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Background Respiratory distress is the most common cause of morbidity in premature babies in the delivery room. Nasal continuous positive airway pressure (nCPAP) is widely used as the preferred modality of treatment, although it may cause nasal trauma. Heated, humidified high-flow nasal (HHHFN) cannula is an alternative oxygen therapy, yet the safe...
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... In our previous study at Dr. Cipto Mangunkusumo Hospital, Jakarta, among 100 infants with moderate respiratory distress (Downes scores 4 to 6) who received nasal continuous positive pressure (nCPAP), 26% experienced failure and subsequently needed invasive mechanical ventilation support. 3 Surfactant deficiency leads to fluid-filled and collapsed alveoli, reducing oxygen uptake and CO 2 removal from the alveoli. Hypoxemia and respiratory acidosis causes diminished decrease in pulmonary vascular resistance, further weakening cardiac contractility, in turn leading to cardiac failure. ...
Background Lung recruitment maneuvers (LRMs) are a strategy to gradually increase mean positive airway pressure (MAP) to expand the alveoli, leading to decreased pulmonary vascular resistance and increased cardiac output (CO). However, the hemodynamic impact of LRM using assist control volume guarantee (AC-VG) ventilator mode done in preterm infants born at 24 to 32 weeks' gestation, especially in the first 72 hours of life, remains unknown. Objective To determine the effect of LRM on right-and left cardiac ventricular output (RVO and LVO), ductus arteriosus (DA) diameter and its pulmonary hypertension (PH) flow pattern, as well as superior mesenteric artery (SMA) flow. Methods This randomized, controlled, single-blinded clinical trial was performed in 24-32-week preterm neonates with birth weights of >600 grams. Subjects were allocated by block randomization to the LRM and control groups, each containing 55 subjects. We measured RVO, LVO, DA diameter, PH flow pattern, and SMA resistive index (RI) at 1 and 72 hours after mechanical ventilation was applied. We analyzed for hemodynamic differences between the two groups. Results During the initial 72 hours of mechanical ventilation, there were no significant differences between the control vs. LRM groups in mean changes of LVO [41.40 (SD 91.21) vs. 15.65 (SD 82.39) mL/kg/min, respectively; (P=0.138)] or mean changes of RVO [65.56 (SD 151.20) vs. 70.59 (SD 133.95) mL/kg/min, respectively; (P=0.859)]. Median DA diameter reduction was-0.08 [interquartile range (IQR)-0.55; 0.14] mm in the control group and-0.10 (IQR-0.17 to-0.01) mm in the LRM group (P=0.481). Median SMA resistive index was 0.02 (IQR-0.16 to 0.24) vs. 0.01(IQR-0.20 to 0.10) in the control vs. LRM group, respectively. There was no difference in proportion of pulmonary hypertension flow pattern at 72 hours (25.4% vs. 20% in the control vs. LRM group, respectively) (P=0.495). Conclusion When preterm infants of 24-32 weeks gestational age are placed on mechanical ventilation, LRM gives neither additional hemodynamic benefit nor harm compared to standard ventilator settings.
... Several NICU centers are now using the High Flow Nasal Cannula (HFNC) in recent years. However, several studies have doubted the efficacy and efficiency of HFNC (6,7). HFNC is a method of supplying high-volume oxygen (flow> 1 liter/minute) with warm air (37⁰C) and humidified air (humidification>96%) through the nasal cannula (7). ...
... However, several studies have doubted the efficacy and efficiency of HFNC (6,7). HFNC is a method of supplying high-volume oxygen (flow> 1 liter/minute) with warm air (37⁰C) and humidified air (humidification>96%) through the nasal cannula (7). Based on a systematic review, the use of HFNC as a breath aid in preterm infants, HFNC had the same efficacy ratio as nasal CPAP (continuous or intermittent), even though it was associated with a lower incidence of nasal trauma and pneumothorax than nasal CPAP (8). ...
