Treatment Of Respiratory Distress Syndrome Research Articles

Nitric oxide for the treatment of preterm infants with severe RDS and pulmonary hypertension.

Inhaled nitric oxide (iNO) cannot be recommended for the routine treatment of respiratory failure in premature neonates, but it has been suggested that the effectiveness of iNO therapy should be further studied in more select preterm infants, such as those with persistent pulmonary hypertension of the newborn (PPHN). To evaluate the frequency of PPHN in very preterm infants with severe respiratory distress syndrome (RDS), to assess the effectiveness of iNO in these patients, and to individuate possible predictive factors for the response to iNO in preterm infants with RDS. We retrospectively studied infants <30 weeks of gestational age or birth weight <1250 g, who were affected by severe RDS and treated with iNO during the first week of life. Clinical characteristics of infants with or without echocardiographic diagnosis of PPHN were compared, as well as those of responder or no responder to iNO therapy. Effectiveness of iNO was evaluated by recording changes of MAP, FiO2 , SpO2 /FiO2 ratio, and oxygenation index (OI) before, and 3 ± 1, 6 ± 1, 12 ± 3, 24 ± 6, 48 ± 6, and 72 ± 12 h after beginning therapy. We studied 42 (4.6%) infants, of whom 28 (67%) had PPHN and 14 (33%) did not. iNO therapy was associated with improved oxygenation in both the groups but it was quicker in the PPHN than in the no PPHN group. Multivariate analysis showed that FiO2 >0.65, diagnosis of PPHN, and birth weight >750 g independently predicts effectiveness of iNO in very preterm infants with RDS. We found that PPHN is a frequent complication of severe RDS in very preterm infants and iNO therapy can improve their oxygenation earlier than in infants without PPHN. iNO therapy is not recommended for the routinely treatment of RDS in premature neonates but in cases of concurrent diagnosis of PPHN it should be considered carefully.

Comparison of the Therapeutic Effects of Bubble CPAP and Ventilator CPAP on Respiratory Distress Syndrome in Premature Neonates

Background: Respiratory distress syndrome is one of the main complications associated with low birth weight, and a main cause of mortality in premature neonates. The present study aimed to compare the efficacy of ventilator continuous positive airway pressure (CPAP) and bubble CPAP in the treatment of respiratory distress syndrome (RDS) in premature neonates. Methods: This randomized controlled clinical trial was conducted on 119 neonates diagnosed with RDS, with the gestational age of 28-34 weeks and birth weight of 1000-2200 grams, who were admitted in the neonatal intensive care unit (NICU). Infants were allocated to two groups of ventilator CPAP (VCPAP) and bubble CPAP (BCPAP) therapy. Results: Mean weight, gestational age, and one-minute Apgar score were not significantly different between the two groups. However, duration of treatment with mechanical ventilation in the BCPAP group was significantly lower compared to the VCPAP group. In addition, frequency of complications had no significant difference between the two groups. Conclusion: In the treatment of RDS, duration of mechanical ventilation was lower in the BCPAP group compared to the VCPAP group in premature neonates

Comparison of three non-invasive ventilation strategies (NSIPPV/BiPAP/NCPAP) for RDS in VLBW infants

Background: Non-invasive ventilation (NIV) significantly changed the management of respiratory distress syndrome (RDS) in preterm infants. Further perspectives for neonatologists regard the assessment of different NIV strategies in terms of availability, effectiveness, and failure.Objective: The aim of the present study is to evaluate the effectiveness of three different NIV strategies: nasal continuous positive airway pressure (N-CPAP), nasal synchronized intermittent positive pressure ventilation (N-SIPPV), and nasal bilevel-CPAP (BiPAP), as first intention treatment for RDS in very low birth-weight infants (VLBW).Methods: A multicenter retrospective study was conducted in three neonatal intensive care unit (NICUs) that enrolled 191 VLBW infants complicated by RDS, who received, as first intention treatment for RDS, three different NIV approaches (N-CPAP: n = 66; N-SIPPV: n = 62, BiPAP: n = 63). We evaluated the performance of different NIV strategies by primary (failure within the first 5 d of life) and some selected secondary end-points.Results: The incidence of NIV failure was significantly higher in the N-CPAP group (22/66) versus N-SIPPV/BiPAP groups (11/62; 11/63) (p < .05 for both), while no difference was observed between N-SIPPV and BiPAP groups. Moreover, no differences were found between the three groups regarding secondary outcomes.Conclusions: The present study shows that first intention N-SIPPV/BiPAP, as NIV support, augment the beneficial effects of N-CPAP contributing to a reduced risk of failure in VLBW infants complicated by RDS. Data open up to further RCTs on a wider population to evaluate NIV effectiveness on long-term outcomes.

