Noninvasive Respiratory Support of Preterm Infants with RDS

Morgan Stanley Children’s Hospital

Columbia University

Richard A. Polin M.D.

Milestones in Neonatal Intensive Care

Epidemiology of bronchopulmonary dysplasia (BPD) and strategies

for prevention.

Rationale for use of CPAP as an initial mode of respiratory support

Randomized Clinical Trials of NIPPV or HFNC versus CPAP

Conclusions and Recommendations

Outline

✶ A 0.75 kg infant is born following a 27 week gestation. The infant exhibits

immediate signs of respiratory distress and is administered 30% O2 in the

delivery room. He is given ampicillin and gentamicin and transported to the

NICU. A chest x-ray demonstrates a ground glass appearance with air

bronchograms. What should be done now?

Case

A. Intubate, administer surfactant and rapidly extubate to NPCPAP (INSURE).

B. Withhold surfactant. Place the infant IMV-NPCPAP or HHHFN.

C. Withhold surfactant. Place on the infant on NPCPAP and observe.

Modified from Thomas W &

Speer CP Neonatology 2011

Immature Lung Genetic Predisposition

• Nitric oxide

• Diuretics

• Superoxide

Dismutase

• Gentle

Resuscitation

• Antenatal steroids

• Surfactant

• Permissive

Hypercapnia

• Permissive

hypoxemia

• Caffeine

• Postnatal

steroids

• Vitamin A

• CPAP

Lung Injury in the Neonate: Fundamental Concept

S If you don’t ventilate an infant, it’s hard to cause BPD!

Gregory et al. N Engl J Med 284: 1333, 1971

Treatment of idiopathic respiratory distress syndrome with

continuous positive airway pressure

Weight N PaO2 (pre) PaO2 (post)

930-1500 10 37.1 116.4

1501-2000 5 38.1 114.8

2001-3830 5 48.6 96.0

Treatment of idiopathic respiratory distress syndrome with

continuous positive airway pressure

Gregory et al. N Engl J Med 284: 1333, 1971

CPAP is Controversial

Practical skepticism “ the position that new information may be

worthy of confidence, but that acceptance depends on the

strength of the supportive data.

Skepticism and CPAP

*Kamper et al Acta Paediatr. 1992

The fundamental concept of the Kamper* study that the “softly-

softly” approach will decrease morbidity is fundamentally flawed.

Putting seriously ill babies on CPAP alone gives the clinician much

less control of cardio-respiratory function at a time when the baby is

at major risk of sudden deterioration”

NRC Robertson Cambridge UK 1993

2003-2007

N =8546

2008-2012

N=8034

2012

N=1756

Any conventional

ventilation

82% 87% 83%

Any non-invasive

ventilation

80% 96% 100%

CPAP highest 8 % 9% 11%

Respiratory support for infants 22-28 weeks gestation

surviving more than 12 hours of life

Stoll JAMA 2015

Delivery Room Intubation

Birth Year

Infa

nts

Wh

o R

eceiv

ed

Pra

cti

ce,

%

1993 1996 1999 2002 2005 2008 2011

100

80

60

40

20

0

Surfactant Therapy

Birth Year

Infa

nts

Wh

o R

eceiv

ed

Pra

cti

ce,

%

1993 1996 1999 2002 2005 2008 2011

100

80

60

40

20

0

Bronchopulmonary Dysplasia

Birth Year

Infa

nts

Wh

o R

eceiv

ed

Pra

cti

ce,

%

1993 1996 1999 2002 2005 2008 2011

100

80

60

40

20

0

Surfactant: Systematic Reviews-Mortality

RR 95%CI NNT 95% CI

Natural surfactant 0.86 0.76-0.98 50 20-1000

Multiple doses 0.63 0.39-1.02 14 7-1000

Prophylaxis 0.61 0.48-0.77 20 14-50

Early 0.87 0.77-0.99 33 17-1000

HL Halliday Journal of Perinatology 28: s47, 2008

Critique of the Surfactant Trials

✶ Low rates of exposure to antenatal steroids

✶ Infants randomized to control arms of these trials were

routinely ventilated (without surfactant) rather than receiving

CPAP

“Simplicity is the Ultimate

sophistication”

KISS: Keep it simple stupid!

