Lung and diaphragm ultrasound as predictors of successful weaning from nasal continuous positive airway pressure in preterm infants.

OBJECTIVE: Assessment of the utility of lung and diaphragm ultrasound in the prediction of successful weaning from nasal continuous positive airway pressure (NCPAP) in preterm infants. STUDY DESIGN: This prospective cohort study was conducted on preterm infants who were considered ready for weaning off NCPAP. Lung and diaphragm ultrasound were performed just before and 3 h after weaning off NCPAP. The primary outcome was to evaluate the accuracy of lung ultrasound (LUS) in predicting successful weaning from NCPAP. RESULTS: Out of 65 enrolled preterm infants, 30 (46.2%) were successfully weaned from NCPAP to room air. The successful weaning group had higher gestational ages, lower incidences of previous invasive mechanical ventilation, and treated hemodynamically significant patent ductus arteriosus before the trial weaning. A LUS score of ≤6, measured before discontinuation of NCPAP, exhibited a predictive sensitivity of 80% and specificity of 75% for successful weaning (Area under the curve (AUC) = 0.865, ≤.001). When the LUS score was assessed 3 h after weaning from NCPAP, a cutoff point of ≤7 predicted successful weaning with a sensitivity and specificity of 90% and 60% respectively (AUC = 0.838, p ≤ .001). The diaphragmatic thickness fraction (DTF) was significantly lower in the successful weaning group. After adjustment for various factors, LUS score remained the only independent predictor of successful weaning. CONCLUSION: LUS score before weaning from NCPAP has a good sensitivity and specificity for predicting successful weaning from NCPAP in preterm infants. Diaphragmatic excursion and DTF were not good predictors.

Severe Pneumonia Caused by Respiratory Syncytial Virus and Adenovirus in Children from 2 to 24 Months at Children's Hospital 1 in Ho Chi Minh City, Vietnam.

In Vietnam, due to the lack of facilities to detect respiratory viruses from patients' specimens, there are only a few studies on the detection of viral pathogens causing pneumonia in children, especially respiratory syncytial virus (RSV) and adenovirus (Adv). Here, we performed a cross-sectional descriptive prospective study on 138 children patients from 2 to 24 months old diagnosed with severe pneumonia hospitalized at the Respiratory Department of Children's Hospital 1 from November 2021 to August 2022. The number of patients selected in this study was based on the formula n = ([Z(1 - α/2)]2 × P [1 - P])/d2, with α = 0.05, p = 0.5, and d = 9%, and the sampling technique was convenient sampling until the sample size was met. A rapid test was used to detect RSV and Adv from the nasopharyngeal swabs and was conducted immediately after the patient's hospitalization. Laboratory tests were performed, medical history interviews were conducted, and nasotracheal aspirates were collected for multiplex real-time PCR (MPL-rPCR) to detect viral and bacterial pathogens. The results of the rapid test and the MPL-rPCR in the detection of both pathogens were the same at 31.9% (44/138) for RSV and 8.7% (7/138) for Adv, respectively. Using MPL-rPCR, the detection rate was 21% (29/138) for bacterial pathogens, 68.8% (95/138) for bacterial-viral co-infections, and 6.5% (9/138) for viral pathogens. The results showed few distinctive traits between RSV-associated and Adv-associated groups, and the Adv group children were more prone to bacterial infection than those in the RSV group. In addition, the Adv group experienced a longer duration of treatment and a higher frequency of re-hospitalizations compared to the RSV group. A total of 100% of Adv infections were co-infected with bacteria, while 81.82% of RSV co-infected with bacterial pathogens (p = 0.000009). This study might be one of the few conducted in Vietnam aimed at identifying viral pathogens causing severe pneumonia in children.

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.

Effect of Yakson touch and mother's voice on pain and comfort level during nasal CPAP application in Turkey: A randomized controlled study.

