International randomised controlled trial of patient triggered ventilation in neonatal respiratory distress syndrome

Abstract

Aim-To compare the eVects of patient triggered ventilation (PTV) with conventional ventilation (IMV) in preterm infants ventilated for respiratory distress syndrome (RDS).Methods-Nine hundred and twenty four babies from 22 neonatal intensive care units were assessed. They were under 32 weeks of gestation and had been ventilated for respiratory distress syndrome (RDS) for less than 6 hours within 72 hours of birth. The infants were randomly allocated to receive either PTV or IMV. Analysis was on an "intention to treat" basis. Death before discharge home or oxygen therapy at 36 weeks of gestation; pneumothorax while ventilated; cerebral ultrasound abnormality nearest to 6 weeks; and duration of ventilation in survivors were the main outcome measures. Results-There was no significant diVerence in outcome between the two groups. Unadjusted rates for death or oxygen dependency at 36 weeks of gestation were 47.4% and 48.7%, for PTV and IMV, respectively; for pneumothorax these were 13.4% and 10.3%; and for cerebral ultrasound abnormality nearest to 6 weeks these were 35.4% and 36.9%. Median duration of ventilation for survivors in both groups was 6 days. Overall, 79% of babies received only their assigned ventilation. PTV babies were more likely to depart from their intended ventilation (27% vs 15%). The trend towards higher pneumothorax rates with PTV occurred only in infants below 28 weeks of gestation (18.8% vs 11.8%). Conclusions-There was no observed benefit from the use of PTV, with a trend towards a higher rate of pneumothorax under 28 weeks of gestation. Although PTV has a similar outcome to IMV for treatment of RDS in infants of 28 weeks or more gestation, within 72 hours of birth, it was abandoned more often. It cannot be recommended for infants of less than 28 weeks' gestation with the ventilators used in this study.

Outcome of Extremely Preterm Infants Randomized at Birth to Different PaCO₂ Targets during the First Seven Days of Life

“…New data suggest that our practice to administer bicarbonate in combined acidosis, done to avoid side effects of low pH [19,20] , may have actually reduced the benefi ts of hypercapnia in preventing lung injury [29,30] . Avoiding synchronized ventilation, however, was probably unrelated to the outcomes of this study, as two large randomized trials have failed to demonstrate any outcome benefi t associated with synchronization [21,22] . This study also highlights the diffi culties in achieving high PaCO 2 targets in non-paralyzed preterm infants with moderate lung disease.…”

“…After 7 days, PaCO 2 targets were increased also in the standard ventilation group, in accordance with standard practice in our unit, to hasten extubation. Synchronization was not used, as it has not yet been shown to improve the outcome and therefore was not standard practice in our unit [21,22] . Tidal volumes and dynamic compliance were measured daily in the fi rst 22 randomized patients, as long as they remained intubated, with a CP100 pulmonary function monitor (Bicore Monitoring Systems, Irvine, Calif., USA), which also enabled confi rmation that the auto-PEEP did not occur with our ventilatory strategy.…”

Optimal Ventilatory Strategies and Surfactant to Protect the Preterm Lungs

“…Different modes of patient-triggered ventilation (PTV), such as SIMV, assist-control, volume limit or volume guarantee, and pressure or volume support ventilation, are widely used in preterm infants. Randomized controlled trials using different modes of PTV have shown short-term benefits such as decrease in the duration of mechanical ventilation or days on oxygen [25,26] . Volume-guaranteed or volume-targeted ventilation results in improved ventilation and stable gas exchange.…”

Lung protective ventilatory strategies in very low birth weight infants

“…Randomized, controlled trails using different modes of PTV have been associated with short-term benefits, such as a decrease in the duration of mechanical ventilation or days on oxygen. 21,22 PTV use was also associated with a decreased need for sedation in VLBW infants. None of these studies demonstrated a significant benefit in terms of reducing lung injury.…”