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Peter G Davis - One of the best experts on this subject based on the ideXlab platform.
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continuous distending pressure for respiratory distress in preterm infants
Cochrane Database of Systematic Reviews, 2015Co-Authors: Jacqueline J Ho, Prema Subramaniam, Peter G DavisAbstract:Background Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition, but it is invasive, potentially resulting in airway and lung injury. Continuous distending pressure (CDP) has been used for the prevention and treatment of RDS, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae. Objectives To determine the effect of continuous distending pressure (CDP) on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress. Subgroup analyses were planned on the basis of birth weight (> or < 1000 or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), methods of application of CDP (i.e. CPAP and CNP), application early versus late in the course of respiratory distress and high versus low pressure CDP and application of CDP in tertiary compared with non-tertiary hospitals, with the need for sensitivity analysis determined by trial quality. At the 2008 update, the objectives were modified to include preterm infants with respiratory failure. Search methods We used the standard search strategy of the Neonatal Review Group. This included searches of the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, 2015 Issue 4), MEDLINE (1966 to 30 April 2015) and EMBASE (1980 to 30 April 2015) with no language restriction, as well as controlled-trials.com, clinicaltrials.gov and the International Clinical Trials Registry Platform of the World Health Organization (WHO). Selection criteria All random or quasi-random trials of preterm infants with respiratory distress were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, Nasal Prong, nasopharyngeal tube or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and the lower body, compared with spontaneous breathing with oxygen added as necessary. Data collection and analysis We used standard methods of The Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each review author. Main results We included six studies involving 355 infants - two using face mask CPAP, two CNP, one Nasal CPAP and one both CNP (for less ill babies) and endotracheal CPAP (for sicker babies). For this update, we included no new trials. Continuous distending pressure (CDP) is associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.52 to 0.81; typical risk difference (RD) -0.20, 95% CI -0.29 to -0.10; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; six studies; 355 infants), lower overall mortality (typical RR 0.52, 95% CI 0.32 to 0.87; typical RD -0.15, 95% CI -0.26 to -0.04; NNTB 7, 95% CI 4 to 25; six studies; 355 infants) and lower mortality in infants with birth weight above 1500 g (typical RR 0.24, 95% CI 0.07 to 0.84; typical RD -0.28, 95% CI -0.48 to -0.08; NNTB 4, 95% CI 2.00 to 13.00; two studies; 60 infants). Use of CDP is associated with increased risk of pneumothorax (typical RR 2.64, 95% CI 1.39 to 5.04; typical RD 0.10, 95% CI 0.04 to 0.17; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 17.00 to 25.00; six studies; 355 infants). We found no difference in bronchopulmonary dysplasia (BPD), defined as oxygen dependency at 28 days (three studies, 260 infants), as well as no difference in outcome at nine to 14 years (one study, 37 infants). Authors' conclusions In preterm infants with respiratory distress, the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax. Four out of six of these trials were done in the 1970s. Therefore, the applicability of these results to current practice is difficult to assess. Further research is required to determine the best mode of administration.
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An authentic animal model of the very preterm infant on Nasal continuous positive airway pressure
Intensive Care Medicine Experimental, 2015Co-Authors: Pa Dargaville, Anna Lavizzari, Priscila Padoin, Don Black, Elroy Zonneveld, Elizabeth Perkins, Magdy Sourial, Anushi E Rajapaksa, Peter G Davis, Stuart B HooperAbstract:Background The surge in uptake of Nasal continuous positive airway pressure (CPAP) for respiratory support in preterm infants has occurred in the absence of an authentic animal model. Such a model would allow investigation of research questions of physiological and therapeutic importance. We therefore aimed to develop a preterm lamb model of the non-intubated very preterm infant on CPAP. Methods After staged exteriorisation and instrumentation, preterm lambs were delivered from anaesthetised ewes at 131 to 133 days gestation. Via a single Nasal Prong (4-mm internal diameter, 6- to 7-cm depth), positive pressure was delivered from the outset, with Nasal intermittent positive pressure ventilation (NIPPV) used until transition to Nasal CPAP was attempted, and periodically thereafter for hypoventilation. Caffeine and doxapram were used as respiratory stimulants. Gastric distension was prevented with an oesophageal balloon. Cardiorespiratory parameters and results of arterial blood gas analyses were monitored throughout the study period, which continued for 150 min after first transition to CPAP. Results Ten preterm lambs were studied, at gestation 132 ± 1 days (mean ± SD) and birth weight 3.6 ± 0.45 kg. After stabilisation on NIPPV, transition to Nasal CPAP was first attempted at 28 ± 11 min. There was transient respiratory acidosis, with gradual resolution as spontaneous respiratory activity increased. In the final hour, 79% ± 33% of time was spent on CPAP alone, with typical respiratory rates around 60 breaths per minute. PaCO_2 at end-experiment was 58 ± 36 mmHg. Conclusions Non-intubated preterm lambs can be effectively transitioned to Nasal CPAP soon after birth. This animal model will be valuable for further research.
