High CPAP vs. NIPPV in preterm neonates - A physiological cross-over study.
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ABSTRACT: Objective
To evaluate the physiological impact of high CPAP (≥9 cmH2O) vs. NIPPV at equivalent mean airway pressures.Study design
In this cross-over study, preterm neonates on high CPAP or NIPPV were placed on the alternate mode. After 30 min, left and right ventricular cardiac output and work of breathing indices were assessed, following which patients were placed back on the original mode and a similar procedure ensued.Results
Fifteen infants with mean (SD) postmenstrual age 32.7 (3.0) weeks, and weight 1569 (564) grams were included. No differences in LVO [320 (63) vs. 331 (86) mL/kg/min, P = 0.46] or RVO [420 (135) vs. 437 (141) mL/kg/min, P = 0.19] were noted during high CPAP vs. NIPPV, along with no differences in work of breathing indices.Conclusion
High CPAP pressures did not adversely impact cardiac output or work of breathing compared to NIPPV at equivalent mean airway pressure.
SUBMITTER: Mukerji A
PROVIDER: S-EPMC8179075 | biostudies-literature | 2021 Jul
REPOSITORIES: biostudies-literature
Publications
High CPAP vs. NIPPV in preterm neonates - A physiological cross-over study.
Mukerji Amit A Abdul Wahab Muzafar Gani MG Razak Abdul A Rempel Emily E Patel Waseemoddin W Mondal Tapas T Beck Jennifer J
Journal of perinatology : official journal of the California Perinatal Association 20210605 7
<h4>Objective</h4>To evaluate the physiological impact of high CPAP (≥9 cmH<sub>2</sub>O) vs. NIPPV at equivalent mean airway pressures.<h4>Study design</h4>In this cross-over study, preterm neonates on high CPAP or NIPPV were placed on the alternate mode. After 30 min, left and right ventricular cardiac output and work of breathing indices were assessed, following which patients were placed back on the original mode and a similar procedure ensued.<h4>Results</h4>Fifteen infants with mean (SD) p ...[more]
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Project description:BackgroundVarious noninvasive respiratory support modalities are available in neonatal critical care in order to minimize invasive ventilation. Continuous positive airway pressure (CPAP) is the more commonly used but noninvasive positive pressure ventilation (NIPPV) seems more efficacious in the early post-extubation phase, although it is not clear if NIPPV may influence longterm outcomes. A recently introduced alternative is noninvasive high frequency oscillatory ventilation (NHFOV) which might be especially useful in babies needing high constant distending pressure. Preterm neonates may receive these respiratory supports for several weeks. Nonetheless, no data are available for the longterm use of NIPPV and NHFOV; few data exist on NHFOV and clinical outcomes, although its safety and suitability are reported in a number of preliminary short-term studies.MethodsWe designed an assessor-blinded, multicenter, three-arms, parallel, pragmatic, randomized, controlled trial with a superiority design, investigating the use of CPAP vs NIPPV vs NHFOV during the whole stay in neonatal intensive care units in China. Since safety data will also be analyzed it may be considered a phase II/III trial. Moreover, subgroup analyses will be performed on patients according to prespecified criteria based on physiopathology traits: these subgroup analyses should be considered preliminary. At least 1440 neonates are supposed to be enrolled. The trial has been designed with the collaboration of international colleagues expert in NHFOV, who will also perform an interim analysis at the about 50% of the enrolment.DiscussionThe study is applying the best trial methodology to neonatal ventilation, a field where it is often difficult to do so for practical reasons. Nonetheless, ours is also a physiology-driven trial, since interventions are applied based on physiological perspective, in order to use ventilatory techniques at their best. The pragmatic design will increase generalizability of our results but subgroup analyses according to predefined physiopathological criteria are also previewed trying to have some advantages of an explanatory design. Since not all clinicians are well versed in all respiratory techniques, the training is pivotal. We intend to apply particular care to train the participating units: a specific 3-month period and several means have been dedicated to this end.Trial registrationNCT03181958 (registered on June 9, 2017).
