The Danish national study in infants with extremely low gestational age and birthweight (the ETFOL study): respiratory morbidity and outcome

Abstract

Aim: To describe and analyse neonatal care, short and long‐term morbidity with special reference to ventilatory support and chronic lung disease (CLD) in a population‐based study. Methods: During 1994 and 1995 a prospective, nation‐wide, multicentre study was conducted, comprising 477 liveborn infants with gestational age (GA) >28 wk and/or birthweight >1000 g. Of these, 407 infants received active treatment. The ventilatory treatment was based on the principle of permissive hypercapnia and early nasal continuous positive airway pressure (NCPAP) supplemented with surfactant and ventilator therapy in case of CPAP failure. Results: Among actively treated infants 85% received CPAP and 23% mechanical ventilation from the first day of life. A total of 269 infants (56%) survived to discharge. Of these, 195 had a GA >28wk. One‐hundred and five survivors with GA >28 wk survived with NCPAP as sole respiratory support. In surviving infants, periventricular leucomalacia/intraventricular haemorrhage grade 3–4 was found in 10%, retinopathy of prematurity grade >2 in 4%, and oxygen requirement at 36 and 40 wk of postmenstrual age (CLD) in 16 and 5%, respectively. Three infants either died of CLD (n= 1) or required oxygen therapy beyond 43 wk of postmenstrual age. Logistic regression analysis showed significant associations between oxygen requirement at 40 wk and GA, septicaemia, mechanical ventilation, symptomatic patent ductus arteriosus and Clinical Risk Index for Babies score. Only the two last‐mentioned factors proved significant in infants with GA >28 wk. No infant died after discharge and 253 (94%) were followed up at 2 y of corrected age; one or more moderate to severe impairments were found in 66 (26%) of the examined children. Conclusion: Ventilatory treatment in extremely premature and extremely low‐birthweight infants based on early NCPAP and permissive hypercapnia may result in comparable survival rates and sensorineural outcome; however, the incidence of CLD seems lower than that reported on conventional treatment.

Surfactant-Replacement Therapy for Respiratory Distress in the Preterm and Term Neonate

“…140 In preterm infants of less than 28 weeks' gestation or with birth weights of less than 1000 g, the need for mechanical ventilation has been reported to range between 40% and 90% in uncontrolled studies of continuous positive airway pressure. 133,134,137,141 In large cohorts of extremely preterm infants, 80% received mechanical ventilation and 70% received exogenous surfactant. 19,31 A small trial of 104 infants who were born at or earlier than 27 weeks' gestation and randomly assigned to stabilization with or without continuous end-distending pressure in the delivery room revealed that nearly 80% of these infants received mechanical ventilation, mostly because of respiratory distress within the first hours after birth.…”

“…143,144 Likewise, preliminary success with a strategy of early continuous positive airway pressure with or without rescue surfactant administration in observational, historical control, and small randomized trials has influenced some clinicians to substitute an early rescue strategy for a surfactant prophylaxis strategy for infants of less than 30 weeks' gestation. 19,31,[128][129][130][131][132][133][134][135][136][137][138][139][140][141][142] In preterm infants of more than 27 weeks' gestation, observational studies have suggested that early continuous positive airway pressure to prevent or treat respiratory distress syndrome without mechanical ventilation may reduce the incidence of bronchopulmonary dysplasia. 136,143,144 In contrast, a multicenter, randomized, controlled trial that compared prophylactic to rescue continuous positive airway pressure revealed no difference in surfactant use, mechanical ventilation, bronchopulmonary dysplasia, air leaks, or other complications of preterm birth.…”

A randomized controlled trial of synchronized nasal intermittent positive pressure ventilation in RDS

“…8,9 Although use of nasal continuous positive airway pressure (NCPAP) post-surfactant (InSUrE, intubation, surfactant and extubation) has met with some success, [9][10][11][12] some infants have failed that approach. 13,14 Nasal intermittent positive pressure ventilation (NIPPV) is a form of non-invasive respiratory support that combines NCPAP with intermittent ventilator breaths. The use of synchronized NIPPV (SNIPPV) for supporting infants who are extubated has been advocated by many investigators.…”

Outcomes of Infants Born at 22 and 23 Weeks’ Gestation

“…[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21] There recently have been several notable reports on 22 and 23 weeks' gestational age; the short-term outcomes of these extremely premature infants seem to have improved, but the long-term outcomes are still unfavorable. [6][7][8][9][10][11][12][13][14][15][16][17][18] Decisions to initiate or withhold intensive care for these extremely premature infants are highly controversial, in contrast to those for infants born at 24 and 25 weeks' gestational age. [22][23][24] Physicians and parents contemplating the prognosis of extremely preterm infants require reliable information based on gestational age with which to plan care around the time of birth and thereafter.…”