Nasal Continuous Positive Pressure Research Articles

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.

Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial

Study objectiveTo determine if a nasal positive airway pressure (nasal CPAP) mask would decrease the number of hypoxemic events in obese and obstructive sleep apnea patients undergoing colonoscopy. DesignSingle-center prospective randomized controlled trial. SettingTertiary academic center. PatientsWe enrolled 109 patients with diagnosis of obesity and/or obstructive sleep apnea scheduled to undergo colonoscopy under propofol general anesthesia without planned tracheal intubation. InterventionPatients were randomly allocated (1:1 ratio) to receive supplementary oxygen at a flow of 10 L/min, either through a nasal CPAP or a simple facemask. MeasurementsThe primary endpoint was the difference in the mean percentage of time spent with oxygen saturation below 90% between the two groups. Secondary outcomes included the need for airway maneuvers/interventions, average SpO2 during the case, duration and severity of oxygen desaturation, incidence and duration of procedural interruptions, and satisfaction and tolerance scores. Main results54 were allocated to the simple face mask and 55 to the nasal CPAP mask arms, respectively. A total of 6 patients experienced a hypoxemic event. Among these patients, the difference in the percentage of time spent with oxygen saturation below 90% was not clinically relevant (p = 1.0). However, patients in the nasal CPAP group required less chin lift (20% vs. 42.6%; p = 0.01) and oral cannula insertion (12.7% vs.29.6%; p = 0.03). The percentage of patients with at least one airway maneuver was higher in the simple face mask arm (68.5% vs. 41.8%; p = 0.005). Patient tolerance to device score was lower in the nasal CPAP group (8.85 vs. 9.56; p = 0.003). ConclusionsA nasal CPAP did not prevent hypoxemia and should not be used routinely for colonoscopy in obese or OSA patients if a simple face mask is an alternative therapy. However, potential advantages of its use include fewer airway maneuvers or interventions, which may be desirable in certain clinical settings. Trial registrationClinicaltrials.gov, identifier: NCT05175573.

Effect of the measurement of the work of breathing on the respiratory outcome of preterms

Rationale There are no validated criteria for the choice of the optimal type of noninvasive respiratory support (NRS) and most appropriate settings in preterms. Methods The work of breathing (WOB) during oxygen (O2) alone, nasal continuous positive pressure (nCPAP) and high flow nasal cannula (HFNC) was compared in preterm babies (23–30 weeks’ gestation, “physiological group”) needing any type of noninvasive respiratory support (“baseline” NRS) at 4 weeks of life. Babies were thereafter treated with the NRS associated with the greatest reduction in WOB (“optimal NRS”). The respiratory outcome at 36 weeks” gestation of these babies was compared to a “control” group treated with NRS based on standard noninvasive parameters. Preterm babies were prospectively enrolled in 3 centers and randomized into the “physiological” or “control” group. Results Thirty babies were randomized. WOB with “baseline” NRS was higher than the “optimal” NRS and the consequent NRS chosen by physicians (p = 0.001). WOB was lower during HFNC than during O2 (p = 0.032) but WOB was comparable between nCPAP and HFNC, and between nCPAP and O2. Notably, WOB was near to normal during spontaneous breathing with O2. Respiratory outcome at 36 week’ gestation was comparable between the 2 groups. Conclusion The optimization of NRS by means of the measurement of WOB in preterms requiring any type of NRS at 4 weeks of life was able to decrease the WOB but had no effect on the clinical outcome at 36 weeks’ gestation.

Influenced CD cells and ICAM-1 by pulmonary surfactant combined with high-frequency oscillatory ventilation and its effects on immune function in children with neonatal respiratory distress syndrome

This study aimed to explore the clinical efficacy of pulmonary surfactant combined with high-frequency oscillatory ventilation (HFOV) on neonatal respiratory distress syndrome (NRDS) and its influence on immune function in children. Children admitted to our hospital from March 2017 to March 2019 who received HFOV combined with pulmonary surfactant therapy as a research group. Sixty-two children received conventional nasal continuous positive pressure combined with pulmonary surfactant therapy as a control group. Clinical efficacy, blood gas and immune function of patients were compared between the two groups. The clinical efficacy of the research group was better than that of the control group (P&lt; 0.050). PaO2 and PaO2/FiO2 were both higher after treatment (P&lt; 0.050). CD3+ and NK cells in the research group were higher than those in the control group, while CD8+ cells and ICAM-1 were lower than those in the control group (P&lt; 0.050). CD3+, CD4+ and NK cells decreased in both groups after treatment, while CD8+ cells and ICAM-1 increased (P&lt; 0.050). HFOV combined with pulmonary surfactant has significant clinical efficacy and high safety on NRDS, and has a certain protective effect on children's immune function. Hence, it is worthy of being the first choice for the clinical treatment of NRDS in the future.

