Predictors of CPAP failure with RAM cannula interface for primary respiratory support in preterm neonates.

Background: RAM cannula is used as interface for delivering nasal continuous positive airway pressure (nCPAP) in many neonatal care units though the bench to bedside evidence for its use in clinical settings in lacking. Methods: In this prospective cohort study from tertiary care neonatal care unit, the primary objective was to determine the rate of CPAP failure using RAM interface, within 72 h of starting of therapy and secondary objective was to look for the incidence and severity of nasal trauma with the use of RAM interface for CPAP delivery. All inborn preterm neonates between 28 and 32 weeks of gestation and weight more than 1000 g who required non-invasive respiratory support within 6 h of life were included in the study. Results: The enroled cohort of 250 neonates had mean gestational age of 30.73 ± 1.32 weeks and mean birth weight of 1410 ± 210 g. CPAP failure rate with the use of RAM interface was 31.2% (78/250) in the overall cohort. The failure rate was higher in subgroup of gestation between 28 and 30 week (52.1%) in comparison with the 31-32-week gestation (18.2%; p-value = 0.0001). Nasal trauma was present in 36 (14%) neonates; of whom 33 (91%) had mild and 2 (6%) and 1 (3%) had moderate and severe, respectively. On multivariate analysis, birth weight less than 1250 g, incomplete antenatal steroids, need for PEEP more than 5 cm & FiO2 > 30% at onset of distress and administration of surfactant were found be statistically significantly associated with CPAP failure with RAM interface. Conclusion: The clinical outcomes with the use of RAM interface for CPAP administration are comparable to those with other interfaces with lesser incidence of nasal injury. The results of this study warrant future randomized trials to compare different CPAP interfaces for clinical outcomes and nasal injuries from the developing countries.

Utilisation of RAM cannula for non-invasive respiratory support for infants in the cardiac ICU.

BACKGROUND: Children with CHD carry an additional burden of pulmonary insufficiency, often necessitating prolonged ventilatory support, especially in the peri-operative phase. There has been an increase in the utilisation of non-invasive ventilatory support for these children. The objective of this study was to evaluate the utilisation, safety, and outcomes of RAM cannula as a tool for escalation and de-escalation of respiratory support in paediatric cardiac patients less than one year of age. METHODS: A single-centre retrospective cohort study of patients supported with RAM cannula. RESULTS: A total of 275 instances of RAM use were included in the study, 81.1% being post-operative. Patients were stratified into escalation and de-escalation cohorts based on the indication of non-invasive ventilation. The success rate of using RAM cannula was 69.5% overall, 66.1% in the escalation group, and 72.8% in the de-escalation group. At baseline, age at cardiac ICU admission >30 days, FiO2 ≤ 40%, PaCO2 ≤ 50 mmHg; and after 12 hours of non-invasive ventilation support respiratory rate ≤ 60/min, PaO2 ≥ 50 mmHg, PaCO2 ≤ 50 mmHg; and absence of worsening on follow-up chest X-ray predicted the success with a sensitivity of 95% in the logistic regression model. Successful support was associated with a significantly shorter unit stay. CONCLUSIONS: RAM cannula can be safely used to provide non-invasive support to infants in the cardiac ICU for escalation and de-escalation of respiratory support. Factors associated with success can be used to make decisions about candidacy and appropriate timing of non-invasive ventilation use to maximise effectiveness.

Comparison of two different Nasal Interfaces used in Non-Invasive Respiratory support in terms of Neonate comfort.

Background: Non-Invasive Ventilation (NIV) is the first choice approach in neonates with sufficient respiratory effort that require respiratory support. The type of nasal interface used in NIV affects both efficacy and patient comfort. The aim of this study is to investigate the effects of different nasal interfaces used in NIV support on neonatal patient comfort. Methods: Our study evaluated patients who received NIV support for 24 hours. The patients were randomly divided into two groups according to the type of nasal interface used, which were RAM cannula and short binasal prong (SBP). The patients' demographic and clinical data were noted. Their sleep was monitored for 24 hours with an actigraphy device. Results: A total of 82 patients were evaluated. The sleep efficiency in the RAM cannula group was significantly higher (respectively, 65.7% [10.22-95.25] vs. 57.81% [2.49-77], p=0.004). Although not statistically significant, the neonates in the RAM cannula group exhibited longer total sleep time (respectively, 10.4 ± 4.28 hours vs. 9.02 ± 3.73 hours, p=0.161). Comparison of heart rates and respiratory rates indicate that the patients in the RAM cannula group were more comfortable. Conclusions: Our study found that infants who received NIV support through a RAM cannula experienced more efficient sleep. Holistic approaches in neonatal intensive care units are vital for better neurodevelopmental outcomes in newborns. Although non-invasive, the interface used in NIV should also be a part of this holistic approach.

