Less invasive surfactant administration: a word of caution

Luca, Danièle De; Shankar-Aguilera, Shivani; Centorrino, Roberta; Fortas, Feriel; Yousef, Nadya; Carnielli, Virgilio P.

doi:10.1016/s2352-4642(19)30405-5

Cited by 46 publications

(42 citation statements)

References 82 publications

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“…CPAP is better transmitted if delivered through nasal mask in the first days of life and this seems also to reduce the risk of local skin injury. 53,54 However, we have to acknowledge that nasal CPAP unavoidably has relevant leaks up to around 40% with mouth opening, 55 irrespective of the nasal interface used 56e59 and the same applies for more complex techniques of non-invasive respiratory failure. 60 As the optimal CPAP level to be provided in preterm neonates with RDS is not known, we also ignore if active mouth closure may be beneficial.…”

Section: Optimization Of Cpap Therapymentioning

confidence: 99%

“…so-called "less invasive surfactant administration techniques" have spread, but they cannot provide the same advantages, as they require sedation and intubation. 55 In absence of sedation these techniques may be ethically questionable. 55 Furthermore, they have significant problems as CPAP is not transmitted during these procedures, and the surfactant distribution may not be as effective.…”

Section: Surfactant Administration Techniquesmentioning

confidence: 99%

“…55 In absence of sedation these techniques may be ethically questionable. 55 Furthermore, they have significant problems as CPAP is not transmitted during these procedures, and the surfactant distribution may not be as effective. 56,66 Moreover, the theoretical advantages of these techniques are unclear, since trials have been significantly biased and they lack a clear background to be superior to the actual intubation-surfactant-extubation (INSURE) technique.…”

Section: Surfactant Administration Techniquesmentioning

confidence: 99%

“…56,66 Moreover, the theoretical advantages of these techniques are unclear, since trials have been significantly biased and they lack a clear background to be superior to the actual intubation-surfactant-extubation (INSURE) technique. 55 Conversely, supraglottic devices are being developed and investigated in preliminary trials, although with delay compared to their use in adult and pediatric anesthesia. The use of these devices can finally be a significant improvement, since they can be placed easily and without any sedation.…”

Section: Surfactant Administration Techniquesmentioning

confidence: 99%

See 3 more Smart Citations

Respiratory distress syndrome in preterm neonates in the era of precision medicine: A modern critical care-based approach

Luca

2021

Pediatrics & Neonatology

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Section: Optimization Of Cpap Therapymentioning

confidence: 99%

Section: Surfactant Administration Techniquesmentioning

confidence: 99%

Section: Surfactant Administration Techniquesmentioning

confidence: 99%

Section: Surfactant Administration Techniquesmentioning

confidence: 99%

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Respiratory distress syndrome in preterm neonates in the era of precision medicine: A modern critical care-based approach

Luca

2021

Pediatrics & Neonatology

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“…Noninvasive management strategies have also been enhanced with the use of synchronized noninvasive mechanical ventilation (sNIMV) as a rescue treatment in the event of nCPAP failure [31] and less-invasive surfactant administration (LISA) techniques in spontaneously breathing preterm infants [32], but neither of these strategies has been shown to clearly reduce the incidence of BPD [33][34][35].…”

Section: Introductionmentioning

confidence: 99%

Effect of a new respiratory care bundle on bronchopulmonary dysplasia in preterm neonates

et al. 2020

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The development of devices that can fix the tidal volume in high-frequency oscillatory ventilation (HFOV) has allowed for a significant improvement in the management of HFOV. At our institution, this had led to the earlier use of HFOV and promoted a change in the treatment strategy involving the use of higher frequencies (above 15 Hz) and lower high-frequency tidal volumes (VThf). The purpose of this observational study was to assess how survival without bronchopulmonary dysplasia grades 2 and 3 (SF-BPD) is influenced by these modifications in the respiratory strategy applied to preterm infants (gestational age < 32 weeks at birth) who required mechanical ventilation (MV) in the first 3 days of life. We compared a baseline period (2012-2013) against a period in which this strategy had been fully implemented (2016-2017). A total of 182 patients were exposed to MV in the first 3 days of life being a higher proportion on HFOV at day 3 in the second period 79.5% (n 35) in 2016-2017 vs 55.4% (n 31) in 2012-2013. After adjusting for perinatal risk factors, the second period is associated with an increased rate of SF-BPD (OR 2.28; CI 95% 1.072-4.878); this effect is more evident in neonates born at a gestational age of less than 29 weeks (OR 4.87; 95% CI 1.9-12.48). Conclusions : The early use of HFOV combined with the use of higher frequencies and very low VT was associated with an increase in the study population's SF-BPD. What is Known: • High-frequency ventilation with volume guarantee improve ventilation stability and has been shown to reduce lung damage in animal models. What is New: • The strategy of an earlier use of high-frequency oscillatory ventilation combined with the use of higher frequencies and lower tidal volume is associated to an increase in survival without bronchopulmonary dysplasia in our population of preterm infants. Keywords High-frequencyventilation. Lung protection. Bronchopulmonary dysplasia. Ventilatory-induced lung injury. Target tidal volume. Preterm infants Abbreviations ΔPhf Delta pressure BPD Bronchopulmonary dysplasia type 2-3 BW Birth weight CMV Conventional mechanical ventilation CRIB Critical index for babies DOL Days of life GA Gestational age HFOV High-frequency oscillatory ventilation Hz Hertz INSURE Intubation-surfactant administration-extubation LISA Less-invasive surfactant administration MV Mechanical ventilation nCPAP Nasal continuous airway pressure NEC Necrotizing enterocolitis Communicated by Daniele De Luca

