Relationship between platelet count and severity of neonatal respiratory distress syndrome.

BACKGROUND: Neonatal respiratory distress syndrome (NRDS) is a primary cause of morbidity and mortality in premature infants. Platelets have a unique role in lung repair and remodeling. This study aimed to determine the relationship between platelet count and NRDS severity. METHODS: The study included 234 newborns diagnosed with NRDS from January 2019 to August 2023. This study employed two methods of grouping: the first based on platelet count, dividing participants into thrombocytopenia (platelet count < 150 × 109/L, n = 50) and non-thrombocytopenia groups (platelet count ≥ 150 × 109/L, n = 184), and the second based on the severity of NRDS, categorizing them into severe (n = 24) and mild-moderate (n = 210) groups. Within the first grouping method, the thrombocytopenia group was further subdivided into moderate-severe group (platelet count < 100 × 109/L, n = 4) and mild group (platelet count was between 100.0 × 109/L and 150.0 × 109/L, n = 46). This study aimed to analyze the clinical characteristics of NRDS with thrombocytopenia, explore the correlation between platelet count and clinical indicators of NRDS. Binary Logistic regression analysis was employed to identify independent risk factors for thrombocytopenia in NRDS. RESULTS: A higher proportion of newborns in the severe group exhibited thrombocytopenia (severe group = 41.7%, mild-moderate group = 19.0%). Hospital stay, ventilation time, oxygen therapy duration were longer in the thrombocytopenia group compared to the non-thrombocytopenia group. Hospital stay, ventilation time, oxygen therapy duration, chest radiography score, and C-reactive protein (CRP) levels were inversely associated with platelet count. Conversely, Apgar scores at 1 and 5 min, gestational age, and birth weight showed positive correlations with platelet count. Point-biserail correlation showed that thrombocytopenia was more likely to occur in newborns whose mothers had gestational hypertension, and the lower platelet count, the more severe NRDS. Oxygen therapy duration, birth weight < 1500 g, gestational hypertension and CRP levels emerged as independent risk factors for thrombocytopenia in NRDS. All differences were statistically significant (p all < 0.05). CONCLUSION: NRDS accompanied by thrombocytopenia indicates a more severe condition and poorer clinical outcomes. It is hypothesized that NRDS with thrombocytopenia involves a complex multifactorial etiology, including severe lung inflammation.

Effect of different CPAP levels on ultrasound-assessed lung aeration and gas exchange in neonates.

BACKGROUND: Respiratory distress syndrome (RDS) and transient tachypnoea (TTN) are the two commonest neonatal respiratory disorders. The optimal continuous positive airway pressure (CPAP) to treat them is unknown. We aim to clarify the effect of different CPAP levels on lung aeration and gas exchange in patients with RDS and TTN. METHODS: Prospective, observational, pragmatic, physiological cohort study. CPAP was sequentially increased from 4 to 6 and 8 cmH2O and backwards, with interposed wash-out periods. Lung aeration was assessed with a validated neonatal lung ultrasound score. Gas exchange was non-invasively evaluated with transcutaneous monitoring. Ultrasound score and PtcO2/FiO2 ratio were the co-primary outcomes. PtcCO2 and other oxygenation metrics were the secondary outcomes. RESULTS: 30 neonates with RDS and 30 with TTN were studied. Each CPAP increment significantly (overall always p < 0.001) improved both lung aeration and oxygenation, but the increase from 6 to 8 cmH2O achieved a small absolute benefit. In RDS patients, the absolute improvements were small and the diagnosis of TTN was significantly associated with greater improvement of lung aeration (ß= -1.4 (95%CI: -2.4; -0.3), p = 0.01) and oxygenation (ß = 39.6 (95%CI: 4.1; 75.1), p = 0.029). Aeration improved in 16 (53.3%) and 27 (90%) patients in the RDS and TTN groups, respectively (p = 0.034). Lung aeration showed significant hysteresis in TTN patients. Secondary outcomes gave similar results. CONCLUSIONS: Increasing CPAP from 4 to 8 cmH2O improves ultrasound-assessed lung aeration and oxygenation in RDS and TTN. The absolute improvements are small when CPAP is beyond 6 cmH2O or for RDS patients.

Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants.

BACKGROUND: Preterm infants who are extubated following a period of invasive ventilation via an endotracheal tube are at risk of developing respiratory failure, leading to reintubation. This may be due to apnoea, respiratory acidosis, or hypoxia. Historically, preterm infants were extubated to head box oxygen or low-flow nasal cannulae. Support with non-invasive pressure might help improve rates of successful extubation in preterm infants by stabilising the upper airway, improving lung function, and reducing apnoea. This is an update of a review first published in 1997 and last updated in 2003. OBJECTIVES: To determine whether nasal continuous positive airway pressure (NCPAP), applied immediately after extubation of preterm infants, reduces the incidence of extubation failure and the need for additional ventilatory support, without clinically important adverse events. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and trial registries on 22 September 2023 using a revised strategy. We searched conference abstracts and the reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: Eligible trials employed random or quasi-random allocation of preterm infants undergoing extubation. Eligible comparisons were NCPAP (delivered by any device and interface) versus head box oxygen, extubation to room air, or any other form of low-pressure supplemental oxygen. We grouped the comparators under the term no continuous positive airway pressure (no CPAP). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias and extracted data from the included studies. Where studies were sufficiently similar, we performed a meta-analysis, calculating risk ratios (RRs) with their 95% confidence intervals (CIs) for dichotomous data. For the primary outcomes that showed an effect, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to assess the certainty of the evidence for clinically important outcomes. MAIN RESULTS: We included nine trials (with 726 infants) in the quantitative synthesis of this updated review. Eight studies were conducted in high-income countries between 1982 and 2005. One study was conducted in Chile, which was classified as upper-middle income at the time of the study. All studies used head box oxygen in the control arm. Risk of bias was generally low. However, due to the inherent nature of the intervention, no studies incorporated blinding. Consequently, the neonatal intensive care unit staff were aware of the assigned group for each infant, and we judged all studies at high risk of performance bias. However, we assessed blinding of the outcome assessor (detection bias) as low risk for seven studies because they used objective criteria to define both primary outcomes. NCPAP compared with no CPAP may reduce the risk of extubation failure (RR 0.62, 95% CI 0.51 to 0.76; risk difference (RD) -0.17, 95% -0.23 to -0.10; NNTB 6, 95% CI 4 to 10; I2 = 55%; 9 studies, 726 infants; low-certainty evidence) and endotracheal reintubation (RR 0.79, 95% 0.64 to 0.98; RD -0.07, 95% CI -0.14 to -0.01; NNTB 15, 95% CI 8 to 100; I2 = 65%; 9 studies; 726 infants; very low-certainty evidence), though the evidence for endotracheal reintubation is very uncertain. NCPAP compared with no CPAP may have little or no effect on bronchopulmonary dysplasia, but the evidence is very uncertain (RR 0.89, 95% CI 0.47 to 1.68; RD -0.03, 95% CI -0.22 to 0.15; 1 study, 92 infants; very low-certainty evidence). No study reported neurodevelopmental outcomes. AUTHORS' CONCLUSIONS: NCPAP may be more effective than no CPAP in preventing extubation failure in preterm infants if applied immediately after extubation from invasive mechanical ventilation. We are uncertain whether it can reduce the risk of reintubation or bronchopulmonary dysplasia. We have no information on long-term neurodevelopmental outcomes. Although there is only low-certainty evidence for the effectiveness of NCPAP immediately after extubation in preterm infants, we consider there is no need for further research on this intervention, which has become standard practice.

A rare cause of respiratory distress in preterm infants: a case report of acquired subglottic cysts.

