Neonatal care of very‐low‐birthweight infants in special‐care units and neonatal intensive‐care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilation: gains and losses

Jónsson, Baldvin; Katz‐Salamon, Miriam; Faxelius, Gerd; Broberger, U.; Lagercrantz, Hugo

doi:10.1111/j.1651-2227.1997.tb18303.x

Cited by 107 publications

(64 citation statements)

References 23 publications

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“…3 A number of observational cohort studies have demonstrated that the use of early CPAP, usually initiated within minutes to hours after delivery, has been associated with a decrease in the use of mechanical ventilation, without any corresponding increases in other morbidities, including death, intraventricular hemorrhage, periventricular leukomalacia, and bronchopulmonary dysplasia. [4][5][6] None of these observations was from prospective controlled trials, and in none was there a contemporaneous control group that did not receive early CPAP.…”

Section: Delivery Room Continuous Positive Airway Pressure/positive Ementioning

confidence: 99%

Delivery Room Continuous Positive Airway Pressure/Positive End-Expiratory Pressure in Extremely Low Birth Weight Infants: A Feasibility Trial

et al. 2004

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Objective. Although earlier studies have suggested that early continuous airway positive pressure (CPAP) may be beneficial in reducing ventilator dependence and subsequent chronic lung disease in the extremely low birth weight (ELBW) infant, the time of initiation of CPAP has varied, and there are no prospective studies of infants who have received CPAP or positive end-expiratory pressure (PEEP) from initial resuscitation in the delivery room (DR). Current practice for the ELBW infant includes early intubation and the administration of prophylactic surfactant, often in the DR. The feasibility of initiating CPAP in the DR and continuing this therapy without intubation for surfactant has never been determined prospectively in a population of ELBW infants. This study was designed to determine the feasibility of randomizing ELBW infants of <28 weeks’ gestation to CPAP/PEEP or no CPAP/PEEP during resuscitation immediately after delivery, avoiding routine DR intubation for surfactant administration, initiating CPAP on neonatal intensive care unit (NICU) admission, and assessing compliance with subsequent intubation criteria. Methods. Infants who were of <28 weeks’ gestation, who were born in 5 National Institute of Child Health and Human Development Neonatal Research Network NICUs from July 2002 to January 2003, and for whom a decision had been made to provide full treatment after birth were randomized to receive either CPAP/PEEP or not using a neonatal T-piece resuscitator (NeoPuff). Infants would not be intubated for the sole purpose of surfactant administration in the DR. After admission to the NICU, all nonintubated infants were placed on CPAP and were to be intubated for surfactant administration only after meeting specific criteria: a fraction of inspired oxygen of >0.3 with an oxygen saturation by pulse oximeter of <90% and/or an arterial oxygen pressure of <45 mm Hg, an arterial partial pressure of carbon dioxide of >55 mm Hg, or apnea requiring bag and mask ventilation. Results. A total of 104 infants were enrolled over a 6-month period: 55 CPAP and 49 control infants. No infant was intubated in the DR for the exclusive purpose of surfactant administration. Forty-seven infants were intubated for resuscitation in the DR: 27 of 55 CPAP infants and 20 of 49 control infants. Only 4 of the 43 infants who had a birth weight of <700 g and 3 of the 37 infants of <25 weeks’ gestation were resuscitated successfully without positive pressure ventilation, and no difference was observed between the treatment groups. All infants of 23 weeks’ gestation required intubation in the DR, irrespective of treatment group, whereas only 3 (14%) of 21 infants of 27 weeks’ required such intubation. For infants who were not intubated in the DR, 36 infants (16 CPAP infants and 20 control infants) were subsequently intubated in the NICU by day 7, in accordance with the protocol. Overall, 80% of studied infants required intubation within the first 7 days of life. The care provided for 52 (95%) of 55 CPAP infants and 43 (88%) of the 49 control infants was in compliance with the study protocol, with an overall compliance of 91%. Conclusions. This study demonstrated that infants could be randomized successfully to a DR intervention of CPAP/PEEP compared with no CPAP/PEEP, with intubation provided only for resuscitation indications, and subsequent intubation for prespecified criteria. Forty-five percent (47 of 104) of infants <28 weeks’ gestation required intubation for resuscitation in the DR. CPAP/PEEP in the DR did not affect the need for intubation at birth or during the subsequent week. Overall, 20% of infants did not need intubation by 7 days of life. This experience should be helpful in facilitating the design of subsequent prospective studies of ventilatory support in ELBW infants.