PURPOSE: This study was conducted to evaluate the effects of Yakson touch and mother's voice on pain and comfort levels of preterm infants during nasal CPAP application. DESIGN AND METHODS: The study was conducted as a randomized experimental study with a control group. It included 124 premature infants (mother's voice group = 31, Yakson touch group = 31, mother's voice+ Yakson touch group= 31, control group = 31) of 28-37 weeks of age who had nasal CPAP application in the NICU of a state hospital in souteastern Turkey between April 2019 and August 2020. While the infants in the experimental group received mother's voice, Yakson touch, and mother's voice+ Yakson touch procedures before, during and after nasal CPAP application, the infants in the control group received nasal CPAP application without extra intervention. "Newborn Infant Pain Scale (NIPS)" and "Premature Infant Comfort Scale (PICS)" were used to collect data. RESULTS: Further analysis revealed that the Yakson Touch was the most beneficial intervention for reducing NIPS scores and PICS scores during and after nasal CPAP application in the experimental groups, followed by mother's voice + Yakson touch and lastly mother's voice. CONCLUSION: Yakson touch and mother's voice+Yakson touch methods, are effective in neonatal pain and comfort management during and after the nasal CPAP application.

Clinical characteristics and outcomes in neonates with perinatal acute respiratory distress syndrome in China: A national, multicentre, cross-sectional study.

Background: Neonatal acute respiratory distress syndrome (NARDS) was defined in 2017 and the epidemiological data remain unknown. Our objective was to explore aetiological factors, clinical characteristics and outcomes in patients with perinatal NARDS. Methods: A multicentre, prospective, cross-sectional study was performed in 58 tertiary neonatal intensive care units in China from Jan 1, 2018 to June 30, 2019. Neonates diagnosed with NARDS were included. Primary outcomes were aetiological factors, clinical characteristics and outcomes. Binary logistic regression and multivariate cox proportional regression were performed to identify independent predictors for bronchopulmonary dysplasia (BPD) and/or death or single death. This study was registered with ClinicalTrials.Gov, NCT03311165. Findings: Among 70,013 admitted neonates, the incidence of NARDS was 1.44% (1005). The cumulative incidences were 65.6%, 86.7%, 94.1% within one, two and three days after birth. The median gestational age and birth weight were 36.4 weeks and 2700 g. Three main aetiological triggers included pneumonia (58.1%), asphyxia (24.3%) and early-onset sepsis (EOS) (21.3%). BPD and/or death was observed in 213 (21.2%) infants, consisting 104 (10.3%) BPD and 126 (12.6%) deaths. The numbers of mild, moderate and severe NARDS were 537 (53.4%), 286 (28.4%) and 182 (18.2%). Two or more doses of surfactant was associated with increased mortality as compared with one or less doses of surfactant (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.20-3.10, P = 0.006). Similarity also appeared in the comparison between EOS and non-EOS triggers (OR 1.57, 95% CI 1.06-2.33, P = 0.023). Interpretation: NARDS incidence was 1.44% and the three main aetiologies were pneumonia, asphyxia and EOS. The cumulative incidences were 65.6%, 86.7%, and 94.1% within one, two and three days after birth. Our results suggested that two or more doses of surfactant increased mortality compared with one or less doses of surfactant. Funding: The National Clinical Research Center of China and Clinical Medical Study Program of Children's Hospital of Chongqing Medical University (NCRC-2019-GP-13) and Natural Science Foundation of Chongqing (cstc2020jcyj-msxmX0197).

Noninvasive ventilation of air transported infants with respiratory distress in the Canadian Arctic.

Objectives: Since 2016, use of nasal continuous positive airway pressure (nCPAP) in Nunavut for air transport in select patients has become common practice. This study examines the outcomes of patients transferred by air from the Qikiqtaaluk Region during air transport. We examined intubation rates, adverse events during transfer, and respiratory parameters at departure and upon arrival. Methods: This was a retrospective review from September 2016 to December 2019 including patients under 2 years of age transferred by air on nCPAP from the Qikiqtaaluk Region of Nunavut. Results: Data were collected for 40 transfers involving 34 unique patients. Six transfers were from remote communities in Nunavut to Iqaluit, and 33 transfers were from Iqaluit to CHEO. The primary outcome measure was whether the patient required intubation during transport, or urgent intubation upon arrival to CHEO. The median nCPAP setting during transport was 6 cm H2O (5-7 cm H2O) and at arrival to CHEO was 6 cm H2O (6-7 cm H2O). Six of the 33 (18.2%) patients required intubation during their hospital stay and five (15.2%) in a controlled ICU setting. There were no discernible adverse events that occurred during transport for 28 patients (84.5%). Four patients (12.1%) required a brief period of bag-mask ventilation and one patient had an episode of bradycardia. Conclusions: nCPAP on air transport is a safe and useful method for providing ventilatory support to infants and young children with respiratory distress.

