratory strategy for preterm with moderate respiratory distress.

PO-0749 Cpap Failure In Very Preterm Infants In European Regions With Different Respiratory Management Strategies: Results From The Epice Cohort

Background Many very preterm infants managed on early nasal continuous positive airway pressure (nCPAP) subsequently require intubation and ventilation and may suffer the consequences of delayed surfactant administration. We investigated risk factors for early nCPAP failure in European regions with diverse approaches to respiratory support. Methods The EPICE cohort included all births between 22+0 and 31+6 weeks of gestation in 19 European regions in 2011–2012. nCPAP failure was defined as mechanical ventilation in the first 72 h. Independent variables were gestational age, sex, multiple pregnancy, prenatal corticosteroids, pregnancy complications, small for gestational age (SGA), caesarean delivery, 5 min Apgar and region of birth. We classified regions into low ( Results Of 7566 infants admitted to neonatal care, 3360 (44%) received early CPAP with a range from 21% to 81% across regions; 22% of infants failed CPAP, with a regional range of 11% to 61%. Failure rates were 47% at Conclusions Perinatal factors identify infants likely to experience nCPAP failure. However, experience and training may also play an important role in effective nCPAP.

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

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. 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). 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). 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.

Efficacy of continuous positive airway pressure treatment on 5-year survival in patients with ischaemic stroke and obstructive sleep apnea: a randomized controlled trial.

The main purpose of the present analysis is to assess the influence of introducing early nasal continuous positive airway pressure (nCPAP) treatment on cardiovascular recurrences and mortality in patients with a first-ever ischaemic stroke and moderate-severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) ≥20 events h(-1) during a 5-year follow-up. Patients received conventional treatment for stroke and were assigned randomly to the nCPAP group (n = 71) or the control group (n = 69). Cardiovascular events and mortality were registered for all patients. Survival and cardiovascular event-free survival analysis were performed after 5-year follow-up using the Kaplan-Meier test. Patients in the nCPAP group had significantly higher cardiovascular survival than the control group (100 versus 89.9%, log-rank test 5.887; P = 0.015) However, and also despite a positive tendency, there were no significant differences in the cardiovascular event-free survival at 68 months between the nCPAP and control groups (89.5 versus 75.4%, log-rank test 3.565; P = 0.059). Early nCPAP therapy has a positive effect on long-term survival in ischaemic stroke patients and moderate-severe OSA.

Effects of nasal continuous positive airway pressure or intubation in very low birth weight preterm infants

Objective To investigate the effects of nasal continuous positive airway pressure (nCPAP) and intubation in very low birth weight preterm infants. Methods One hundred and twenty-three very low birth weight preterm infants with respiratory distress within 60 minutes after birth were randomly assigned to nCPAP (n=63) or intubation group (n=60).Outcomes at 7,28 days and 36 corrected gestational weeks were assessed with x2 or t-test. Results There were no significant difference in fatality rate and incidence of bronchopulmonary dysplasia between nCPAP group and intubation group [7.9％ (5/63) vs 6.6％(4/60),4.8％(3/63) vs 3.3％(2/60),x2 =0.07and 0.16,P＞0.05].In nCPAP group,the use of pulmonary sulfactant was 27.0％ (17/63),lower than that (83.3 ％,50/60) in intubation group (x2 =39.34,OR=0.3,90 ％ CI:0.2-0.6,P＜0.05) ;The nCPAP group had fewer ventilation support in 28 days [17.5％ (11/63) vs 25.0％ (15/60),OR=0.7,90％ CI:0.4-1.4] and 36 weeks [6.3％ (4/63) vs 8.3％ (5/60),OR=0.8,90％ CI:0.2-2.4] than those in intubation group but without statistical difference (x2=1.05 and 0.01,P＞0.05,respectively).The incidence of air leak in nCPAP group were lower than intubation group [11.1％ (7/63) vs 33.3％ (20/60),x2 =8.86,OR=0.3,90％00 CI:0.2-0.7,P＜0.05].There was no significant difference for other complications between two groups. Conclusions In very low birth weight preterm infants,early nCPAP dose not significantly reduce the fatality rate and the incidence of bronchopulmonary dysplasia as compared with intubation ventilation,but shorten the time of ventilation and lower the incidence of air leak. Key words: Infant, premature; Infant, very low birth weight; Continuos positive airway pressure; Respiration, artificial

Randomized Trial Comparing 3 Approaches to the Initial Respiratory Management of Preterm Neonates