Early application of nasal continuous positive pressure ventilation in the treatment of moderate to severe bronchiolitis

目的 探讨尽早应用经鼻持续正压通气(nCPAP)治疗中－重度毛细支气管炎的疗效。 方法 选择2016年10月至2017年9月河北省儿童医院急诊科收治的中－重度毛细支气管炎患儿150例为研究对象，进行前瞻性临床观察性研究，将患儿按随机数字表法分为对照组和nCPAP组，每组75例。对照组应用面罩吸氧(流量2～4 L/min)。nCPAP组患儿雾化、吸痰后直接第一时间尽早应用nCPAP治疗，比较2组治疗前、治疗12 h、24 h后动脉血氧分压[pa(O2)]、动脉血二氧化碳分压[pa(CO2)]、血氧饱和度(SpO2)、呼吸频率、心率及患儿喘息、三凹征主要症状消失时间、住院时间及气管插管率等指标。 结果 与对照组比较，nCPAP组治疗12 h、24 h pa(O2)增高[(78.97±11.23) mmHg比(68.46±9.83) mmHg、(82.97±10.46) mmHg比(72.47±9.83) mmHg，1 mmHg＝0.133 kPa，t＝2.610、2.564，均P<0.05]，SpO2升高[(94.79±1.68)%比(92.92±1.76)%、(96.81±1.55)%比(94.47±1.41)%，t＝2.390、2.386，均P<0.05]，pa(CO2)降低[(46.21±5.41) mmHg比(49.38±5.76) mmHg、(43.89±5.37) mmHg比(45.38±5.19) mmHg，t＝2.315、2.328，均P<0.05]，呼吸频率减慢[(58.26±5.17)次/min比(62.61±6.31)次/min、(50.62±5.35)次/min比(55.73±5.90)次/min，t＝2.319、2.321，均P<0.05]，心率减慢[(150.75±17.17)次/min比(156.48±12.69)次/min、(142.39±15.57)次/min比(148.76±12.36)次/min，t＝2.965、2.785，均P<0.05]，差异均有统计学意义。与对照组比较，nCPAP组喘息缓解时间、三凹征消失时间及平均住院天数明显缩短[(3.61±1.33) d比(5.76±1.67) d、(1.92±0.73) d比(2.87±0.95) d、(7.58±1.79) d比(9.28±2.67) d，t＝2.891、2.859、2.762，均P<0.05]，气管插管率降低[1例(1.33%)比7例(9.33%)，χ2＝4.844，P<0.05]，差异均有统计学意义。 结论 尽早第一时间应用nCPAP治疗中－重度毛细支气管炎疗效显著，可阻止病情进展，降低气管插管率，缩短住院时间，是一种值得推广的无创呼吸支持技术。

A rare case of congenital pyloric atresia with situs inversus abdominalis

Congenital pyloric atresia and situs inversus are rare conditions. The combination of congenital pyloric atresia and situs inversus is extremely rare, only two such cases reported in the literature so far. We present third such case of a term, male baby born to a primigravida mother. All antenatal ultrasound up to 31 weeks were unremarkable. Follow-up antenatal ultrasound was suggestive of duodenal atresia. The baby was noted to have respiratory distress at birth requiring respiratory support in the form of nasal continuous positive air pressure. X-ray abdomen revealed a single bubble sign, but toward the right side of the abdomen, cardiac shadow being on the left side, suggestive of congenital pyloric atresia along with situs inversus abdominalis. The baby was operated, laparotomy done, findings confirmed, and retrograde side-to-side gastroduodenostomy was done. Postoperatively, feeds were started and baby discharged on day 17 of life. Isolated congenital pyloric atresia has a good prognosis and all attempts should be made to identify other possible associations (since there are different anomalies associated with congenital pyloric atresia such as junctional epidermolysis bullosa, renal anomalies [hydroureteronephrosis, multicystic kidney, absent bladder], aplasia cutis congenita, and colonic atresia).