EFFECTS OF BOVINE LIPID EXTRACT SURFACTANT (BLES) ADMINISTRATION IN PRETERM INFANTS TREATED FOR RESPIRATORY DISTRESS SYNDROME

BACKGROUND: Surfactant therapy is effective in improving the clinical outcomes of premature infants with respiratory distress syndrome (RDS). Bovine Lipid Extract Surfactant (BLES®) is commonly used to treat RDS in premature infants in Neonatal Intensive Care Units (NICU) across Canada. OBJECTIVES: To describe the length of time to wean to room air following the administration of BLES for the treatment of RDS in premature infants as per local evidence-based practice guideline. DESIGN/METHODS: Retrospective review of data collected from infants born < 37 weeks with RDS treated with surfactant replacement therapy between February 1, 2015 and March 1, 2016. Data were analysed to determine the timing of initial surfactant administration, length of time to wean to room air and number of doses required. Infants were sub grouped within gestational age stratum; 230 weeks to 276 weeks (extreme preterm - group 1), 280 weeks to 316 weeks (very preterm - group 2) and 320 weeks to 366 weeks (group 3). RESULTS: Ninety eight premature infants with RDS were treated with surfactant during the study period. Twenty one infants were excluded due to incomplete data collection (16/21) and ongoing oxygen requirement prior to second dose of surfactant (5/21).Seventy seven infants were analysed; mean gestational age and birth weight were 286 weeks (SD 3.5) and 1250 grams (SD 602). Forty infants (52%) were in group 1, 21 (27%) in group 2 and 16 (21%) in group 3.The initial dose of surfactant in group 1 was given at a median time of 29 minutes (IQR=24) after birth compared to 150 minutes (IQR=595) in group 2 and 990 minutes (IQR=1973) in group 3 (c2=21.89, p<0.001). Median length of time to wean to room air was 14 minutes (IQR=51) in group 1, 10 minutes (IQR=48) in group 2, and 10 minutes (IQR=33) in group 3 (p=0.88). Only 6% of all infants required repeated doses of BLES, 4 infants in group 1 and 1 infant in group 3. CONCLUSION: Extreme preterm infants received their initial dose of BLES® earlier in their RDS management. Given the rapid response to BLES® in the entire patient population, careful monitoring of ventilator parameters should be made, allowing for rapid weaning and eventual extubation after surfactant administration.

The fascinating story of surfactant.

The fascinating story of surfactant.

Effect of Surfactant Therapy Using Orogastric Tube for Tracheal Catheterization in Preterm Newborns with Respiratory Distress.

To assess the outcome of a modified method of Minimally Invasive Surfactant Therapy (MIST) therapy where an orogastric tube was used for tracheal catherization to deliver surfactant in preterm newborns less than 34 wk of gestation with respiratory distress syndrome (RDS). A single centre, prospective observational study was conducted to enroll eligible inborn preterm neonates with gestation age more than 24 wk but less than 34 wk and suffering from RDS to receive surfactant using MIST. Results were compared with a historical cohort of preterms who received surfactant with InSurE (Intubate, Surfactant, Extubate) technique. Sixty four cases in the modified MIST group were compared with a historic cohort of 68 cases in the InSurE group. There were no differences in the requirement of intubation and mechanical ventilation (MV) in the first 72h but the duration of MV and continuous positive airway pressure (CPAP) were significantly less in modified MIST group. Other neonatal morbidities and mortality rates were similar in either of the groups. The modified MIST technique is an effective method for the treatment of RDS in preterms with better clinical efficacy and comparable outcomes than the more invasive InSurE procedure and deserves further evaluation.