Prediction of weaning readiness off nasal CPAP in preterm infants using point-of-care lung ultrasound.

This study's primary aim was to assess whether end-expiratory lung ultrasound severity score (expLUSsc) at Day 3 of life, the second week of life, and before weaning off nasal continuous positive airway pressure (nCPAP) can predict the weaning readiness off nCPAP trial in preterm infants. The secondary aim was to evaluate the value of adding lung tidal recruitment (LTR) to expLUSsc (expLUSsc-plus-LTR) to improve predictability. We conducted a prospective study on premature infants <33 weeks of gestation. Point-of-care lung ultrasound (POC-LUS) was performed on Day 3, the second week of life, before and after the trial off nCPAP. expLUSsc, pleural thickness, and LTR were assessed. A receiver operator curve was constructed to evaluate the ability of POC-LUS to predict the weaning readiness off nCPAP. A total of 148 studies were performed on 39 infants, of them 12 weaned off nCPAP from the first trial and 27 infants failed attempts off nCPAP. An expLUSsc cut-off 8 before the first trial of weaning off nCPAP has a sensitivity and specificity of 88% and 90%, and positive and negative predictive values of 87% and 92%, respectively, with area under the curve (AUC) was 0.87 (CI: 0.8-0.93), p < .0001. If LTR is added to an expLUSsc cut-off 8 (expLUSsc-plus-LTR) before the first trial of weaning, then sensitivity and specificity of 95% and 90%, and positive and negative predictive values of 88% and 90%, respectively, with AUC was 0.95 (CI: 0.91-0.99), p < .0001. In conclusion, this study demonstrated the ability of POC-LUS to predict the weaning readiness off nCPAP in premature infants. The use of this simple bedside noninvasive test can potentially avoid the exposure of premature infants to multiple unsuccessful weaning cycles.

With or Without Nasal Continuous Positive Airway Pressure During Delayed Cord Clamping in Premature Infants <32 Weeks: A Randomized Controlled Trial Using an Intention-To-Treat Analysis.

Objective: To assess whether providing nasal continuous positive airway pressure (nCPAP) during delayed cord clamping is beneficial for preterm infants <32 weeks. Study Design: A randomized controlled trial was performed from March 2020 to May 2021. Premature infants (<32 weeks of gestational age; n = 160) were allocated to receive at least 60 s of delayed cord clamping with nCPAP (DCC+nCPAP; n = 80) or without nCPAP (DCC only; n = 80). For both groups, after the umbilical cord was clamped, the infants were carried immediately to the resuscitation room to continue receiving standard transition. The primary outcome was the mechanical ventilation (MV) rate within 24 h of life. The measurements related to early respiratory support effect before cord clamping including positive end-expiratory pressure (PEEP) and FiO2 during transition/leaving the delivery room, intubation rate during transition, pulmonary surfactant (PS) administration ≥2 times after birth, extubation failure, and incidence of bronchopulmonary dysplasia (BPD) were collected as the secondary outcomes. Furthermore, other neonatal short-term outcomes and safety assessment were also included. Results: The measurements were calculated using intention-to-treat analysis. The median time for cord clamping were 60 s with interquartile range (IQR) (60.00-60.00 vs. 60.00-70.00) in both groups. There were no difference in the primary outcome of MV rate within 24 h of life (p = 0.184). The arterial blood gas pH at 1 h after birth in the DCC+nCPAP group was 7.28 ± 0.08 vs. 7.25 ± 0.07 in the control group (mean difference = 0.01, 95% CI: -0.01-0.05, p = 0.052), which approached statistical significance. There was no significant statistical difference in the other short-term neonatal outcomes and the safety indicators between the two groups. Conclusions: Our study showed that delayed cord clamping with nCPAP was feasible and safe in preterm infants with gestational age <32 weeks. Although there was a trend toward a higher arterial blood gas pH at 1 h after birth in the DCC+nCPAP group, DCC+nCPAP neither resulted in a corresponding measurable clinical improvement nor did it reduce subsequent neonatal morbidity. A larger multi-center study including more infants with gestational age <28 weeks is needed to evaluate the full effects of DCC in combination with nCPAP in preterm infants.