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continuous distending pressure for respiratory distress syndrome in preterm infants
Cochrane Database of Systematic Reviews, 2000Co-Authors: Jacqueline J Ho, Prema Subramaniam, David J Hendersonsmart, Peter G DavisAbstract:Background Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998 Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactants is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive resulting in airway and lung injury and contributing to the development of chronic lung disease. Objectives In spontaneously breathing preterm infants with RDS to determine if continuous distending pressure (CDP) reduces the need for IPPV and associated morbidity without adverse effects. Search strategy The standard search strategy of the Neonatal Review group was used. This included searches of the Oxford Database of Perinatal Trials Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3 2004) MEDLINE (1966-August 2004) and EMBASE (1980-August 2004) previous reviews including cross references abstracts conference and symposia proceedings expert informants journal hand searching mainly in the English language. Selection criteria All trials using random or quasi-random allocation of preterm infants with RDS were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask Nasal Prong nasopharyngeal tube or endotracheal tube or continuous negative pressure (CNP) via a chamber enclosing the thorax and lower body compared with standard care. Data collection and analysis Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used including independent assessment of trial quality and extraction of data by each author. Main results CDP is associated with a lower rate of failed treatments (death or use of assisted ventilation) [summary RR 0.70 (0.55 0.88) (0.55 0.88) RD - 0.22 (-0.35 -0.09) NNT 5 (3 11)] overall mortality [summary RR 0.52 (0.32 0.87) RD -0.15 (-0.26 -0.04) NNT 7 (4 25)] and mortality in infants with birthweights above 1500 g [summary RR 0.24 (0.07 0.84) RD -0.281 (-0.483 - 0.078) NNT 4 (2 13)]. The use of CDP is associated with an increased rate of pneumothorax [summary RR 2.36 (1.25 5.54) RD 0.14 (0.04 0.23) NNH 7 (4 24)]. Authors conclusions In preterm infants with RDS the application of CDP either as CPAP or CNP is associated with benefits in terms of reduced respiratory failure and reduced mortality. CDP is associated with an increased rate of pneumothorax. The applicability of these results to current practice is difficult to assess given the intensive care setting of the 1970s when four out of five of these trials were done. Where resources are limited such as in developing countries CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings. (authors)
Soraya Abbasi - One of the best experts on this subject based on the ideXlab platform.
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factors influencing delivered mean airway pressure during Nasal cpap with the ram cannula
Pediatric Pulmonology, 2016Co-Authors: Emidio M. Sivieri, Soraya Abbasi, Jeffrey S GerdesAbstract:SummaryObjective To measure mean airway pressure (MAP) delivered through the RAM Cannula® when used with a ventilator in CPAP mode as a function of percent nares occlusion in a simulated Nasal interface/test lung model and to compare the results to MAPs using a Nasal continuous positive airway pressure (NCPAP) interface with nares fully occluded. Study Design An artificial airway model was connected to a spontaneous breathing lung model in which MAP was measured at set NCPAP levels between 4 and 8 cmH2O provided by a Drager Evita XL® ventilator and delivered through three sizes of RAM cannulae. Measurements were performed with varying leakage at the Nasal interface by decreasing occlusion from 100% to 29%, half-way Prong insertion, and simulated mouth leakage. Comparison measurements were made using the Drager BabyFlow® NCPAP interface with a full Nasal seal. Results With simulated mouth closed, the Drager interface delivered MAPs within 0.5 cmH2O of set CPAP levels. For the RAM cannula, with 60–80% nares occlusion, overall delivered MAPs were 60 ± 17% less than set CPAP levels (P < 0.001). Further, MAP decreased progressively with decreasing percent nares occlusion. The simulated open mouth condition resulted in significantly lower MAPs to <1.7 cmH2O. The one-half Prong insertion depth condition, with closed mouth, yielded MAPs approximately 35 ± 9% less than full insertion pressures (P < 0.001). Conclusions In our bench tests, the RAM interface connected to a ventilator in NCPAP mode failed to deliver set CPAP levels when applied using the manufacturer recommended 60–80% nares occlusion, even with closed mouth and full Nasal Prong insertion conditions. Pediatr Pulmonol. 2016;51:60–69. © 2015 Wiley Periodicals, Inc.