Effect of surfactant therapy using an orogastric tube for tracheal catheterization in preterm newborns with respiratory distress

Introduction: Respiratory distress syndrome (RDS) due to surfactant deficiency requires surfactant therapy for which InSurE method (Intubate, Surfactant, Extubate) has been widely used. However this method requires intubation and positive pressure ventilation, even for a short time which is enough to initiate significant lung injury. Recently, surfactant administration by Minimally Invasive Surfactant Therapy (MIST) using a fine catheter under direct laryngoscopy in spontaneously breathing preterms while on nCPAP has reported good outcomes. We prospectively assessed the outcome of a modified MIST method of surfactant administration using an orogastric tube in preterms with RDS. Materials &amp; Methods: A single centre, prospective observational study was conducted where all consecutive eligible inborn preterm neonates with gestation age more than 24 weeks but less than 34 weeks and suffering from RDS were enrolled to receive surfactant using MIST. Results were compared with a historical cohort of preterm who received surfactant with INSURE techniques. Results: Sixty four cases in the modified MIST group were compared with a historic cohort of 68 cases in INSURE group. There were no differences in the requirement of intubation and mechanical ventilation in the first 72 hours but the duration of MV and CPAP were significantly less in modified MIST group. Other neonatal morbidities and mortality rates were similar in either of the groups. Conclusion: The modified MIST technique is an effective method for the treatment of RDS in preterms with better clinical efficacy and comparable outcomes than the more invasive INSURE procedure and deserves further evaluation.

The Improvement of Respiratory Performance After Phototherapy-Induced EPC Mobilization in Preterm Infants With RDS.

Many infants who develop bronchopulmonary dysplasia (BPD) are born with serious respiratory distress syndrome (RDS), which is associated with impaired vascular and alveolar growth. RDS is a breathing disorder that mostly affects preterm infants and occurs in infants whose lungs have not yet been fully developed. The use of surfactant in RDS treatment does not necessarily prevent BPD. Endothelial progenitor cells (EPCs) may contribute to lung angiogenesis for the prevention and treatment of BPD. The aim of this study was to evaluate the therapeutic efficacy of phototherapy for EPC release in preterm infants born with RDS. Seventy-five RDS preterm infants were divided into two groups: RDS with phototherapy and RDS without phototherapy. Respiratory indices were recorded for each patient. Circulating EPCs were isolated before and after phototherapy and colony forming efficiency, chemotactic, tubulogenic, proliferative, and functional properties of these cells were analyzed. Our results showed that phototherapy increased the release of EPCs into the circulation in RDS preterm infants, with augmentation of cell proliferation, tubulogenic, chemotactic, and proliferative properties of EPCs. Phototherapy-induced EPC release was associated with improved lung function as was recorded by significantly decrease in continuous positive airway pressure (CPAP) days, CPAP plus ventilator days, and PCO2 along with a significant increase in PO2 and PaO2 /FiO2 , resulting in markedly decreased rate of BPD occurrence in preterm infants with RDS. Overall, phototherapy is touted as a promising modality for the amelioration of respiratory performance and prohibition of BPD occurrence in RDS preterm infants. J. Cell. Biochem. 118: 594-604, 2017. © 2016 Wiley Periodicals, Inc.

Comparison of Complications and Efficacy of NIPPV and Nasal CPAP in Preterm Infants With RDS

Background:Respiratory distress syndrome (RDS) is one of the most common diseases in neonates admitted to NICU. For this important cause of morbidity and mortality in preterm neonates, several treatment methods have been used. To date, non-invasive methods are preferred due to fewer complications.Objectives:Herein, two non-invasive methods of ventilation support are compared: NCPAP vs. NIPPV.Patients and Methods:This is a randomized clinical trial. Premature neonates with less than 34 weeks gestation, suffering from RDS entered the study, including 151 newborns admitted to Vali-Asr NICU during 2012-2013. Most of these patients received surfactant as early rescue via INSURE method and then randomly divided into two NCPAP (73 neonates) and NIPPV (78 neonates) groups. Both early and late complications are compared including extubation failure, hospital length of stay, GI perforation, apnea, intraventricular hemorrhage (IVH) and mortality rate.Results:The need for re-intubation was 6% in NIPPV vs. 17.6% in NCPAP group, which was statistically significant (P = 0.031). The length of hospital stay was 23.92 ± 13.5 vs. 32.61 ± 21.07 days in NIPPV and NCPAP groups, respectively (P = 0.002). Chronic lung disease (CLD) was reported to be 4% in NCPAP and 0% in NIPPV groups (P = 0.035). The most common complication occurred in both groups was traumatization of nasal skin and mucosa, all of which fully recovered. Gastrointestinal perforation was not reported in either group.Conclusions:This study reveals the hospital length of stay, re-intubation and BPD rates are significantly declined in neonates receiving NIPPV as the treatment for RDS.

