Early Nasal Continuous Positive Airway Pressure and Minimal Handling in the Treatment of Very-Low-Birth-Weight Infants

Abstract

Continuous positive airway pressure (CPAP) was introduced in 1971 and at that time welcomed as ‘the missing link’ between oxygen and ventilator treatment of premature infants. Originally CPAP was administered by tracheal tube (or head box) which because of the inherent risk of complications necessitated a cautious approach. New, more simple and less risky methods of application, such as nasal CPAP (N-CPAP), permitted earlier treatment which in randomized trials showed a reduction in inspired oxygen concentration, reduced need for mechanical ventilation and a reduction in the rate of death. Early N-CPAP/minimal handling today is an established first-line treatment in a number of centers in Denmark and Sweden, while N-CPAP outside Scandinavia apparently is used less often. However, recently the method has gained new interest as more publications have demonstrated that N-CPAP/minimal handling is both feasible and effective in most very-low-birth-weight infants. Early rescue treatment with fast-acting surfactant, given during a brief intubation, has increased the effectiveness of N-CPAP further. Descriptive studies on N-CPAP suggest that the risk of bronchopulmonary dysplasia may be lower than in conventional intensive treatment because of the relatively low need for mechanical ventilation. This question is at the present time being addressed in a randomized controlled trial in England.

Implementation of surfactant treatment during continuous positive airway pressure

“…This is likely to be particularly important for infants with gestational age X27 weeks and, in fact, early nCPAP alone will prevent progression to respiratory failure in many infants and in combination with antenatal steroids, the number of infants without clinical symptoms of RDS is further decreased. 21 Previous data from our region shows that approximately 1/3 of infants with RDS do well with nCPAP as only ventilatory support. 14 We choose to administer surfactant as rescue treatment to infants with moderate to severe RDS.…”

A Randomized Trial Comparing Surfactant Administration Using InSurE Technique and the Minimally Invasive Surfactant Therapy in Preterm Infants (28 to 34 Weeks of Gestation) with Respiratory Distress Syndrome

“…Today, healthcare providers prefer to use noninvasive ventilation techniques for mitigating these complications (9,10). CPAP is an alterna-tive method to endotracheal intubation that can prevent such complications in infants who are capable of spontaneous breathing, and together with the prenatal administration of corticosteroids, this technique can help reduce the number of infants with clinical symptoms of RDS to a significant degree (11). Nevertheless, these measures are not sufficient per se.…”

Nasal CPAP vs. mechanical ventilation in 28-32 weeks preterm infants with early surfactant administration

“…Estos resultados se unen a los de muchas otras series citadas en la literatura científica, en las que se ha encontrado que la CPAP disminuye la incidencia de displasia broncopulmonar (3,4,(6)(7)(8)18,19,21,24,32,33). En otros estudios no se han encontrado diferencias en la incidencia de la displasia broncopulmonar, pero en ninguno de ellos se empleó la misma intervención evaluada en el presente estudio.…”

“…En los metaanálisis publicados en los últimos años, que incluyen gran cantidad de estudios sobre intervenciones sin uso de surfactante, se concluye que: la CPAP reduce el tiempo de intervención de la enfermedad de membrana hialina; que es equivalente a la respiración mecánica en cuanto a mortalidad, presencia de enterocolitis necrosante y hemorragia intraventricular (con la ventaja de que puede usarse incluso en prematuros muy pequeños), y que la gravedad de la displasia broncopulmonar es menor, por lo que también se reduce el uso de oxígeno y esteroides (1,2,(4)(5)(6)(7)(8).…”

“…Sin embargo, los ensayos clínicos y metaanálisis publicados hasta el momento no incluyen el efecto que tiene la aplicación de surfactante pulmonar en los resultados cuando se comparan la CPAP y la respiración mecánica asistida. Se encuentran estudios en los que se compara la CPAP sin administración de surfactante y la respiración mecánica asistida con surfactante, pero no así estudios que comparen estas dos estrategias empleadas con surfactante, por lo que existe la necesidad de llevarlos a cabo (2,(4)(5)(6)(7)(8), objetivo al que se abocó el presente estudio de cohorte.…”