✶ Is the use of CPAP as an initial treatment for preterm infants

with RDS evidence-based?

Yes

Summary of CPAP Trials

Gestational age N Death or BPD Air-leaks

CPAP/control CPAP/control

✶ Support 240/7-276/7 1316 47.8%/51.1% 6.8%/7.4%

✶ COIN 250/7-286/7 610 33.9%/38.9% 9.1%/3.0%

✶ VON 266/7-296/7 648 29.6%/36.5% 4.8%/5.4%

✶ Neocosur 800-1500g 256 13.7%/19.2% 3.1%/5.6%

✶ CURPAP 250/7-286/7 208 21.0%/21.9% 4.9%/9.5%

Total 3038 29.2%/33.52% 5.7%/6.18%

If CPAP is going to be compared to any

other respiratory support modality

(intubation/surfactant or HFNC) it has be

used optimally

Why Has CPAP Been Only Marginally Better?

✶ Inexperience with CPAP in the centers participating in RCTs

(and greater skill with other forms of respiratory support)

✶ Thresholds for abandoning CPAP were too low.

✶ Limited duration of ventilation in the RCTs

✶ Some CPAP delivery stems, may be more effective than others.

Pre-CPAP (%)

Tercile 1 (%)

Tercile 2 (%)

Tercile 3 (%)

ENCPAP application

11.1% 17.6 61.8 66.7

CPAP failure 18.2* 38.5 13.8 7.4

Surfactant 51.5 48.0 13.3 33.3

BPD 33.3% 46.2 25.9 11.1

Aly et al. Pediatrics 114: 697, 2004 * First week of life

There’s a Learning Curve to Success with CPAP

% intubated nCPAP/control

% surfactant nCPAP/control

FiO2 treatment failure

Support 67.1% : 100% 67.1% : 98.9%

50%

COIN 46% : 100% 38% : 77% 60%

VON-DRM 17.9% :98.8% 14.8% : 98.3% 40%

Neocosur 29.8% : 50.4%** 27.5% : 46.4% 50%

CURPAP 33% : 31.4% 48.5% : 100% 40%

Thresholds for abandoning CPAP are too low.

** DR or NICU

Duration ventilation

nCPAP/control

✶ Support 10 days / 13 days@

✶ COIN 3 days /4 days

✶ VON* 9.2 days / 12.5 days

✶ Neocosur 3.3 days / 4.3 days

✶ CURPAP 5.5 days / 5.4 days@

* CPAP vs. INSURE

Short Duration of Ventilation Limits the Utility of

BPD as an Endpoint.

All CPAP Devices are not Created Equal

Poli et al Respiratory care 2015

Bias Flow (L/min)

2 4 6 8 10 12

Homemade

Airways Development

Fisher & Paykel

Babi. Plus

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0

V

(m

L)

Poli et al Respiratory care 2015

Lung volume oscillations as a result of bias flow

Time (s)

10

Paw (

cm

H2O

)

Homemade

Airways Development

Fisher & Paykel

Babi.Plus

5

0

10

Paw (

cm

H2O

) 5

0

10

Paw (

cm

H2O

)

5

0

10

Paw (

cm

H2O

)

5

0 2 1.5 1 0.5 0

Time (s) 2 1.5 1 0.5 0

Time (s) 2 1.5 1 0.5 0

Time (s) 2 1.5 1 0.5 0

Pressure Waveform (nasal prongs) in 4 different bubble CPAP

systems

Homemade

Fisher & Paykel*

Airways

Development

Babi Plus

Lower Frequency*

Gupta et al 2009 (n=140, mean GA ~ 27 weeks) BCPAP vs. Infant

Flow Driver IFD). No significant differences in the rate of post

extubation failure; however, in infants intubated < 14 days, infants on

BCPAP had a significantly lower extubation failure rate.