Effect of parenterally l-arginine supplementation on the respiratory distress syndrome in preterm newborns

l-Arginine (l-Arg) is the precursor of nitric oxide which plays an important role on pulmonary circulation and pulmonary vascular tone. Earlier studies suggested that l-Arg levels in preterm newborns with respiratory distress syndrome (RDS) were low due to its consumption and l-Arg supplementation may reduce the severity of RDS. Our aim was detect the effect of the parenterally l-Arg supplementation on RDS severity. The subjects were chosen between preterm newborns (gestational age <34 weeks) (n = 30). Twenty of the subjects were diagnosed with permaturity and RDS, and 10 of the subjects were healthy preterm newborns. Ten of the subjects was taken l-Arg (1.5 mmol/kg/d) in addition to routine RDS treatment and assumed as “Group 1”. In this group, daily l-Arg supplementation was started end of the first day, and continued at end of fifth day. The others of the subjects diagnosed with RDS was take routine RDS treatment and assumed as “Group 2”. Healthy preterm newbors assumed as “Group 3”. Blood collections for l-Arg levels via tandem mass spectrometry were made in first day and repeated on the seventh days. Oxygenation index was used to determine severity of RDS. l-Arg consentrations in Group 1 were 8.7 ± 4.1 μM/L and 11.9 ± 5.0 μM/L in first and seventh day, respectively. l-Arg consentrations were 12.6±4.5 μM/Land 10.9 ± 5.4 μM/L in Group 2 and 8.6 ± 5.1 μM/L and 9.4 ± 4.1 μM/L in Group 3. There is no correlation between l-Arg concentrations and OI also duration of the mechanical ventilation of the subjects in patient groups (Group 1 and 2).

Continuous distending pressure for respiratory distress in preterm infants.

Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition, but it is invasive, potentially resulting in airway and lung injury. Continuous distending pressure (CDP) has been used for the prevention and treatment of RDS, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae. To determine the effect of continuous distending pressure (CDP) on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress.Subgroup analyses were planned on the basis of birth weight (> or < 1000 or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), methods of application of CDP (i.e. CPAP and CNP), application early versus late in the course of respiratory distress and high versus low pressure CDP and application of CDP in tertiary compared with non-tertiary hospitals, with the need for sensitivity analysis determined by trial quality.At the 2008 update, the objectives were modified to include preterm infants with respiratory failure. We used the standard search strategy of the Neonatal Review Group. This included searches of the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, 2015 Issue 4), MEDLINE (1966 to 30 April 2015) and EMBASE (1980 to 30 April 2015) with no language restriction, as well as controlled-trials.com, clinicaltrials.gov and the International Clinical Trials Registry Platform of the World Health Organization (WHO). All random or quasi-random trials of preterm infants with respiratory distress were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharyngeal tube or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and the lower body, compared with spontaneous breathing with oxygen added as necessary. We used standard methods of The Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each review author. We included six studies involving 355 infants - two using face mask CPAP, two CNP, one nasal CPAP and one both CNP (for less ill babies) and endotracheal CPAP (for sicker babies). For this update, we included no new trials.Continuous distending pressure (CDP) is associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.52 to 0.81; typical risk difference (RD) -0.20, 95% CI -0.29 to -0.10; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; six studies; 355 infants), lower overall mortality (typical RR 0.52, 95% CI 0.32 to 0.87; typical RD -0.15, 95% CI -0.26 to -0.04; NNTB 7, 95% CI 4 to 25; six studies; 355 infants) and lower mortality in infants with birth weight above 1500 g (typical RR 0.24, 95% CI 0.07 to 0.84; typical RD -0.28, 95% CI -0.48 to -0.08; NNTB 4, 95% CI 2.00 to 13.00; two studies; 60 infants). Use of CDP is associated with increased risk of pneumothorax (typical RR 2.64, 95% CI 1.39 to 5.04; typical RD 0.10, 95% CI 0.04 to 0.17; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 17.00 to 25.00; six studies; 355 infants). We found no difference in bronchopulmonary dysplasia (BPD), defined as oxygen dependency at 28 days (three studies, 260 infants), as well as no difference in outcome at nine to 14 years (one study, 37 infants). In preterm infants with respiratory distress, the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax. Four out of six of these trials were done in the 1970s. Therefore, the applicability of these results to current practice is difficult to assess. Further research is required to determine the best mode of administration.

