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

Abstract

Within the last decades, therapeutic advances, such as antenatal corticosteroids, surfactant replacement, monitored administration of supplemental oxygen, and sophisticated ventilatory support have significantly improved the survival of extremely premature infants. In contrast, the incidence of some neonatal morbidities has not declined. Rates of bronchopulmonary dysplasia (BPD) remain high and have prompted neonatologists to seek effective strategies of non-invasive respiratory support in high risk infants in order to avoid harmful effects associated with invasive mechanical ventilation. There has been a stepwise replacement of invasive mechanical ventilation by early continuous positive airway pressure (CPAP) as the preferred strategy for initial stabilization and for early respiratory support of the premature infant and management of respiratory distress syndrome. However, the vast majority of high risk babies are mechanically ventilated at least once during their NICU stay. Adjunctive therapies aiming at the prevention of CPAP failure and the support of functional residual capacity have been introduced into clinical practice, including alternative techniques of administering surfactant as well as non-invasive ventilation approaches. In contrast, the strategy of applying sustained lung inflations in the delivery room has recently been abandoned due to evidence of higher rates of death within the first 48 h of life.

Surfactant Administration Through Laryngeal or Supraglottic Airways (SALSA): A Viable Method for Low-Income and Middle-Income Countries

“…Continuous positive airway pressure (CPAP) is a simple, cost efficient, non-invasive respiratory support considered an optimal first line therapy for RDS. It aims to support functional residual capacity and prevent the need for mechanical ventilation (MV) ( 45 , 46 ). CPAP alone without need for surfactant administration is an appropriate initial management strategy for mild RDS, but extremely premature infants may require subsequent surfactant administration ( 47 ).…”

Weaning of invasive ventilation in the neonatal intensive care: Towards standardising practice: A narrative review

“…In the neonatal population, especially the preterm infant, the benefits of early non‐invasive ventilation for respiratory support have been well established 1 . Despite this, 50% of infants get ventilated either at delivery or due to the failure of non‐invasive support 2 . With the increased survival of the extremes of gestational age (GA), the natural course and pattern of lung disease encountered in the neonatal intensive care unit have also changed, with more instances of severe bronchopulmonary dysplasia (BPD) and long‐term ventilation.…”

The Miracles of Surfactant: Less Invasive Surfactant Administration, Nebulization, and Carrier of Topical Drugs

“…Conflicting data exist on the reduction for intracerebral hemorrhage [28,29]. Of note, the inclusion criteria of studies and their methodological quality are subject to bias, requiring further evidence by RCTs [30,31]. In line with this, the first adequately powered RCT to study the effect of surfactant administration to spontaneously breathing infants on the composite outcome of mortality or BPD (OPTI-MIST trial, n = 606 infants) has recently finished recruitment [32].…”