Nasal High-Flow Therapy as Primary Respiratory Support for Preterm Infants without the Need for Rescue with Nasal Continuous Positive Airway Pressure

Abstract

Aim: To evaluate the effectiveness of nasal high-flow therapy (nHFT) as primary respiratory support for preterm infants with respiratory distress syndrome (RDS) in two tertiary neonatal units. Methods: A retrospective outcome analysis of initial respiratory support strategies was performed in two tertiary neonatal units in the UK: John Radcliffe Hospital (JRH), Oxford and St Peter’s Hospital (SPH), Chertsey. Infants born between 28⁺⁰ and 36⁺⁶ weeks gestational age (GA) between May 2013 and June 2015 were included. Results: A total of 381 infants, 191 from JRH and 190 from SPH, were analysed. Infants were stabilised in the delivery room using mask continuous positive airway pressure followed by nHFT. Endotracheal intubation was performed according to local protocols, depending on the severity of RDS. There were significant differences in initial intubation rates according to GA (26% JRH vs. 16.9% SPH, p < 0.001 for babies < 32 weeks GA, and 8.2% JRH vs. 6.5% SPH, p < 0.001 for babies > 32 weeks GA); however, most infants were successfully transitioned to nHFT. Intubation rates during the first 72 h were comparable between centres (14.7% JRH vs. 11.1% SPH, p = 0.29). There were no differences in neonatal morbidities, including air leak, duration of oxygen supplementation, bronchopulmonary dysplasia, sepsis, retinopathy of prematurity, intraventricular haemorrhage, necrotising enterocolitis, or median time to full-suck feeds. Conclusion: Use of nHFT for primary respiratory support, without use of nasal continuous positive airway pressure as “rescue” treatment, resulted in intubation rates lower or comparable to published data from randomised controlled trials.

Observational cohort study of changing trends in non-invasive ventilation in very preterm infants and associations with clinical outcomes

“…In a two-centre study in the UK, Zivanovic et al, found that use of HFNC without the need for CPAP as "rescue" was successful in preventing intubation in infants between 28 and 36 weeks' gestation. [17] Similarly, we found an increase in the use of HFNC later in neonatal care with significant increases in the number of infants who received any HFNC and the number of days on HFNC per infant. In addition, we also found that HFNC was given increasingly earlier with 12 days difference in initiation between 2010 and 2017.…”

Systematic review found that using thin catheters to deliver surfactant to preterm neonates was associated with reduced bronchopulmonary dysplasia and mechanical ventilation

“…Furthermore, an editorial by Pandita et al proposed a novel classification, the first of its kind for surfactant delivery methods(Figure 1), to clarify these points 41. Studies assessing the effectiveness of LISA/SURE techniques in neonates on heated humidified high-flow therapy are lacking and this may be of relative importance, especially to centres that rely on this non-invasive ventilation mode 42,43. This aspect, together with the urgent need for standardisation of practice and clear indications, may account for the patchy uptake of this technique in some countries 44.…”

Fine Tuning Non-invasive Respiratory Support to Prevent Lung Injury in the Extremely Premature Infant

“…Perceived benefits include increased comfort and reduced nasal trauma. There are some studies describing the use of nHF as primary respiratory support of preterm infants (76). However, a Cochrane review on nHF vs. CPAP for respiratory support in preterm infants reported that zero infants <28 weeks had been randomized to nHF as primary support, thus making any conclusions in this group impossible (77).…”