Nasal reconstruction surgery after continuous positive airway pressure delivered by prongs: A case report.

INTRODUCTION AND IMPORTANCE: Deformities resulting from nasal continuous positive airway pressure delivered using prongs can cause functional and aesthetic issues for patients. Resultant severe tissue damage to the nasal structures often requires surgical intervention and techniques continue to evolve. CASE PRESENTATION: This case report describes a 6-year-old male presenting with a full-thickness columella defect; contracture causing deformities involving the nasal tip, ala nasi, and left nasal cavity wall; missing left lateral-medial cruris cartilage; and partially missing right medial cruris cartilage. The abnormalities initially appeared when the patient was 7 days old after receiving treatment by nasal continuous positive airway pressure for 7 days. A one-stage procedure was performed as follows: left ala nasi reconstruction with skin excision followed by an ear cartilage graft; a nasal cartilage shield graft to form the nasal tip; reconstruction of the columella with a cartilage graft combined with bilateral soft tissue flaps taken from the nasal floor and mucosa vestibulum; and a full-thickness skin graft to cover the secondary defect resulting from the flaps. At 1-month post-surgery, satisfactory results were reported. CLINICAL DISCUSSION AND CONCLUSION: Our approach combining two flaps taken from the nasal floor and the inner layer of the ala nasi, a cartilage graft from the ear, and a full-thickness skin graft delivered a one-stage surgical technique that yielded satisfactory results without deformities of the donor site. However, the surgical technique should be individualized to patients. This case report adds to the literature and offers surgeons an alternative approach for managing nasal deformities.

Optimal level of positive end-expiratory pressure during nasal continuous airway pressure for severe bronchiolitis: a prospective study.

BACKGROUND: Nasal continuous positive airway pressure (nCPAP) has been increasingly applied in the pediatric setting. However, there is no uniform standard for setting and titrating positive end-expiratory pressure (PEEP) level, which is paramount to the effectiveness of the treatment. This study aimed to investigate the optimal parameters for nCPAP in the treatment of severe bronchiolitis based on clinical efficacy and pulmonary function parameters. METHODS: A before-after prospective study was conducted with a total of 152 study subjects. These 152 hospitalized patients with severe bronchiolitis were treated and observed from December 2018 to February 2019. Comparisons were made between subjects for clinical symptoms, oxygenation improvement, correction of CO2 retention, degree of airway obstruction and respiratory mechanics improvement between three different positive end-expiratory pressure levels (PEEP). RESULTS: nCPAP could effectively improve the clinical manifestations, blood gas analysis, pulmonary function and respiratory muscle energy consumption. The m-WCAS score, PaCO2, TPTEF/TE, VPEF/VE, respiratory system compliance (Crs) and resistance (Rrs) were significantly different at different PEEP levels (P<0.05). Although there were no hemodynamic changes at peep parameter levels in the three groups. Group 2 (PEEP: 6 cmH2O) had optimal clinical effects, and improvement in airway obstruction and respiratory mechanics compared with the group 1 (PEEP: 4 cmH2O) and the group 3 (PEEP: 7 cmH2O). CONCLUSIONS: PEEP of 6 cmH2O via nCPAP is considered as the optimal level in the treatment of infants with severe bronchiolitis.

Impact of 1% chlorhexidine gluconate bathing and emollient application on bacterial pathogen colonization dynamics in hospitalized preterm neonates - A pilot clinical trial.