Randomized controlled Trial of Post-extubation Bubble CPAP vs.

Infant Flow Driver in Preterm Infants with RDS

0

10

20

30

40

50

60

70

80

14.1%

Ventilated for ≤14 days

28.6%

Bubble

CPAP

IFD

CPAP

p=0.046

%*

IFD CPAP

Bubble CPAP

1.0

0.8

0.6

0.4

0.2

0.0

Cu

m S

urv

iva

l

Days CPAP Use

0 10 20 30 40 50 60

*% CPAP failure

Randomized controlled Trial of Post-extubation Bubble CPAP vs. Infant

Flow Driver in Preterm Infants with RDS

Gupta S et al J Pediatr. 154: 645, 2009

Columbia Experience

• 4 year retrospective analysis (2008-11)

• 297 consecutive inborn infants BW ≤ 1000 gm

Respiratory Outcomes with CPAP 2008-2011

CPAP success@ CPAP failure Ventilated

Started

(n = 151) (n = 84) (n =62)

Weeks 26.9 ± 1.8* 25.6 ± 1.3* 24.8 ± 1.5*

Weight (g) 792.7 ± 136.1 723.1 ± 152.0 658.6 ± 141.2

*P < .001 CPAP success vs. CPAP failure & ventilated vs. CPAP failure

@ CPAP success rate 64%

Respiratory Outcomes with CPAP 2008-2011

CPAP success CPAP failure Ventilated Started

(n = 151) (n = 84) (n =62)

Oxygen at 28 days 31.8% 73.8% 72.9%

Oxygen at 36 weeks 3.6% 15.4% 13.5%

Pneumothorax 3.2% 13.4% 8.1%

Mortality 8.6% 22.6% 40.3%

Death or O2 (36 wks) 11.9% 34.5% 48.4%

Why Do infants Fail CPAP?

7.5 Total Lung Sat PC 80

Success Fail Success Fail

BALF Sat PC

Large Aggregate % Secreted

60

40

20

0

10

8

6

4

2

0

5.0

2.5

0.0

75

50

25

0

% %

(µm

ol/k

g)

(µm

ol/k

g)

A

C D

B

Surfactant pools were lower in lambs that failed BCPAP

Mulrooney et al. Am. J Respir. Crit. Care Med. 171: 488, 2005

Intubation >> Surfactant >> Extubation

INSURE

Cochrane Database Analysis of the Need for Mechanical

Ventilation ≥ 1 hr & Air-leak Using the INSURE Approach.

RR CI

FiO2 < 0.45 0.72 (0.58-0.87)

FiO2 ≥ 0.45 0.55 (0.40-0.77)

Total 0.67 (0.57-0.79)

Stevens Cochrane Database 2007

Mechanical Ventilation Air-Leak

RR CI

FiO2 < 0.45 0.46 (0.23-0.93)

FiO2 ≥ 0.45 0.80 (0.22-2.89)

Total 0.52 (0.26-0.96)

Decreased need for O2 (RR 0.51 (0.26. 0.99) at 28 days, but not 36 weeks

Noninvasive ventilation (CPAP) with or without early surfactant:

A systematic review and Meta-analysis

Isiyama et al JAMA Pediatrics 2015

✶ Nine studies were included in the meta-analysis (including 4 since

the last Cochrane review)

✶ There were no significant differences in any outcomes (CLD, death

and/or BPD, CLD, Mortality, IVH or air-leak.

✶ There was a 12% reduction in CLD or death** RR (CI 0.88-1.02), a

14% decrease in CLD** (CI 0.71-1.03) and a 50% reduction in

pneumothoraces* (CI 0.24-1.07)

✶ “CPAP and INSURE are at least equivalent”

* Low quality evidence

** Moderate quality evidence

Clinical trials; Surfactant administration using a thin catheter

Study N Need for CMV

Catheter vs.

Endotracheal

tube

BPD

Catheter vs.

