Reviews

Delivering non-invasive positive pressure to prevent extubation failure in preterm infants: nasal CPAP remains the standard of care

CPAP Lowering extubation failures in very preterm infants remains an important goal. For this purpose and upon extubation, high-flow nasal cannulae (HFNC) and nasal CPAP were compared. Extubation failure occurred in 34% randomized to HFNC, and in 26% randomized to CPAP. Apnea was the most common cause of extubation failure in both groups. These data provide no compelling argument that HFNC should be considered as equivalent to nasal CPAP as the current standard of care to prevent extubation failure.

Sustained lung inflation in extreme preterm infants

SUSTAINED LUNG INFLATION Preventing CPAP failure remains an elusive goal. Providing prophylactic sustained lung inflation (SLI) in the delivery room is one potential intervention that may prevent CPAP failure, and ultimately improve both pulmonary and neurodevelopmental outcomes in the highest-risk infants. Thus, the ability of prophylactic SLI to prevent the need for mechanical ventilation in the first 3 days of life in infants born at 25-28 weeks was evaluated. This trial showed that use of SLI reduced the need for mechanical ventilation in the first 72 hours of life. However, there was a higher, non-statistically significant increased incidence in pneumothorax in the group randomized to receive SLI. These data show that prophylactic SLI can decrease rates of CPAP failure, but larger studies are necessary to demonstrate safety and the effecton long-term outcomes.

Establishing ventilation in the delivery room: T-piece resuscitator versus self-inflating bag

RESUSCITATION There are different devices for neonatal ventilation. Newborn infants ventilated with a facemask at birth were randomized to use of self-inflating bag (SIB) or T-piece. There was no difference between SIB and T-piece in establishing ventilation, as assessed by heart rate. However, T-piece was associated with lower rates of DR-intubations and BPD. The T-piece resuscitator is less injurious to the lung than the SIB. Future studies should define relations between pressures & volumes during neonatal resuscitation, and respiratory outcomes in preterm infants.

Does fluconazole prophylaxis reduce the incidence of death or invasive candida infection in extremely preterm infants?

CANDIDA Invasive candidiasis remains relatively common and is frequently deadly among extremely low birthweight infants. Thus, strategies to prevent invasive disease are needed. For this purpose, the effectiveness of prophylactic fluconazole to prevent invasive candidiasis in infants born at <750 g was evaluated. The combined outcome of death or invasive candidiasis was not different between treatment and control groups. These data provide no compelling argument that prophylactic fluconazole should be used routinely to prevent invasive candidiasis in infants weighing <750 g at birth.

A randomized blinded trial to assess whether near infrared spectroscopy measures of cerebral saturation in infants

NIRS Cerebral oxygenation after extremely preterm birth may be unstable. Extremely preterm infants (<28 wks) were randomized to NIRS for 3-72 hours after birth and an algorithm to stabilize it, or not (NIRS-data blinded). NIRS-monitoring resulted in longer periods of cerebral oxygen saturation on target (55-85%), but did not significantly reduce IVH or mortality. This report found no significant difference in clinical outcomes. Further validation and clinical demonstration must be provided before NIRS-monitors become standard of care.

Humidification and heating of inspired gas during delivery room stabilization improves admission temperature in preterm infants

NORMOTHERMIA Maintaining normothermia in preterm infants after birth remains a challenge. Meyer and colleagues have demonstrated that the use of heated humidified gas during preterm infants stabilization improves temperature on admission to NICU. However, firm recommendations for clinical practice cannot be given at this time based on the limited evidence currently available.