BACKGROUND: The Subglottic Cysts (SGCs) are a rare cause of respiratory distress in infants. Typical risk factors include male gender, extreme prematurity, gastro-oesophageal reflux and invasive ventilation, the latter being associated with mucosal damage and blockage of the subglottic cysts' ducts. We describe a case of acquired subglottic cysts in a premature infants presented with respiratory distress. CASE PRESENTATION: A premature male infant was born at 25 weeks + 2 days with a history of monochorionic diamniotic twin pregnancy with twin-to-twin transfusion syndrome. During hospitalization, invasive mechanical ventilation was necessary for a total of 18 days; the patient was discharged at postmenstrual age of 40 weeks + 1 day in good condition. At 43 weeks post-menstrual age, he presented to our department with mixed stridor and worsening of respiratory dynamics. A laryngotracheoscopy evaluation was performed. The exam showed the presence of multiple SGCs causing an almost complete obstruction of the airway. Because of the significant reduction of the airway's patency, the child underwent a tracheotomy and thereafter cysts' removal using cold steel microinstruments. A better airway patency was restored although a slight glottic edema persisted. The histopathology confirmed the benign nature of the lesions. Successive controls showed a completely patent airway and absence of SGCs. CONCLUSION: In conclusion, SGCs should be considered in preterm infants with respiratory distress previously intubated, which cannot be explained by the most common causes. Early diagnosis and treatment are fundamental to reducing the morbidity and mortality associated with this disease.

Noninvasive neurally-adjusted ventilatory assist in preterm infants: a systematic review and meta-analysis.

BACKGROUND: Noninvasive neurally-adjusted ventilatory assist (NIV-NAVA) improves patient-ventilator synchrony and may reduce treatment failure in preterm infants compared with nasal continuous positive airway pressure (NCPAP) and noninvasive positive-pressure ventilation (NIPPV). We conducted a systematic review and meta-analysis to assess the effects of NIV-NAVA in preterm infants with respiratory distress. METHODS: Four investigators independently assessed the eligibility of studies in CENTRAL, CINAHL, ClinicalTrials.gov, Embase, MEDLINE, PubMed, and WHO ICTRP databases, and extracted data. The included studies were randomized controlled trials (RCTs) comparing NIV-NAVA with other noninvasive ventilation modalities in preterm infants. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. The objective of the meta-analysis was to compare NIV-NAVA vs CPAP/NIPPV as a primary mode post extubation. RESULTS: Five RCTs which examined 279 preterm infants were included. In the subgroup of post-extubation respiratory support, NIV-NAVA decreased treatment failure compared with NCPAP/NIPPV (risk ratio 0.29; 95% confidence interval [0.10, 0.81], 2 RCTs, 96 infants, low certainty of the evidence). NIV-NAVA did not significantly reduce the risk of treatment failure in the subgroup of primary respiratory support (very low certainty of the evidence). There were no significant differences in secondary outcomes with low to very low certainty of evidence. CONCLUSIONS: In a small cohort with low certainty of evidence, NIV-NAVA may prevent reintubation in preterm infants. Further large-scale RCTs are needed to determine the effects and safety of NIV-NAVA in preterm infants.

Comparing the Effects of Two Surfactant Administration Methods: Minimally Invasive Surfactant Therapy (MIST) with Intubation (INSURE) in Infants with Respiratory Distress Syndrome.

BACKGROUND: The aim of this study is to investigate and compare the effects of administering a surfactant through a fine intra-tracheal catheter during spontaneous breathing with the usual INSURE method in premature infants. MATERIALS AND METHODS: In this clinical trial, premature babies with respiratory distress syndrome who required surfactant administration were randomly assigned to two groups: an intervention group (MIST) and a control group (INSURE). The treatment results were compared in terms of complications related to treatment (desaturation, apnea, bradycardia, and surfactant reflux), respiratory complications (requirement for mechanical ventilation, duration of nCPAP, duration of oxygen requirement, frequency of pneumothorax, and pulmonary hemorrhage), complications related to prematurity (incidence of IVH, NEC, BPD, and PDA), the need for a second dose of surfactant, and the duration of hospitalization. RESULTS: a total of 160 premature babies with a gestational age of 26-34 weeks were randomly divided into two groups. The results showed that the need for mechanical ventilation, the duration of CPAP needed, and the duration of oxygen therapy were significantly lower in the MIST group than in the INSURE group. Additionally, the incidence of BPD was less common in the MIST group compared to the INSURE group. However, surfactant reflux was more common in the MIST group than in the INSURE group. There were no significant differences between the two groups in other outcomes, including the length of hospital stay and complications such as IVH, PDA, NEC, pneumothorax, and pulmonary hemorrhage. CONCLUSION: The results of this research demonstrate that the less invasive method of surfactant therapy (MIST) is a feasible, effective, and low-risk alternative to the INSURE method.

