Long-term outcome of preterm infants treated with nasal continuous positive airway pressure

This study’s aim was to assess neurodevelopmental and growth outcome until the age of 4 years of premature infants placed on early nCPAP, in the setting of the neonatal intensive care unit (NICU) and follow-up program of the Division of Neonatology of the Department of Pediatrics of the University Hospital, Lausanne, Switzerland. All consecutive inborn infants weighing <1500 g or <32 weeks of gestational age admitted to the NICU during two periods of 12 months—7.1996–6.1997 and 7.1998–6.1999—were compared before and after the systematic application of early nCPAP. Of 172 infants admitted to the NICU, 150 (87%) survived. 126 (84%) were tested at 6 months’ corrected age, 121 (81%) at 18 months’ corrected age, and 117 (78%) at the age of 4 years. Detailed perinatal data were collected. Follow-up included neurological examination, developmental testing and measurement of growth parameters. Statistical analyses were performed. Early application of nCPAP and avoidance of mechanical ventilation showed no adverse effects on neurodevelopment and growth. A significantly higher developmental quotient was found in the nCPAP group at 18 months’ corrected age. Several trends were also noted in the nCPAP group with a decrease of intraventricular hemorrhage and in “abnormal neurodevelopment” at 6 months corrected age, a bigger head circumference at all different tested ages and a greater height at 6 and 18 months corrected ages. In conclusion, our study of developmental outcome documents the absence of any harmful effect of early application of nCPAP to treat respiratory failure in very low birthweight infants.     

Early treatment with nasal continuous positive airway pressure in very low-birth-weight infants

During 1988 and 1989, a regional cohort of 81 infants with birth weights less than 1501 g were treated with oxygen only ( n = 11), early continuous positive airway pressure (CPAP) ( n = 68) or mechanical ventilation from birth ( n = 2). We used an easily applicable lightweight CPAP system with nasal prongs and a gas jet supplemented with ventilator treatment if necessary, but with conservative criteria for ventilator treatment with tolerance of high PCO₂. A total of 65 infants (80%) survived to discharge, 61 of whom were supported solely with CPAP or oxygen. Nineteen infants (26%) developed periventricular-intraventricular haemorrhage, but only 4 survivors (6%) developed prognostically significant bleedings grade 2–4. No survivors had bronchopulmonary dysplasia. Follow-up at 12–39 months of age revealed definite disabilities in 6 (10%) and suspected disabilities in 2 of 62 long-term survivors. The results suggest that treatment by early CPAP with nasal prongs with tolerance of high PCO₂ may be effective and lenient in most infants more than 25 weeks' gestation.     

Pharyngeal pressure in preterm infants receiving nasal continuous positive airway pressure

Pharyngeal pressures in 11 preterm infants, receiving binasal Hudson prong continuous positive airway pressure (CPAP) pressurised by bubbling bottles, were measured. The mean (95% confidence interval) pressure drop from the prongs to the pharynx was 3.2 (2.6 to 3.7) cm H(2)O with mouths open and 2.2 (1.6 to 2.8) cm H(2)O with mouths closed. Mouth closure augments CPAP transmission.     

Early nasal continuous positive airway pressure and low threshold for intubation in very preterm infants

AIM: To determine if selective intubation, use of early nasal continuous positive airway pressure (NCPAP) at birth with a low threshold for early surfactant treatment, reduces the need for intubation in very preterm infants in the first days after birth. METHODS: Two cohorts of very preterm infants < or = 32 weeks, born at the Leiden University Medical Center in the Netherlands, were compared retrospectively before (1996-1997) and after (2003-2004) introducing selective intubation and use of early NCPAP. A FiO(2)> or = 0.40 was used as criterion for intubation. Primary outcome measure was intubation < 72 h of age. Bronchopulmonary dysplasia (BPD) was a secondary outcome. RESULTS: The rate of intubation in the delivery room (69% vs. 46%, p < 0.001) and within 72 h of age (73% vs. 57%, p < 0.001) was lower following the change in policy. Early NCPAP was, in 2003-2004, increasingly used as primary treatment (10% vs. 33%, p < 0.001) with higher maximum NCPAP levels (4.0 (0.9) vs. 5.8 (1.5), p < 0.001). There was no change in BPD (14.3% vs. 15.2%, p = 0.82). CONCLUSION: Avoiding intubation by using early NCPAP while maintaining a low-threshold for surfactant treatment decreased the need for intubation.     

