Effect of Nasal Continuous Positive Airway Pressure vs Heated Humidified High-Flow Nasal Cannula on Feeding Intolerance in Preterm Infants With Respiratory Distress Syndrome

Abstract

ImportanceRespiratory distress syndrome and feeding intolerance are common conditions that are often associated with preterm infants. Showing similar efficacy, nasal continuous positive airway pressure (NCPAP) and heated humidified high-flow nasal cannula (HHHFNC) are the most widespread noninvasive respiratory support (NRS) in neonatal intensive care units, but their effect on feeding intolerance is unknown.ObjectiveTo evaluate the effect of NCPAP vs HHHFNC on high-risk preterm infants with respiratory distress syndrome.Design, Setting, and ParticipantsThis multicenter randomized clinical trial involved infants who were born in 1 of 13 neonatal intensive care units in Italy between November 1, 2018, and June 30, 2021. Preterm infants with a gestational age of 25 to 29 weeks, who were suitable for enteral feeding and who proved to be medically stable on NRS for at least 48 hours were enrolled in the study within the first week of life and randomized to receive either NCPAP or HHHFNC. Statistical analysis was performed according to the intention-to-treat approach.InterventionNCPAP or HHHFNC.Main Outcomes and MeasuresThe primary outcome was the time to full enteral feeding (FEF), defined as an enteral intake of 150 mL/kg per day. Secondary outcomes were the median daily increment of enteral feeding, signs of feeding intolerance, effectiveness of the assigned NRS, peripheral oxygen saturation (SpO2)–fraction of inspired oxygen (FIO2) ratio at changes of NRS, and growth.ResultsTwo-hundred forty-seven infants (median [IQR] gestational age, 28 [27-29] weeks; 130 girls [52.6%]) were randomized to the NCPAP group (n = 122) or the HHHFNC group (n = 125). There were no differences in the primary and secondary nutritional outcomes between the 2 groups. The median time to reach FEF was 14 days (95% CI, 11-15 days) in the NCPAP group and 14 days (95% CI, 12-18 days) in the HHHFNC group, and similar results were observed in the subgroup of infants with less than 28 weeks’ gestation. On the first NRS change, higher SpO2–FIO2 ratio (median [IQR], 4.6 [4.1-4.7] vs 3.7 [3.2-4.0]; P < .001) and lower rate of ineffectiveness (1 [4.8%] vs 17 [73.9%]; P < .001) were observed in the NCPAP vs HHHFNC group.Conclusions and relevanceThis randomized clinical trial found that NCPAP and HHHFNC had similar effects on feeding intolerance, despite different working mechanisms. Clinicians may tailor respiratory care by selecting and switching between the 2 NRS techniques on the basis of respiratory effectiveness and patient compliance, without affecting feeding intolerance.Trial RegistrationClinicalTrials.gov Identifier: NCT03548324

Nutritional Strategies for Preterm Neonates and Preterm Neonates Undergoing Surgery: New Insights for Practice and Wrong Beliefs to Uproot

“…Cresi et al recently published the results of the ENTARES randomized clinical trial [ 92 ], in agreement with the previous retrospective results reported by Amendolia et al [ 93 ]. They found that continuous positive airway pressure (NCPAP) and heated humidified high-flow nasal cannula (HHHFNC) had similar effects on feeding intolerance in 247 preterm infants <30 weeks GA. Clinicians may modify respiratory treatment by switching between the two non-invasive approaches based on efficacy and patient compliance without influencing feeding intolerance and no differences in the achievement of full enteral feeding [ 92 ].…”

High Flow Nasal Cannula for Weaning Nasal Continuous Positive Airway Pressure in Preterm Infants: A Systematic Review and Meta-Analysis

“…After thoroughly examining the full texts of 42 records, 35 were further excluded for various reasons, including incorrect interventions ( n = 19), inappropriate study design ( n = 15), and irrelevant outcomes ( n = 1). Consequently, a total of 7 RCTs were included in the analysis (Cresi F, 2023 [ 11 ], Clements J, 2022 [ 5 ], Gregoraci Fernández A, 2021 [ 6 ], Soonsawad S, 2016 [ 12 ], Tang J, 2015 [ 13 ], Badiee Z, 2015 [ 14 ], and Abdel-Hady H, 2011 [ 7 ]). Included studies were conducted in Afghanistan, Australia, Egypt, Italy, New Zealand, Spain, and Thailand.…”

“…Three trials [ 7 , 13 , 14 ] were at high risk of performance bias due to unblinded interventions with insufficient information on adherence to the protocol; however, the other trials were rated as low risk, as they were conducted according to suitable protocols, and all participants received the interventions as per protocol with no deviations. Additionally, two trials [ 5 , 11 ] had unclear detection bias risk due to insufficient information about whether the outcome could be influenced by knowledge of the intervention received, while the other trials were at a high risk of detection bias since knowledge of the intervention received could likely affect the outcome assessment. Attrition bias was not observed in any of the studies, and while four trials were considered low risk for reporting bias, two trials [ 7 , 14 ] were registered after the study's completion and were therefore scored as unclear.…”

“…The meta-analysis incorporated five trials [6,7,[11][12][13] that provided data on the duration of respiratory support. The findings showed that using HFNC for weaning CPAP did not result in a statistically significant difference in the duration of respiratory support compared to weaning CPAP alone (MD (95% CI) in days 3.52 (−0.02, 7.05); 5 RCTs; participants = 488; I 2 = 29%).…”

Characterizing continuous positive airway pressure (CPAP) Belly Syndrome in preterm infants in the neonatal intensive care unit (NICU)

“…This diagnostic uncertainty may lead to unnecessary exposure to diagnostic radiographs and pauses in enteral feeds. Several studies comparing the effects of high ow nasal cannula (HFNC) to the effects of CPAP on enteral feeding have shown no clear bene t, likely in part because HFNC also causes pressurized air to pass into the enteric tract [22][23][24][25] .…”