Clinical observation and nursing care of calf pulmonary surfactant for injection on respiratory distress syndrome in full term infant of cesarean section

Objective To evaluate the efficacy and safety of calf pulmonary surfactant for injection on respiratory distress syndrome (RDS) in full term infant of cesarean section. Methods A total of 30 RDS in full term infant of cesarean section were divided into 2 groups according to family members intend. A group with 17 cases was given endotracheal drip into the calf pulmonary surfactant for injection and breath machine treatment according to the illness needs. B group with 13 cases was given the same treatment with A group except for calf pulmonary surfactant for injection. The changes of blood gas analysis before and after treatment, mechanical ventilation time, X -ray recovery time and hospital stays were compared between 2 groups. Results Arterial blood oxygen partial pressure after treatment in A, B group were (75.6±16.2), (54.8±12.4) mmHg (1 mmHg=0.133 kPa),and there was significant difference between 2 groups, t=3.84, P<0.01. The incidence of cure, ventilation related lung injury and oxygen time needs, hospital stays were 16/17, 1/17, (3.2±1.4) d, (7.2±1.8) d in A group , and 7/13, 6/13, (5.6±2.1) d, (14.7±2.4) d in B group, and there were significant differences, P<0.05 or <0.01. Conclusion Calf pulmonary surfactant for injection in treatment of RDS in full term infant of cesarean section, which is safe and effective and is worthy of promotion. Key words: Cesarean section; Respiratory distress syndrome,newborn; Nursing care; Full term infant

Noninvasive Ventilation Strategies for Early Treatment of RDS in Preterm Infants: An RCT

There is evidence that new methods of noninvasive ventilation (NIV) support have significantly changed respiratory distress syndrome (RDS) management in preterm infants. Further perspectives for neonatologists involve the assessment of different NIV strategies in terms of availability, effectiveness, and failure. This study evaluates the efficacy of 2 different NIV strategies for RDS treatment in very low birth weight (VLBW) infants: nasal synchronized intermittent positive pressure ventilation (NSIPPV), which is a modality of conventional ventilation with intermittent peak inspiratory pressure, and bilevel continuous positive airway pressure (BiPAP), not synchronized, with 2 alternate levels of continuous positive airway pressure. We conducted a 2-center randomized control study in 124 VLBW infants (<1500 g and <32 weeks of gestational age) with RDS who received NIV support (NSIPPV, n = 62; BiPAP, n = 62) within 2 hours of birth. We evaluated the performance of NIV strategies by selected primary outcomes (failure rate and duration of ventilation) and secondary outcomes. The number of failures and duration of ventilation support did not differ between NSIPPV and BiPAP strategies (P > .05 for both). Moreover, no differences between groups were found regarding secondary outcomes (P > .05 for all). The present data show no statistically significant differences between NSIPPV and BiPAP strategies in terms of duration of ventilation and failures, suggesting that both NIV techniques are effective in the early treatment of RDS in VLBW infants. Further randomized investigations on wider populations are needed to evaluate the effect of NIV techniques on long-term outcomes.

Early administration of surfactant via a thin intratracheal catheter in preterm infants with respiratory distress syndrome: Feasibility and outcome.

Objective:Currently, the method of early nasal continuous positive airway pressure (nCPAP) and selective administration of surfactant via an endotracheal tube is widely used in the treatment of respiratory distress syndrome (RDS) in premature infants. To prevent complications related to endotracheal intubation and even a brief period of mechanical ventilation, in this study, we compared the effectiveness of surfactant administration via a thin intratracheal catheter versus the current method using an endotracheal tube.Methods:Thirty eight preterm infants ≤34 weeks' gestation with birth weight of 1000–1800 g who were putted on nCPAP for RDS within the first hour of life, were randomly assigned to receive surfactant either via endotracheal tube (ET group) or via thin intratracheal catheter (CATH group). The primary outcomes were the need for mechanical ventilation and duration of oxygen therapy. Data were analyzed by independent t-test, Mann-Whitney U-test, and Chi-square test, using SPSS v. 21.Findings:There was no significant difference between groups regarding to need for mechanical ventilation during the first 72 h of birth (3 [15.8%] in ET group vs. 2 [10.5%] in CATH group; P = 0.99). Duration of oxygen therapy in CATH group was significantly lower than ET group (243.7 ± 74.3 h vs. 476.8 ± 106.8 h, respectively; P = 0.018). The incidence of adverse events during all times of surfactant administration was not statistically significant between groups (P = 0.14), but the number of infants who experienced adverse events during surfactant administration was significantly lower in CATH group than ET group (6 [31.6%] vs. 12 [63.2%], respectively; P = 0.049). All other outcomes, including duration of treatment with CPAP and mechanical ventilation, times of surfactant administration and the need for more than one dose of the drug, the rate of intraventricular hemorrhage, mortality and combined outcome of chronic lung disease or mortality were statistically similar between the groupsConclusion:Surfactant administration via thin intratracheal catheter in preterm infants receiving nCPAP for treatment of RDS has similar efficacy, feasibility and safety to its administration via endotracheal tube.