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ps 376 non invasive ventilation in neonates effect of Nasal cannula size insertion depth and nares diameter on mean airway pressure an in vitro study
Archives of Disease in Childhood, 2014Co-Authors: J Gerdes, Emidio M. Sivieri, Soraya AbbasiAbstract:Background Increased neonatal Non-Invasive Ventilation (NIV) use, such as nCPAP and high flow Nasal cannula (HFNC) prompted re-evaluation of Nasal interface devices – specifically short bi-Nasal Prongs, and their size and fit relative to the nares. Objective To quantify the effect of Nasal Prong size and insertion depth on generated mean airway pressure (MAP) during NIV. Design/methods A Drager traditional nCPAP interface, three sizes of RAM cannulae (Neotech, Valencia, CA, USA) and two Fisher and Paykel (FP) (Auckland, NZ) HFNC cannulae were tested with 8 simulated nares sizes. A simulated Nasal airway was connected to an active lung model set at: Vt 8–10 ml, 60 b/m, Ti 0.35–0.40 s. A Drager Evita XL ventilator delivered 4,5,6,7 and 8 cmH2O to the RAM and the Drager nCPAP cannulae and a FP HFNC system delivered 1–6 L/m flows. MAP was measured for open and closed-mouth conditions. Results MAP decreased progressively as the percent nares occlusion (%Occl) decreased. At one-half insertion and closed-mouth conditions, close fitting Prongs with high% Occl yielded MAP’s of one-half of set CPAP levels. Delivered MAP’s were significantly lower during open-mouth condition using either HFNC or CPAP cannulae. MAP increased with both flowrate and%Occl. A rapid rise in pressure was associated with% Occl’s >74%. Complete nares occlusions generated the highest pressures. Simulated closed-mouth produced 12 ± 7 SD higher MAP’s than open-mouth over all%Occl’s at HFNC flows >1 L/m. Conclusion RAM ‘CPAP’ does not deliver MAP as effectively as standard Nasal Prong CPAP. Optimum delivered airway pressure is dependent on appropriate %Occl, insertion depth and NIV settings. ![Abstract PS-376 Figure 1][1] Abstract PS-376 Figure 1 [1]: pending:yes
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effect of hfnc flow rate cannula size and nares diameter on generated airway pressures an in vitro study
Pediatric Pulmonology, 2013Co-Authors: Emidio M. Sivieri, Jeffrey S Gerdes, Soraya AbbasiAbstract:Increased use of non-invasive forms of respiratory support such as CPAP and HFNC in premature infants has generated a need for further investigation of the pulmonary effects of such therapies. In a series of in vitro tests, we measured delivered proximal airway pressures from a HFNC system while varying both the cannula flow and the ratio of Nasal Prong to simulated nares diameters. Neonatal and infant sized Nasal Prongs (3.0 and 3.7 mm O.D.) were inserted into seven sizes of simulated nares (range: 3-7 mm I.D. from anatomical measurements in 1-3 kg infants) for Nasal Prong-to-nares ratios ranging from 0.43 to 1.06. The nares were connected to an active test lung set at: TV 10 ml, 60 breaths/min, Ti 0.35 sec, compliance 1.6 ml/cm H₂O and airway resistance 70 cm H₂O/(L/sec), simulating a 1-3 kg infant with moderately affected lungs. A Fisher & Paykel Healthcare HFNC system with integrated pressure relief valve was set to flow rates of 1-6 L/min while cannula and airway pressures and cannula and mouth leak flows were measured during simulated mouth open, partially closed and fully closed conditions. Airway pressure progressively increased with both increasing HFNC flow rate and Nasal Prong-to-nares ratio. At 6 L/min HFNC flow with mouth open, airway pressures remained 0.9 and 50% mouth leak, airway pressures rapidly increased to 18 cm H₂O at 2 L/min HFNC flow followed by a pressure relief valve limited increase to 24 cm H₂O at 6 L/min. Safe and effective use of HFNC requires careful selection of an appropriate Nasal Prong-to-nares ratio even with an integrated pressure relief valve.