| S-EPMC6659219 | biostudies-literature
Project description:ObjectiveTo compare clinical outcomes of premature infants on synchronized nasal intermittent positive pressure ventilation (SNIPPV) vs nasal intermittent positive pressure ventilation (NIPPV) in the neonatal intensive care unit. Use of NIPPV in the neonatal intensive care unit has shown promise with better clinical outcomes in premature neonates. It is not known if synchronization makes a significant clinical impact when using this technique.Study designRetrospective data were obtained (1/04 to 12/09) of infants who received NIPPV anytime during their stay in the neonatal intensive care unit. SNIPPV (Infant Star with StarSync) was utilized from 2004 to 2006, whereas NIPPV (Bear Cub) was used from 2007 to 2009. Bronchopulmonary dysplasia (BPD) was defined using the NIH consensus definition. Unadjusted associations between potential risk factors and BPD/death were assessed using the χ (2) or Wilcoxon rank-sum test. Adjusted analyses were performed using generalized linear mixed models, taking into account correlation among infants of multiple gestation.ResultThere was no significant difference in the mean gestational age and birth weight in the two groups: SNIPPV (n=172; 27.0w; 1016 g) and NIPPV (n=238; 27.7w; 1117 g). There were no significant differences in maternal demographics, use of antenatal steroids, gender, multiple births, small for gestational age or Apgar scores in the two groups. More infants in the NIPPV group were given resuscitation in the delivery room (SNIPPV vs NIPPV: 44.2 vs 63%, P<0.001). Use of surfactant (84.4 vs 70.2%; P<0.001) was significantly higher in the SNIPPV group. There were no differences in the rate of patent ductus arteriosus, intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity and necrotizing enterocolitis in the two groups. After adjusting for the significant variables, use of NIPPV vs SNIPPV (odds ratio 0.74; 95% confidence interval: 0.42, 1.30) was not associated with BPD/death.ConclusionThese data suggest that use of SNIPPV vs NIPPV is not significantly associated with a differential impact on clinical outcomes.
| S-EPMC3534723 | biostudies-literature
Project description:BackgroundNon-invasive ventilation (NIV) has been recommended as the best respiratory support for preterm infants with respiratory distress syndrome (RDS). However, the best NIV technique to be used as first intention in RDS management has not yet been established. Nasal intermittent positive pressure ventilation (NIPPV) may be synchronized (SNIPPV) or non-synchronized to the infant's breathing efforts. The aim of the study is to evaluate the short-term effects of SNIPPV vs. NIPPV on the cardiorespiratory events, trying to identify the best ventilation modality for preterm infants at their first approach to NIV ventilation support.MethodsAn unmasked randomized crossover study with three treatment phases was designed. All newborn infants < 32 weeks of gestational age with RDS needing NIV ventilation as first intention or after extubation will be consecutively enrolled in the study and randomized to the NIPPV or SNIPPV arm. After stabilization, enrolled patients will be alternatively ventilated with two different techniques for two time frames of 4 h each. NIPPV and SNIPPV will be administered with the same ventilator and the same interface, maintaining continuous assisted ventilation without patient discomfort. During the whole duration of the study, the patient's cardiorespiratory data and data from the ventilator will be simultaneously recorded using a polygraph connected to a computer. The primary outcome is the frequency of episodes of oxygen desaturation. Secondary outcomes are the number of the cardiorespiratory events, FiO2 necessity, newborn pain score evaluation, synchronization index, and thoracoabdominal asynchrony. The calculated sample size was of 30 patients.DiscussionIt is known that NIPPV produces a percentage of ineffective acts due to asynchronies between the ventilator and the infant's breaths. On the other hand, an ineffective synchronization could increase work of breathing. Our hypothesis is that an efficient synchronization could reduce the respiratory work and increase the volume per minute exchanged without interfering with the natural respiratory rhythm of the patient with RDS. The results of this study will allow us to evaluate the effectiveness of the synchronization, demonstrating whether SNIPPV is the most effective non-invasive ventilation mode in preterm infants with RDS at their first approach to NIV ventilation.Trial registrationClinicalTrials.gov NCT03289936 . Registered on September 21, 2017.
| S-EPMC8200781 | biostudies-literature
Project description:Objectives This meta-analysis evaluated and compared the efficacy and safety of noninvasive high-frequency oscillatory ventilation (NHFOV) and nasal intermittent positive-pressure ventilation (NIPPV) for preterm newborns after extubation. Methods We searched the PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, Wanfang and VIP databases from inception to August 28, 2022. Randomized controlled trials (RCTs) that evaluated and compared the efficacy and safety of NHFOV and NIPPV in newborns were included in the review and meta-analysis, which followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Results Eight studies involving 1,603 patients were included. Compared with NIPPV, NHFOV could reduce the reintubation rates (RR = 0.68, 95% CI 0.53, 0.86, P = 0.002). Subgroup analysis showed that the significant difference was found in reintubation rates within 72 h (RR = 0.48, 95% CI 0.32, 0.73, P = 0.0005). NHFOV also could decrease the duration of non-invasive ventilation (standard mean difference (SMD) = −1.52, 95% CI −2.58, −0.45, P = 0.005). However, all included studies had a high risk of bias, and the overall quality of the evidence of the outcomes was low or very low. Conclusion In our study, compared with NIPPV, NHFOV seems to reduce the reintubation rates without increasing adverse outcomes. Nevertheless, definite recommendations cannot be made based on the quality of the published evidence.