BACKGROUND: Chlorhexidine gluconate (CHG) body washes and emollient application may modulate bacterial pathogen colonization and prevent neonatal hospital-acquired infections. METHODS: This pilot, non-randomized, open-label trial, enrolled preterm neonates (1000-1500g; day 1-3 of life) at a tertiary hospital in Cape Town, South Africa. Participants were sequentially allocated to 4 trial arms (n=20 each): 1% aqueous CHG (CHG), 1% CHG plus emollient (CHG+EM), emollient only (EM) and standard of care (SOC: no antiseptic/emollient). Trial treatment/s were applied daily for 10 days (d) post-enrolment, documenting neonatal skin condition score. Anterior nose, neck, umbilical and perianal swabs for bacterial culture were collected at d1, d3, d10 and d16 post-enrolment, (±1 day), reporting pathogen acquisition rates and semi-quantitative bacterial colony counts. (ClinicalTrials.gov identifier: NCT03896893; trial status: closed). FINDINGS: Eighty preterm neonates (mean gestational age 30 weeks [SD 2]) were enrolled between 4 March and 26 August 2019. The bacterial pathogen acquisition rate (comparing d1 and d16 swabs) varied from 33·9% [95%CI 22·9-47·0] at the umbilicus, 39·3% [95%CI 27·6-52·4] at the neck, to 71·4% [95%CI 58·5-81·7] at both the nose and perianal region. At d10, CHG babies had reduced bacterial density detected from neck, umbilicus, and perianal swabs compared to other groups (see Table 3). Following intervention cessation, colonization density was similar across all trial arms, but S. aureus colonization was more prevalent among EM and CHG+EM babies. Neonatal skin condition score improved in babies receiving emollient application (EM: -0·87 [95%CI 0·69-1·06] and CHG+EM: -0·73 [0·45-0·99]), compared to the SOC and CHG arms (Table 2); no CHG-related skin reactions occurred. INTERPRETATION: Bacterial colonization density was significantly reduced in babies receiving 1% CHG washes but colonization levels rebounded rapidly post-intervention. Emollient application improved skin condition but was associated with higher rates of S. aureus colonization. FUNDING: South African Medical Research Council; National Institutes of Health (TW010682).

Efficacy comparison of high-frequency oscillatory ventilation with continuous nasal positive airway pressure in neonatal respiratory distress syndrome treatment.

OBJECTIVES: To compare the treatment efficacy of high-frequency oscillatory ventilation (HFOV) with nasal continuous positive airway pressure (NCPAP) in the treatment of neonatal respiratory distress syndrome (NRDS) and its effect on the expression of high-mobility group protein B1 (HMGB1). METHODS: A total of 180 infants with NRDS admitted to our hospital were included and randomly assigned into the HFOV group (receiving conventional therapy and HFOV), the NCPAP group (receiving conventional therapy and NCPAP), and the conventional group (receiving conventional therapy). Qi and blood indicators, heart rate, respiratory frequency, PCO2, and PaO2 were observed and recorded before and after treatment, together with complications after treatment. ELISA was performed for HMGB1 Results: A distinctly lower partial pressure of carbon dioxide (PCO2) but higher arterial partial pressure of oxygen (PaO2) was observed in the HFOV and NCPAP groups than in the conventional group (P < 0.05), whereas infants in the HFOV group exhibited slight differences in these two indicators from their counterparts in the NCPAP group (P > 0.05). The serum HMGB1 levels in both groups were significantly higher than those in the conventional group (P < 0.05). DISCUSSION: Both HFOV and NCPAP are feasible in the treatment of NRDS and may play a role in the inhibition of HMGB1.

Non-Invasive Ventilatory Strategies to Decrease Bronchopulmonary Dysplasia-Where Are We in 2021?