... A study found that there was no significant difference between the use of HFNC and nasal CPAP on the success of therapy at less than 72 hours (nasal CPAP 18% vs. HFNC 20%) and more than 72 hours (nasal CPAP 2% vs. HFNC 6%). Still, on nasal complications, trauma on day 3 showed a significant difference (nasal CPAP 14% vs. HFNC 0%) (7). ...
Introduction: NRSD (Neonatal Respiratory Distress Syndrome) is one of the most frequent causes of newborns in intensive care (NICU). Several NICU centers are now using the High Flow Nasal Cannula (HFNC) in recent years. With the use of HFNC as a breath aid in preterm infants, HFNC had the same efficacy ratio as nasal Continuous Positive Airway Pressure (CPAP) (continuous or intermittent). Case Report: A three-day-old baby boy was admitted to anesthesia with respiratory failure due to grade II HMD with suspicion of congenital heart failure. The initial condition showed that a respiratory rate of 70-80x / minute, breathing of the nostrils and retractions in the intercostals and abdomen with 85% post ductal SpO2 with the help of a CPAP mask (Pinsp 10, Fio2 70%). There was a Ronchi sound in the right and left basal lungs, and hemodynamics obtained a pulse of 180-195x / minute, non-invasive blood pressure 95/34 mmHg (54), heart murmurs were not found. During day 1 - day three, the patient uses a CPAP mask until the patient vomits and being consulted to an Anesthesiologist. On day 3 - day seven, the patient uses HFNC; after day seven until day 10, the patient uses neonatal nasal canularis oxygen. Until day 10, the patient is still being treated at the NICU by administering oxygen 0.5 liters/minute with SpO2 ranging from 93-96% with stable conditions but still needing oxygen. Conclusion: The use of Modified High Flow Nasal Cannula (HFNC) in preterm infants with Neonatal Respiratory Distress Syndrome (NRSD) is more effective and efficient than CPAP. The use of HFNC was associated with a lower incidence of nasal trauma and pneumothorax than nasal CPAP.
Background:
Nasal high flow (nHF) therapy provides heated, humidified air and oxygen via two small nasal prongs, at gas flows of more than 1 litre/minute (L/min), typically 2 L/min to 8 L/min. nHF is commonly used for non-invasive respiratory support in preterm neonates. It may be used in this population for primary respiratory support (avoiding, or prior to the use of mechanical ventilation via an endotracheal tube) for prophylaxis or treatment of respiratory distress syndrome (RDS). This is an update of a review first published in 2011 and updated in 2016.
Objectives:
To evaluate the benefits and harms of nHF for primary respiratory support in preterm infants compared to other forms of non-invasive respiratory support.
Search methods:
We used standard, extensive Cochrane search methods. The latest search date March 2022.
Selection criteria:
We included randomised or quasi-randomised trials comparing nHF with other forms of non-invasive respiratory support for preterm infants born less than 37 weeks' gestation with respiratory distress soon after birth.
Data collection and analysis:
We used standard Cochrane Neonatal methods. Our primary outcomes were 1. death (before hospital discharge) or bronchopulmonary dysplasia (BPD), 2. death (before hospital discharge), 3. BPD, 4. treatment failure within 72 hours of trial entry and 5. mechanical ventilation via an endotracheal tube within 72 hours of trial entry. Our secondary outcomes were 6. respiratory support, 7. complications and 8. neurosensory outcomes. We used GRADE to assess the certainty of evidence.