We designed a multicenter randomized trial to compare 3 approaches to the initial respiratory management of preterm neonates: prophylactic surfactant followed by a period of mechanical ventilation (prophylactic surfactant [PS]); prophylactic surfactant with rapid extubation to bubble nasal continuous positive airway pressure (intubate-surfactant-extubate [ISX]) or initial management with bubble continuous positive airway pressure and selective surfactant treatment (nCPAP). Neonates born at 26 0/7 to 29 6/7 weeks' gestation were enrolled at participating Vermont Oxford Network centers and randomly assigned to PS, ISX, or nCPAP groups before delivery. Primary outcome was the incidence of death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age. 648 infants enrolled at 27 centers. The study was halted before the desired sample size was reached because of declining enrollment. When compared with the PS group, the relative risk of BPD or death was 0.78 (95% confidence interval: 0.59-1.03) for the ISX group and 0.83 (95% confidence interval: 0.64-1.09) for the nCPAP group. There were no statistically significant differences in mortality or other complications of prematurity. In the nCPAP group, 48% were managed without intubation and ventilation, and 54% without surfactant treatment. Preterm neonates were initially managed with either nCPAP or PS with rapid extubation to nCPAP had similar clinical outcomes to those treated with PS followed by a period of mechanical ventilation. An approach that uses early nCPAP leads to a reduction in the number of infants who are intubated and given surfactant.

Predictors of early nasal CPAP failure and effects of various intubation criteria on the rate of mechanical ventilation in preterm infants of

IntroductionDelivery room management using early nasal continuous positive airway pressure (nCPAP) may delay surfactant therapy.ObjectiveTo identify factors associated with early nCPAP failure and effects of various intubation criteria on rate...

Early treatment of obstructive apnoea and stroke outcome: a randomised controlled trial

The aim of the present study was to assess the impact of nasal continuous positive airway pressure (nCPAP) in ischaemic stroke patients followed for 2 yrs. Stroke patients with an apnoea-hypopnoea index ≥ 20 events·h⁻¹ were randomised to early nCPAP (n = 71; 3-6 days after stroke onset) or conventional treatment (n = 69). The Barthel Index, Canadian Scale, Rankin Scale and Short Form-36 were measured at baseline, and at 1, 3, 12 and 24 months. The percentage of patients with neurological improvement 1 month after stroke was significantly higher in the nCPAP group (Rankin scale 90.9 versus 56.3% (p < 0.01); Canadian scale 88.2 versus 72.7% (p < 0.05)). The mean time until the appearance of cardiovascular events was longer in the nCPAP group (14.9 versus 7.9 months; p = 0.044), although cardiovascular event-free survival after 24 months was similar in both groups. The cardiovascular mortality rate was 0% in the nCPAP group and 4.3% in the control group (p = 0.161). Early use of nCPAP seems to accelerate neurological recovery and to delay the appearance of cardiovascular events, although an improvement in patients' survival or quality of life was not shown.

Prophylactic or Early Selective Surfactant Combined With nCPAP in Very Preterm Infants

Early surfactant followed by extubation to nasal continuous positive airway pressure (nCPAP) compared with later surfactant and mechanical ventilation (MV) reduce the need for MV, air leaks, and bronchopulmonary dysplasia. This randomized, controlled trial investigated whether prophylactic surfactant followed by nCPAP compared with early nCPAP application with early selective surfactant would reduce the need for MV in the first 5 days of life. A total of 208 inborn infants who were born at 25 to 28 weeks' gestation and were not intubated at birth were randomly assigned to prophylactic surfactant or nCPAP within 30 minutes of birth. Outcomes were assessed within the first 5 days of life and until death or discharge of the infants from hospital. Thirty-three (31.4%) infants in the prophylactic surfactant group needed MV in the first 5 days of life compared with 34 (33.0%) in the nCPAP group (risk ratio: 0.95 [95% confidence interval: 0.64-1.41]; P = .80). Death and type of survival at 28 days of life and 36 weeks' postmenstrual age and incidence of main morbidities of prematurity (secondary outcomes) were similar in the 2 groups. A total of 78.1% of infants in the prophylactic surfactant group and 78.6% in the nCPAP group survived in room air at 36 weeks' postmenstrual age. Prophylactic surfactant was not superior to nCPAP and early selective surfactant in decreasing the need for MV in the first 5 days of life and the incidence of main morbidities of prematurity in spontaneously breathing very preterm infants on nCPAP.