Effectiveness of High-Flow Nasal Cannula (RAM Cannula) With T-piece Resuscitator to Deliver Continuous Positive Airway Pressure (CPAP) During Neonatal Transport.

Background Newborns frequently experience respiratory distress (RD), necessitating preventive management during transportation. The use of Continuous Positive Airway Pressure (CPAP) is crucial in mitigating RD in neonates, particularly during transit. This study aims to assess the feasibility and efficacy of utilizing a RAM cannula (Neotech Products, Valencia, USA) with a T-piece resuscitator to deliver CPAP during neonatal transport. The objective is to evaluate the response of transported neonates to this intervention, including improvements in distress, surfactant requirements, ventilator dependency, and complications. Method and material Neonates with RD qualifying for CPAP support at birth and requiring transport to Neonatal Intensive Care Unit (NICU) care were included. The average duration of transport was 38 minutes (range 12 minutes to 2 hours). RAM cannula with a T-piece resuscitator was used for CPAP delivery during transportation. Vital parameters and interventions were monitored during transit, and outcomes were compared with inborn neonates receiving standard CPAP in the labor room. Results Out of 48 babies, nine babies required surfactant, and four needed invasive ventilation, with three developing a nasal injury. Compared to in-house preterm babies, these babies had more Positive End Expiratory Pressure (PEEP) knob adjustment, desaturation episodes, late surfactant administration, and intubation needs. Conclusion A high-flow nasal cannula combined with a T-piece resuscitator emerges as a promising modality for CPAP delivery during neonatal transportation, demonstrating efficacy with minimal complications.

Outpatient Utilization of the RAM Cannula for Nasal Noninvasive Ventilation in Children.

Background: The RAM cannula® consists of nasal prongs that can be used to administer oxygen, continuous, and bilevel positive airway pressure therapies. Studies have reported the efficacy and utility of the RAM cannula in inpatients requiring noninvasive ventilation (NIV); however, there is limited literature on the use of the RAM cannula to provide NIV in the outpatient setting. Objectives: This study aimed to describe the clinical features and outcomes of children who used NIV via RAM cannula in the outpatient setting. Design: Retrospective review. Methods: We conducted a retrospective review of children treated with outpatient NIV via RAM cannula at our institution between January 2010 and March 2023. The analyzed data included age, diagnoses, indications for NIV, duration of RAM cannula use, complications, and outcomes at 6 months. Results: We identified 20 patients who used outpatient NIV via RAM cannula during the study period. The median age at initiation of NIV via RAM cannula was 5.8 months (IQR 2.4-9.9 months). Indications for NIV included sleep-related hypoventilation (15%), restrictive lung disease (25%), obstructive sleep apnea (45%), and chronic respiratory failure (50%), with 6 patients having ⩾2 indications for NIV. RAM cannula was utilized for inability to tolerate conventional NIV interfaces (80%), to alleviate dyspnea (60%), and to avoid tracheostomy (55%). Patients used NIV via RAM cannula for a median duration of 7.7 months (IQR 3.7-20.6 months). Patient outcomes included ongoing usage of RAM cannula (55%), changing to conventional NIV interfaces (15%) or oxygen (10%), weaning off respiratory support (5%), and death (15%). There were no complications related to using the RAM cannula. Conclusion: Our study demonstrates the utility of outpatient NIV via RAM cannula in children with a variety of diagnoses until clinical improvement or tolerance of conventional interfaces, and for avoidance of tracheostomy.

Measured CPAP in a Noninvasive Pediatric Airway and Lung Model.