| S-EPMC9874940 | biostudies-literature
Project description:Background: Preterm infants are commonly supported with 5-8 cmH2O CPAP. However, animal studies demonstrate that high initial CPAP levels (12-15 cmH2O) which are then reduced (termed physiological based (PB)-CPAP), improve lung aeration without adversely affecting cardiovascular function. We investigated the feasibility of PB-CPAP and the effect in preterm infants at birth. Methods: Preterm infants (24-30 weeks gestation) were randomized to PB-CPAP or 5-8 cmH2O CPAP for the first 10 min after birth. PB-CPAP consisted of 15 cmH2O CPAP that was decreased when infants were stabilized (heart rate ≥100 bpm, SpO2 ≥85%, FiO2 ≤ 0.4, spontaneous breathing) to 8 cmH2O with steps of ~2/3 cmH2O/min. Primary outcomes were feasibility and SpO2 in the first 5 min after birth. Secondary outcomes included physiological and breathing parameters and short-term neonatal outcomes. Planned enrollment was 42 infants. Results: The trial was stopped after enrolling 31 infants due to a low inclusion rate and recent changes in the local resuscitation guideline that conflict with the study protocol. Measurements were available for analysis in 28 infants (PB-CPAP n = 8, 5-8 cmH2O n = 20). Protocol deviations in the PB-CPAP group included one infant receiving 3 inflations with 15 cmH2O PEEP and two infants in which CPAP levels were decreased faster than described in the study protocol. In the 5-8 cmH2O CPAP group, three infants received 4, 10, and 12 cmH2O CPAP. During evaluations, caregivers indicated that the current PB-CPAP protocol was difficult to execute. The SpO2 in the first 5 min after birth was not different [61 (49-70) vs. 64 (47-74), p = 0.973]. However, infants receiving PB-CPAP achieved higher heart rates [121 (111-130) vs. 97 (82-119) bpm, p = 0.016] and duration of mask ventilation was shorter [0:42 (0:34-2:22) vs. 2:58 (1:36-6:03) min, p = 0.020]. Infants in the PB-CPAP group required 6:36 (5:49-11:03) min to stabilize, compared to 9:57 (6:58-15:06) min in the 5-8 cmH2O CPAP group (p = 0.256). There were no differences in short-term outcomes. Conclusion: Stabilization of preterm infants with PB-CPAP is feasible but tailoring CPAP appeared challenging. PB-CPAP did not lead to higher SpO2 but increased heart rate and shortened the duration of mask ventilation, which may reflect faster lung aeration.
| S-EPMC8678466 | biostudies-literature
Project description:ObjectiveTo determine leakage for two neonatal continuous positive airway pressure (CPAP) interfaces and evaluate leak-corrective manoeuvres.DesignThe ToNIL (Trial of NCPAP Interface Leakage) study was a randomised, clinical, cross-over trial with data collection between August 2018 and October 2019. The primary outcome was blinded to the treating staff.SettingOne secondary, 8-bed neonatal intensive care unit (NICU) and three larger (>15 beds), academic NICU referral centres.PatientsNewborn infants with CPAP were screened (n=73), and those with stable spontaneous breathing, low oxygen requirement, postmenstrual age (PMA) over 28 weeks and no comorbidities were eligible. In total, 50 infants were included (median PMA 33 completed weeks).InterventionsLeakage was measured for both prongs and nasal mask, before and after leak-corrective manoeuvres. Interface application was performed in a randomised order by a nurse, blinded to the measured leakage.Main outcome measures30 s average leakage, measured in litres per minute (LPM).ResultsAnalyses showed a significantly lower leakage (mean difference 0.86 LPM, 95% CI 0.07 to 1.65) with prongs (median 2.01 LPM, IQR 1.00-2.80) than nasal mask (median 2.45 LPM, IQR 0.99-5.11). Leak-corrective manoeuvres reduced leakage significantly for both prongs (median 1.22 LPM, IQR 0.54-1.87) and nasal mask (median 2.35 LPM, IQR 0.76-4.75).ConclusionsLarge leakages were common for both interfaces, less with prongs. Simple care manoeuvres reduced leakage for both interfaces. This is the first report of absolute leakage for nasal interfaces and should encourage further studies on leakage during CPAP treatment.