Impact of surfactant administration through a thin catheter in the delivery room: A quality control chart analysis coupled with a propensity score matched cohort study in preterm infants.

IntroductionMost infants born before 30 weeks gestational age (GA) develop respiratory distress syndrome soon after birth. Methods of surfactant administration that avoid ventilation have been recently introduced. The aim of this study was to evaluate the impact of implementing a new procedure of less invasive surfactant administration (LISA) and determine whether it is associated with an improvement in respiratory outcome.MethodsThis single center cohort quality improvement study analyzed preterm infants born before 30 weeks GA between May 2010 and April 2016. Changes in health care practices and respiratory outcomes following the implementation of a LISA, i.e. the administration of surfactant through a thin catheter, were analyzed using quality control charts. Then, the effect of LISA on respiratory outcome was assessed by propensity score matching and logistic regression weighted by the inverse of the propensity score.ResultsDuring the study period, 379 infants were included. Of those that were not intubated at ten minutes of life, 129 received surfactant and were ventilated for one hour or more (InVent), 127 received LISA, five received surfactant with tracheal mechanical ventilation for less than one hour (InSurE), and 55 were only treated with nasal continuous positive pressure during the first hour of neonatal care (nCPAP). Quality-chart analysis revealed rapid implementation of the method with a concomitant decrease in required ventilation. LISA was associated with fewer tracheal ventilation days and a lower incidence of supplemental oxygen on day 28. When controlling for the propensity to be exposed or not to LISA, this procedure was not associated with a lower risk of death or bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age.ConclusionIn this study, the successful implementation of the new method was associated with lower rates of mechanical ventilation, but without a significant reduction of grade I/II/III BPD or death.

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

PurposeTo investigate the effectiveness of transient intubation for surfactant administration and extubated to nasal continuous positive pressure (INSURE) for treatment of respiratory distress syndrome (RDS) and to identify the factors associated with INSURE failure in extremely premature infants.MethodsEighty-four infants with gestational age less than 28 weeks treated with surfactant administration for RDS for 8 years were included. Perinatal and neonatal characteristics were retrospectively reviewed, and major pulmonary outcomes such as duration of mechanical ventilation (MV) and bronchopulmonary dysplasia (BPD) plus death at 36-week postmenstrual age (PMA) were compared between INSURE (n=48) and prolonged MV groups (n=36). The factors associated with INSURE failure were determined.ResultsDuration of MV and the occurrence of BPD at 36-week PMA were significantly lower in INSURE group than in prolonged MV group (P<0.05), but BPD plus death at 36-week PMA was not significantly different between the 2 groups. In a multivariate analysis, a reduced duration of MV was only significantly associated with INSURE (P=0.001). During the study period, duration of MV significantly decreased over time with an increasing rate of INSURE application (P<0.05), and BPD plus death at 36-week PMA also tended to decrease over time. A low arterial-alveolar oxygen tension ratio (a/APO2 ratio) was a significant predictor for INSURE failure (P=0.001).ConclusionINSURE was the noninvasive ventilation strategy in the treatment of RDS to reduce MV duration in extremely premature infants with gestational age less than 28 weeks.

The Difference between High Flow Nasal Cannula and Continuous Positive Airway Pressure.

Background: Nasal Continuous Positive Airway Pressure (NCPAP) has been the mainstay for non-invasive respiratory support for at risk neonates. Recent advances in High Flow Nasal Cannula (HFNC) usage including enhanced humidity and improved comfort factors have led to its widespread use, at times replacing NCPAP in many neonatal settings. Although ease of application cannot be matched by traditional CPAP devices, concerns about appropriate delivery of volume at a given pressure must be validated given that HFNC rarely exceeds 4 LPM. However, the NCPAP apparatus is often set at 8 …

