Post-extubation use of non-invasive respiratory support in preterm infants: a network meta-analysis

ObjectiveTo evaluate the performance of a rapidly responsive adaptive algorithm (VDL1.1) for automated oxygen control in preterm infants with respiratory insufficiency.DesignInterventional cross-over study of a 24-hour period of automated oxygen control compared with aggregated data from two flanking periods of manual control (12 hours each).SettingNeonatal intensive care unit.ParticipantsPreterm infants receiving non-invasive respiratory support and supplemental oxygen; median birth gestation 27 weeks (IQR 26–28) and postnatal age 17 (12–23) days.InterventionAutomated oxygen titration with the VDL1.1 algorithm, with the incoming SpO2 signal derived from a standard oximetry probe, and the computed inspired oxygen concentration (FiO2) adjustments actuated by a motorised blender. The desired SpO2 range was 90%–94%, with bedside clinicians able to make corrective manual FiO2 adjustments at all times.Main outcome measuresTarget range (TR) time (SpO2 90%–94% or 90%–100% if in air), periods of SpO2 deviation, number of manual FiO2 adjustments and oxygen requirement were compared between automated and manual control periods.ResultsIn 60 cross-over studies in 35 infants, automated oxygen titration resulted in greater TR time (manual 58 (51–64)% vs automated 81 (72–85)%, p<0.001), less time at both extremes of oxygenation and considerably fewer prolonged hypoxaemic and hyperoxaemic episodes. The algorithm functioned effectively in every infant. Manual FiO2 adjustments were infrequent during automated control (0.11 adjustments/hour), and oxygen requirements were similar (manual 28 (25–32)% and automated 26 (24–32)%, p=0.13).ConclusionThe VDL1.1 algorithm was safe and effective in SpO2 targeting in preterm infants on non-invasive respiratory support.Trial registration numberACTRN12616000300471.

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High-flow nasal cannula as a post-extubation respiratory support strategy in preterm infants: a systematic review and meta-analysis

Jornal de Pediatria ◽

10.1016/j.jped.2019.11.004 ◽

2020 ◽

Vol 96 (4) ◽

pp. 422-431 ◽

Cited By ~ 2

Author(s):

José Colleti Junior ◽

Rafael de Azevedo ◽

Orlei Araujo ◽

Werther Brunow de Carvalho

Keyword(s):

Systematic Review ◽

Preterm Infants ◽

Meta Analysis ◽

High Flow ◽

Nasal Cannula ◽

Respiratory Support ◽

High Flow Nasal Cannula ◽

Support Strategy

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Heated Humidified High-Flow Nasal Cannula for Preterm Infants: An Updated Systematic Review and Meta-analysis

International Journal of Technology Assessment in Health Care ◽

10.1017/s0266462319000424 ◽

2019 ◽

Vol 35 (4) ◽

pp. 298-306 ◽

Cited By ~ 7

Author(s):

Nigel Fleeman ◽

Yenal Dundar ◽

Prakesh S Shah ◽

Ben NJ Shaw

Keyword(s):

Systematic Review ◽

Preterm Infants ◽

Primary Outcome ◽

Meta Analysis ◽

High Flow ◽

Nasal Cannula ◽

Respiratory Support ◽

Cochrane Library ◽

High Flow Nasal Cannula ◽

Safe Alternative

AbstractBackgroundHeated humidified high-flow nasal cannula (HHHFNC) is gaining popularity as a mode of respiratory support. We updated a systematic review and meta-analyses examining the efficacy and safety of HHHFNC compared with standard treatments for preterm infants. The primary outcome was the need for reintubation for preterm infants following mechanical ventilation (post-extubation analysis) or need for intubation for preterm infants not previously intubated (analysis of primary respiratory support)MethodsWe searched PubMed, MEDLINE, Embase, and the Cochrane Library for randomized controlled trials (RCTs) of HHHFNC versus standard treatments. Meta-analysis was conducted using Review Manager 5.3.ResultsThe post-extubation analysis included ten RCTs (n = 1,201), and the analysis of primary respiratory support included ten RCTs (n = 1,676). There were no statistically significant differences for outcomes measuring efficacy, including the primary outcome. There were statistically significant differences favoring HHHFNC versus nasal cannula positive airway pressure (NCPAP) for air leak (post-extubation, risk ratio [RR] 0.29, 95 percent confidence interval [CI] 0.11 to 0.76, I2 = 0) and nasal trauma (post-extubation: 0.35, 95 percent CI 0.27 to 0.46, I2 = 5 percent; primary respiratory support: RR 0.52, 95 percent CI 0.37 to 0.74; I2 = 27 percent). Studies, particularly those of primary respiratory support, included very few preterm infants with gestational age (GA) <28 weeks.ConclusionsHHHFNC may offer an efficacious and safe alternative to NCPAP for some infants but evidence is lacking for preterm infants with GA ≤28 weeks.

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Pharmacoepidemiology of Drug Exposure in Intubated and Non-Intubated Preterm Infants With Severe Bronchopulmonary Dysplasia

Frontiers in Pharmacology ◽

10.3389/fphar.2021.695270 ◽

2021 ◽

Vol 12 ◽

Author(s):

T. Lewis ◽

W. Truog ◽

L. Nelin ◽

N. Napolitano ◽

R. L. McKinney ◽

...