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Effectiveness of Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation vs Noninvasive High-Frequency Oscillatory Ventilation as Support After Extubation of Neonates Born Extremely Preterm or With More Severe Respiratory Failure

Zhu

Shi

et al. 2023

JAMA Netw Open

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ImportanceThe NASONE (Nasal Oscillation Post-Extubation) trial showed that noninvasive high-frequency oscillatory ventilation (NHFOV) slightly reduces the duration of invasive mechanical ventilation (IMV) in preterm infants, whereas NHFOV and noninvasive intermittent positive pressure ventilation (NIPPV) result in fewer reintubations than nasal continuous positive airway pressure (NCPAP). It is unknown whether NHFOV is similarly effective in extremely preterm neonates or in those with more severe respiratory failure (based on the duration of previous ventilation and CO2 levels).ObjectiveTo clarify whether NHFOV is better than NIPPV and NCPAP in reducing the duration of IMV in extremely preterm neonates or those with severe respiratory failure.Design, Setting, and ParticipantsThis study is a predefined secondary analyses of a multicenter randomized clinical trial that was performed at tertiary academic neonatal intensive care units (NICUs) in China. Participants included neonates enrolled in the NASONE trial between December 2017 and May 2021 and belonging to 3 predefined subgroups: (1) born at less than or equal to 28 weeks’ (plus 6 days) gestation, (2) invasively ventilated for more than 1 week from birth, and (3) with CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Data analysis was performed in August 2022.InterventionNCPAP, NIPPV, or NHFOV since the first extubation and until NICU discharge, with airway pressure higher in NHFOV than in NIPPV and than in NCPAP.Main Outcomes and MeasuresThe co–primary outcomes were total duration of IMV during the NICU stay, need for reintubation, and ventilator-free days calculated as per the original trial protocol. Outcomes were analyzed on an intention-to-treat basis as for the whole trial, and subgroup analyses followed the original statistical plan.ResultsAmong 1137 preterm infants, 455 (279 boys [61.3%]) were born at 28 weeks’ gestation or less, 375 (218 boys [58.1%]) underwent IMV for more than 1 week from birth, and 307 (183 boys [59.6%]) had CO2 greater than 50 mm Hg before or in the 24 hours after extubation. Both NIPPV and NHFOV were associated with significantly fewer reintubations (risk difference range, −28% [95% CI, −39% to −17%] to −15% [95% CI, −25% to −4%]; number needed to treat, 3-7 infants) and early reintubations (risk difference range, −24% [95% CI, −35% to −14%] to −20% [95% CI, −30% to −10%]) than NCPAP, and these reintubations were less frequently due to refractory hypoxemia. IMV was shorter in the NIPPV and NHFOV groups (mean difference range, −5.0 days [95% CI, −6.8 to −3.1 days] to −2.3 days [95% CI, −4.1 to −0.4 days]) than in the NCPAP group. Co–primary outcomes were not different between NIPPV and NHFOV; there was no significant interaction effect. Infants in the NHFOV group showed significantly less moderate-to-severe bronchopulmonary dysplasia than infants in the NCPAP group (range, −12% to −10%; number needed to treat, 8-9 infants) and better postextubation gas exchange in all subgroups. The 3 interventions were provided at different mean airway pressure and were equally safe.Conclusions and RelevanceThe subgroup analyses of extremely preterm or more ill infants confirm the results obtained in the whole population: NIPPV and NHFOV appeared equally effective in reducing duration of IMV compared with NCPAP.Trial RegistrationClinicalTrials.gov Identifier: NCT03181958

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Less invasive surfactant administration: a word of caution

Cited by 46 publications

References 82 publications

Respiratory distress syndrome in preterm neonates in the era of precision medicine: A modern critical care-based approach

Respiratory distress syndrome in preterm neonates in the era of precision medicine: A modern critical care-based approach

Effect of a new respiratory care bundle on bronchopulmonary dysplasia in preterm neonates

Effectiveness of Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation vs Noninvasive High-Frequency Oscillatory Ventilation as Support After Extubation of Neonates Born Extremely Preterm or With More Severe Respiratory Failure

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