Recent advances in neonatology have led to the increased survival of extremely low-birth weight infants. However, the incidence of bronchopulmonary dysplasia (BPD) has not improved proportionally, partly due to increased survival of extremely premature infants born at the late-canalicular stage of lung development. Due to minimal surfactant production at this stage, these infants are at risk for severe respiratory distress syndrome, needing prolonged ventilation. While the etiology of BPD is multifactorial with antenatal, postnatal, and genetic factors playing a role, ventilator-induced lung injury is a major, potentially modifiable, risk factor implicated in its causation. Infants with BPD are at a higher risk of developing complications including sepsis, pulmonary arterial hypertension, respiratory failure, and death. Long-term problems include increased risk of hospital readmissions, respiratory infections, and asthma-like symptoms during infancy and childhood. Survivors who have BPD are also at increased risk of poor neurodevelopmental outcomes. While the ultimate solution for avoiding BPD lies in the prevention of preterm births, strategies to decrease its incidence are the need of the hour. It is time to focus on gentler modes of ventilation and the use of less invasive surfactant administration techniques to mitigate lung injury, thereby potentially decreasing the burden of BPD. In this article, we discuss the use of non-invasive ventilation in premature infants, with an emphasis on studies showing an effect on BPD with different modes of non-invasive ventilation. Practical considerations in the use of nasal intermittent positive pressure ventilation are also discussed, considering the significant heterogeneity in clinical practices and management strategies in its use.

Oral feeding for infants and children receiving nasal continuous positive airway pressure and high flow nasal cannula: a systematic review.

BACKGROUND: The aim of this systematic review was to determine whether introduction of oral feeding for infants and children receiving nasal continuous positive airway pressure (nCPAP) or high flow nasal cannula (HFNC) respiratory support facilitates achievement of full oral feeding without adverse effects, compared to no oral feeding (NPO; nil per oral) on CPAP or HFNC. METHODS: A protocol was lodged with the PROSPERO International Prospective Register of Systematic Reviews. We searched Medline, Embase, CINAHL, CENTRAL and AustHealth from database inception to 10th June 2020. Study population included children (preterm to < 18 years) on nCPAP or HFNC who were orally feeding. Primary outcomes included full or partial oral feeding and oropharyngeal aspiration. Secondary outcomes examined adverse events including clinical signs of aspiration, aspiration pneumonia and deterioration in respiratory status. RESULTS: The search retrieved 1684 studies following duplicate removal. Title and abstract screening identified 70 studies for full text screening and of these, 16 were included in the review for data extraction. Methods of non-invasive ventilation (NIV) included nCPAP (n = 6), nCPAP and HFNC (n = 5) and HFNC (n = 5). A metanalysis was not possible as respiratory modes and cohorts were not comparable. Eleven studies reported on adverse events. Oral feeding safety was predominantly based on retrospective data from chart entries and clinical signs, with only one study using an instrumental swallow evaluation (VFSS) to determine aspiration status. CONCLUSIONS: Findings are insufficient to conclude whether commencing oral feeding whilst on nCPAP or HFNC facilitates transition to full oral feeding without adverse effects, including oropharyngeal aspiration. Further research is required to determine the safety and efficacy of oral feeding on CPAP and HFNC for infants and children. TRIAL REGISTRATION: PROSPERO registration number:  CRD42016039325 .

Non-invasive high flow oscillatory ventilation in comparison with nasal continuous positive pressure ventilation for respiratory distress syndrome, a literature review.

BACKGROUND: Noninvasive high-frequency oscillatory ventilation (NHFOV) keeps the lung open with add-on effective rhythmic oscillations in addition to allowing spontaneous breathing. This review aims at reconstructing the different pieces of available research articles and evidence into a more solid collective evidence for NHFOV in preterm infants with respiratory distress syndrome (RDS). METHODS: A thorough systemic search was conducted in Medline, Embase, Web of Science, Google Scholar, CINAHL, and Cochrane. Randomized controlled trials (RCTs) on preterm infants with RDS comparing NHFOV with nasal continuous positive airway pressure (NCPAP) in terms of PCO2 change, need for ventilation, duration of respiratory support, mortality air leak, or BPD were included. Data quality assessment and meta-analyses were carried out. RESULTS: Five RCTs involving 270 preterm infants included in the review. PCO2 relatively decreased on NHFOV (MD = 3.84, confidence interval (CI) 7.32-0.35, p = .03). On the other hand, relative risk (RR) of intubation was unquestionably decreased with NHFOV in comparison with NCPAP (RR = 0.43, CI 0.25-0.75, p = .003) without statistical heterogeneity I2 = 0%. Although the risk of mortality was less in NHFOV, the difference was statistically insignificant (RR = 0.72, CI 0.24-2.18, p = .56). Other outcomes reported in single studies only. Duration of respiratory support was significantly shorter in NHFOV compared with NCPAP (37.35 ± 8.96 versus 49.77 ± 10.33, p = .009), whereas air leak and BPD were reported in very few cases without a significant difference between the two interventions. CONCLUSIONS: NHFOV improved the PCO2 elimination and decreased the risk of intubation without a significant change in mortality compared with NCPAP.