Gastric emptying in very-low-birth-weight infants treated with nasal continuous positive airway pressure

OBJECTIVE: Nasal continuous positive airway pressure (NCPAP) is frequently used for prolonged periods in very low birth weight infants. We asked if NCPAP affects gastric emptying. STUDY DESIGN: Preterm newborn infants (n = 16) with a mean body weight of 935 g (SD, 155) and a mean gestational age of 27.7 weeks (SD, 1.9) were treated with NCPAP and fed by orogastric tube. A comparison group of 20 newborn infants with a mean body weight of 1090 grams (SD, 130) and a mean gestational age of 28.2 weeks (SD, 1.2) were not receiving NCPAP. All newborn infants received a milk formula containing 81 kcal/dL given in similar quantities. The antral cross-sectional area was measured by means of an ultrasound technique. RESULTS: Mean half-time of antral cross-sectional area was 28 minutes (SD, 12) in the NCPAP group and 40 minutes (SD, 17) in the comparison group ( P < .05). There were no differences in gastrointestinal complications between the two groups. CONCLUSIONS: The gastric emptying time was shorter for newborn infants treated with NCPAP.     

Tracheal colonization in preterm infants supported with nasal continuous positive airway pressure

Background: The aim of this study was to examine endotracheal bacteriological status in premature infants who are supported by nasal continuous positive airway pressure (CPAP) without any history of tracheal intubation. Methods: In this prospective study, we enrolled 60 premature infants with respiratory distress; of these, 30 were supported by CPAP without tracheal intubation, and 30 were intubated and mechanically ventilated. Infants were enrolled at a postnatal age of <24 h. Endotracheal (ET) cultures were taken at 24 h and at the 5th day of life. In the CPAP group, a suction catheter was sterilely inserted into the trachea while directly visualizing the vocal cords using a laryngoscope. Results: ET cultures taken on the 1st day of life showed colonization in 7/30 (23%) in the CPAP group versus 19/30 (63%) in the mechanically ventilated group (P= 0.002). Tracheal cultures on day 5 were positive in 5/30 (17%) and 11/30 (37%), respectively (P= 0.093). Klebsiella ssp. represented the most frequently isolated organism in both groups. A positive tracheal culture at 5 days was associated with a longer duration of respiratory support in the CPAP group (P= 0.05) but not in the ventilation group. Endotracheal culture at 5 days was associated with mortality in the ventilation group (8/11 vs 5/19, P= 0.02), but not in the CPAP group (1/5 vs 2/25, P= 0.45). Early endotracheal cultures did not relate with mortality in either of the groups. Conclusion: The trachea of premature infants supported with CPAP is at risk for bacterial colonization. Predisposing factors, mechanisms and clinical implications of these novel findings need to be studied.     

Developmental outcomes at the age of two years for very premature babies managed with nasal prong continuous positive airway pressure

AIMS: To describe the developmental progress of very premature babies at the age of 2 years, who were managed in an era where nasal prong continuous positive airway pressure (CPAP) was the preferred method for the management of initial respiratory disease. METHODS: Two groups of very premature babies of <32 weeks gestation were compared, the first being managed with an intubation and mandatory ventilation approach, and the second being managed with a CPAP approach. The groups are compared with regard to the presence of brain injury, retinopathy and requiring discharge home on oxygen and then at 2 years, for language impairment, non-ambulatory cerebral palsy and significant developmental delay. The study is designed as an audit of data collected prospectively and longitudinally for babies born from 1998 to 2002. RESULTS: A significant number of babies were successfully managed on CPAP in the second era and significantly fewer received post-natal steroids. The number being discharged home on oxygen, brain injury and retinopathy were similar in the two groups. Developmental outcome assessed at 2 years of age was the same in both eras. CONCLUSIONS: A CPAP approach to the management of initial respiratory disease in premature babies of less than 32 weeks gestation at birth is associated with no measurable developmental advantage or disadvantage at 2 years of age.     