Lung Recruitment Before Surfactant Administration in Extremely Preterm Neonates: 2-Year Follow-Up of a Randomized Clinical Trial.

Importance: A multicenter randomized clinical trial (RCT) showed a lung recruitment maneuver using high-frequency oscillatory ventilation just before surfactant administration (ie, intubate-recruit-surfactant-extubate [IN-REC-SUR-E]) improved the efficacy of treatment compared with the standard intubate-surfactant-extubate (IN-SUR-E) technique without increasing the risk of adverse neonatal outcomes. Objective: To examine follow-up outcomes at corrected postnatal age (cPNA) 2 years of preterm infants previously enrolled in an RCT and treated with IN-REC-SUR-E or IN-SUR-E in 35 tertiary neonatal intensive care units. Design, Setting, and Participants: This was a follow-up study of infants recruited into the primary RCT from 2015 to 2018 at 35 tertiary neonatal intensive care units (NICUs) in Italy. Follow-up examinations included neurodevelopmental, growth, and respiratory outcomes of these children at cPNA 2 years. Participants included spontaneously breathing extremely preterm neonates (24 0/7 to 27 6/7 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 hours of life. Data were analyzed from April 2023 to January 2024. Intervention: Infants were randomly assigned (1:1) to IN-REC-SUR-E or IN-SUR-E and then followed up. Main Outcomes and Measures: The primary outcome was the occurrence of death after discharge or major disability at cPNA 2 years. Secondary outcomes were neurodevelopmental outcomes (major disability, cerebral palsy, cognitive impairment, visual deficit, or auditory deficit), anthropometric measurements (weight, length, and head circumference), and recurrent respiratory infections and hospitalizations because of respiratory causes at 2y cPNA. Results: A total of 137 extremely preterm infants (median [IQR] gestational age, 26.5 [25.3-27.5] weeks and 75 [54.7%] female), initially enrolled in the original RCT, were followed up at cPNA 2 years, including 64 infants in the IN-SUR-E group and 73 infants in the IN-REC-SUR-E group. There were no significant differences in the occurrence of death after discharge or major disability at cPNA 2 years (IN-SUR-E: 13 children [20.3%] vs IN-REC-SUR-E: 10 children [13.7%]; P = .36). There were no significant differences in incidence of disability, cerebral palsy, or cognitive impairment in the IN-REC-SUR-E group compared with the IN-SUR-E group. There were no significant differences in anthropometric measurements (weight, length, and head circumference) between groups. There were no significant differences in the incidence of recurrent respiratory infections or in hospitalizations because of respiratory causes between groups. Conclusions and Relevance: In this RCT of lung recruitment before surfactant vs standard care there were no significant differences between the 2 groups in death, neurodevelopmental outcomes, anthropometric measurements, or recurrent respiratory infections at the 2-year follow-up. These findings can aid clinicians in decision-making for the best strategy to administer surfactant, considering long-term outcomes.