A Preterm Newborn with Abnormal Development of the Lower Abdomen and Genitalia

A preterm newborn is noted after delivery to have abnormal development of the lower abdomen and genitalia. ### Prenatal and Birth Histories ### Presentation (Newborn Day) Immediately after birth, the neonatology team that was present at delivery examined the infant and noted a lower abdominal mass and ambiguous genitalia (Fig 1). The infant was transferred to the NICU for further evaluation. On admission, the newborn was noted to have central cyanosis and given nasal prong continuous positive airway pressure (CPAP). Figure 1. Exstrophy and epispadiasis. ### Vital Signs ### Physical Examination

Case 4: A Preterm Infant with a Necrotic Ulcer Over the Perianal Area

A 1.07-kg male infant with severe growth restriction is born at 30 weeks’ gestational age to a 36-year-old gravida 3, para 2 mother by emergency cesarean delivery for nonreassuring heart tracing. The parents are of low socioeconomic status and are first-degree consanguineous relatives. The mother received steroids and her membranes ruptured at delivery. At birth, the infant’s cord clamping was delayed, and after an initial weak cry he underwent intubation for poor respiratory efforts. Apgar scores were 4 and 7 at 1 and 5 minutes, respectively. His initial stabilization included surfactant administration, mechanical ventilation with volume guarantee, catheter line placement (umbilical venous and arterial catheters), initiation of total parenteral nutrition, antibiotics, and inotropic support. On day 3, he underwent extubation and received noninvasive intermittent positive pressure ventilation (NIPPV), inotropic support was discontinued, and antibiotics were stopped, because his blood culture was sterile. He demonstrated steady clinical improvement in the next 3 days, was weaned from NIPPV to nasal continuous positive pressure, and nasogastric feeds progressed gradually. On day 6, the bedside nurse noticed a small macule and blister with surrounding erythema over the lateral aspect of his right thigh, which progressed rapidly in hours to blackish-gray discoloration of skin in an area 4 × 1 cm in size with a small hemorrhagic lesion in the center (Fig 1). The infant’s clinical condition worsened rapidly in the next 24 hours; he became lethargic, hypothermic, tachycardic, hypotensive with poor perfusion, and apneic with increased oxygen requirement. He underwent elective reintubation for recurrent apnea and mixed respiratory and metabolic acidosis. A limited sepsis screening (complete blood cell count and cultures from blood, skin wound, and urine) was performed. Empiric antibiotic treatment with piperacillin-tazobactam was commenced. The infant received a bolus of normal saline, and dopamine treatment was commenced for low mean blood pressure. …

Findings of the Maintenance of Wakefulness Test and its relationship with response to modafinil therapy for residual excessive daytime sleepiness in obstructive sleep apnea patients adequately treated with nasal continuous positive airway pressure

ObjectiveWe aimed to examine the relationship between subjective and objective sleepiness in obstructive sleep apnea syndrome (OSAS) patients with residual sleepiness, and to determine whether baseline objective sleepiness severity predicts the response to modafinil therapy. MethodsData were obtained from a randomized, placebo-controlled modafinil (200 mg/day) study in Japanese OSAS patients with residual sleepiness receiving nasal continuous positive pressure (n-CPAP) treatment. We analyzed 50 participants whose subjective (Epworth Sleepiness Scale [ESS] total score) and objective (Maintenance of Wakefulness Test [MWT] sleep latency) sleepiness were evaluated before and after treatment. Subjects were dichotomized into two subgroups according to the mean baseline MWT sleep latency. ESS total score and MWT sleep latency changes after treatment were compared between the placebo and modafinil groups in both subgroups. ResultsThe mean baseline ESS total score and MWT sleep latency were 14.1 ± 2.8 and 14.2 ± 4.9 min, respectively; there was no significant correlation between these two variables. Patient characteristics were similar between the two subgroups (MWT sleep latency: <14 min, n = 23; ≥14 min, n = 27). In the <14-min subgroup, changes in ESS total score and MWT sleep latency after treatment were significantly greater in the modafinil group than in the placebo group (p = 0.005). In the ≥14-min subgroup, changes in these parameters did not differ between the treatment groups. ConclusionIn OSAS patients with residual sleepiness, the objective sleepiness level was not as high as expected, despite increased subjective sleepiness. Improvements in subjective and objective sleepiness seemed difficult to achieve with modafinil treatment among subjects with less objective sleepiness.

Prospective economic evaluation alongside the non-invasive ventilation trial.

