Effect of a new respiratory care bundle on bronchopulmonary dysplasia in preterm neonates

Abstract

The development of devices that can fix the tidal volume in high-frequency oscillatory ventilation (HFOV) has allowed for a significant improvement in the management of HFOV. At our institution, this had led to the earlier use of HFOV and promoted a change in the treatment strategy involving the use of higher frequencies (above 15 Hz) and lower high-frequency tidal volumes (VThf). The purpose of this observational study was to assess how survival without bronchopulmonary dysplasia grades 2 and 3 (SF-BPD) is influenced by these modifications in the respiratory strategy applied to preterm infants (gestational age < 32 weeks at birth) who required mechanical ventilation (MV) in the first 3 days of life. We compared a baseline period (2012-2013) against a period in which this strategy had been fully implemented (2016-2017). A total of 182 patients were exposed to MV in the first 3 days of life being a higher proportion on HFOV at day 3 in the second period 79.5% (n 35) in 2016-2017 vs 55.4% (n 31) in 2012-2013. After adjusting for perinatal risk factors, the second period is associated with an increased rate of SF-BPD (OR 2.28; CI 95% 1.072-4.878); this effect is more evident in neonates born at a gestational age of less than 29 weeks (OR 4.87; 95% CI 1.9-12.48). Conclusions : The early use of HFOV combined with the use of higher frequencies and very low VT was associated with an increase in the study population's SF-BPD. What is Known: • High-frequency ventilation with volume guarantee improve ventilation stability and has been shown to reduce lung damage in animal models. What is New: • The strategy of an earlier use of high-frequency oscillatory ventilation combined with the use of higher frequencies and lower tidal volume is associated to an increase in survival without bronchopulmonary dysplasia in our population of preterm infants. Keywords High-frequencyventilation. Lung protection. Bronchopulmonary dysplasia. Ventilatory-induced lung injury. Target tidal volume. Preterm infants Abbreviations ΔPhf Delta pressure BPD Bronchopulmonary dysplasia type 2-3 BW Birth weight CMV Conventional mechanical ventilation CRIB Critical index for babies DOL Days of life GA Gestational age HFOV High-frequency oscillatory ventilation Hz Hertz INSURE Intubation-surfactant administration-extubation LISA Less-invasive surfactant administration MV Mechanical ventilation nCPAP Nasal continuous airway pressure NEC Necrotizing enterocolitis Communicated by Daniele De Luca

Target volume‐guarantee in high‐frequency oscillatory ventilation for preterm respiratory distress syndrome: Low volumes and high frequencies lead to adequate ventilation

“…These high frequencies and subsequent very low tidal volumes may protect the immature lung and could be of special benefit for the long‐term development of preterm newborns. This has been proved in preclinical studies 10 and in previous clinical studies showing lower rates of BPD in newborns ventilated with this strategy when using HFOV as early rescue ventilatory therapy, 9 but evidence is still limited and more studies are needed to confirm this protective effect, the lower grade of VILI and inflammation in human preterm lungs and its impact on long‐term respiratory outcomes.…”

“…Volume-guarantee HFOV stabilizes tidal volumes over time and offers better ventilation control and better outcomes than classical HFOV. 5,6,9 However, data are scarce regarding which tidal volumes should be initially set: Belteki and Morley 12 published data from 17 neonates ventilated with frequencies between 7 and 12 Hz and a F I G U R E 2 Patient distribution by gestational age. The chart includes all patients ventilated with HFOV during the first 72 h of life.…”

“…Volume-guarantee HFOV stabilizes tidal volumes over time and offers better ventilation control and better outcomes than classical HFOV. 5,6,9 However, data are scarce regarding which tidal volumes should be initially set: Belteki and Morley 12 13 published data from of 1.65 and 1.50 ml/kg, respectively. Unlike these authors, we analyzed data limited to infants with adequate ventilation, and we limited our sample to preterm newborns HFOV-ventilated before 72 h of life, since ventilation could change with lung inflammation and development during the first days of life.…”

“…3,4 This strategy has proved to better maintain tidal volumes, partial pressure of CO 2 (pCO 2 ) and oxygen saturation, [5][6][7] and although evidence remains unclear, some studies have suggested that VG might lead to lower rates of death and BPD. 8,9 In experimental models, the protective effect of HFOV-VG has been proved when using smaller volumes and very high frequencies, 10 which have been successfully used in preterm newborns in a pilot study. 11 Despite the growing evidence that HFOV-VG could be an alternative for conventional mechanical ventilation in very immature newborns, there are few studies describing which volumes and frequencies lead to adequate ventilation and should initially be set.…”

“…These studies are limited to small and heterogeneous samples of patients, and only include respiratory frequencies up to 12 Hz. More data are needed to stablish the optimal parameters that should be set in HFOV‐VG, especially in higher frequencies, which may in fact be the ones providing optimal lung protection and best outcomes 9 . There is currently no published data at all regarding frequencies >12 Hz.…”