Regulation of PACAP receptors in respiratory distress syndrome (RDS) of preterms and newborns

s of the 51st Workshop for Pediatric Research 51st Workshop for Pediatric Research Gottingen, Germany 16-17 April 2015 This supplement has not been sponsored. Meeting abstracts Background Prevalence of respiratory distress syndrome (RDS) caused by primary surfactant deficiency reaches 50% in infants below 32 weeks of gestational age. Increased alveolar surface tension leads to atelectatic and/or dystelectatic lung areas followed by inflammation resulting in development of a bronchopulmonary dysplasia (BPD) in 8% of these children. Standard RDS treatment consists of administration of exogenous surfactant. With the introduction of less invasive application (LISA) of exogenous surfactant, the use of Surfactant has significantly increased. Pituitary adenylate cyclase-activating polypeptide (PACAP) and its receptors (VPAC1, VPAC2, PAC1) trigger inflammatory reactions as well as anti-inflammatory processes. Materials and methods Using cell cultures, FACS and ELISA methods we analyzed surfactant effects on inflammation and PACAP-regulation and of its receptors in vivo and ex vivo. Results We were able to show that lipopolysaccharide (LPS) in prestimulated cells (PBMC) after surfactant treatment resulted in a significant up-regulation of pro-inflammatory interleukin (IL)-8. In tracheal secretory cells of surfactant-treated neonates we found an up-regulation of pro-inflammatory receptor VPAC1. Furthermore, in cell cultures we identified changes in the proliferation rates. Amniotic infection syndrome (AIS) is one of the major causes for premature birth resulting in RDS requiring exogenous surfactant. After pre-stimulation of PBMCs and subsequent addition of surfactant, pro-inflammatory signals were fortified. These results were confirmed by analysis of tracheal secretions of preterms and newborns. Conclusions Current findings may imply that safety and efficacy of routine surfactant administration should be reassessed as surfactant potentially triggers pulmonary inflammation and thus may contribute to BPD development.

Bi-level CPAP does not change central blood flow in preterm infants with respiratory distress syndrome.

BackgroundCurrent literature provides limited data on the hemodynamic changes that may occur during bi-level continuous positive airway pressure (CPAP) support in preterm infants. However, the application of a positive end-expiratory pressure may be transmitted to the heart and the great vessels resulting in changes of central blood flow.ObjectiveTo assess changes in central blood flow in infants with respiratory distress syndrome (RDS) during bi-level CPAP support.DesignA prospective study was performed in a cohort of 18 Very-Low-Birth-Weight Infants who were put on nasal CPAP support (4–5 cmH2O) because they developed RDS within the first 24–72 hours of life. Each subject was switched to bi-level CPAP support (Phigh 8 cmH2O, Plow 4–5 cmH2O, Thigh 0.5-0.6 seconds, 20 breaths/min) for an hour. An echocardiographic study and a capillary gas analysis were performed before and after the change of respiratory support.ResultsNo differences between n-CPAP and bi-level CPAP in left ventricular output (LVO, 222.17 ± 81.4 vs 211.4 ± 75.3 ml/kg/min), right ventricular output (RVO, 287.8 ± 96 vs 283.4 ± 87.4 ml/kg/min) and superior vena cava flow (SVC, 135.38 ± 47.8 vs 137.48 ± 46.6 ml/kg/min) were observed. The hemodynamic characteristics of the ductus arteriosus were similar. A significant decrease in pCO2 levels after bi-level CPAP ventilation was observed; pCO2 variations did not correlate with modifications of central blood flow (LVO: ρ = 0.11, p = 0,657; RVO: ρ = −0.307, p = 0.216; SVC: ρ = −0.13, p = 0.197).ConclusionsCentral blood flow doesn’t change during bi-level CPAP support, which could become a hemodinamically safe tool for the treatment of RDS in preterm infants.