To determine the cost-effectiveness of nasal continuous positive pressure (nCPAP) compared with nasal intermittent positive pressure ventilation (NIPPV) in the context of the reported randomized clinical trial. Using patient-level data from the clinical trial, we undertook a prospectively planned economic evaluation. We measured costs, from a third-party payer perspective in all patients, and from a societal perspective in a subgroup with a time horizon through the earlier of discharge, death or 44 weeks post-menstrual age. From the third-party payer perspective, the mean cost of hospitalization per infant was statistically similar, $143 745 in the NIPPV group compared to $140 403 in the nCPAP group. Cost-effectiveness evaluation revealed a 61% probability that NIPPV is more expensive and less effective than nCPAP. Similar results were found in subgroup analysis from a societal perspective. In addition to being clinically equivalent, economic evaluation confirms that NIPPV, as employed in this trial, is also not economically favorable.

Effect of Nasal Continuous Positive Pressure on the Nostrils of Patients with Sleep Apnea Syndrome and no Previous Nasal Pathology. Predictive Factors for Compliance

ObjectiveTo evaluate the effect of continuous positive airway pressure (CPAP) on the nostrils of patients with sleep apnea–hypopnea syndrome and its impact on quality of life, and to identify predictive factors for compliance. MethodsLongitudinal prospective study. Thirty-six consecutive patients evaluated before and 2 months after CPAP using the following variables: clinical (eye, nose and throat [ENT] symptoms, Epworth test, anxiety/depression scales, general and rhinoconjunctivitis-specific quality of life); anatomical (ENT examination, computed tomography); functional (auditive and Eustachian tube function, nasal flow, mucociliary transport); biological (nasal cytology); and polisomnographics. The sample was divided into partients with good adherence (≥4h/d) and patients with bad adherence (<4h/d). ResultsA significant improvement was observed in daytime sleepiness (P=.000), anxiety (P=.006), and depression (P=.023). Nasal dryness (P=.000), increased neutrophils in nasal cytology (P=.000), and deteriorating ciliary function were evidenced, particularly in partients with good adherence. No significant differences were observed in the other variables. Baseline sleepiness was the only factor predictive of compliance. ConclusionsCPAP in patients without previous nasal pathology leads to an improvement in a series of clinical parameters and causes rhinitis and airway dryness. Some ENT variables worsened in partients with good adherence. Sleepiness was the only prognostic factor for poor tolerance.

CONTRIBUTING FACTORS FOR DEVELOPMENT OF NECROTIZING ENTEROCOLITIS IN PRETERM INFANTS IN THE NEONATAL INTENSIVE CARE UNIT.

Background:necrotizing enterocolitis is a serious condition that affects mostly preterm infants, with high mortality rate.Aim:to estimate the influence of potentially contributing factors of this multifactorial disease.Methods:the study group included 51 necrotizing enterocolitis infants who were less than 37 week gestation who were hospitalized in NICU during a five year period. The control group consisted of 71 patients with approximately the same gestational age and birth weight. Average gestational age in the study group was 30.2 weeks (SD 3.7), average birth weight 1502g (SD 781.5). Average postnatal age in the time of the presenting NEC was 18.2 days (SD 12.8).Results:Logistic regression estimates the influence of risk factors, which in our study related to the treatment of preterm infants on the likelihood of NEC development. Our regression model consisted of seven independent variables (nosocomial infections, mechanical ventilation, nasal continuous positive pressure, morphine, inotropes, blood transfusions, and H2 blockers), which were shown to have a statistically significant impact, X2 (7, n=1222) = 49.522, p<0.0001; two independent variables (nosocomial infection and H2 blockers use) were statistically significant. Preterm infants with nosocomial infection had a three times greater chance of developing NEC, and infants who received H2 blockers had a 1.5 higher risk.Conclusions:Underlying pathology of very low birth weight infants and their treatment in NICU contribute to NEC development. Identifying risk factors can be crucial for the early diagnosis and outcome of disease. Awareness of risk factors should influence changes in practice to reduce the risk of NEC.

Complicated airway management in a neonate of congenital trachea-oesophageal fistula with subglottic stenosis.