| S-EPMC8543197 | biostudies-literature
Project description:Background: Although evidence suggests that methylxanthines may lower the seizure threshold, the effect of high-dose caffeine on seizure burden in preterm infants is not known. This study reports a secondary post hoc analysis of a randomized controlled trial of early high-dose caffeine citrate therapy in preterm infants, evaluating the effect of caffeine on the seizure burden using amplitude-integrated electroencephalography (aEEG). Methods: Seventy-four preterm infants (≤30 weeks gestation) were randomized to receive high-dose (n = 37, 80 mg/kg over 36 hours) or standard-dose (n = 37, 30 mg/kg over 36 hours) caffeine citrate over the first 36 hours followed by standard maintenance therapy. Simultaneous recording of two-channel amplitude-integrated EEG was conducted over the first 72 hours of life. The primary outcome of this post hoc analysis was cumulative seizure burden over the first 72 hours of life, measured in seconds. Results: Fifteen infants were excluded due to short recordings (≤5 hours) or corrupted data files (n = 7 standard dose; n = 8 high dose). The high-dose caffeine group displayed a trend toward an increased incidence of seizures (40% vs. 58%; p = 0.1) and a threefold increase in seizure duration (48.9 vs. 170.9 seconds; p = 0.1). Conclusion: Early high-dose caffeine therapy was associated with a trend toward an increase in seizure incidence and burden. Future studies of alternative caffeine dosing regimens should include continuous EEG monitoring.
| S-EPMC5031091 | biostudies-literature
Project description:ImportanceFortification of expressed breast milk (EBM) using commercially available human milk fortifiers (HMF) increases short-term weight and length in preterm very low-birth-weight (VLBW) neonates. However, the high cost and increased risk of feed intolerance limit their widespread use. Preterm formula powder fortification (PTF) might be a better alternative in resource-limited settings.ObjectiveTo demonstrate that fortification of EBM by preterm formula powder is noninferior to fortification by HMF, in terms of short-term weight gain, in VLBW neonates.Design, setting, and participantsOpen-label, noninferiority, randomized trial conducted from December 2017 to June 2019 at a level 3 neonatal unit in India. The trial enrolled preterm (born at or before 34 weeks of gestation) VLBW neonates receiving at least 100 mL/kg/d of feeds and consuming 75% of milk or more as EBM.InterventionsNeonates were randomly assigned to receive fortification by either PTF or HMF. Calcium, phosphorus, iron, vitamin D, and multivitamins were supplemented in PTF and only vitamin D in the HMF group to meet the recommended dietary allowances.Main outcomes and measuresThe primary outcome was the weight gain until discharge from the hospital or 40 weeks' postmenstrual age, whichever was earlier; the prespecified noninferiority margin was 2 g/kg/d. Secondary outcomes included morbidities such as necrotizing enterocolitis, feed intolerance, and extrauterine growth restriction (<10th percentile on the Fenton chart at 40 weeks' postmenstrual age).ResultsOf the 123 neonates enrolled, 60 and 63 were randomized to the PTF and HMF groups, respectively. The mean gestation (30.5 vs 29.9 weeks) and birth weight (1161 vs 1119 g) were comparable between the groups. There was no difference in the mean (SD) weight gain between the PTF and HMF groups (15.7 [3.9] vs 16.3 [4.0] g/kg/d; mean difference, -0.5 g/kg/d; 95% CI, -1.9 to 0.7). The lower bound of 95% CI did not cross the noninferiority margin. The incidence of feed intolerance was lower in the PTF group (1.4 vs 6.8 per 1000 patient-days; incidence rate ratio 0.19; 95% CI, 0.04 to 0.95), and fewer neonates required withholding of fortification for 24 hours or more (5% vs 22%; risk ratio, 0.22; 95% CI, 0.07 to 0.75). The incidence of necrotizing enterocolitis stage II or more (0 vs 5%) and extrauterine growth restriction (73% vs 81%) was comparable between the groups.Conclusions and relevanceFortification with preterm formula powder is not inferior to fortification with human milk fortifiers in preterm neonates. Given the possible reduction in feed intolerance and lower costs, preterm formula might be a better option for fortification, especially in resource-restricted settings.Trial registrationClinical Trial Registry, India Identifier: CTRI/2017/11/010593.