Early prediction of nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation

Aim: To predict early nasal continuous positive airway pressure failure within the first 2 h after birth in preterm infants. Methods: Patient and respiratory support variables significantly associated with continuous positive airway pressure failure in the first 72 h after birth were identified in a cohort of preterm infants <30 weeks gestation. Using multivariable logistic regression analysis, risk estimates for early nasal continuous positive airway pressure failure were calculated. Results: From 182 infants included, 62(34%) failed early nasal continuous positive airway pressure. Birth weight ≤800 g, male gender and a fraction of inspired oxygen >0.25 at 1 and 2 h of age were significantly associated with early nasal continuous positive airway pressure failure. Combining these variables in a logistic regression model provided a minimal risk estimate for failure of 0.04[0.01–0.23] (female >800 g, FiO₂ ≤ 0.25 at 1, and 2 h) and maximal estimate of 0.92[0.44–0.99] (male ≤800 g, FiO₂ > 0.25 at 1 and 2 h). Conclusion: Combining gender, birth weight and the fraction of inspired oxygen at 1 and 2 h of age allows for a better and more individualized prediction of early nasal continuous positive airway pressure failure in preterm infants less than 30 weeks gestation.     

Early nasal intermittent positive pressure ventilation versus continuous positive airway pressure for respiratory distress syndrome

Aim:  To determine whether early nasal intermittent positive pressure ventilation (NIPPV), in comparison to early continuous positive airway pressure (CPAP), can reduce the need for intubation and mechanical ventilation in preterm neonates with suspected respiratory distress syndrome (RDS).
Methods:  In this stratified open-label randomized controlled trial, neonates (28–34 weeks gestation) with respiratory distress within 6 h of birth and Downe's score ≥ 4 were eligible. Subjects were randomly allocated to 'early-NIPPV' or 'early-CPAP' after stratifying for gestation (28–30 weeks, 31–34 weeks) and surfactant use. Primary outcome was failure of the allocated mode within 48 h.
Results:  Seventy-six neonates were enrolled (37 in 'early-NIPPV' and 39 in 'early-CPAP' groups). Failure rate was less with 'early-NIPPV' versus 'early-CPAP'[13.5% vs. 35.9%, respectively, RR 0.38 (95% CI 0.15–0.89), p = 0.024]. Similarly, need for intubation and mechanical ventilation by 7 days (18.9% vs. 41%, p = 0.036) was less with NIPPV. Failure rate with NIPPV was less in the subgroups of subjects born at 28–30 weeks (p = 0.023) and who did not receive surfactant (p = 0.018).
Conclusion:  Among preterm infants with suspected RDS, early use of NIPPV reduces the need for intubation and mechanical ventilation compared to CPAP.     

Early nasal continuous positive airway pressure treatment reduces the need for intubation in very low birth weight infants

Nasal continuous positive airway pressure (CPAP) applied shortly after birth is said to be an effective treatment of respiratory distress in very low birth weight infants (VLBW). We tested the hypothesis that the use of early nasal CPAP (applied as soon as signs of respiratory distress occurred, usually within 15 min after birth) reduces the need for intubation, the duration of intermittent mandatory ventilation and the incidence of bronchopulmonary dysplasia. All liveborn VLBW infants (birth weight < 1500 g) admitted to our tertiary neonatal intensive care unit in 1990 (historical controls) and in 1993 (early nasal CPAP group) entered the study. The intubation rate was significantly lower after introduction of nasal CPAP (30% vs 53%, P = 0.016). Median duration of intubation was 4.5 days (interquartile range 3–7 days) before versus 6.0 days (2.8–9 days) after nasal CPAP was introduced (P = 0.73). The incidence of bronchopulmonary dysplasia was not reduced significantly (32% vs 30%, P = 0.94). Survival until discharge was 89.5% before versus 92.9% after introduction of nasal CPAP (P = 0.54). Conclusion Early nasal CPAP is an effective treatment of respiratory distress in VLBW infants, significantly reducing the need for intubation and intermittent mandatory ventilation, without worsening other stan dard measures of neonatal outcome. We found no significant decrease in the incidence of bronchopulmo nary dysplasia. Received: 5 February 1996 and in revised form: 12 September 1996 / Accepted: 23 October 1996     