Randomized Longitudinal Study Comparing Three Nasal Respiratory Support Modes to Prevent Intermittent Hypoxia in Very Preterm Infants.

Nasal continuous positive airway pressure (NCPAP) devices using variable (vf-) and continuous (cf-) flow or synchronized nasal intermittent positive pressure ventilation (s-NIPPV) are used to prevent or treat intermittent hypoxia (IH) in preterm infants. Results concerning which is most effective vary. We aimed to investigate the effect of s-NIPPV and vf-NCPAP compared to cf-NCPAP on the rate of IH episodes. Preterm infants with a gestational age of 24.9-29.7 weeks presenting with IH while being treated with cf-NCPAP were monitored for eight hours, then randomized to eight hours of treatment with vf-NCPAP or s-NIPPV. Data from 16 infants were analyzed. Due to an unexpectedly low sample size, the results were only reported descriptively. No relevant changes in the rate of IH events were detected between cf- vs. vf-NCPAP or between cf-NCPAP vs. s-NIPPV. Although limited by its small sample size, s-NIPPV, vf- and cf-NCPAP seemed to be similarly effective in the treatment of IH in these infants.

Comparison of three different noninvasive ventilation strategies as initial respiratory support in very low birth weight infants with respiratory distress syndrome: A retrospective study.

BACKGROUND: There is inadequate evidence regarding which noninvasive ventilation (NIV) is superior for initial respiratory support of preterm infants with respiratory distress syndrome. OBJECTIVES: To compare the failure of noninvasive ventilation (NIV) and neonatal outcomes between nasal continuous positive airway pressure (NCPAP), bi-level positive airway pressure (BiPAP), and nasal intermittent positive pressure ventilation (NIPPV) as the initial respiratory support with less invasive surfactant administration (LISA) in very low birth weight (VLBW) infants. METHODS: Medical records of 419 VLBW infants born at 26-30weeks' gestation who did not require intubation in the delivery room and were initially supported with either NCPAP (n=221), BiPAP (n=101), or NIPPV (n=97) were retrospectively reviewed. The LISA approach was preferred in cases of surfactant requirement. The primary outcome was the failure of NIV within the first 72h of life. Failure of NIV was defined as the persistence or recurrence of one or more of the following: hypoxemia, respiratory acidosis, more than one episode of apnea requiring bag and mask ventilation or more than six episodes of apnea requiring stimulation over a 6-h period. Data were analyzed using univariate and multivariate logistic regression analysis. RESULTS: Failure of NIV within the first 72h of life was significantly higher in the NCPAP group (29.4%) compared with the BiPAP (12.9%) or NIPPV (12.4%) group (P<0.001). However, the BiPAP and NIPPV groups were not different in terms of NIV failure (P=0.91). Multivariable logistic regression analysis showed that antenatal steroid administration (OR: 0.49, 95% CI: 0.27-0.90; P=0.02) and gestational age˂28weeks (OR: 2.03, 95% CI: 1.18-3.49; P=0.01) were independent factors that influence failure of NIV within the first 72h of life. CONCLUSION: Compared with NCPAP, the use of NIPPV/BiPAP strategies for initial respiratory support can reduce the need for invasive ventilation in infants born at 26-30weeks' gestation.

Effect of Body Position on Cardiorespiratory Stabilization and Comfort in Preterm Infants on Continuous Positive Airway Pressure.