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OBJECTIVES: To investigate the risk factors and adverse prognosis associated with initial non-invasive ventilation (NIV) failure in very low birth weight infants (VLBWI) with gestational age <32 weeks. METHODS: A retrospective collection of clinical data from preterm infants admitted to the neonatal intensive care unit (NICU) in 28 tertiary hospitals in Jiangsu Province from January 2019 to December 2021 was conducted. Based on the outcomes of initial NIV, the infants were divided into a successful group and a failure group to analyze the risk factors for NIV failure and adverse prognosis. RESULTS: A total of 817 infants were included, with 453 males (55.4%) and 139 failures (17.0%). The failure group had lower gestational age, birth weight, and 1-minute and 5-minute Apgar scores compared to the successful group (P<0.05). The failure group also had a higher proportion of respiratory distress syndrome (RDS) diagnosed upon NICU admission, higher maximum positive end-expiratory pressure during NIV, and higher percentages of reaching the required maximum fraction of inspired oxygen (FiO2) ≥30%, ≥35%, and ≥40% throughout the initial NIV process compared to the successful group (P<0.05). Gestational age (OR=0.671, 95%CI: 0.581-0.772), RDS (OR=1.955, 95%CI: 1.181-3.366), and FiO2 ≥30% (OR=2.053, 95%CI: 1.106-4.044) were identified as risk factors for initial NIV failure in these infants with gestational age <32 weeks (P<0.05). The failure group had higher incidences of complications such as pulmonary infections, pneumothorax, retinopathy of prematurity, moderate to severe bronchopulmonary dysplasia, and severe intraventricular hemorrhage during hospitalization, as well as longer hospital stays and higher total costs compared to the successful group (P<0.05). CONCLUSIONS: Smaller gestational age, a diagnosis of RDS in the NICU, and achieving a maximum FiO2 ≥30% during the initial NIV process are risk factors for initial NIV failure in infants with gestational age <32 weeks. Initial NIV failure significantly increases the risk of adverse outcomes in this population.

Utility of saturation trends to predict successful weaning of nasal CPAP in very preterm neonates - A prospective study.

BACKGROUND: There is no objective criteria to wean CPAP in preterm neonates. We aimed to assess the accuracy of 'saturation trends' to predict successful CPAP discontinuation. METHODS: We included very preterm neonates who required CPAP. Index tests were 'saturation trends'. Outcome was successful CPAP discontinuation, defined as baby stable in room air for 72 h. RESULTS: We had 120 neonates with mean±SD gestation 28.6±1.8 weeks. 96 (80%) neonates had successful discontinuation and 24 (20%) failed. Neonates with successful discontinuation had significantly greater 'saturation trends' during 24 h before discontinuing CPAP compared to those who failed [64.3 (48.1-83.7) vs. 47.3 (23.0-65.0), p = 0.001]. Saturations > 95% while on CPAP with 21% FiO2 for > 60% time had 63% sensitivity and 70% specificity to predict successful CPAP discontinuation. CONCLUSION: 'Saturation trends' is a readily available objective parameter that can be used to guide weaning CPAP in preterm neonates.

Impact of implementation of 2019 European respiratory distress syndrome guidelines on bronchopulmonary dysplasia in very preterm infants.

BACKGROUND: To evaluate the impact of implementation of 2019 European respiratory distress syndrome (RDS) guidelines on the incidence of bronchopulmonary dysplasia (BPD). METHOD: We retrospectively collected the clinical data of very preterm infants (VPIs) born before 32 gestational weeks from January 1st 2018 to December 31st 2021. VPIs were divided into group A and group B according to their birth date which was before or at/after January 1st 2020, when the 2019 European RDS guidelines were introduced. BPD is considered as primary outcome. We statistically analyzed all the data, and we compared the general characteristics, ventilation support, medication, nutrition and the outcomes between the two groups. RESULTS: A total of 593 VPIs were enrolled, including 380 cases in group A and 213 cases in group B. There were no statistic differences regarding to gender ratio, gestational age, birth weight and delivery mode between the two groups. Compared with group A, group B showed higher rate of antenatal corticosteroid therapy (75.1% vs. 65.5%). The improvement of ventilation management in these latter patients included lower rate of invasive ventilation (40.4% vs. 50.0%), higher rate of volume guarantee (69.8% vs. 15.3%), higher positive end expiratory pressure (PEEP) [6 (5, 6) vs. 5 (5, 5) cmH2O] and higher rate of synchronized nasal intermittent positive pressure ventilation (sNIPPV) (36.2% vs. 5.6%). Compared with group A, group B received higher initial dose of pulmonary surfactant [200 (160, 200) vs. 170 (130, 200) mg/Kg], shorter antibiotic exposure time [13 (7, 23) vs. 17 (9, 33) days], more breast milk (86.4% vs. 70.3%) and earlier medication for hemodynamically significant patent ductus arteriosus (hsPDA) treatment [3 (3, 4) vs. 8 (4, 11) days] (p < 0.05). As the primary outcome, the incidence of BPD was significantly decreased (16.9% vs. 24.2%) (p < 0.05), along with lower extrauterine growth retardation (EUGR) rate (39.0% vs. 59.7%), while there were no statistic differences regarding to other secondary outcomes, including mortality, intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), retinopathy of preterm (ROP) and necrotizing enterocolitis (NEC). However, in the subgroups of infants less than 28 gestational weeks or infants less than 1,000 g, the incidence of BPD was not significantly decreased (p > 0.05). CONCLUSIONS: After implementation of 2019 European RDS guidelines, the overall incidence of BPD was significantly decreased in VPIs. Continuous quality improvement is still needed in order to decrease the incidence of BPD in smaller infants who are less than 28 gestational weeks or less than 1,000 g.