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Section: Delivery Room Continuous Positive Airway Pressure/positive Ementioning

confidence: 99%

Delivery Room Continuous Positive Airway Pressure/Positive End-Expiratory Pressure in Extremely Low Birth Weight Infants: A Feasibility Trial

et al. 2004

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“…11,12 In Scandinavia, early nCPAP is the first line of treatment for very low-birth-weight infants and many infants can be successfully managed without MV. 13,14 In 1997, Jonsson et al 14 evaluated ventilatory treatment strategies for all infants with a birth weight <1500 g in Stockholm County. Of infants receiving early nCPAP treatment, 34% later required MV and failure of nCPAP was significantly associated with the presence of RDS.…”

Section: Introductionmentioning

confidence: 99%

“…Of infants with the diagnosis of RDS cared for at neonatal units in Stockholm without available MV, 85% had a gestational age of X27 weeks and 91% required transfer for neonatal intensive care. 14 The majority of these infants would likely have benefited from surfactant therapy.…”

Section: Introductionmentioning

confidence: 99%

Implementation of surfactant treatment during continuous positive airway pressure

et al. 2007

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Objective: To study the effects of implementing a method for surfactant administration by transient intubation, INSURE (i.e. INtubation SURfactant Extubation) during nasal continuous positive airway pressure (nCPAP) for moderately preterm infants with respiratory distress syndrome (RDS).Study design: A descriptive, retrospective, bi-center study in Stockholm, Sweden, comparing mechanical ventilation (MV) rates, surfactant use, treatment response and outcome of all inborn infants with gestational age 27 to 34 weeks and RDS, (n ¼ 420), during the 5-year periods before and after the introduction of the INSURE-strategy at one of the centers (Karolinska Huddinge) in 1998. The other center (Karolinska Solna) continued conventional surfactant therapy in conjunction with MV throughout the study.Results: Implementation of INSURE at Karolinska Huddinge reduced the number of infants requiring MV by 50% (P<0.01), resulted in earlier surfactant administration and increased overall surfactant use. INSURE-treatment improved oxygenation and the treatment response was sustained over time with only 17% of the infants requiring >1 dose of surfactant. At Karolinska Solna, the MV rates were unaltered between the first and second 5-year period.Conclusion: Implementing a strategy of surfactant administration by transient intubation during nCPAP reduces the need for MV without adverse effects on outcome and may be an option to more effectively treat RDS, particularly in a care setting where transfer is necessary to provide MV.

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“…Unfortunately, these results are not always taken into account in neonatal intensive care units, and MV is often initiated after endotracheal intubation for surfactant administration, without consideration of the fact that many infants who are able to breathe spontaneously could be supported with NCPAP only. [4][5][6][7] The present study was planned to test the hypothesis that preterm infants (Ͻ30 weeks' gestation) with iRDS who were treated with NCPAP and surfactant administration followed by immediate reinstitution of NCPAP could fare better than those who received MV after surfactant administration and who were weaned progressively from MV. In particular, our aim was to determine whether the first strategy could reduce the need for MV during the subsequent clinical course of our patients.…”

mentioning

confidence: 99%

Early Extubation and Nasal Continuous Positive Airway Pressure After Surfactant Treatment for Respiratory Distress Syndrome Among Preterm Infants <30 Weeks’ Gestation