Does nasal CPAP reduce bronchopulmonary dysplasia (BPD)?

Early nasal continuous positive airway pressure (nCPAP) or early surfactant therapy with early extubation onto nCPAP rather than continued mechanical ventilation has been adopted by many centres, particularly in Scandinavia, as part of the treatment of newborns with respiratory distress syndrome. It has been suggested that bronchopulmonary dysplasia is less of a problem in centres adopting such a policy. Results from randomized trials suggest prophylactic or early nCPAP may reduce bronchopulmonary dysplasia (BPD), but further studies are required to determine the relative contributions of an early lung recruitment policy, early surfactant administration and nCPAP in reducing BPD. In addition, the optimum method of generating and delivering CPAP needs to be determined. The efficacy of nCPAP in improving long-term respiratory outcomes needs to be compared with the newer ventilator techniques with the optimum and timing of delivery of surfactant administration.

Outcome of very low birthweight infants after introducing a new standard regime with the early use of nasal CPAP

In this paper, a retrospective study was performed to find out whether the introduction of early nasal continuous positive airway pressure (nCPAP) as a new standard regime of very low birthweight infants will lead to a decreasing tracheal intubation and ventilation rate, as well as to a lower incidence of bronchopulmonary dysplasia in a tertiary-level perinatal centre. Ninety-three infants (study group) with early nCPAP as the first respiratory support were compared to 63 infants (historical control group) born before the use of early nCPAP. No statistically significant differences were found in the baseline characteristics. The main results of the study include reduced intubation mainly in infants with a birthweight <1,000 g (study group): 58% vs. 81% (p < 0.05). The mean duration of ventilation was 248 h (control group) vs. 128 h (study group) (p < 0.001) and 437 h vs. 198 h in infants <1,000 g (p < 0.001). There was significantly reduced incidence of bronchopulmonary dysplasia from 55% to 18% for all surviving infants (p < 0.001), and for infants <1,000 g, it was 90% vs. 30% (p < 0.001). No significant differences for other outcome criteria were noted, but a significant reduction in the use of central i.v. lines, fluids, drugs, volume expansion, sedation, catecholamines, surfactant, steroids and buffer, as well as antibiotics, was observed (p < 0.05). Therefore, we can conclude that early nCPAP is an easy-to-use and safe procedure for very low birthweight infants to treat respiratory distress.

Long-term outcome of preterm infants treated with nasal continuous positive airway pressure

This study's aim was to assess neurodevelopmental and growth outcome until the age of 4 years of premature infants placed on early nCPAP, in the setting of the neonatal intensive care unit (NICU) and follow-up program of the Division of Neonatology of the Department of Pediatrics of the University Hospital, Lausanne, Switzerland. All consecutive inborn infants weighing <1500 g or <32 weeks of gestational age admitted to the NICU during two periods of 12 months-7.1996-6.1997 and 7.1998-6.1999-were compared before and after the systematic application of early nCPAP. Of 172 infants admitted to the NICU, 150 (87%) survived. 126 (84%) were tested at 6 months' corrected age, 121 (81%) at 18 months' corrected age, and 117 (78%) at the age of 4 years. Detailed perinatal data were collected. Follow-up included neurological examination, developmental testing and measurement of growth parameters. Statistical analyses were performed. Early application of nCPAP and avoidance of mechanical ventilation showed no adverse effects on neurodevelopment and growth. A significantly higher developmental quotient was found in the nCPAP group at 18 months' corrected age. Several trends were also noted in the nCPAP group with a decrease of intraventricular hemorrhage and in "abnormal neurodevelopment" at 6 months corrected age, a bigger head circumference at all different tested ages and a greater height at 6 and 18 months corrected ages. In conclusion, our study of developmental outcome documents the absence of any harmful effect of early application of nCPAP to treat respiratory failure in very low birthweight infants.

Early variable-flow nasal continuous positive airway pressure in infants ⩽1000 grams at birth

To compare the incidence of chronic lung disease (CLD) in extremely low birth weight (ELBW, < or =1000 g) infants before and after the introduction of early, preferential application of nasal continuous airway pressure (NCPAP) utilizing a variable flow delivery system. A retrospective cohort study of ELBW infants 2 years prior to (Pre-early NCPAP, n=96) and 2 years following (Early NCPAP, n=75) the initiation of an early NCPAP policy. There were no significant changes (Pre-early NCPAP vs Early NCPAP) in the incidences of CLD (35 vs 33%, P=0.81) or CLD or death (50 vs 43%, P=0.34). Infants in the Early NCPAP group weaned off mechanical ventilation and supplemental oxygen more rapidly than infants in the Pre-early NCPAP group (hazard ratio (HR) 1.80, P=0.002 and HR 1.69, P=0.01). A policy of early NCPAP has not decreased the incidence of CLD despite a decrease in time to successful tracheal extubation.