PURPOSE: The purpose of the study is to investigate the effect of four body positions (supine, prone, left lateral, right lateral) on cardiorespiratory stabilization and comfort in preterm infants receiving Nasal Continuous Positive Airway Pressure (NCPAP). DESIGN AND METHODS: In the study conducted as a randomized crossover design, the sample was composed of 20 preterm infants receiving NCPAP therapy. At each change of position, the baby was allowed to stabilize for 15 min, and heart rate and oxygen saturation values were recorded every 10 min for the next 60 min. The comfort levels of the infants in each position were evaluated at 30th and 60th minutes using the Premature Infant Comfort Scale. RESULTS: At the end of the study, it was determined that there was no statistically significant difference between heart rate (p = .83), respiratory rate (p = .90) and oxygen saturation (p = .15) of the infants in terms of their positions. When the mean comfort scores of the preterm infants were compared in terms of position, it was found that there was a difference between the positions (p < .01). According to the scale evaluation, the highest comfort level of the infants was in the prone position, which was followed by right lateral, supine and left lateral positions. PRACTICE IMPLICATIONS: Prone position was the most comfortable for preterm infants. However, comfort levels of preterm infants were also high enough in other positions so that no intervention is needed. In order to ensure comfort and cardiorespiratory stabilization, any of the four body positions can be chosen.

A Comparison of Moderate to Late Preterm Neonates Receiving Nasal Continuous Positive Airway Pressure in Australian Tertiary and Nontertiary Centers.

PURPOSE: Transfer of neonates ≥32 weeks' gestation with acute respiratory distress to tertiary (T) centers can be reduced by treatment with nasal continuous positive airway pressure (nCPAP) in nontertiary (NT) centers. This can lead to considerable financial and emotional benefits. The aim of this project was to compare management of nCPAP in T and NT centers. DESIGN: Five-year retrospective, observational cohort study (2010-2014). SAMPLE: All NT eligible neonates from four sites (n = 484) were compared with a similar randomized cohort of inborn neonates at two T centers (n = 601) in Victoria, Australia. MAIN OUTCOME VARIABLE: Any difference in management or short-term outcome. RESULTS: Moderately preterm and term neonates born in NT centers had lower Apgar scores at five minutes of age and received more conservative management delivered by different equipment. Despite a higher incidence of air leaks in NT centers, the short-term outcomes were otherwise similar between centers. T centers were more likely to administer nCPAP to term babies for <24 hours.

Optiflow vs Vapotherm as extended weaning mode from nasal continuous positive airway pressure in preterm infants ≤ 28 weeks gestational age.

INTRODUCTION: Current evidence supports nasal continuous positive airway pressure (NCPAP) weaning. Heated humidified high-flow nasal cannula (HHFNC) reduces NCPAP time in infants less than 28 weeks gestational age (GA) without increasing morbidity. The aim of the study was to compare the two most frequently used HHFNC devices in weaning from NCPAP. METHODOLOGY: We performed a retrospective matched-pair case-control study of infants less than or equal to 28 GA born in a single tertiary neonatal center managed with Optiflow or Vapotherm after being weaned from NCPAP. Patients were matched for antenatal steroid doses, delivery mode, birth plurality, GA, birthweight, gender, surfactant doses, length of mechanical ventilation, and length of NCPAP. Outcome measures were duration of HHFNC, low-flow nasal cannula, nasal bridge lesions, pneumothorax, bronchopulmonary dysplasia, postnatal steroids, necrotizing enterocolitis, sepsis, intraventricular hemorrhage, retinopathy of prematurity, length of stay, discharge weight, and mortality. Results were displayed as median (interquartile range) or ratio (percentage). Statistical analysis was performed using Mann-Whitney U and χ2 tests. RESULTS: 70 patients were recruited retrospectively. Thirty-five infants were weaned from NCPAP to Optiflow and 35 infants to Vapotherm with gestational ages and birthweights of 27 GA (26-27) and 1010 g (835-1165) and 27 GA (26-28) and 960 g (788-1191), respectively. There was no statistically significant difference in any outcome measure. Infants managed with Vapotherm required a not statistically significant shorter length of time on HHFNC and low-flow nasal cannula. CONCLUSIONS: Optiflow and Vapotherm seem to be equally effective and safe for weaning from NCPAP. However, infants weaned to Vapotherm appear to spend less time on non-invasive respiratory support.