My tribute to Mary ellen avery.

My tribute to Mary ellen avery.

A randomized pilot study comparing heated humidified high‐flow nasal cannulae with NIPPV for RDS

To compare the requirement for endotracheal ventilation in preterm infants treated with heated, humidified high-flow nasal cannula (HHHFNC) with those treated with nasal intermittent positive pressure ventilation (NIPPV) for the primary treatment of respiratory distress syndrome (RDS). Randomized, controlled, prospective, single-center pilot study. Infants (gestational age [GA] <35 weeks, birth weight [BW] >1,000 g) with RDS were randomly assigned to receive HHHFNC (38 infants) delivered by Vapotherm® device (Precision Flow™ or 2000 i, Vapotherm Inc., Stevensville, MD), at flows between 1.0 and 5.0 L/min, or NIPPV (38 infants) delivered by the SLE 2000 or 5000. Surfactant was administered as rescue therapy. Analysis was done by intention-to-treat. Infant's characteristics ([mean ± SD] GA 31.8 ± 2.3 vs. 32.0 ± 2.3 weeks) and cardio-respiratory status at study entry (FiO2 0.25 ± 0.05 vs. 0.26 ± 0.07; SpO2 90 ± 6% vs. 87 ± 12; PCO2 54.4 ± 10.4 vs. 52.6 ± 8.0 mmHg) were comparable for the HHHFNC and NIPPV groups. There was no significant difference in the need for endotracheal ventilation (28.9% vs. 34.2%) between HHHFNC and NIPPV groups. One infant failed HHHFNC and succeeded on NIPPV. The rate of neonatal morbidities (pneumothorax, bronchopulmonary dysplasia, intra-ventricular hemorrhage, necrotizing enterocolitis, patent ductus arteriosus, and nasal trauma) was comparable in both groups. Duration of nasal support was longer with HHHFNC compared with NIPPV (5.4 ± 4.0 vs. 2.6 ± 1.9 days, P = 0.006) but the duration of endotracheal ventilation, time to full feeds, and length of stay were comparable. Our pilot study suggests that HHHFNC maybe as effective as NIPPV in preventing endotracheal ventilation in the primary treatment of RDS in premature infants (<35 weeks GA and BW >1,000 g).

Comparison of Effectiveness of Nasal Continuous Positive Airway Pressure and Nasal Intermittent Positive Pressure Ventilation for the Initial Treatment of Preterm Respiratory Distress Syndrome: A Prospective Pilot Study

Purpose: To compare respiratory and clinical outcomes between the currently used strategy of Intubation, Surfactant, Extubation (InSurE) and nasal continuous positive airway pressure (NCPAP) and the alternative strategy of InSurE and nasal intermittent positive pressure ventilation (NIPPV) for the initial treatment of respiratory distress syndrome (RDS) in preterm newborns ≤32 weeks. Methods: Twenty-six comparable preterm infants with RDS were included in the study; 13 were randomized to NCPAP and 13 to NIPPV. In both groups, the InSurE procedure consisted of intubation, surfactant instillation and 2 h positive pressure ventilation followed by extubation, after which spontaneously breathing newborns were placed on NCPAP or NIPPV. Results: There were no differences in demographic characteristics or cardiorespiratory status among preterm infants enrolled in the study. The reinutation rate was lower among the infants treated with NIPPV than among those on NCPAP (8% vs. 46%, P<0.05) and the rate of aminophylline use between 4 and 7 days of age of was lower in the NIPPV group compared to the NCPAP group (8% vs. 30%, P <0.05). In addition, “InSurE with NIPPV” significantly reduced the overall duration of endotracheal ventilation and shortened the time to first feed compared to “InSurE with NCPAP” . Conclusion: “InSurE with NIPPV” displayed therapeutic benefits as the initial treatment of preterm RDS when compared with the currently used ventilator strategy, “InSurE with NCPAP” by preventing re-intubation and shortening the duration of endotracheal ventilation.

Bubble CPAP: An Alternative That Is as Good as it Gets!

