Variables Associated with the Early Failure of Nasal CPAP in Very Low Birth Weight Infants

Ammari, Amer; Suri, Mandhir; Milisavljevic, Vladana; Sahni, Rakesh; Bateman, David A.; Sanocka, Ulana; Ruzal-Shapiro, Carrie; Wung, Jen-Tien; Polin, Richard A.

doi:10.1016/j.jpeds.2005.04.062

Cited by 307 publications

(208 citation statements)

References 25 publications

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“…Those failing CPAP in the first 72 h are known to be at risk of adverse outcomes, in particular pneumothorax and BPD [50,51,52]. Moreover, infants at higher risk of CPAP failure are identifiable based on oxygen requirement in the first hours of life [51] suggesting that further improvement in outcome for infants managed initially with CPAP may be possible with early identification and selective surfactant treatment for the subgroup with more severe RDS. …”

Section: Surfactant Administration Via Fluid Bolus Using Minimally Inmentioning

confidence: 99%

Innovation in Surfactant Therapy I: Surfactant Lavage and Surfactant Administration by Fluid Bolus Using Minimally Invasive Techniques

Dargaville¹

2012

Neonatology

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Innovation in the field of exogenous surfactant therapy continues more than two decades after the drug became commercially available. One such innovation, lung lavage using dilute surfactant, has been investigated in both laboratory and clinical settings as a treatment for meconium aspiration syndrome (MAS). Studies in animal models of MAS have affirmed that dilute surfactant lavage can remove meconium from the lung, with resultant improvement in lung function. In human infants both non-randomised studies and two randomised controlled trials have demonstrated a potential benefit of dilute surfactant lavage over standard care. The largest clinical trial, performed by our research group in infants with severe MAS, found that lung lavage using two 15-ml/kg aliquots of dilute surfactant did not reduce the duration of respiratory support, but did appear to reduce the composite outcome of death or need for extracorporeal membrane oxygenation. A further trial of lavage therapy is planned to more precisely define the effect on survival. Innovative approaches to surfactant therapy have also extended to the preterm infant, for whom the more widespread use of continuous positive airway pressure (CPAP) has meant delaying or avoiding administration of surfactant. In an effort to circumvent this problem, less invasive techniques of bolus surfactant therapy have been trialled, including instillation directly into the pharynx, via laryngeal mask and via brief tracheal catheterisation. In a recent clinical trial, instillation of surfactant into the trachea using a flexible feeding tube was found to reduce the need for subsequent intubation. We have developed an alternative method of brief tracheal catheterisation in which surfactant is delivered via a semi-rigid vascular catheter inserted through the vocal cords under direct vision. In studies to date, this technique has been relatively easy to perform, and resulted in rapid improvement in lung function and reduced need for subsequent ventilation and duration of oxygen therapy. We are now commencing large-scale clinical trials of this method in preterm infants on CPAP.

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Section: Surfactant Administration Via Fluid Bolus Using Minimally Inmentioning

confidence: 99%

Innovation in Surfactant Therapy I: Surfactant Lavage and Surfactant Administration by Fluid Bolus Using Minimally Invasive Techniques

Dargaville¹

2012

Neonatology

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“…Afortunadamente, no se encontró estratificación de la población estudiada, por lo que, a pesar de las diferencias intrínsecas debidas a la forma de remitir a los pacientes a cada servicio y, por ende, al tipo de soporte respiratorio administrado, fue posible utilizar un modelo multivariado para ajustar la potencial confusión que podían generar dichas discrepancias en la evaluación de los resultados. Ahora bien, la incidencia acumulada del fracaso de la CPAP en los pacientes del estudio (16,5 %; IC 95% 11,3 a 22,8 %), fue inferior a la registrada en otros estudios: por un lado, Bohlin (7) informa 19 %, mientras que Ammari, et al, (27) reportan 24 %; sin embargo, estos últimos atendieron a los pacientes sin administrarles surfactante; en el estudio de Rojas (2), llevado a cabo en Colombia en neonatos tratados con CPAP y surfactante, dicha incidencia fue de 25 %. Esta menor proporción de fracaso correspondió a una duración menor de la CPAP hasta la resolución de la dificultad respiratoria en estos prematuros, comparada con la de la respiración mecánica asistida: 34,0 Vs. 75,8 horas en promedio, respectivamente.…”

