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ORIGINAL ARTICLE
Year : 2014  |  Volume : 27  |  Issue : 4  |  Page : 711-716

Early nasal continuous positive airway pressure compared with mechanical ventilation in very-low-birth-weight neonates


1 Department of Pediatric, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Pediatric, National Liver Institute, Menoufia University, Menoufia, Egypt
3 Shebin-Elkom Teaching Hospital, Shebin El-Kom, Egypt

Date of Submission13-Jun-2014
Date of Acceptance14-Aug-2014
Date of Web Publication22-Jan-2015

Correspondence Address:
Nagwa N Ghorab
Sirs-Ellian
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.149707

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  Abstract 

Objectives
To determine whether prophylactic nasal continuous positive airway pressure (CPAP) applied soon after birth, regardless of the respiratory status, in very-low-birth-weight (VLBW) neonates reduces the use of mechanical ventilation and its hazards.
Background
Using nasal CPAP early in VLBW neonates is highly beneficial and associated with lower complications compared with mechanical ventilation.
Patients and methods
This prospective clinical trial was performed on 40 preterm neonates less than 37 weeks old and with body weight greater than 1000 g and less than 1500 g, who were admitted to the neonatal intensive care unit of Shibin El-Kom teaching hospital because of VLBW. Patients were randomly allocated into the following treatment groups. Group I included 20 preterm neonates supported by nasal CPAP immediately after birth regardless of their respiratory status. Group II included 20 preterm neonates receiving routine neonatal care. Survival analysis was applied to estimate and compare survival rates, the duration of oxygen therapy, and the hospital stay using the independent sample t-test.
Results
Regarding the initial and the final arterial blood gases in the CPAP group, there was a statistically significant difference with respect to the PO 2 . In contrast, there were no statistically significant differences in the initial and the final arterial blood gases in the non-CPAP group.
There was a statistically significant difference between the CPAP group and the non-CPAP group with regard to the whole duration of stay in the neonatal intensive care unit (the duration was 19.60 ± 3.44 and 32.10 ± 12.28, respectively) and the whole duration of ventilation (the duration was 4.0 ± 5.32 and 24.70 ± 13.0, respectively).
Conclusion
The use of nasal CPAP was associated with a lower duration of stay, a lower incidence of complications (pneumothorax, bronchopulmonary dysplasia, pulmonary hemorrhage, and sepsis), and a decreased need for mechanical ventilation.

Keywords: Bubble CPAP, continuous positive airway pressure, prophylactic early nCPAP in VLBW neonates, respiratory distress syndrome, ventilator-derived CPAP


How to cite this article:
Bahbah MH, El-araby HA, Khedr MA, Ghorab NN. Early nasal continuous positive airway pressure compared with mechanical ventilation in very-low-birth-weight neonates. Menoufia Med J 2014;27:711-6

How to cite this URL:
Bahbah MH, El-araby HA, Khedr MA, Ghorab NN. Early nasal continuous positive airway pressure compared with mechanical ventilation in very-low-birth-weight neonates. Menoufia Med J [serial online] 2014 [cited 2020 Feb 16];27:711-6. Available from: http://www.mmj.eg.net/text.asp?2014/27/4/711/149707


  Introduction Top


Continuous positive airway pressure (CPAP) is the application of a positive pressure to the airways of the spontaneously breathing patient throughout the respiratory cycle [1].

Nasal CPAP (nCPAP) is one of the most frequently used modes of respiratory support in preterm infants [2]. Its main physiologic effects on the preterm lung are a decrease in airway resistance and a pressure-dependent increase in the often-compromised end-expiratory lung volume [3]. As a result, preterm infants on nCPAP expend less effort breathing, have less paradoxical breathing, less apnea, and have improved gas exchange [4]. nCPAP is also considered as a lung-protective mode of respiratory support because it reduces the need for invasive mechanical ventilation, which can cause secondary lung injury leading to bronchopulmonary dysplasia (BPD) [5]. Regional overdistension and atelectasis caused by a heterogeneous distribution of aeration and ventilation are considered important pathways in the development of ventilator-induced lung injury [6],[7]. However, in recent randomized controlled trials, investigators failed to show a clear benefit of (early) nCPAP over invasive mechanical ventilation in terms of lung injury in preterm infants [8].