Nemyun Boo - One of the best experts on this subject based on the ideXlab platform.
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incidence of Nasal trauma associated with Nasal Prong versus Nasal mask during continuous positive airway pressure treatment in very low birthweight infants a randomised control study
Archives of Disease in Childhood-fetal and Neonatal Edition, 2005Co-Authors: Sinchuen Yong, Seongjoon Chen, Nemyun BooAbstract:Objective: To compare the incidence of Nasal trauma associated with the use of Prong or mask during Nasal continuous positive airway pressure (nCPAP) support in very low birthweight ( Design: Randomised controlled clinical trial. Setting: Tertiary care university hospital, Department of Paediatrics, Kuala Lumpur, Malaysia. Methods: All very low birthweight infants admitted to the neonatal intensive care unit between July 2001 and December 2003 who received nCPAP through the Infant Flow Driver were randomised to the use of either Nasal Prong or mask. The Nasal cavity of these infants was inspected daily during the first week and then weekly until they were weaned off nCPAP. Results: Of the 89 infants recruited, 41 were randomised to the mask group and 48 to the Prong group. There was no significant difference in the incidence of Nasal trauma between the two groups (p = 0.5). The primary site of trauma was at the junction between the Nasal septum and the philtrum in infants in the mask group and the walls of the Nasal septum in the Prong group. Logistic regression analysis showed that duration of nCPAP was the only significant risk factor associated with development of Nasal injury, after birth weight, gestational age, and Nasal device used had been controlled for (adjusted odds ratio 1.04; 95% confidence interval 1.01 to 1.07; p = 0.003). Conclusion: Irrespective of the type of Nasal device used, Nasal trauma is common during nCPAP treatment, which should therefore be terminated as soon as possible.
Jeffrey S Gerdes - One of the best experts on this subject based on the ideXlab platform.
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factors influencing delivered mean airway pressure during Nasal cpap with the ram cannula
Pediatric Pulmonology, 2016Co-Authors: Emidio M. Sivieri, Soraya Abbasi, Jeffrey S GerdesAbstract:SummaryObjective To measure mean airway pressure (MAP) delivered through the RAM Cannula® when used with a ventilator in CPAP mode as a function of percent nares occlusion in a simulated Nasal interface/test lung model and to compare the results to MAPs using a Nasal continuous positive airway pressure (NCPAP) interface with nares fully occluded. Study Design An artificial airway model was connected to a spontaneous breathing lung model in which MAP was measured at set NCPAP levels between 4 and 8 cmH2O provided by a Drager Evita XL® ventilator and delivered through three sizes of RAM cannulae. Measurements were performed with varying leakage at the Nasal interface by decreasing occlusion from 100% to 29%, half-way Prong insertion, and simulated mouth leakage. Comparison measurements were made using the Drager BabyFlow® NCPAP interface with a full Nasal seal. Results With simulated mouth closed, the Drager interface delivered MAPs within 0.5 cmH2O of set CPAP levels. For the RAM cannula, with 60–80% nares occlusion, overall delivered MAPs were 60 ± 17% less than set CPAP levels (P < 0.001). Further, MAP decreased progressively with decreasing percent nares occlusion. The simulated open mouth condition resulted in significantly lower MAPs to <1.7 cmH2O. The one-half Prong insertion depth condition, with closed mouth, yielded MAPs approximately 35 ± 9% less than full insertion pressures (P < 0.001). Conclusions In our bench tests, the RAM interface connected to a ventilator in NCPAP mode failed to deliver set CPAP levels when applied using the manufacturer recommended 60–80% nares occlusion, even with closed mouth and full Nasal Prong insertion conditions. Pediatr Pulmonol. 2016;51:60–69. © 2015 Wiley Periodicals, Inc.