BACKGROUND: Bronchiolitis is the most common cause of admission in children < 2 y of age in the United States. The standard of care involves supportive measures, including noninvasive interventions such as CPAP. CPAP is traditionally delivered through a full face mask; however, pediatric ICUs have been exploring the use of the RAM cannula by Neotech as a mode of CPAP delivery. The level of CPAP delivered via the RAM cannula is uncertain. We performed an in vitro study to determine the level of CPAP delivered via the RAM cannula utilizing a pediatric lung model. METHODS: Models of 7 sizes of pediatric upper airways, produced with a 3-dimensional printer, were connected to a breathing simulator. We applied each size of RAM cannula to weight-appropriate airway and lung compliance parameters, delivering pressures of 5, 7, and 10 cm H2O using a ventilator in the CPAP mode. Leaks of 0%, 20%, 40%, and 60% were generated to emulate a complete seal, a poor fit, and open-mouth breathing. The outcome measure was the difference in CPAP, referred to as "%leak effect," measured by the lung simulator relative to the CPAP set on the ventilator. RESULTS: We found that set CPAP of 5-10 cm H2O generated measured CPAP ranging from 2.6 to 9.7 cm H2O. For the set CPAP levels of 5, 7, and 10 cm H2O, the mean %leak effect values of measured CPAP from the set CPAP were -25%, -26%, and -25.7%, respectively. For each specific cannula-airway combination, increasing the set pressure and decreasing the air leak resulted in higher levels of CPAP delivered. CONCLUSIONS: The RAM cannula delivered varying amounts of CPAP, with a percent loss of approximately -25% depending on the level of leak in the system. With minimal leak, it is conceivable that the RAM cannula can be used to deliver clinically meaningful CPAP.

A randomized trial comparing the short binasal prong to the RAM cannula for noninvasive ventilation support of preterm infants with respiratory distress syndrome.

PURPOSE: In this study, we compared the efficacy of the RAM cannula and the short binasal prong (SBP) as noninvasive ventilation (NIV) interfaces in preterm infants with respiratory distress syndrome (RDS). MATERIALS AND METHODS: Premature infants with RDS who required NIV were randomized in the RAM cannula and SBP groups within the first half hour. The groups were compared in terms of their need for invasive ventilation, their surfactant use, and their morbidities. RESULTS: We assessed 126 patients (62 SBPs and 64 RAM cannulas). Clinical and demographic features of the groups were similar. Within the first 72 hours, the RAM cannula group showed a higher need for invasive ventilation (32.8 and 9.6%, p = .002, respectively), surfactant (42.1 and 19.3%, p = .007, respectively), and rate of pulmonary hemorrhage was also higher. There were no differences between the groups in terms of other morbidities. CONCLUSIONS: In preterm infants with RDS, RAM cannula use as an interface for NIV results in increased invasive ventilation and surfactant use.

Comparison of Bubble CPAP Devices Using RAM Cannula for Extubation Failure in Very Low Birth Weight Infants: Randomized and Cohort Studies.

INTRODUCTION: Bubble continuous positive airway pressure (bCPAP) generates a variable pressure due to bubble size and frequency, and these pressure oscillations may contribute to lung recruitment and gas exchange. Single-outlet bCPAP devices generate larger pressure fluctuation than bCPAP devices with diffusers, but clinical efficacy is unclear. Our hypothesis was that a single-outlet bCPAP device (B&B Bubbler©) would decrease extubation failure and improve oxygenation compared with a bCPAP device with a diffuser (BabiPlus©). METHODS: Bench testing of bCPAP devices with the RAM© cannula determined pressure averages, fluctuations, and CPAP transmission at prongs. The B&B Bubbler© and the BabiPlus© devices were compared for oxygenation and bCPAP failure within 72 h of extubation in a randomized trial in infants less than 1,250 g (n = 43). Additionally, a cohort study with infants extubated to BabiPlus© (n = 128), B&B Bubbler© (n = 119), and noninvasive positive pressure ventilation (NIPPV) (n = 107) were compared. RESULTS: Small differences in pressure fluctuations between bCPAP devices are attenuated by the RAM© cannula. Pressures at RAM© prongs are 62% of set pressure. The bCPAP extubation failure rate (35%) and oxygenation were similar between the bCPAP devices. bCPAP success was associated with lower FiO2 at extubation and decreased need for additional FiO2 in both groups. In the setting of the RAM© cannula, there were no differences in extubation failure rate for infants extubated to bCPAP or NIPPV. CONCLUSIONS: There were no clinical differences at extubation between the B&B Bubbler© and BabiPlus© devices. Oxygenation may predict bCPAP failure. The use of the RAM© cannula as a bCPAP interface should be more closely examined.