Keyword(s):

Preterm Infants ◽

Bronchopulmonary Dysplasia ◽

Drug Exposure ◽

Respiratory Support ◽

Rank Test ◽

Multiple Drug ◽

Continuous Variables ◽

Short Acting ◽

Non Invasive ◽

Drug Classes

Background: Infants with severe bronchopulmonary dysplasia (BPD) are commonly treated with off-label drugs due to lack of approved therapies. To prioritize drugs for rigorous efficacy and safety testing, it is important to describe exposure patterns in this population.Objective: Our objective was to compare rates of drug exposure between preterm infants with severe bronchopulmonary dysplasia based on respiratory support status at or beyond 36 weeks post-menstrual age.Methods: A cross-sectional cohort study was performed on October 29, 2019. Preterm infants with severe BPD were eligible and details of respiratory support and drug therapy were recorded. Wilcoxon paired signed rank test was used to compare continuous variables between the invasive and non-invasive groups. Fisher’s exact test was used to compare binary variables by respiratory support status.Results: 187 infants were eligible for the study at 16 sites. Diuretics were the drug class that most subjects were receiving on the day of study comprising 54% of the entire cohort, followed by inhaled steroids (47%) and short-acting bronchodilators (42%). Infants who were invasively ventilated (verses on non-invasive support) were significantly more likely to be receiving diuretics (p 0.013), short-acting bronchodilators (p < 0.01), long-acting bronchodilators (p < 0.01), systemic steroids (p < 0.01), systemic pulmonary hypertension drugs (p < 0.01), and inhaled nitric oxide (p < 0.01).Conclusion: Infant with severe BPD, especially those who remain on invasive ventilation at 36 weeks, are routinely exposed to multiple drug classes despite insufficient pharmacokinetic, safety, and efficacy evaluations. This study helps prioritize sub-populations, drugs and drug classes for future study.

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Association of Non-Invasive Respiratory Support with Mortality and Intubation Rates in Acute Respiratory Failure: A Systematic Network Meta-Analysis

SSRN Electronic Journal ◽

10.2139/ssrn.3696809 ◽

2020 ◽

Author(s):

Hideto Yasuda ◽

Hiromu Okano ◽

Takuya Mayumi ◽

Masaki Nakane ◽

Nobuaki Shime

Keyword(s):

Respiratory Failure ◽

Acute Respiratory Failure ◽

Meta Analysis ◽

Respiratory Support ◽

Non Invasive

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14 Diaphragmatic Electrical Activity in Preterm Infants on Non-Invasive High Frequency Oscillatory Ventilation (DEAP-NHFO Study)

Paediatrics & Child Health ◽

10.1093/pch/pxab061.010 ◽

2021 ◽

Vol 26 (Supplement_1) ◽

pp. e9-e10

Author(s):

Jonathan Wong ◽

Soonsawad Sasivimon ◽

Rawan Abu Omar ◽

Michael Dunn ◽

Eugene Ng ◽

...

Keyword(s):

Energy Expenditure ◽

Electrical Activity ◽

Preterm Infants ◽

High Frequency ◽

Respiratory Support ◽

Respiratory Pattern ◽

High Frequency Ventilation ◽

Respiratory Drive ◽

General Sequence ◽

Non Invasive

Abstract Primary Subject area Neonatal-Perinatal Medicine Background Continuous Positive Airway Pressure (CPAP) is a common form of non-invasive respiratory support for preterm infants. Non-invasive high frequency ventilation (NHFOV) is a relatively new method of non-invasive respiratory support. NHFOV is being increasingly utilized in clinical practice in an attempt to prevent intubation and minimize ventilator-induced lung injury in preterm infants. Preliminary studies suggest superiority of NHFOV over CPAP, but little is known about its mechanism of action and its effect on respiratory control in the newborn. We hypothesize that NHFOV reduces respiratory drive and improves ventilation, resulting in decreased patient diaphragm energy expenditure, which can be assessed by measuring the electrical activity of the diaphragm (Edi). Objectives The objective of this study is to compare the effects of non-invasive respiratory support delivered by nasal CPAP versus NHFOV on respiratory pattern, as assessed by the Edi in very low birth weight (VLBW) preterm infants. Design/Methods In a prospective, randomized, crossover study, 20 preterm infants with birth weights ≤1500 g requiring CPAP were randomized to either NHFOV or CPAP for 105 min, followed by crossover to the other method for the same duration. Edi was continuously measured by a feeding catheter with miniaturized sensors embedded in its wall (Maquet, Solna). The general sequence was 15 minutes for acclimation to the mode, 75 minutes for a feed to be completed, followed by 15 minutes for breath-by-breath analyses of neural breathing pattern. Primary outcome was difference in the peak Edi between CPAP and NHFOV. Secondary outcomes included difference in other measures of respiratory drive: neural respiratory rate, neural inspiratory time, diaphragm energy expenditure, transcutaneous pCO2, number of apnea episodes on the Edi, and episodes of clinically significant apnea. Results No significant differences in Edi timing, Edi min, Edi peak, apnea, or CO2 were observed between the two modes of respiratory support. Conclusion In this cohort of VLBW preterm infants, neural respiratory pattern was not significantly different between NHFOV and CPAP. With this baseline information in stable preterm infants, it would now be important to assess whether these results hold true in infants with more severe lung disease, where NHFOV is often used as escalating support from CPAP.

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