气泡式与鼻塞式持续气道正压通气在早产儿呼吸窘迫综合征的疗效比较

目的 比较气泡式持续气道正压通气（BNCPAP）与鼻塞式持续气道正压通气（nCPAP）在早产儿呼吸窘迫综合征（NRDS）呼吸支持中的疗效及安全性。方法 回顾性分析使用过BNCPAP（69例）或nCPAP（61例）呼吸支持的130例早产NRDS患儿的临床资料,比较两组的死亡率、呼吸支持时间、是否使用肺表面活性物质（PS）以及治疗失败、支气管肺发育不良（BPD）、早产儿视网膜病（ROP）的发生情况,和上机后血气分析的pH、氧分压、二氧化碳分压的变化情况,并评价其安全性。结果 BNCPAP、nCPAP两组患儿在性别分布、出生胎龄及体重、1 min及5 min Apgar评分及出生方式、NRDS严重程度等方面的差异无统计学意义（P > 0.05）。BNCPAP组无患儿死亡,nCPAP组有1例死亡,但两组病死率的差异无统计学意义（P > 0.05）。BNCPAP组及nCPAP组无创辅助通气的时长、治疗失败率、BPD和ROP的发生率以及需要使用或需要重复使用PS比例的差异均无统计学意义（P > 0.05）。两组患儿上机后8~12 h的pH值变化及氧合指数变化的差异无统计学意义（P > 0.05）,但BNCPAP组患儿的二氧化碳分压下降较nCPAP组患儿多（P < 0.05）。两组患儿气胸及鼻中隔、鼻黏膜损伤发生率的差异无统计学意义（P > 0.05）。结论 BNCPAP和nCPAP在早产儿NRDS呼吸支持中的疗效和安全性相近。     

Post-extubation prophylactic nasal continuous positive airway pressure in preterm infants: Systematic review and meta-analysis

OBJECTIVES: To determine whether management with nasal continuous positive airway pressure (NCPAP) in preterm infants having their endotracheal tube removed following a period of intermittent positive pressure ventilation (IPPV), leads to an increased proportion remaining free of additional ventilatory support, compared to extubation directly to headbox oxygen. METHODOLOGY: Search Strategy - Searches were made of the Oxford Database of Perinatal Trials, Medline, abstracts of conferences and symposia proceedings, expert informants, journal hand searching mainly in the English language and expert informant searches in the Japanese language. Selection criteria - All trials utilising random or quasi-random patient allocation, in which NCPAP (delivered by any method) was compared with headbox oxygen for postextubation care were included. Methodological quality was assessed independently by the two authors. Data collection and analysis - Data were extracted independently by the two authors. Meta-analysis using event rate ratios (ERRs) and event rate differences (ERDs) was performed using Revman 3.0 statistical software. Prespecified subgroup analysis to determine the impact of different levels of NCPAP and use of aminophylline were also performed using the same package. Similar analysis to investigate the effect of postnatal age on outcomes of interest was also undertaken. RESULTS: Nasal CPAP, when applied to preterm infants being extubated following IPPV, reduces the incidence of adverse clinical events (apnoea, respiratory acidosis and increased oxygen requirements) indicating the need for additional ventilatory support. This result is both statistically significant and clinically important; ERR, 0.62 (0.49, 0.79) and ERD, - 0.175 (- 0.256, - 0.095). A trend towards reduction in the incidence of oxygen dependency at 28 days of age is also seen in the group extubated to NCPAP; ERR, 0.86 (0.67, 1.10) and ERD, - 0.069 (- 0.177, 0.039). CONCLUSION: Nasal CPAP is effective in preventing failure of extubation in preterm infants following a period of endotracheal intubation and IPPV. Further definition of the patient gestational age and weight groups to whom these results apply is required. Optimal levels of NCPAP as well as methods of administration remain to be determined.     

Effects of nasal continuous positive airway pressure on apnoea index and sleep in infants

Objectives: We examined the effectiveness of nasal continuous positive airway pressure (CPAP) for treatment of sleep apnoea in infants.
Methodology: We studied five infants who all had significant central and mixed apnoea and severe sleep fragmentation. Polysomnographic recordings were performed on 2 consecutive nights in these infants. One night was used as a control study and during the second night nasal CPAP was applied throughout the night
Results: Nasal CPAP significantly reduced apnoea in each infant, with the apnoea index (apnoeas/h) decreasing from 65.6± 14.6 during the control study to 10.5± 14.6 during CPAP in non-rapid eye movement (non-REM) sleep, and from 106± 13.9 during the control study to 26.6± 13.9 during CPAP in REM sleep. Nasal CPAP also improved the sleep fragmentation markedly; REM sleep increased from 14.2± 1.2% of sleep during the control study to 27.1 ± 1.2% of sleep during CPAP.
Conclusions: We conclude that nasal CPAP is an effective treatment for infantile apnoea. Sleep apnoea in these infants is associated with profound sleep fragmentation, which is reversed by nasal CPAP.     