Treatment of RDS aims to decrease further alveolar atelectasis, the side effects of asphyxia, and poor perfusion. Many experts believe that it is appropriate to intubate all infants weighing less than 1000 g at birth and to initiate mechanical ventilation with positive end-expiratory pressure (PEEP) in the delivery room, and another approach is early utilization of nCPAP. Centers using the delivery room management approach of nCPAP have a low incidence of BPD, and these centers have no differences in the mortality rate, the occurrence of intraventricular hemorrhage, or other important morbidities [9].


  Patients and methods Top


Patients

The present study was carried out in the neonatal intensive care unit of Menoufia University and Shebin El-Koom teaching hospitals. The study included 40 neonates: they were divided into two groups.

Group I

Twenty preterm neonates supported by nCPAP (bubbling CPAP) immediately after birth according to their respiratory status.

Group II

Twenty preterm neonates receiving nasal oxygen by nasal cannula 2 l/min.

On the basis of close follow-up of these neonates (clinically and by blood gases) and according to their response, two patients improved on nasal cannula, eight patients needed nCPAP, and 10 patients needed MV.

Inclusion criteria

Preterm neonates less than 37 weeks old and with body weight more than 1000 g and less than 1500 g.

Exclusion criteria

Neonatal sepsis, major congenital anomalies, and neonatal asphyxia.

Methods

All patients were evaluated regularly every 6 h with special emphasis on physical examination.

  1. Detailed history (antenatal and natal history).
  2. Thorough examination.
  3. Investigations: complete blood count, C-reactive protein, arterial blood gases (ABG), the blood glucose level, and a plain chest radiography.
  4. Management: nCPAP (bubbling CPAP) and mechanical ventilation.


Ventilator strategy

  1. nCPAP: bubbling CPAP was initiated at 5-6 cm H 2 O and increased to a maximum of 7-8 cm H 2 O.
  2. Mechanical ventilation was used when the V/Q mismatching was so severe that increased fraction of inspired oxygen (FiO 2 ) and nCPAP were inadequate or in infants who tired from the increased work of breathing.


Setting

Long Ti, 0.5-0.6 s; PIP, 20-25 cm H 2 O; PEEP, 4-5 cm H 2 O, up to 6 cm H 2 O; flow rate, 7-12 l/min; rate, initiated at 20-40 breaths/min, and adjusted by blood gas result.

Weaning

When the patient became stable, FiO 2 and PIP were weaned first, and then the rate was reduced. Once the rate = 12/min, PIP = 16, PEEP = 4 cm H 2 O, and FiO 2 less than 0.30, they were changed to CPAP.

Close follow-up of the patients was carried out clinically and by blood gases.

Regarding group I, 12 out of 20 neonates who were connected to nCPAP soon after birth improved on nCPAP without need for mechanical ventilation: five patients had no RD after birth, three patients had RD grade I, and the remaining four patients had RD grade II. Three of the patients required MV as they developed apnea of prematurity on the third day of life and the other five patients required FiO 2 greater than 60%, and so were changed to MV.

Regarding group II, two out of 20 patients who received O 2 by a nasal prong improved without needing CPAP or MV; their gestational age was 35 weeks and their birth weight was 1.47 and 1.45 kg, respectively. Eight patients in this group showed respiratory distress on nasal prong and were changed to nCPAP: three of them improved on nCPAP and the remaining five patients required MV. Ten patients required MV; the criteria for failure of nasal support were clinical deterioration (increased respiratory distress) accompanied by at least one of the following: PH<7.20, PCO 2 >60 mmHg, and a PaO 2 <50 mmHg, or arterial oxygen saturation by pulse-oximetry<88% on FiO 2 >50%, or recurrent significant apnea.