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effect of hfnc flow rate cannula size and nares diameter on generated airway pressures an in vitro study
Pediatric Pulmonology, 2013Co-Authors: Emidio M. Sivieri, Jeffrey S Gerdes, Soraya AbbasiAbstract:Increased use of non-invasive forms of respiratory support such as CPAP and HFNC in premature infants has generated a need for further investigation of the pulmonary effects of such therapies. In a series of in vitro tests, we measured delivered proximal airway pressures from a HFNC system while varying both the cannula flow and the ratio of Nasal Prong to simulated nares diameters. Neonatal and infant sized Nasal Prongs (3.0 and 3.7 mm O.D.) were inserted into seven sizes of simulated nares (range: 3-7 mm I.D. from anatomical measurements in 1-3 kg infants) for Nasal Prong-to-nares ratios ranging from 0.43 to 1.06. The nares were connected to an active test lung set at: TV 10 ml, 60 breaths/min, Ti 0.35 sec, compliance 1.6 ml/cm H₂O and airway resistance 70 cm H₂O/(L/sec), simulating a 1-3 kg infant with moderately affected lungs. A Fisher & Paykel Healthcare HFNC system with integrated pressure relief valve was set to flow rates of 1-6 L/min while cannula and airway pressures and cannula and mouth leak flows were measured during simulated mouth open, partially closed and fully closed conditions. Airway pressure progressively increased with both increasing HFNC flow rate and Nasal Prong-to-nares ratio. At 6 L/min HFNC flow with mouth open, airway pressures remained 0.9 and 50% mouth leak, airway pressures rapidly increased to 18 cm H₂O at 2 L/min HFNC flow followed by a pressure relief valve limited increase to 24 cm H₂O at 6 L/min. Safe and effective use of HFNC requires careful selection of an appropriate Nasal Prong-to-nares ratio even with an integrated pressure relief valve.
Jacqueline J Ho - One of the best experts on this subject based on the ideXlab platform.
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continuous distending pressure for respiratory distress in preterm infants
Cochrane Database of Systematic Reviews, 2015Co-Authors: Jacqueline J Ho, Prema Subramaniam, Peter G DavisAbstract:Background Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants. In infants with progressive respiratory insufficiency, intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition, but it is invasive, potentially resulting in airway and lung injury. Continuous distending pressure (CDP) has been used for the prevention and treatment of RDS, as well as for the prevention of apnoea, and in weaning from IPPV. Its use in the treatment of RDS might reduce the need for IPPV and its sequelae. Objectives To determine the effect of continuous distending pressure (CDP) on the need for IPPV and associated morbidity in spontaneously breathing preterm infants with respiratory distress. Subgroup analyses were planned on the basis of birth weight (> or < 1000 or 1500 g), gestational age (groups divided at about 28 weeks and 32 weeks), methods of application of CDP (i.e. CPAP and CNP), application early versus late in the course of respiratory distress and high versus low pressure CDP and application of CDP in tertiary compared with non-tertiary hospitals, with the need for sensitivity analysis determined by trial quality. At the 2008 update, the objectives were modified to include preterm infants with respiratory failure. Search methods We used the standard search strategy of the Neonatal Review Group. This included searches of the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, 2015 Issue 4), MEDLINE (1966 to 30 April 2015) and EMBASE (1980 to 30 April 2015) with no language restriction, as well as controlled-trials.com, clinicaltrials.gov and the International Clinical Trials Registry Platform of the World Health Organization (WHO). Selection criteria All random or quasi-random trials of preterm infants with respiratory distress were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask, Nasal Prong, nasopharyngeal tube or endotracheal tube, or continuous negative pressure (CNP) via a chamber enclosing the thorax and the lower body, compared with spontaneous breathing with oxygen added as necessary. Data collection and analysis We used standard methods of The Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each review author. Main results We included six studies involving 355 infants - two using face mask CPAP, two CNP, one Nasal CPAP and one both CNP (for less ill babies) and