et al. 2004

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ABSTRACT.Objective. To test the hypothesis that preterm infants with infant respiratory distress syndrome who are treated with nasal continuous positive airway pressure (NCPAP) and surfactant administration followed by immediate extubation and NCPAP application (SURF-NCPAP group) demonstrate less need for mechanical ventilation (MV), compared with infants who receive MV after surfactant administration (SURF-MV group).Methods. A prospective randomized study was conducted, in which infants <30 weeks' gestation were randomized to the SURF-NCPAP group or the SURF-MV group.Results. At 7 days of life, no patient in the SURF-NCPAP group but 6 patients (43%) in the SURF-MV group still were undergoing MV. The duration of oxygen therapy, NCPAP, and MV, the need for a second dose of surfactant, and the length of stay in the intensive care unit were significantly greater in the SURF-MV group.Conclusions. The immediate reinstitution of NCPAP after surfactant administration for infants with infant respiratory distress syndrome is safe and beneficial, as indicated by the lesser need for MV and the briefer requirement for respiratory supports, compared with the institution of MV after surfactant treatment. Moreover, this strategy contributed to reducing the need for surfactant treatment and reducing the time and costs involved in keeping the infants in the neonatal intensive care unit. Pediatrics 2004;113:e560 -e563. URL: http: //www.pediatrics.org/cgi/content/full/113/6/e560; continuous positive airway pressure, mechanical ventilation, surfactant, respiratory distress syndrome, infant.ABBREVIATIONS. a/APo 2 , arterial/alveolar oxygen tension ratio; iRDS, infant respiratory distress syndrome; MV, mechanical ventilation; NCPAP, nasal continuous positive airway pressure; SURF-MV, mechanical ventilation after surfactant treatment; SURF-NCPAP, nasal continuous positive airway pressure after surfactant treatment; Fio 2 , fraction of inspired oxygen; IVH, intraventricular hemorrhage; BPD, bronchopulmonary dysplasia; ROP, retinopathy of prematurity; PDA, patent ductus arteriosus.T he cornerstones of treatment of infant respiratory distress syndrome (iRDS) are artificial respiratory support and surfactant treatment. Among respiratory support techniques, nasal continuous positive airway pressure (NCPAP) 1 and mechanical ventilation (MV) 2 are known for their effectiveness in reducing the mortality and morbidity rates associated with iRDS. Moreover, early application of NCPAP 1 and early treatment with surfactant 3 are effective in decreasing the need for MV, with its related adverse effects. Unfortunately, these results are not always taken into account in neonatal intensive care units, and MV is often initiated after endotracheal intubation for surfactant administration, without consideration of the fact that many infants who are able to breathe spontaneously could be supported with NCPAP only. [4][5][6][7] The present study was planned to test the hypothesis that preterm infants (Ͻ30 weeks' gestation) with iRDS who were treated with N...

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Neonatal care of very‐low‐birthweight infants in special‐care units and neonatal intensive‐care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilation: gains and losses

Cited by 107 publications

References 23 publications

Delivery Room Continuous Positive Airway Pressure/Positive End-Expiratory Pressure in Extremely Low Birth Weight Infants: A Feasibility Trial

Delivery Room Continuous Positive Airway Pressure/Positive End-Expiratory Pressure in Extremely Low Birth Weight Infants: A Feasibility Trial

Implementation of surfactant treatment during continuous positive airway pressure

Early Extubation and Nasal Continuous Positive Airway Pressure After Surfactant Treatment for Respiratory Distress Syndrome Among Preterm Infants <30 Weeks’ Gestation

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Neonatal care of very‐low‐birthweight infants in special‐care units and neonatal intensive‐care units in Stockholm. Early nasal continuous positive airway pressure versus mechanical ventilation: gains and losses

Cited by 107 publications

References 23 publications

Delivery Room Continuous Positive Airway Pressure/Positive End-Expiratory Pressure in Extremely Low Birth Weight Infants: A Feasibility Trial

Delivery Room Continuous Positive Airway Pressure/Positive End-Expiratory Pressure in Extremely Low Birth Weight Infants: A Feasibility Trial

Implementation of surfactant treatment during continuous positive airway pressure

Early Extubation and Nasal Continuous Positive Airway Pressure After Surfactant Treatment for Respiratory Distress Syndrome Among Preterm Infants &lt;30 Weeks’ Gestation

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Early Extubation and Nasal Continuous Positive Airway Pressure After Surfactant Treatment for Respiratory Distress Syndrome Among Preterm Infants <30 Weeks’ Gestation