Main results:
We included 13 studies (2540 infants) in this updated review. There are nine studies awaiting classification and 13 ongoing studies. The included studies differed in the comparator treatment (continuous positive airway pressure (CPAP) or nasal intermittent positive pressure ventilation (NIPPV)), the devices for delivering nHF and the gas flows used. Some studies allowed the use of 'rescue' CPAP in the event of nHF treatment failure, prior to any mechanical ventilation, and some allowed surfactant administration via the INSURE (INtubation, SURfactant, Extubation) technique without this being deemed treatment failure. The studies included very few extremely preterm infants less than 28 weeks' gestation. Several studies had unclear or high risk of bias in one or more domains. Nasal high flow compared with continuous positive airway pressure for primary respiratory support in preterm infants Eleven studies compared nHF with CPAP for primary respiratory support in preterm infants. When compared with CPAP, nHF may result in little to no difference in the combined outcome of death or BPD (risk ratio (RR) 1.09, 95% confidence interval (CI) 0.74 to 1.60; risk difference (RD) 0, 95% CI -0.02 to 0.02; 7 studies, 1830 infants; low-certainty evidence). Compared with CPAP, nHF may result in little to no difference in the risk of death (RR 0.78, 95% CI 0.44 to 1.39; 9 studies, 2009 infants; low-certainty evidence), or BPD (RR 1.14, 95% CI 0.74 to 1.76; 8 studies, 1917 infants; low-certainty evidence). nHF likely results in an increase in treatment failure within 72 hours of trial entry (RR 1.70, 95% CI 1.41 to 2.06; RD 0.09, 95% CI 0.06 to 0.12; number needed to treat for an additional harmful outcome (NNTH) 11, 95% CI 8 to 17; 9 studies, 2042 infants; moderate-certainty evidence). However, nHF likely does not increase the rate of mechanical ventilation (RR 1.04, 95% CI 0.82 to 1.31; 9 studies, 2042 infants; moderate-certainty evidence). nHF likely results in a reduction in pneumothorax (RR 0.66, 95% CI 0.40 to 1.08; 10 studies, 2094 infants; moderate-certainty evidence) and nasal trauma (RR 0.49, 95% CI 0.36 to 0.68; RD -0.06, 95% CI -0.09 to -0.04; 7 studies, 1595 infants; moderate-certainty evidence). Nasal high flow compared with nasal intermittent positive pressure ventilation for primary respiratory support in preterm infants Four studies compared nHF with NIPPV for primary respiratory support in preterm infants. When compared with NIPPV, nHF may result in little to no difference in the combined outcome of death or BPD, but the evidence is very uncertain (RR 0.64, 95% CI 0.30 to 1.37; RD -0.05, 95% CI -0.14 to 0.04; 2 studies, 182 infants; very low-certainty evidence). nHF may result in little to no difference in the risk of death (RR 0.78, 95% CI 0.36 to 1.69; RD -0.02, 95% CI -0.10 to 0.05; 3 studies, 254 infants; low-certainty evidence). nHF likely results in little to no difference in the incidence of treatment failure within 72 hours of trial entry compared with NIPPV (RR 1.27, 95% CI 0.90 to 1.79; 4 studies, 343 infants; moderate-certainty evidence), or mechanical ventilation within 72 hours of trial entry (RR 0.91, 95% CI 0.62 to 1.33; 4 studies, 343 infants; moderate-certainty evidence). nHF likely results in a reduction in nasal trauma, compared with NIPPV (RR 0.21, 95% CI 0.09 to 0.47; RD -0.17, 95% CI -0.24 to -0.10; 3 studies, 272 infants; moderate-certainty evidence). nHF likely results in little to no difference in the rate of pneumothorax (RR 0.78, 95% CI 0.40 to 1.53; 4 studies, 344 infants; moderate-certainty evidence). Nasal high flow compared with ambient oxygen We found no studies examining this comparison. Nasal high flow compared with low flow nasal cannulae We found no studies examining this comparison.
Authors' conclusions:
The use of nHF for primary respiratory support in preterm infants of 28 weeks' gestation or greater may result in little to no difference in death or BPD, compared with CPAP or NIPPV. nHF likely results in an increase in treatment failure within 72 hours of trial entry compared with CPAP; however, it likely does not increase the rate of mechanical ventilation. Compared with CPAP, nHF use likely results in less nasal trauma and likely a reduction in pneumothorax. As few extremely preterm infants less than 28 weeks' gestation were enrolled in the included trials, evidence is lacking for the use of nHF for primary respiratory support in this population.