Delayed sustained lung inflation for preterm neonates in neonatal intensive care unit: a randomized controlled trial.

INTRODUCTION: Sustained lung inflation (SLI) right after birth to decrease the use of mechanical ventilation of preterm infants is controversial because of potential harm. This randomized controlled trial was conducted to evaluate the effectiveness and safety of delayed SLI in neonatal intensive care unit (NICU). METHODS: Preterm neonates requiring continuous positive airway pressure after birth were eligible for enrollment. In the experimental group, SLI with 20 cm H2O for 15 s was conducted by experienced staff in the NICU between 30 min and 24 h after birth. RESULTS: A total of 45 neonates were enrolled into this study, including 24 in the experimental group and 21 in the control group. There was no significant difference in the birth condition between the experimental and control groups, including gestational age (p = 0.151), birth weight (p = 0.692), and Apgar score at 1 min (p = 0.410) and 5 min (p = 0.518). The results showed the duration of respiratory support was shorter in the experimental group than the control group (p = 0.044). In addition, there was no significant difference in the other outcomes, such as pneumothorax, patent ductus arteriosus, and bronchopulmonary dysplasia. CONCLUSION: Our findings indicate that sustained inflation conducted by experienced staff in the NICU is safe. The data suggest that SLI conducted by experienced staff in the NICU after stabilization could serve as an alternative management for preterm infants with respiratory distress. However, the reduction in use of respiratory support should be interpreted cautiously as a result of limited sample size. TRIAL REGISTRATION: University hospital Medical Information Network (UMIN) Clinical Trials Registry: UMIN000052797 (retrospectively registered).

Less Invasive Surfactant Administration for Preterm Infants - State of the Art.

BACKGROUND: Less invasive surfactant administration (LISA) has become the preferred method of surfactant administration for spontaneously breathing babies on continuous positive airway pressure (CPAP). SUMMARY: The development of LISA followed the need to combine CPAP and surfactant replacement as mainstay treatment options for respiratory distress syndrome, thereby avoided exposure to positive pressure ventilation. KEY MESSAGES: This review summarises the current knowns and unknowns of LISA including the physiological concept, its relevance for short-term and long-term outcomes and the challenges for practical implementation of LISA as part of a less invasive respiratory care bundle. Further, we provide an update of the evidence on alternatives to LISA, for example, nebulised surfactant administration, pharyngeal deposition of surfactant and delivery via supraglottic airway.

A nationwide survey on the management of neonatal respiratory distress syndrome: insights from the MUNICH survey in 394 Chinese hospitals.