endotracheal CPAP (for sicker babies). For this update, we included no new trials. Continuous distending pressure (CDP) is associated with lower risk of treatment failure (death or use of assisted ventilation) (typical risk ratio (RR) 0.65, 95% confidence interval (CI) 0.52 to 0.81; typical risk difference (RD) -0.20, 95% CI -0.29 to -0.10; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; six studies; 355 infants), lower overall mortality (typical RR 0.52, 95% CI 0.32 to 0.87; typical RD -0.15, 95% CI -0.26 to -0.04; NNTB 7, 95% CI 4 to 25; six studies; 355 infants) and lower mortality in infants with birth weight above 1500 g (typical RR 0.24, 95% CI 0.07 to 0.84; typical RD -0.28, 95% CI -0.48 to -0.08; NNTB 4, 95% CI 2.00 to 13.00; two studies; 60 infants). Use of CDP is associated with increased risk of pneumothorax (typical RR 2.64, 95% CI 1.39 to 5.04; typical RD 0.10, 95% CI 0.04 to 0.17; number needed to treat for an additional harmful outcome (NNTH) 17, 95% CI 17.00 to 25.00; six studies; 355 infants). We found no difference in bronchopulmonary dysplasia (BPD), defined as oxygen dependency at 28 days (three studies, 260 infants), as well as no difference in outcome at nine to 14 years (one study, 37 infants). Authors' conclusions In preterm infants with respiratory distress, the application of CDP as CPAP or CNP is associated with reduced respiratory failure and mortality and an increased rate of pneumothorax. Four out of six of these trials were done in the 1970s. Therefore, the applicability of these results to current practice is difficult to assess. Further research is required to determine the best mode of administration.
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continuous distending pressure for respiratory distress syndrome in preterm infants
Cochrane Database of Systematic Reviews, 2000Co-Authors: Jacqueline J Ho, Prema Subramaniam, David J Hendersonsmart, Peter G DavisAbstract:Background Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998 Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactants is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive resulting in airway and lung injury and contributing to the development of chronic lung disease. Objectives In spontaneously breathing preterm infants with RDS to determine if continuous distending pressure (CDP) reduces the need for IPPV and associated morbidity without adverse effects. Search strategy The standard search strategy of the Neonatal Review group was used. This included searches of the Oxford Database of Perinatal Trials Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3 2004) MEDLINE (1966-August 2004) and EMBASE (1980-August 2004) previous reviews including cross references abstracts conference and symposia proceedings expert informants journal hand searching mainly in the English language. Selection criteria All trials using random or quasi-random allocation of preterm infants with RDS were eligible. Interventions were continuous distending pressure including continuous positive airway pressure (CPAP) by mask Nasal Prong nasopharyngeal tube or endotracheal tube or continuous negative pressure (CNP) via a chamber enclosing the thorax and lower body compared with standard care. Data collection and analysis Standard methods of the Cochrane Collaboration and its Neonatal Review Group were used including independent assessment of trial quality and extraction of data by each author. Main results CDP is associated with a lower rate of failed treatments (death or use of assisted ventilation) [summary RR 0.70 (0.55 0.88) (0.55 0.88) RD - 0.22 (-0.35 -0.09) NNT 5 (3 11)] overall mortality [summary RR 0.52 (0.32 0.87) RD -0.15 (-0.26 -0.04) NNT 7 (4 25)] and mortality in infants with birthweights above 1500 g [summary RR 0.24 (0.07 0.84) RD -0.281 (-0.483 - 0.078) NNT 4 (2 13)]. The use of CDP is associated with an increased rate of pneumothorax [summary RR 2.36 (1.25 5.54) RD 0.14 (0.04 0.23) NNH 7 (4 24)]. Authors conclusions In preterm infants with RDS the application of CDP either as CPAP or CNP is associated with benefits in terms of reduced respiratory failure and reduced mortality. CDP is associated with an increased rate of pneumothorax. The applicability of these results to current practice is difficult to assess given the intensive care setting of the 1970s when four out of five of these trials were done. Where resources are limited such as in developing countries CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings. (authors)