Endotracheal

Tube

Entry

criteria for

catheter

Gopel n =2206

26-28

weeks

41% / 62%

P < .001

12% / 18%

P = .001

Cohort study

Not specified

Gopel n = 220

26-28

weeks

33% / 73%

P < .0001

8%/ 13%

P = .268

FiO2 > 0.3 &

CPAP

Kanmaz n =200

< 32 wks.

40% / 49%

P = NS

Moderate-Severe

10.3.% / 20.2%

P = .009

FiO2 ≥ 0.4 &

CPAP

Kribs N = 211

23.0-26.8

weeks

74.8% / 99%

P < .001

67.3% / 58.7%

Survival without

BPD

P = NS

FiO2 ≥ 0.3 &

CPAP in first 2

hours

Mohammad-

izadeh

N = 38

< 34

weeks

15.8% / 10.5%

NS CPAP & Need

for Surfactant

VON Delivery Room Management (DRM) Groups

✶ Intubation, prophylactic surfactant administration with subsequent

stabilization on ventilator support (PS Group)

✶ Intubation, prophylactic surfactant administration and rapid

extubation to NCPAP (ISX Group)

✶ Early stabilization on NCPAP and selective intubation and surfactant

administration for clinical indications (NCPAP Group)

Gestational age 26+0 to 29+6 weeks

Study assignment was made prior to delivery

Von Delivery Room Management Trial

Death or CLD At 36 Weeks Post Menstrual Age

36.5% 28.5% 30.5%

36.5%

50

40

30

20

10

0

% C

ase

s

Death or CLD

RR 0.78

(95% CI 0.59, 1.03)

RR 0.83

(95% CI 0.64, 1.09)

PS ISX NCPAP

28.5% 30.5%

Rojas and Soll 2010 unpublished

VON-DRM

✶ In the nasal CPAP group 48% were managed without intubation and 54%

without surfactant.

1. Studies without routine application of CPAP

Dunn 1991 16/62 12/60 3.1% 1.29 [0.67, 2.49]

Subtotal (95% Cl) 62 60 3.1% 1.29 [0.67, 2.49]

Total events 16 (Prophylactic), 12 (Selective)

2. Studies with routine application of CPAP

Dunn 2011 76/208 67/220 16.4% 1.29 [0.92, 1.57]

Support 2010 353/653 323/663 80.6% 1.11 [1.00, 1.23]

Subtotal (95% Cl) 861 883 96.9% 1.12 [1.02, 1.24]

Total events 429 (Prophylactic), 390 (Selective)

Total (95% Cl) 923 943 100.0% 1.13 [1.02, 1.25]

Total events 445 (Prophylactic), 402 (Selective)

0.5 0.7 1 1.5 2

Favors

experiments

Favors

control

Study or subgroup

Prophylactic

n/N Selective

n/N

Risk Ratio

M-H, Fixed,

95% Cl Weight

Risk Ratio

M-H, Fixed,

95% Cl

Prophylactic surfactant vs. treatment of established respiratory

distress in preterm infants, Chronic lung disease or death

Prophylactic

Nasal Intermittent Positive Pressure Ventilation

Nasal Intermittent Positive Pressure Ventilation

NIPPV commonly uses a ventilator to provide intermittent breaths

Theoretically, NIPPV provides better ventilation by delivering

breaths to the lower airway.

Randomized clinical trials in babies are very heterogeneous:

Wide range of set peak pressures (10-25 cm H2O pressure)

Different ventilator rates (10-60/minute)

Variable Inflation times (0.3-0.5 seconds)

Non-synchronized or Synchronized (Not available in the United

States)

30

25

20

15

10

5

0

14 18 22 26 30 34

Set PIP on Ventilator (cm H2O)

RAM - Vent

SBP - Vent

Measured Pressures at Ventilator for Short bi-

nasal prongs and RAM cannula interfaces

Me

as

ure

d P

IP (

cm

H2O

)

5.0 M

ea

su

red

PIP

(c

m H

2O

)