BACKGROUND: At present, preterm infants with respiratory distress syndrome (RDS) in China present higher mortality and morbidity rates than those in high-income countries. The aim of this nationwide survey was to assess the clinical management of RDS in China. METHODS: A nationwide cross-sectional survey to assess adherence to RDS management recommendations was performed. One neonatologist per hospital was randomly selected. The primary outcome was the key care of RDS management. RESULTS: Among the 394 participating hospitals, 88·3% were birthing centres. The number of doctors and nurses per bed were 0·27 and 0·72, respectively. Antenatal corticosteroids (any dose) were administered to 90% of the women at risk of preterm birth at < 34 weeks of gestation (90·0% inborn vs. 50·0% outborn, p < 0·001). The median fraction of inspired oxygen (FiO2) for initial resuscitation was 0·30 for babies born at ≤ 32 weeks of gestation and 0·25 for those born at > 32 weeks. T-piece resuscitators were available in 77·8% of delivery rooms (DRs) (tertiary hospitals: 82·5% vs. secondary hospitals: 63·0%, p < 0·001). Surfactant was used in 51·6% of the DRs. Less invasive surfactant administration (LISA) was used in 49·7% of the hospitals (tertiary hospitals: 55·3% vs. secondary hospitals: 31·5%, p < 0·001). Primary non-invasive ventilation was initiated in approximately 80·0% of the patients. High-frequency oscillation ventilation was primarily reserved for rescue after conventional mechanical ventilation (MV) failure. Caffeine was routinely used during MV in 59·1% of the hospitals. Bedside lung ultrasonography was performed in 54·3% of the health facilities (tertiary hospitals: 61·6% vs. secondary hospitals: 30·4%, p < 0·001). Qualified breast milk banks and Family Integrated Care (FICare) were present in 30·2% and 63·7% of the hospitals, respectively. CONCLUSIONS: Significant disparities in resource availability and guidelines adherence were evident across hospitals. Future strategies should address DR facilities and medication access, technical training, staff allocation, and ancillary facility development for a better management of RDS patients in China.

Non-Invasive Ventilatory Support in Preterm Neonates in the Delivery Room and the Neonatal Intensive Care Unit: A Short Narrative Review of What We Know in 2024.

BACKGROUND: Guidelines recommend non-invasive ventilatory (NIV) support as first-line respiratory support mode in preterm infants as NIV is superior to intubation and mechanical ventilation in preventing death or bronchopulmonary dysplasia. However, with an ever-expanding variety of NIV modes available, there is much debate about which NIV modality should ideally be used, how, and when. The aims of this work were to summarise the evidence on different NIV modalities for both primary and secondary respiratory support: nCPAP, nasal high-flow therapy (nHFT), and nasal intermittent positive airway pressure ventilation (nIPPV), bi-level positive airway pressure (BiPAP), nasal high-frequency oscillatory ventilation (nHFOV), and nasally applied, non-invasive neurally adjusted ventilatory assist (NIV-NAVA) modes, with particular focus on their use in preterm infants. SUMMARY: This is a narrative review with reference to published guidelines by European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. nCPAP is currently the most commonly used primary and secondary NIV modality for premature infants. However, there is increasing evidence on the superiority of nIPPV over nCPAP. No beneficial effect was found for BiPAP over nCPAP. For the use of nHFT, nHFOV, and NIV-NAVA, more studies are needed to establish their place in neonatal respiratory care. KEY MESSAGES: The superiority of nIPPV over nCPAP needs to be confirmed by contemporaneous trials comparing nCPAP to nIPPV at comparable mean airway pressures. Future trials should study NIV modalities in preterm infants with comparable respiratory pathology and indications, at comparable pressure settings and with different modes of synchronisation. Importantly, future trials should not exclude infants of the smallest gestational ages.

Impact of early caffeine administration on respiratory outcomes in very preterm infants initially receiving invasive mechanical ventilation.

OBJECTIVE: The guidelines recommend early caffeine administration for preterm infants requiring non-invasive mechanical ventilation since earlier treatment is associated with better outcomes. The objective was to evaluate the impact of early caffeine therapy (within 24 hours after birth) on respiratory outcomes in very preterm infants who were initially receiving invasive mechanical ventilation. METHODS: This was an observation cohort study from 1 January 2018 to 31 December 2022 based on a database that was prospectively collected and maintained. Infants who initially received invasive mechanical ventilation were divided into two groups based on the timing of caffeine initiation: within the first 24 hours after birth (early) and within 48 hours of birth or later (late). Generalised linear mixed models with a random effect model for the centre were used to assess the impact of different caffeine initiation times on neonatal outcomes. RESULTS: Among the cohort of 9880 infants born at <32 weeks gestation, 2381 were eligible for this study (early initiation: 1758 (73.8%) and late initiation: 623 (26.2%)). For infants born at more than 28 weeks of gestation, the adjusted generalised linear mixed model showed that the duration of invasive mechanical ventilation was 1.34 (95% CI -2.40 to -0.27) days shorter and the incidence of moderate-to-severe bronchopulmonary dysplasia (BPD) was lower (adjusted OR 0.63; 95% CI 0.41 to 0.96) in the early caffeine group compared with the late caffeine group. CONCLUSION: In very preterm infants who initially receive invasive mechanical ventilation, early administration of caffeine within 24 hours after birth can shorten the duration of invasive mechanical ventilation, reduce the incidence of moderate-to-severe BPD and improve respiratory outcomes. The very early initiation of caffeine treatment does not appear to be associated with any adverse outcomes. TRIAL REGISTRATION NUMBER: ChiCTR1900025234.