Source: Tagare A, Kadam S, Vaidya U, et al. Bubble CPAP versus ventilator CPAP in preterm neonates with early onset respiratory distress - a randomized controlled trial. J Trop Pediatr. 2013; 59(2): 113– 119; doi: 10.1093/tropej/fms061Researchers from India and Australia compared the safety and efficacy of bubble (B) continuous positive airway pressure (CPAP) with ventilator-derived CPAP (VCPAP) in preterm infants. They conducted a randomized controlled trial and enrolled infants at <37 weeks gestation who developed respiratory distress within 6 hours of birth. Only infants who had an oxygen requirement of >30% and who had at least moderate retractions and/or grunting as determined by a Silverman-Anderson (SA) score >4 (range of possible scores 0–10) were eligible for enrollment. At enrollment, study infants were randomized to BCPAP or VCPAP. Commercial brand equipment was used for both groups, including a bubble generator and blender for BCPAP, ventilator equipment for VCPAP, and nasal prongs. Both groups were started on 40% FiO2 and a CPAP pressure of 6 cm of water (cmW). Based on clinical assessment and a goal of maintaining an oxygen saturation of 88% to 93%, FiO2 was changed in increments of 5% and CPAP in increments of 1 cmW. After 1 hour of CPAP support, surfactant replacement was administered to infants requiring ≥40% FiO2, ≥6 cmW CPAP, and having x-ray findings consistent with respiratory distress syndrome (RDS).The primary study outcome was success of the allocated ventilation method. Success was defined as discontinuation of CPAP within 72 hours and no need for mechanical ventilation, oxygen requirement of <30%, and an SA score <3. Secondary outcomes included need for surfactant therapy, nasal injury from CPAP, and overall mortality.One hundred and fourteen infants were enrolled, with 57 in each group. The groups were comparable at baseline with respect to gestational age, birth weight, and SA score.Neonates treated with BCPAP were significantly more likely to have successful treatment than those randomized to VCPAP (82.5% and 63.2%, respectively, P = .3). Surfactant was given to more infants in the VCPAP than BCPAP group (18/57 vs 9/57, P < .05). Overall, infants who required surfactant were significantly less likely to have successful CPAP treatment, regardless of type of CPAP. VCPAP and BCPAP groups were comparable in terms of CPAP duration (30 hours and 36 hours, respectively) and mortality (8.8% and 7%, respectively). Injury to the nasal septum was more frequent in infants randomized to BCPAP (21.1%) than to those receiving VCPAP (7%) (P = .03).The authors conclude that BCPAP is safe and more effective than VCPAP when used early for preterm neonates with moderate to severe RDS.Drs Santisteban-Ponce and Bedrick have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.CPAP emerged in 1971 as an alternative to mechanical ventilation for preterm infants with RDS, reducing the need for intubation.1 CPAP regained popularity with the increased survival of very low birth weight (VLBW) infants, decreasing the incidence of chronic lung disease through its use with many modalities, including endotracheal tube and mechanical ventilator, or the nasal route with a flow-driver CPAP or BCPAP.2BCPAP delivers a pressurized flow of humidified gas through a breathing circuit with nasal prongs. The pressure delivered is controlled by adjusting the depth of a partially submerged tube in a water bottle (depth of 1 cm equals 1 cm of H2O pressure) attached to the end of the infant’s breathing circuit.3 The bubbling of BCPAP generates a small airway pressure oscillation, which is thought to reduce the work of breathing, improve gas exchange, and facilitate alveolar recruitment. BCPAP airway pressure waveforms are similar to those produced by high frequency oscillatory ventilation.3 It is a simple, low-cost apparatus.Studies in VLBW infants treated with BCPAP in the delivery room noted decreased intubations and fewer days on mechanical ventilation. 2,4 BCPAP has been shown to enhance alveolar gas exchange in premature infants compared to VCPAP.3 BCPAP has also been effective in maintaining spontaneous breathing following extubation of newborns and in treating apnea of prematurity, addressing multiple respiratory needs of premature infants.The use of BCPAP in developing countries could be expected to decrease health care costs for the treatment of neonatal RDS, as has been described in resource-rich environments.5 Many nasal septum injuries could be prevented by using experienced nurses.6 The results of the current study support the observation that less invasive respiratory therapy strategies can be successfully used in resource-limited areas, reducing demand for ventilators and exogenous surfactant. The application of respiratory support devices that are user-friendly, inexpensive, and effective for treatment of large numbers of premature babies is as good as it gets!