Section: Discussionunclassified

Nasal CPAP vs. mechanical ventilation in 28-32 weeks preterm infants with early surfactant administration

et al. 2014

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“…Our FiO 2 (≥0.4) may be considered by some to be too low and result in more infants being classified as failing CPAP than if higher FiO 2 was used. Several studies have used FiO 2 >0.6 [2,3,4,18]. CPAP levels used at RWH are higher than those used by other groups [3,5] and these infants might have met CPAP failure criteria at other institutions.…”

Section: Discussionmentioning

confidence: 99%

“…Although these data show that VPIs who start on CPAP and fail have a worse outcome than those who stay on CPAP, it is important to appreciate that the outcome of babies who fail CPAP appears to be similar to babies who are intubated from birth, albeit worse than those who are successfully managed with CPAP [4,5]. …”

Section: Discussionmentioning

confidence: 99%

“…Variables such as low birth weight (<750 g), gestation <26 weeks and severity of RDS (AaDO 2 >180 mm Hg) are strongly associated with CPAP failure, but are weak predictors of the need for early intubation and ventilation on more robust analysis [4]. An inspired fraction of oxygen (FiO 2 ) >0.25 in the first 2 h of life combined with male gender and birth weight <800 g may improve the accuracy of prediction of CPAP failure, although the predictive ability is weak [5].…”

Section: Introductionmentioning

confidence: 99%

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The Stable Microbubble Test for Determining Continuous Positive Airway Pressure (CPAP) Success in Very Preterm Infants Receiving Nasal CPAP from Birth

et al. 2013

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Background: Very preterm infants can be treated with nasal continuous positive airway pressure (CPAP) from birth, but some fail. A rapid test, such as the stable microbubble test (SMT) on gastric aspirate, may identify those who can be managed successfully using CPAP. Objective: To determine if SMT can identify soon after birth, very preterm infants who may be successfully managed on CPAP alone. Methods: Stable microbubbles (diameter <15 µm) were counted in gastric aspirates taken <1 h of age from infants <30 weeks' gestation, who received CPAP from birth. Infants failed CPAP if intubated at <72 h of age. Clinicians were masked to SMT results. A receiver operating characteristic curve was generated to determine the relationship between number of microbubbles/mm² and subsequent intubation. Results: 68 infants of mean (SD) 28.1 (1.4) weeks' gestation received CPAP in the delivery room at a median (interquartile range) pressure 7 (6-8) cmH₂O and FiO₂ 0.25 (0.21-0.3). Gastric aspirates were taken at a median (interquartile range) age of 0.5 (0.3-0.6) hours. The best cut-off point for predicting CPAP success or failure was a SMT count of 8 microbubbles/mm². The area under the receiver operating characteristic curve was 0.8 (95% CI 0.7-0.9). A SMT count ≥8 microbubbles/mm² had a sensitivity of 53%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 60% for predicting CPAP success. Conclusion: Infants treated with CPAP from birth, who hadSMT counts ≥8 microbubbles/mm² on their gastric aspirate, did not fail CPAP.

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Variables Associated with the Early Failure of Nasal CPAP in Very Low Birth Weight Infants

Cited by 307 publications

References 25 publications

Innovation in Surfactant Therapy I: Surfactant Lavage and Surfactant Administration by Fluid Bolus Using Minimally Invasive Techniques

Innovation in Surfactant Therapy I: Surfactant Lavage and Surfactant Administration by Fluid Bolus Using Minimally Invasive Techniques

Nasal CPAP vs. mechanical ventilation in 28-32 weeks preterm infants with early surfactant administration

The Stable Microbubble Test for Determining Continuous Positive Airway Pressure (CPAP) Success in Very Preterm Infants Receiving Nasal CPAP from Birth

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