Use of Nasal Non-Invasive Ventilation with a RAM Cannula in the Outpatient Home Setting.

BACKGROUND: Nasal non-invasive-ventilation (Nasal NIV) is a mode of ventilatory support providing positive pressure to patients via a nasal interface. The RAM Cannula is an oxygen delivery device that can be used as an alternative approach to deliver positive pressure. Together they have been successfully used to provide respiratory support in neonatal in-patient settings. OBJECTIVE: To describe the outpatient use of Nasal NIV/RAM Cannula as a feasible alternative for home respiratory support in children with chronic respiratory failure. METHODS: We performed a retrospective case series of 18 children (4 months to 19 years old) using the Nasal NIV/RAM Cannula in the Pediatric Pulmonary Clinic at the McGovern Medical School, UTHealth (2014-16). Consideration for Nasal NIV/RAM Cannula utilization included: inability to wean-off in-patient respiratory support, comfort for dyspnea, intolerability of conventional mask interfaces and tracheostomy avoidance. RESULTS: Average age was 7 years. 50% were Caucasian, 38% African-American and 11% Hispanics. Pulmonary disorders included: chest wall weakness (38%), central control abnormalities (33%), obstructive lung disease (16%) and restrictive lung disease (11%). Indications for Nasal NIV/RAM Cannula initiation included: CPAP/BPAP masks intolerability (11%), dyspnea secondary to chest wall weakness (38%) and tracheostomy avoidance (50%). Average length of use of Nasal NIV/RAM Cannula was 8.4 months. Successful implementation of Nasal NIV/Ram Cannula was 94%. One patient required a tracheostomy following the use of Nasal NIV/RAM Cannula. Significant decrease in arterial PaCO2 pre and post Nasal NIV/RAM cannula initiation was notable (p=0.001). CONCLUSION: Outpatient use of Nasal NIV/RAM Cannula may prove to be a feasible and save treatment alternative for children with chronic respiratory failure, chest wall weakness, dyspnea and traditional nasal/face mask intolerance to avoid tracheostomy.

Evaluation of a nasal cannula in noninvasive ventilation using a lung simulator.

BACKGROUND: Nasal noninvasive ventilation (NIV) is a common form of noninvasive respiratory mode used in newborn infants. A next-generation nasal cannula (Neotech RAM cannula) has recently been used to provide nasal NIV. The impact of the Neotech RAM cannula on the delivery of pressure needs to be studied. METHODS: In this ex vivo experimental design, a lung simulator (IngMar ASL 5000, version 3.4) was programmed to model a neonate (∼1-3 kg of body weight) with normal-to-moderately affected lungs. We used a Covidien PB840 ventilator with NIV software activated to compensate for leaks. Nasal NIV was set at peak airway pressures of 15, 20, and 25 cm H2O and PEEP of 5, 6, and 7 cm H2O. Three sizes of the Neotech RAM cannula were used (prong outer diameters of 3.0, 3.5, and 4.0 mm). The nose was designed to keep the leak of the nares by the prongs to 30%. We also created a worst case leak (58% leak) by using the largest simulated nostril diameter with the smallest diameter Neotech RAM cannula prong. The outcome measure was the difference in pressures, referred to as leak effect, measured by the lung simulator relative to the set peak airway pressure and PEEP on the ventilator. RESULTS: For the interface with 30% leak, leak effects of peak airway pressure during simulated nasal NIV were similar with all Neotech RAM cannula sizes, with 63-75% of peak airway pressure and 70-90% of PEEP being transmitted across the nasal interface. The worst case scenario produced a 92% leak effect in peak airway pressure and PEEP. CONCLUSIONS: When used with ≤ 30% leak, the Neotech RAM cannula interface results in clinically acceptable transmission of pressures. With > 50% leak, a clinically negligible amount of pressure is transmitted to the artificial lungs.