SBP RAM

Set PIP on Ventilator (cm H2O)

Pressure Transmission to Lung using Short

bi-nasal prongs vs RAM Cannula

14 18 22 26 30 34

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

RAM

SBP

100 C

O2 r

em

ain

ing

in

th

e lu

ng

% Physiologic VT delivered to lungs

CO2 elimination vs delivered fraction of

physiological tidal volume

14 16 18 8 10 12 6 4 2 0

R2 = 0.9508

R2 = 0.9634

95

90

85

80

75

70

65

60

55

50

RAM

SBP

OFF CPAP

5

CPAP

10

NIPPV

14

NIPPV

18

NIPPV

22

NIPPV

26

NIPPV

30

NIPPV

34

100 C

O2O

re

ma

inin

g in

lun

gs

Carbon-dioxide clearance with NIPPV using 2 interfaces

and was proportional to peak inspiratory pressure

95

90

85

80

75

70

65

60

55

50

Non-invasive ventilation mode and set peak

pressures (cm H2O)

Mukerji and Belik J Perinatology 2015

Non-synchronized NIPPV had only modest effects on tidal volume

(~ 15%) When applied during apneic episodes NIPPV increased tidal

volumes only 5% of the time.

Physiological Effects of Non-Synchronized NIPPV

Owen, Morley, Dawson and Davis Arch Dis, Child 96: F422, 2011

Synchronized NIPPV decreased inspiratory effort, but did not increase tidal

volume or minute ventilation. There was an increase in expiratory effort.

*Chang & Bancalari Ped. Res. 69: 84-9, 2011

Physiologic Effects of Synchronized NIPPV

Synchronized NIPPV (SiPAP) worked more than 80% of the time, but

had no effect on tidal volume.

When the RR was > 55 breaths/minute, spontaneous breaths irregularly

triggered SiPAP breaths.

Physiologic Effects of Synchronized NIPPV

Owen, Morley and Davis Arch Dis, Child 2014

An in vitro study using short bi-nasal prongs (SBP) or a small caliber cannula

(RAM)

Using the lung model, a small amount of CO2 was infused and the amount

remaining after 100 seconds was determined.

Pressure transmission to the “lung” and tidal volume were also measured.

NIPPV: Efficacy and lung pressure transmission

Mukerji and Belik J Perinatology 2015

NIPPV: Physiologic Principles

In awake and sleeping adults, NIPPV produces vocal cord

adduction and glottal narrowing resulting in lower tidal volumes

and apneic episodes.

Data suggest that using higher peak pressures does not

consistently increase the likelihood of chest inflation.

N Mean GA

(weeks)

No Benefit

Kugelman 86 30.6 / 31.1 Yes Significant

Bisceglia 88 30.6 / 29.8 No No

Kishore 76 28-34 No Significant

Meneses 200 30.1 / 29.0 No No

Shi 179 24-32 No Significant

Kirpilani 200 26.2 / 26.1 Both No

RCTs: NIPPV or CPAP for Preterm Infants with RDS

Outcome: respiratory failure or need for intubation/surfactant

N Mean GA

(Weeks)

Synchronized Benefit

Ramanathan 100 27.8 /27.8 No Significant

Oncel

(MIST)

200 29.1/ 29.2 No Significant

RCTs: NIPPV or CPAP for Preterm Infants with RDS with INSURE

Outcome: respiratory failure or need for intubation/surfactant

1009 infants < 1,000 g randomized to NCPAP or NIPPV when they required

respiratory support in the first 28 days of life (either as the primary mode of

support (first 7 days of life) or following extubation (through day 28)

Median age of intubation: 3.4 days NIPPV group and 3.7 days nCPAP

group; ~ 50% of infants were never intubated;

Primary outcomes death before 36 weeks gestation or survival without BPD

Death or BPD: NIPPV 38.4%; CPAP 36.7% (aOR 1.09 (CI 0.83-1.43)

In a subgroup analysis synchronization made no difference

No differences in the rates of other morbidities, the duration of

respiratory support or time to reach full feeds.

