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.

Noninvasive ventilation strategies for early treatment of RDS in preterm infants: an RCT.

BACKGROUND AND OBJECTIVES: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Lung function and respiratory health at school age in ventilated very low birth weight infants.

OBJECTIVE: To investigate respiratory health and lung function in school-aged children without broncho-pulmonary dysplasia (BPD), who were very low birth weight (VLBWi) and randomized at birth to high frequency oscillatory ventilation (HFOV) or volume guarantee (VG) ventilation for severe respiratory distress syndrome (RDS). METHODS: In this observational study, 7-y-old ex-preterm infants with severe RDS, randomly assigned at birth to receive assisted/control ventilation + VG (Vt = 5 mL/kg, PEEP = 5 cmH2O)(VG group; mean GA 27 ± 2 wk; mean BW 1086 ± 158 g) or HFOV (HFOV group; mean GA: 27 ± 2; mean BW: 1090 ± 139 g) (both groups were ventilated with Drager Babylog 8000 plus) were recalled. Neonatal clinical data and outcome were known. Actual outcomes were investigated with an interview; lung function was measured by whole-body plethysmography. RESULTS: Twenty five children were studied (VG group, n = 13 vs. HFOV group, n = 12). There were no differences in anthropometric data, drugs (steroids/bronchodilators and antibiotics) or hospital readmission for respiratory disorders. Compliance to the test was adequate. The authors found a similar obstructive deficit (elevated values: airway resistance (RAW), residual volume (RV), total lung capacity (TLC) with near-normal spirometry) in both groups suggesting a persistent airflow limitation even in absence of BPD. CONCLUSIONS: VLBW infants even in absence of BPD, need long term respiratory follow-up, because they frequently show an impairment of lung function, independent from initial respiratory support, even if at birth the choice is a lung protective approach (e.g., HFOV or VG ventilation).

Lung recruitment maneuver during volume guarantee ventilation of preterm infants with acute respiratory distress syndrome.

Preterm infants need the achievement of adequate lung volume. Lung recruitment maneuver (LRM) is applied during high-frequency oscillatory ventilation. We investigated the effect of an LRM with positive end-expiratory pressure (PEEP) on oxygenation and outcomes in infants conventionally ventilated for respiratory distress syndrome (RDS). Preterm infants in assisted controlled ventilation+volume guarantee for RDS after surfactant randomly received an LRM (group A) or did not (group B). LRM entailed increments of 0.2 cm H (2)O PEEP every 5 minutes, until fraction of inspired oxygen (Fi O(2))=0.25. Then PEEP was reduced and the lung volume was set on the deflation limb of the pressure/volume curve. When saturation of peripheral oxygen fell and Fi O(2) rose, we reincremented PEEP until Sp O(2) became stable. Group A ( N=10) and group B ( N=10) infants were similar: gestational age 25 ± 2 versus 25 ± 2 weeks; body weight 747 ± 233 versus 737 ± 219 g; clinical risk index for babies 9.8 versus 8.1; initial Fi O(2) 56 ± 24 versus 52 ± 21, respectively. LRM began at 86 ± 69 minutes of age and lasted for 61 ± 18 minutes. Groups A and B showed different max PEEP during the first 12 hours of life (6.1 ± 0.3 versus 5.3 ± 0.3 cm H (2)O, P=0.00), time to lowest Fi O(2) (94 ± 24 versus 435 ± 221 minutes; P=0.000) and O(2) dependency (29 ± 12 versus 45 ± 17 days; P=0.04). No adverse events and no differences in the outcomes were observed. LRM led to the earlier lowest Fi O(2) of the first 12 hours of life and a shorter O (2) dependency.