Risk factors, incidence, and outcomes of neonatal respiratory extracorporeal membrane oxygenation including association with therapeutic hypothermia in California during 2013-2020.

OBJECTIVE: To evaluate the incidence, indications and outcomes with neonatal extracorporeal membrane oxygenation (ECMO) and its association with therapeutic hypothermia (TH) among infants undergoing invasive mechanical ventilation (IMV) in California during 2013-2020. STUDY DESIGN: We analyzed data on neonates ≥34 weeks gestation with ≥4 h of IMV over an 8-year period (2013-2020) from the California Perinatal Quality Care Collaborative (CPQCC) database. RESULTS: Between 2013 and 2020, the ranges for utilization of iNO (13.9 to 17.2%), ECMO (2.1 to 2.5%), TH (10.2 to 15.7%) and TH + ECMO (0.4 to 0.8%) were observed. The most common association with neonatal ECMO was TH (148 cases, OR 3.2, 95% CI 2.6-4.3, p < 0.01). The combination of meconium aspiration syndrome (MAS) and hypoxic ischemic encephalopathy (HIE) increased risk of iNO and ECMO use (OR 11.3, 1.5-86.9), p = 0.02). CONCLUSION: Ventilated infants ≥34 weeks gestational age undergoing TH are at risk for iNO/ECMO use and need close monitoring.

Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in the neonatal intensive care unit (NICU): an Australian NICU experience.

BACKGROUND: Preterm infants often require non-invasive breathing support while their lungs and control of respiration are still developing. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is an emerging technology that allows infants to breathe spontaneously while receiving support breaths proportional to their effort. This study describes the first Australian Neonatal Intensive Care Unit (NICU) experience of NIV-NAVA. METHODS: Retrospective cohort study of infants admitted to a major tertiary NICU between October 2017 and April 2021 supported with NIV-NAVA. Infants were divided into three groups based on the indication to initiate NIV-NAVA (post-extubation; apnoea; escalation). Successful application of NIV-NAVA was based on the need for re-intubation within 48 h of application. RESULTS: There were 169 NIV-NAVA episodes in 122 infants (82 post-extubation; 21 apnoea; 66 escalation). The median (range) gestational age at birth was 25 + 5 weeks (23 + 1 to 43 + 3 weeks) and median (range) birthweight was 963 g (365-4320 g). At NIV-NAVA application, mean (SD) age was 17 days (18.2), and median (range) weight was 850 g (501-4310 g). Infants did not require intubation within 48 h in 145/169 (85.2%) episodes [72/82 (87.8%) extubation; 21/21 (100%) apnoea; 52/66 (78.8%) escalation). CONCLUSION: NIV-NAVA was successfully integrated for the three main indications (escalation; post-extubation; apnoea). Prospective clinical trials are still required to establish its effectiveness versus other modes of non-invasive support.

Unveiling collodion baby: confronting ectropion and respiratory drama in neonatal care.

A neonate presented to us with respiratory distress with diffuse involvement of skin with thickening, cracking and peeling since birth with severe ectropion and eclabium. The hospital course was complicated by polymicrobial sepsis requiring prolonged antibiotics and antifungals. The skin lesions were treated with acitretin, humidification and topical emollients. With the improvement of pneumonia and clearing of nasal debris, the neonate could be gradually weaned off respiratory support. Despite a stormy course, there was marked improvement in all skin lesions including ectropion and eclabium at discharge. This case highlights and discusses the challenges in diagnosis and underscores the need for multidisciplinary involvement of neonatology, dermatology and ophthalmology for a neonate with collodion baby syndrome.