  Results Top


In the studied groups, there was no significant difference between the two groups regarding their weight and gestational age (P > 0.05) [Table 1].

Regarding maternal risk factors (MRF), there was no significant difference between the two groups (P > 0.05). In our study, 25% of all neonates had no MRF (six neonates in the CPAP group and four neonates in the other group), whereas PROM and pre-eclamsia each occurred in 17.5% (three neonates in the CPAP group and four neonates in the other group), preterm labor occurred in 12.5% (one neonate in the CPAP group and three neonates in the other group), multiple gestation occurred in 10% (three neonates in the CPAP group and one neonate in the other group), hypertension occurred in 7.5% (one neonate in the CPAP group and two neonates in the other group), and previous C.S and antepartum hemorrhage each occurred in 5% of the patients (one neonate in the CPAP group and one neonate in the other group) [Table 2].
Table 1: Weight and gestational age among the studied groups

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Table 2: Maternal risk factors among the studied groups

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Regarding the grade of respiratory distress, there was no statistically significant difference between the studied groups (P > 0.05) [Table 3].

Initial ABG between the studied groups were compared on admission, and showed that there was no statistically significant difference between the CPAP group and the non-CPAP group (P > 0.05) [Table 4].
Table 3: Grades of the studied groups initially

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Table 4: Initial arterial blood gases among the studied groups

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nCPAP followed by MV was associated with a lower rate of complications compared with mechanically ventilated cases after nasal prong (P < 0.05) [Table 5].
Table 5: Complications among mechanically ventilated gro

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In our study, pneumothorax was found in 60% of mechanically ventilated patients after nasal prong (six out of 10 neonates), pneumothorax alone in 20% (two patients), pneumothorax with BPD in 20% (two patients), and pneumothorax with sepsis in 20% (two patients) of the patients. In 36% of the nCPAP patients followed by MV (three out of eight patients), pneumothorax alone occurred in 12% (one patient), pneumothorax with BPD in 12% (one patient), and pneumothorax with sepsis in 12% (one patient) of the patients.

In the present study, pulmonary hemorrhage occurred in 12% of the nCPAP patients followed by MV (one patient) and in 20% of the mechanically ventilated patients after nasal prong (two patients).

BPD occurred in 10% of the ventilated patients after nasal prong (one patient from 10) and 0% of the nCPAP patients followed by MV.

In our study, sepsis occurred in 12% of the nCPAP patients followed by mechanical ventilation (one out of eight patients) and in 30% of the mechanically ventilated patients after nasal prong (three out of 10 patients).

Regarding the initial ABG on admission of patients to the NICU and the final ABG just before weaning in the nCPAP group, there were statistically significant differences with respect to the PO 2 (P < 0.05), and regarding the initial and the final ABG in the non-CPAP group, there were no statistically significant differences (P > 0.05) [Table 6].
Table 6: Initial and final ABG among the CPAP and the non-CPAP groups

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There was a statistically significant difference between the nCPAP group and the non-CPAP group regarding the whole duration of stay in the neonatal intensive care unit (the duration was 19.60 ΁ 3.44 and 32.10 ΁ 12.28, respectively) and the whole duration of ventilation (the duration was 4.0 ΁ 5.32 and 24.70 ΁ 13.0, respectively) (P < 0.05) [Table 7].
Table 7: The whole duration of stay and the duration of ventilation among the studied groups

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  Discussion Top


Ho et al. [9] and Donn and Sinha [10] stated that if a preterm infant of at least 28 weeks old has good respiratory effort, but has respiratory distress/apnea, the infant may be trialed on CPAP rather than intubated immediately.

Regarding MRF, there was no significant difference between the two groups (P>0.05). This was in agreement with Covarrubias et al. [11] who found that premature rupture of membranes and maternal morbidity during pregnancy were the most important risk factors of prematurity.