Intubation was needed 59.1% of the CPAP group and 58.3% of the

NIPPV group.

NIPPV or CPAP for Preterm Infants

Kirpalani H et al NEJM 2013;369:611-20

N Synchronized Benefit

Khalaf 32 Yes Significant

Friedlich 41 Yes Significant

Barrington 54 Yes Significant

Khorana 48 No No

Moretti 63 Yes Significant

Kirpilani 845 Both Marginal

O’Brien

133 No No

RCTs: NIPPV or CPAP for Post-extubation Failure

Outcome: respiratory failure or need for intubation

NIPPV or nCPAP for Post Extubation Failure

The meta-analysis (8 trials 1316 infants) demonstrated a

statistically and clinically significant reduction in the risk of meeting

extubation failure criteria. RR 0.71 (CI 0.61-0.82) NNTB = 8.

No significant reduction in the rates of chronic lung disease

No significant differences in death or NEC

The benefits of synchronization need further study.

Davis PG, Lemyre B, De Paoli AG & Kirpalani H, Cochrane Library 2014

High Flow Nasal Cannula

Who is Using HFNC

2/3 of US academic units

Hochwald, J of Neonatal-Perinatal Medicine, 2010

2/3 of Australia and NZ NICUs

Hough, J Paediatr Child Health, 2012

>80% of UK NICUs

Nath, Pediatrics International, 2010

Why are HFNC So Popular

Easy to use

Safe

Decreased WOB

Nurses love it

Babies are calmer

Less CPAP belly

Less nasal trauma

No pneumothoraces

High Flow Nasal Cannula: Proposed Mechanisms

Reduction of inspiratory resistance

Washout of nasopharyngeal dead space

Provision of positive airway pressure

RCTs: HFNC or CPAP for Prevention of Respiratory Failure

Outcome: respiratory failure or need for intubation

* Abstract only ePAS ** Published in Italian, @comfort scores

N Median GA

(Weeks)

Superiority

HFNC

Nair 38 27-34 No

Joshi 80 32.8 No

Ciuffini* 177 29-366/7 No

Collins 132 < 32.0 No

Manley 302 < 32.0 No

Yoder 432 28-42 No

Klingenberg@ 20 < 34 No

A Randomized Controlled Trial to Compare Heated Humidified High-Flow

Nasal Cannulae with Nasal Continuous Positive Airway Pressure Post-

extubation in Premature Infants

Clare L. Collins, MBChB, FRACP1, James R. Holberton, MBBS, FRACP1,

Charles Barfield, MBBS, FRACP1, and Peter G. Davis, MD, FRACP2

J Pediatr. 2013: 162:949-54.

132 ventilated infants randomized to HHHFNC (n=67) or nCPAP (n=65)

after extubation to prevent post extubation failure within 7 days

Mean BW HFNC (1123 grams) nCPAP (1105 grams); 27-30% received

caffeine.

No difference in the rate of extubation failure (HFNC 22%; nCPAP 34%)

20% of infants assigned to nCPAP were changed to HFNC as a result of

nasal trauma (nasal trauma score).

303 infants (mean gestational age ~ 27 weeks) were randomized to treatment either

with HFNC or nasal CPAP after extubation. (non-inferiority study)

Days after Extubation

100

90

80

70

60

50

40

30

20

10

0

Nasal CPAP

High-flow nasal cannulae

% o

f In

fan

ts W

ith

ou

t T

reatm

en

t F

ailu

re

7

In infants < 26 weeks gestation (n=63) the risk difference was 20 percentage points in favor of nCPAP.