鼻塞持续气道正压对室间隔缺损婴幼儿心肺功能的支持作用

目的　研究鼻塞持续气道正压 (NCPAP)对室间隔缺损合并心力衰竭 (简称心衰 )及Ⅱ型呼吸衰竭 (简称呼衰 )婴儿心肺功能的支持作用。方法　选择合并心衰、呼衰的室间隔缺损婴儿 9例进行NCPAP前瞻性自身对照研究。观察记录NCPAP应用前、应用期间及暂时撤断后临床症状、体征、动脉血气和心功能的变化。结果　应用NCPAP后 ,患儿呼吸频率由 (61± 5 )次 /min降至 (5 3± 4)次 /min (P <0 0 1) ;氧合指数 (PaO2 /FiO2 )由 (15 2± 3 9)mmHg升至 (2 16± 5 1)mmHg (P <0 0 1) ;PaCO2 下降 ,但差异无显著性 [由 (5 2 79± 10 0 7)mmHg降至 (5 0 5 8± 4 5 0 )mmHg,P >0 0 5 ];心率由 (172± 7)次 /min降至 (15 8± 5 )次 /min (P <0 0 5 ) ;左心室每搏输出量由 (10 5± 1 8)ml升至 (12 1± 2 0 )ml;心输出量由 (1 8± 0 3 )L/min升至 (1 9± 0 3 )L/min(P均 <0 0 5 )。结论　NCPAP可提高合并心衰及Ⅱ型呼衰的室间隔缺损婴儿的肺氧合功能及左心室泵血功能 ,不加重高碳酸血症 ;本研究为先天性心脏病合并心衰和Ⅱ型呼衰患儿的无创通气和允许性高碳酸血症策略提供了客观依据     

Early nasal continuous positive airway pressure for preterm neonates: the need for randomized trials

The use of early nasal continuous positive airway pressure (nCPAP) as prophylaxis and treatment for respiratory distress syndrome in preterm neonates, with or without prophylactic surfactant, is becoming increasingly popular. However, the justification for this is limited to comparisons between centres and comparisons of historical controls.

Conclusion: Randomized trials and appropriate evaluation of the nCPAP technique are needed.     

Early rescue administration of surfactant and nasal continuous positive airway pressure in preterm infants <32 weeks gestation

Objective  

This study reports our institutional experience on the outcome after prophylactic and early rescue endotracheal instillation of surfactant within 20 minutes of birth, followed by extubation and nasal continuous positive airway pressure (NCPAP) in preterm infants <32 weeks gestational age.     

经鼻持续正压通气治疗新生儿肺透明膜病的评价

目的评价经鼻持续正压通气(NCPAP)与常规机械通气(CMV)对新生儿肺透明膜病(HMD)的治疗效果和NCPAP是否降低呼吸机相关肺炎(VAP),呼吸机所致肺损伤(VILI)等发生.方法对38例在我院新生儿科住院的HMD患儿进行临床观察,随机分为两组,NCPAP组18例,CMV组20例.所有38例患儿均在生后24小时内给予单剂猪肺表面活性物质(固尔苏120mg/kg).NCPAP组应用INFANTFLOWSYSTEM(英国EME公司产)呼吸机.CMV组应用VIPBIRD(美国产)呼吸机IPPV+PEEP.辅助呼吸.结果存活NCPAP组16/18例,CMV组成活17/20例,两组在存活率、用机时间、颅内出血上无显著差异,而在呼吸机相关性肺炎、呼吸机致肺损伤并发症上,NCPAP组明显低于CMV组,经x2检验两组差异有显著,P＜0.05.结论NCPAP可有效地治疗新生儿HMD,并可明显减少VAP和VILI的发生.