Regarding the grades of respiratory distress, there was no statistically significant difference between the studied groups. This was in contrast to Subramaniam et al. [12] who concluded that if a preterm infant has good respiratory effort, but has respiratory distress/apnea, the infant may be trialed on nCPAP rather than intubated immediately.

Comparison of the arterial blood gases between the studied groups on admission showed that neonates in the non-CPAP group had a lower mean PH and a lower mean PO 2 when compared with neonates in the nCPAP group. The higher PH and PO 2 in the nCPAP group may be related to better general conditions [13].

FiO 2 was statistically significantly higher in neonates on mechanical ventilation than in those on nCPAP (P < 0.05) as shown in Table 6; this is in agreement with the study by Henderson-Smart and Davis [14], who stated that once the diagnosis of RDS is established, the administration of CPAP decreases oxygen requirements, decreases the need for mechanical ventilation, and may reduce mortality.

In the studied groups, we found that mechanically ventilated patients after nasal prongs alone showed the highest mean FiO 2 , mean PIP, and mean ventilatory rates when compared with ventilated patients after nCPAP failure. This is in agreement with Greenough et al. [15] who found that mechanically ventilated neonates require high ventilator settings because of their worse chest condition compared with neonates on CPAP alone or neonates who were mechanically ventilated after CPAP trial failure.

nCPAP followed by MV was associated with a lower rate of complications (pneumothorax, pulmonary hemorrhage, BPD, and sepsis) compared with mechanically ventilated patients after nasal prongs. This was not in agreement with Finer et al. [16] who conducted three multicenter randomized controlled trials that include a total of 459 preterm infants and reported that prophylactic CPAP does not decrease the incidence or the severity of RDS or its complications.

In our study, pnefumothorax was found in 60% of mechanically ventilated patients after nasal prong and in 36% of nCPAP patients followed by MV.

In accordance to our study, the incidence of pneumothorax is related to the type, the level, and the method by which distending pressure is applied, wherein nCPAP is the least dangerous and does not increase the incidence of air leaks above that of spontaneous pneumothorax in the RDS [17].

Pulmonary hemorrhage was found in 12% of the nCPAP patients followed by MV and in 20% of the mechanically ventilated patients after nasal prongs on the same side. The occurrence of pulmonary hemorrhage increases in tiny premature infants, especially after surfactant therapy [18].

In our study, BPD occurred in 10% of the ventilated patients after nasal prongs and 0% of the nCPAP patients followed by MV. This coincides with the study by Halliday [19] who found that the initiation of mechanical ventilation was a major risk factor associated with increased BPD.

There was an increase in the incidence of sepsis in the non-CPAP group compared with the CPAP group. Mahmoud et al. [20] found that noninvasive ventilatory support can reduce the adverse effects associated with intubation and mechanical ventilation, such as BPD, sepsis, and trauma to the upper airways.

Regarding the initial and the final ABG in the CPAP group, there was a statistically significant difference with respect to the PO 2. In contrast, there were no statistically significant differences in the initial and the final ABG in the non-CPAP group. .

There was a statistically significant difference between the nCPAP group and the non-CPAP group with regard to the whole duration of stay in the neonatal intensive care unit and the whole duration of ventilation. Upadhyay and colleagues stated that mechanically ventilated patients usually have more severe clinical states and need more time for weaning as they are exposed to more complications. This increases their number of days on assisted ventilation. This is also prominent if conventional mechanical ventilation follows a trial of nCPAP that was unsuccessful [21].


  Conclusion Top


Current modalities in ventilator assistance provided to neonates suffering from RD should be graded according to the severity of the disease and range from the more benign noninvasive nCPAP to the use of conventional mechanical ventilation.

The use of nCPAP is associated with a shorter duration of stay, a lower incidence of complications, and a decreased need for mechanical ventilation.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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