| S-EPMC8111561 | biostudies-literature
Project description:ObjectiveTo determine whether a limited oxygen strategy (LOX) versus a high oxygen strategy (HOX) during delivery room resuscitation decreases oxidative stress in preterm neonates.MethodsA randomized trial of neonates of 24 to 34 weeks' gestational age (GA) who received resuscitation was performed. LOX neonates received room air as the initial resuscitation gas, and fraction of inspired oxygen (Fio2) was adjusted by 10% every 30 seconds to achieve target preductal oxygen saturations (Spo2) as described by the 2010 Neonatal Resuscitation Program guidelines. HOX neonates received 100% O2 as initial resuscitation gas, and Fio2 was adjusted by 10% to keep preductal Spo2 at 85% to 94%. Total hydroperoxide (TH), biological antioxidant potential (BAP), and the oxidative balance ratio (BAP/TH) were analyzed in cord blood and the first hour of life. Secondary outcomes included delivery room interventions, respiratory support on NICU admission, and short-term morbidities.ResultsForty-four LOX (GA: 30 ± 3 weeks; birth weight: 1678 ± 634 g) and 44 HOX (GA: 30 ± 3 weeks; birth weight: 1463 ± 606 g) neonates were included. LOX decreased integrated excess oxygen (∑Fio2 × time [min]) in the delivery room compared with HOX (401 ± 151 vs 662 ± 249; P < .01). At 1 hour of life, BAP/TH was 60% higher for LOX versus HOX neonates (13 [9-16] vs 8 [6-9]) µM/U.CARR, P < .01). LOX decreased ventilator days (3 [0-64] vs 8 [0-96]; P < .05) and reduced the incidence of bronchopulmonary dysplasia (7% vs 25%; P < .05).ConclusionsLOX is feasible and results in less oxygen exposure, lower oxidative stress, and decreased respiratory morbidities and thus is a reasonable alternative for resuscitation of preterm neonates in the delivery room.
| S-EPMC3838529 | biostudies-literature
Project description:The purposes of our study were to investigate the physiological and biomechanical responses to low-intensity (LI) and high-intensity (HI) roller ski skating on varying terrain and compare these responses between training intensities. Nine elite male skiers performed treadmill roller skiing consisting of two 21 min sessions (7 × 3 min laps) at LI and HI with the same set inclines and intensity-dependent speeds (LI/HI: distance: 5.8/7.5 km, average speed: 16.7/21.3 km/h). Physiological and biomechanical variables were measured continuously, and each movement cycle and sub-technique employed were detected and classified with a machine learning model. Both the LI and HI sessions induced large terrain-dependent fluctuations (relative to the maximal levels) in heart rate (HR, 17.7 vs. 12.2%-points), oxygen uptake ( V.O2 , 33.0 vs. 31.7%-points), and muscle oxygen saturation in the triceps brachii (23.9 vs. 33.4%-points) and vastus lateralis (12.6 vs. 24.3%-points). A sub-technique dependency in relative power contribution from poles and skis exhibited a time-dependent shift from Lap 1 to Lap 7 toward gradually more ski power (6.6 vs. 7.8%-points, both p < 0.01). The terrain-dependent fluctuations did not differ between LI and HI for V.O2 (p = 0.50), whereas HR fluctuated less (p < 0.01) and displayed a time-dependent increase from Lap 2 to Lap 7 (7.8%-points, p > 0.01) during HI. Oxygen saturation shifted 2.4% points more for legs than arms from LI to HI (p > 0.05) and regarding sub-technique, 14.7% points more G3 on behalf of G2 was employed on the steepest uphill during HI (p < 0.05). Within all sub-techniques, cycle length increased two to three times more than cycle rate from LI to HI in the same terrains, while the corresponding poling time decreased more than ski contact time (all p > 0.05). In sum, both LI and HI cross-country (XC) skiing on varying terrain induce large terrain-dependent physiological and biomechanical fluctuations, similar to the patterns found during XC skiing competitions. The primary differences between training intensities were the time-dependent increase in HR, reduced relative oxygen saturation in the legs compared to the arms, and greater use of G3 on steep uphill terrain during HI training, whereas sub-technique selection, cycle rate, and pole vs. ski power distribution were similar across intensities on flat and moderately uphill terrain.
| S-EPMC8543002 | biostudies-literature