Early Nasal Continuous Positive Airway Pressure To Minimize The Need for Endotracheal Intubation and Ventilation

After completing this article, readers should be able to: 1. Describe the mechanism by which early nasal continuous positive airway pressure (nCPAP) may reduce bronchopulmonary dysplasia (BPD). 2. List the limited evidence used to confirm the reduction in BPD. 3. List the limited evidence on which to base patient selection for early nCPAP. 4. Explain the uncertainty regarding whether to treat with surfactant replacement. When Northway and associates (1) initially described BPD in 1967, little was known about the injurious effects of ventilation and oxygen. Today, despite the numerous pharmacologic and technical advances in neonatal lung care, BPD remains a cause of serious morbidity in surviving preterm infants. This “new BPD” differs from that originally described by Northway in that it affects predominantly infants born between 24 and 28 weeks’ gestation who have birthweights of less than 1,000 g, many of whom have received antenatal glucocorticoids, minimal “gentle ventilation,” and exogenous surfactant therapy. (2) A variety of factors, including surfactant deficiency, volutrauma, oxygen exposure, antenatal exposure to proinflammatory cytokines, postnatal infection, patent ductus arteriosus, and inadequate postnatal nutrition, are believed to play roles in the pathogenesis of neonatal BPD. The single greatest predictor for BPD appears to be the initiation of mechanical ventilation in the very low-birthweight infant. (3)(4)(5) The introduction of more complex ventilatory strategies, such as high-frequency oscillatory ventilation (HFOV), (6) patient trigger, (7) and volume techniques have not been associated with a reduction in the incidence of BPD in extremely preterm babies. Long-term animal studies demonstrate that HFOV reduces the severity of lung injury but does not prevent the arrest in alveolarization and vascular development that underlies new BPD. (8)(9)(10) This failure may be due to the fact that all respiratory support strategies that involve endotracheal intubation for any length of …

Septicemia in the First Week of Life in a Norwegian National Cohort of Extremely Premature Infants

To investigate the incidence, causes, predictors, and outcomes of septicemia in the first week of life in a national cohort of extremely premature infants. A prospective study of survival of all infants with gestational age of <28 weeks or birth weight of <1000 g who were born in Norway in 1999-2000 was performed. Data on the maternal prenatal history, delivery, and neonatal course, including detailed information on episodes of microbiologically verified septicemia, were collected on predefined forms. Septicemia was reported in 2 groups, ie, episodes diagnosed on the day of delivery (ie, very early-onset septicemia [VEOS]) and episodes diagnosed from day 2 to day 7 of life (ie, early-onset septicemia [EOS]). Logistic regression models were used for the selection of variables for predictor analysis in each group. Of 462 included infants, VEOS occurred for 15 (32.5 per 1000 population) and EOS for 15 (35.5 per 1000 population). The most prevalent bacteria were Escherichia coli in VEOS (n = 9) and staphylococci (coagulase-negative staphylococci and Staphylococcus aureus) (n = 15) in EOS. Case fatality rates were 40% and 13%, respectively. Independent predictive factors for VEOS were clinical chorioamnionitis (odds ratio [OR]: 10.5; 95% confidence interval [CI]: 3.3-33.4) and high maternal age (OR: 1.2; 95% CI: 1.0-1.3), whereas not receiving systemic antibiotic therapy within 2 days of age (OR: 13.6; 95% CI: 3.7-50.2) and receiving nasal continuous positive airway pressure (n-CPAP) support at 24 hours of age (OR: 9.8; 95% CI: 2.5-38.4) independently predicted septicemia after the first day of life. Whereas vertically transmitted septicemia was dominated by Gram-negative bacteria, with predictors being exclusively of maternal origin, EOS was dominated by typically nosocomial flora, with n-CPAP treatment at 24 hours of age being a powerful predictor. Early n-CPAP treatment, as opposed to mechanical ventilation, as a powerful predictor of septicemia in the early neonatal period, even with adjustment for early systemic antibiotic treatment, is a new observation among extremely premature infants that warrants additional study.