Sir, Tracheo-oesophageal fistula and oesophageal atresia (TOF/OA) in neonates are known to coexist with other congenital anomalies in almost 50% of cases.[1] The congenital subglottic stenosis (SGS) rarely has been reported to occur with TOF/OA. We describe the management of a 31 weeks preterm male neonate weighing 1.1 kg who presented for surgical repair of TOF/OA (Gross C/Vogt III b type) on day 2 of life. He had respiratory distress soon after birth for which intubation was attempted; failing of which nasal continuous positive pressure (CPAP) was provided in Intensive Care Unit (ICU). On further evaluation, the baby was found to have tiny patent ductus arteriosus with ventricular septal defect, bilateral renal agenesis and vertebral defects. On arrival in operation theatre (OT), the vitals were heart rate 135/min, blood pressure 74/40 mm Hg and oxygen saturation of 96% on nasal CPAP. Anticipating difficult airway in view of previous failed attempts at intubation, difficult airway cart with available resources were prepared and availability of ENT surgeons in OT was ensured. Anaesthesia was induced with 3–4% sevoflurane with oxygen and fentanyl 2 μg intravenous (IV) was administered. After adequate depth of anaesthesia, intubation with 2.5 mm endotracheal tube (ETT) using 00 Miller blade laryngoscope was attempted but tube could not be negotiated below vocal cords. We then decided to try intubation with 2.0 mm ETT after giving injection atracurium 0.5 mg and gentle positive pressure ventilation. The intubation attempt again failed. An indigenous ETT made from 6 Fr feeding tube having an internal diameter <2 mm (cut short to match the length of 2.0 mm ETT) was then tried to pass below vocal cords. This tube was very pliable, and we could pass only tip below the vocal cords. We could not use ETT stylet to aid in intubation as the smallest available tube stylet in our OT was not able to pass through the indigenous ETT. The positive pressure ventilation through this ETT (attached to the connector of 2 mm ETT using Jackson Rees breathing circuit) was started but it soon got dislodged. The child was continued on gentle positive pressure ventilation through a face mask. As we were not able to pass even a tube of internal diameter (ID) <2 mm to the trachea, ENT surgeons performed rigid endoscopy under anaesthesia and confirmed grade 3 SGS. The surgical tracheostomy was planned after discussion with surgeons and family members of the child. The tracheostomy was performed and a tracheostomy tube of ID 3.0 mm was inserted. In view of multiple intubation attempts, it was decided to perform gastrostomy under anaesthesia and TOF/OA correction was planned for a later stage. The child was provided adequate anti-inflammatory cover and shifted to ICU postoperatively. There are few case report of SGS associated with TOF/OA. The airway management of such patients is extremely challenging for anaesthesiologist as the nature of surgery demands lateral positioning of patient and ETT is the only safe option of maintain the airway. The tracheal intubation may be successful in grade 1 and 2 SGS; however, in grade 3 and 4, it can be difficult even with smallest available ETT as in our case. The neonatal fibreoptic bronchoscope was not available in our hospital; it can be useful in such cases as apart from airway management, it aids in confirmation of diagnosis. Successful intubation with ETT made from feeding tube of 6 Fr size has been reported for a TOF repair.[2] However, we find the material of feeding tube to be soft and pliable compared to standard ETT and has a risk of dislodgement and occlusion of the lumen of the tube during surgery. Another proposed option for airway management in SGS is to dilate the stenotic segment with Fogarty catheter and then pass ETT. The feasibility of this intervention in emergency cases is doubtful as SGS otherwise requires multiple sessions of dilatation for success. Keeping the tip of ETT above the stenosis in a neonate of SGS, presenting for an abdominal surgery has been reported.[3] However, intra-operatively, the tube was dislodged, re-intubation attempts were unsuccessful and patient developed cardiac arrest. Laryngeal mask airway may not be feasible for major abdominal or thoracic surgeries as in our case. Tracheostomy performed after failure of intubation is reported during TOF/OA with SGS management.[4,5] Postoperatively, the babies responded well to dilatation of stenosis at 15 months of age. Although tracheostomy in neonates is not desirable, it is the only safe option available for SGS after failure to pass smallest ETT to trachea. Other adventurous plans of keeping tube above stenosis or using sheath of IV cannula or feeding tube has a risk of dislodgement with disastrous consequences and should be used only if an emergency condition arises. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Effects of ventilation on hearing loss in preterm neonates: Nasal continuous positive pressure does not increase the risk of hearing loss in ventilated neonates