High Flow Nasal Cannulae in Very Preterm Infants After Extubation

Manley et al NEJM 2013

DOI: 10.1542/peds.2012-2742; originally published online April 22, 2013; 2013;131;e1482PediatricsSoraya Abbasi

Bradley A. Yoder, Ronald A. Stoddard, Ma Li, Jerald King, Daniel R. Dirnberger andRespiratory Support in Neonates

Heated, Humidified High-Flow Nasal Cannula Versus Nasal CPAP for

http://pediatrics.aappublications.org/content/131/5/e1482.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Columbia University on August 26, 2014pediatrics.aappublications.orgDownloaded from at Columbia University on August 26, 2014pediatrics.aappublications.orgDownloaded from

432 infants 28-42 weeks gestation (≥ 1,000 grams) were randomized to

NCPAP or HFNC to prevent post-extubation failure within 72 hours.

66-69% of infants were ventilated and most received surfactant

There were no significant difference in the primary study outcome (nCPAP

8.2% failure; HFNC 10.8% failure).

Yoder et al Pediatrics 2013;131;e1482

Is the HFNC more “comfortable” than CPAP

Pain Scores

Klingenberg, ADC 2013

Outcome HHHFNC CPAP P value

EDIN Score 10.7 11.1 0.35

((cumulative)

nCPAP HHHFNC

PIPP score 10 4

< 6 35% 69%

6-12 51.4% 30.4%

> 12 13.5% 0%

Duration Cry 49 seconds 22 seconds

Osman et al J Perinatology 2015

57

53

p < 0.01 6.0

4.0

2.0

0.0

Sa

liva

ry c

ort

iso

l (n

mo

le/L

)

nCPAP (n=37)

Nasal cannula (n=23)

• “Given the perceived benefit of HHHFNC (being less painful than CPAP) does not necessarily mean that we should shift from using CPAP to HHHFNC in preterm infants requiring respiratory support until the safety and efficacy of HHHFNC is proven.”

0 1.1

7.5

0 0 0 0 1.1

9.7

5.5

15.1

8.8

14.4

2.2

10.8

36.3

41.1

20

4.4

41.1

55.6

22.2

2.2 0 0

44

57 24-week, 500g

26-week, 750g

28-week, 1.2g

30-week, 1.5g

Nursing perceptions of HFNC vs. CPAP for prevention

or respiratory failure

60

50

40

30

20

10

0

Perc

ent

of

Responses

Will never

work

Much less

likely to

work than

NCPAP

A little less

likely to work

than NCPAP

Equal to

NCPAP

A little more

likely to work

than NCPAP

Much more

likely to work

than NCPAP

Will always

work

0

Roberts, Journal of Paediatrics and Child Health, 2014

CPAP: Conclusions

Early use of CPAP with subsequent selective surfactant administration

in extremely preterm infants results in lower rates of BPD/death when

compared to treatment with prophylactic or early surfactant therapy

(LOE 1).

If it is likely that respiratory support with a ventilator will be needed,

early administration of surfactant followed by rapid extubation, is

preferable to prolonged ventilation (LOE 1).

NIPPV: Conclusions

In comparison with nCPAP synchronized NIPPV decreases the frequency

of post-extubation failure

Studies using non-synchronized NIPPV are inconclusive

Data do not support the superiority of NIPPV (synchronized on non-

synchronized) over nasal CPAP for the management of infants with RDS

There is no benefit of NIPPV for apnea of prematurity; however, there

have been no published randomized trials using synchronized NIPPV.

HFNC may be an alternative to nCPAP to prevent post extubation

failure.

HFNC devices may be associated with less nasal trauma and may be

more comfortable (depends on the experience of nurses)

There may be a role for HFNC in infants have been on nCPAP for an

extended period of time.

HHHFNC vs. CPAP: Conclusions

Recommendation for Preterm Infants with RDS

✶ Preterm infants with RDS weighing < 1500 gms. should be allowed time

to demonstrate if they can achieve acceptable ventilation and oxygenation

on CPAP. During that time period, these infants must be monitored

closely. If ventilation is not improving or oxygenation is worsening, or

inadequate with an FiO2 of 60%, these infants should be intubated.

✶ Should infants < 26 weeks gestation receive prophylactic surfactant?

✶ Is there a role for aerosolized surfactant?