High-frequency vs. conventional ventilation at the time of CDH repair is not associated with higher mortality and oxygen dependency: a retrospective cohort study.

PURPOSE: The VICI-trial reported that in patients with congenital diaphragmatic hernia (CDH), mortality or bronchopulmonary dysplasia (BPD) were equivalent using conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation. The purpose of this study was to determine if the mode of ventilation at the time of CDH repair affected mortality or oxygen dependence at 28 days. METHODS: We performed a retrospective cohort study of infants born wih CDH from 1991 to 2015. A generalized linear model was applied to the data using a propensity score analysis. RESULTS: Eighty patients met the inclusion criteria; at the time of surgery 39 (48.8%) patients were on HFV and 41 (51.3%) patients were on CMV. In the HFV group, 16 (47.1%) patients remained oxygen dependent and there were 5 (12.8%) deaths at 28 days. In the CMV group, 5 (12.2%) patients remained oxygen dependent at 28 days but none had died. The base model demonstrated that the HFV group had increased rates of oxygen dependence [OR = 6.40 (2.13, 22.2), p = 0.002]. However, after propensity score analysis, we found no difference between HFV and CMV. CONCLUSION: Our study suggests that in infants with CDH, there is no significant difference between HFV and CMV in oxygen dependency or death.

The Impact of Hypoxemia on the Development of Retinopathy of Prematurity in Infants Less Than 29 Weeks of Gestation.

OBJECTIVE: To study the impact of cumulative exposure to hypoxemia on the development of retinopathy of prematurity (ROP) in preterm infants less than 29 weeks' gestation. STUDY DESIGN: This is a retrospective analysis of the effect of cumulative exposure to hypoxemia during the first 10 weeks of life in preterm infants <29 weeks' gestation. Cumulative time spent at various levels of oxygen saturation was calculated by converting the daily percentage of time to minutes per day. Cumulative exposure to hypoxemia (cT<80 or oxygen saturation <80%) was calculated weekly and compared between outcomes. The primary outcome was the development of ROP requiring treatment. RESULTS: Cumulative hypoxemia exposure was significantly associated with ROP requiring treatment. When adjusted for other neonatal morbidities, only gestation was consistently associated with ROP requiring treatment. CONCLUSION: Cumulative exposure to hypoxemia in the first few weeks was not associated with ROP or treatment of ROP after adjustment for confounders.

Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units.

AIM: To evaluate practice variation with respect to noninvasive respiratory support (NRS) use across Canadian neonatal intensive care units (NICUs). METHODS: A web-based survey was sent to all site investigators of the 30 level 3 NICUs participating in the Canadian Neonatal Network. The survey inquired about the use of five commonly described NRS modes. In addition, the presence and adherence to local guidelines were ascertained. Descriptive analyses were performed to identify variations in practice. RESULTS: In total, 28 (93%) of the 30 tertiary NICUs responded to the survey. Continuous positive airway pressure (CPAP) was employed universally (100%). High-flow nasal cannula (HFNC) was used in 89% of NICUs, biphasic CPAP in 79% and nasal intermittent positive pressure ventilation (NIPPV) in 54%, and nasal high-frequency ventilation was used in 18% of units. Only 61% of all NRS use was guided by local policies, with the lowest being for HFNC (36%). There was a wide range of settings employed and interfaces used for all NRS modes. CONCLUSION: There are significant practice variations in NRS use across Canadian NICUs. Further research is needed to evaluate the significance in relation to pulmonary outcomes to determine optimal NRS strategies.

High frequency jet ventilation versus high frequency oscillatory ventilation for pulmonary dysfunction in preterm infants.

BACKGROUND: Respiratory distress syndrome (RDS) is considered one of the major contributors to severe pulmonary dysfunction and consequent death in preterm infants. Despite widespread improvements in care, including increased utilization of antenatal steroids, use of surfactant replacement therapy, and advances in conventional mechanical ventilation (CMV), chronic lung disease (CLD) occurs in 42% of surviving preterm infants born at less than 28 weeks gestational age (GA). High frequency ventilation (HFV) aims to optimize lung expansion while minimizing tidal volume (Vt) to decrease lung injury. Two methods of HFV - high frequency oscillatory ventilation (HFOV) and high frequency jet ventilation (HFJV) - are widely used, but neither has demonstrated clear superiority in elective or rescue mode. OBJECTIVES: To compare the benefits and side effects of HFJV versus HFOV for mortality and morbidity in preterm infants born at less than 37 weeks GA with pulmonary dysfunction in both elective and rescue modes. SEARCH METHODS: We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 11), MEDLINE via PubMed (1966 to November 30, 2015), EMBASE (1980 to November 30, 2015), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to November 30, 2015). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. We imposed no date, language, or publication restrictions. SELECTION CRITERIA: We planned to include randomized, cluster-randomized, and quasi-randomized controlled trials if study authors stated explicitly that groups compared in the trial were established by a random or systematic method of allocation. We planned to exclude cross-over studies, as they would not allow assessment of the outcomes of interest. DATA COLLECTION AND ANALYSIS: We used the standard methods of the Neonatal Cochrane Review Group, including independent trial assessment and data extraction. We intended to analyze the data by using risk ratios (RRs) and risk differences (RDs) and 1/RD. We planned to calculate the number needed to treat for an additional beneficial outcome (NNTB) or the number needed to treat for an additional harmful outcome (NNTH). MAIN RESULTS: We found no studies that met our inclusion criteria. AUTHORS' CONCLUSIONS: We found no evidence to support the superiority of HFJV or HFOV as elective or rescue therapy. Until such evidence is available, comparison of potential side effects or presumed benefits of either mode is not feasible.

Use of an obturator with nCPAP in a premature infant with a cleft lip and palate.

Premature infants have underdeveloped lungs and their care involves the use of nasal continuous positive airway pressure (nCPAP). For an adequate amount of oxygen to enter the lungs, the palate needs to be intact. Premature infants with a cleft lip and palate remain intubated for extended periods of time with the risks inherent in long-term intubation because of the inability to maintain nCPAP. This paper describes the fabrication of a custom-designed obturator attached to nCPAP variable flow generator tubing for a premature infant with a unilateral cleft lip and palate.

CO(2) inhalation as a treatment for apnea of prematurity: a randomized double-blind controlled trial.

OBJECTIVE: To compare the effect of prolonged inhalation of a low concentration of CO(2) with theophylline for the treatment of apnea of prematurity. STUDY DESIGN: Prospective, randomized, double-blind controlled trial of 87 preterm infants with apnea of prematurity (27-32 weeks' gestational age) assigned to either theophylline plus 0.5 L/min of room air via nasal prongs or placebo plus 0.5 L/min with CO(2) (about 1% inhaled) by nasal prongs for 3 days. RESULTS: Apnea time significantly decreased in the theophylline group from 189±33 s/h (control) to 57±11, 50±9, and 61±13 (days 1-3) (P=.0001) and in the CO(2) group from 183±44 (control) to 101±26, 105±29, and 94±26 s/h (days 1-3) (P=.03). Seven infants in the CO(2) group but none in the theophylline group failed to complete the study due to severe apneas (P=.003). CONCLUSIONS: Because theophylline was more effective in reducing the number and severity of apneas, inhalation of low concentration of CO(2), as used in the present study, cannot be considered as an alternative to theophylline in the treatment of apnea of prematurity. The less effectiveness of CO(2) treatment may have been related to the variability of the delivery of CO(2).