IntroductionThere is increased risk of hearing loss in preterm neonates. This risk is further increased by environmental noise exposure especially from life support equipment such as ventilation. Nasal continuous positive airway pressure (NCPAP) used for respiratory support of preterm neonates is known to be associated with prolonged exposure to high levels of noise. However, there is paucity of information on the effect of NCPAP as compared to mechanical ventilation on hearing loss among preterm neonates. MethodsA retrospective chart review was performed on neonates with birth weight (BW) <1500g. Association of clinical factors including the use of NCPAP and mechanical ventilation with failure of hearing screen were studied. Those who failed hearing screen were followed for 2 years to observe long term effects of NCPAP on the hearing loss. ResultsOf 344 neonates included in the study, 61 failed hearing screen. Gestational age (p=0.008), BW (p=0.03), ventilation (p=0.02), intrauterine growth retardation (p=0.02), necrotizing enterocolitis (NEC) (p=0.02), apnea (p<0.001), use of vancomycin (p=0.01) and furosemide (p=0.01) were associated with failure of hearing screen. On multivariate analysis, ventilation (OR 4.56, p=0.02), apnea (OR 2.2, p<0.001) and NEC (OR 2.4, p=0.02) were predictors of failed hearing screen. As compared to those not ventilated, the odds of failing hearing screen was 4.53 (p<0.01) and 4.59 (p<0.01) for those treated with NCPAP and mechanical ventilation respectively, with there being no difference between these two ventilatory modalities. Of the 61 neonates, 42 were followed for 2 years, of which 19 had confirmed hearing loss. Among these 19 neonates, there was no difference (p=0.12) between those who were treated with NCPAP or with mechanical ventilation. ConclusionThere is no increase in the hearing loss in preterm neonates treated with NCPAP as compared to mechanical ventilation despite being exposed to higher environmental noise generated by the NCPAP.

Sleep-disordered breathing in 15-year-old boy with arterial hypertension

Obstructive sleep apnea/hypopnea syndrome (OSA/HS) is the basis of the spectrum of sleep-disordered breathing (SDB) and is a condition characterized by the presence of snoring, repetitive partial upper airway obstruction (hypopnea) and/or intermittent complete obstruction (apnea), long enough to cause reduce the level of oxygen in the blood (desaturation), fragmented sleep and excessive daytime sleepiness. It is known that OSA/HS in the middle and older age predisposes to arterial hypertension (AH). We discuss a case of 15-year-old boy with AH and OSA/HS. He was treated on nasal continuous positive pressure in the upper airway (nasal CPAP) with good results.

Regular CPAP utilization reduces nasal inflammation assessed by nasal cytology in obstructive sleep apnea syndrome

To analyze nasal inflammation in a group of patients with obstructive sleep apnea syndrome (OSAS) by means of nasal cytology and to describe the changes induced by continuous positive air pressure (CPAP) treatment. Thirty-two consecutive patients affected by OSAS (mean age 46.9 years) and 13 control subjects (mean age 49.1 years) were enrolled. Detailed clinical, laboratory, and polysomnographic studies were obtained in all participants and, in particular, nasal cytology was performed; inflammatory cells (neutrophils, eosinophils, mast cells, lymphocytes), bacteria, and spores were counted. A subgroup of 19 OSAS patients underwent regular nasal CPAP for eight weeks while the remaining 13 were noncompliant. Nasal cytology was repeated after eight weeks in all patients and controls. All patients with OSAS were affected by some form of rhinopathy, mostly subclinical, which was not found to influence compliance to CPAP. Regular CPAP treatment induced a significant reduction of cell infiltration (neutrophils, eosinophils, lymphocytes, and muciparous cells), which was not seen in nontreated patients. Nasal inflammation/infection is a very frequent finding in OSAS and can be reverted by the regular use of CPAP.

Continuous positive air pressure treatment reduces serum advanced glycation end products in patients with obstructive sleep apnoea syndrome: a pilot study

Nasal continuous positive air pressure (nCPAP) treatment may favourably affect serum levels of advanced glycation end products (AGEs) in patients with obstructive sleep apnoea syndrome (OSAS). At baseline, OSAS patients had significantly higher levels of AGEs than controls. Six months after nCPAP initiation, AGEs decreased significantly. nCPAP treatment could lower AGEs in patients with OSAS.