A Randomized Controlled Trial of Synchronized Nasal Intermittent Positive Pressure Ventilation in RDS

V Bhandari; R G Gavino; J H Nedrelow; P Pallela; A Salvador; R A Ehrenkranz; N L Brodsky;

Disclosures

December 05, 2007

In This Article

Abstract and Introduction

Abstract

Objective: Comparison of outcomes of infants with respiratory distress syndrome (RDS), post-surfactant, extubated to synchronized nasal intermittent positive pressure ventilation (SNIPPV) or continued on conventional ventilation (CV).
Study Design: Prospective post-surfactant randomized controlled trial of primary mode SNIPPV compared with CV in infants (born from July 2000 to March 2005) with birth weights (BW) of 600 to 1250 g. Primary mode SNIPPV was defined as its use in the acute phase of RDS, following the administration of the first dose of surfactant.
Result: There were no significant differences in the maternal demographics, antenatal steroid use, mode of delivery, BW, gestational age, gender or Apgar at 5 min between infants continued on CV (n=21) and those extubated to primary mode SNIPPV (n=20). Significantly, more babies in the CV group had the primary outcome of bronchopulmonary dysplasia (BPD)/death, compared to the SNIPPV group (52 versus 20%, P=0.03). There was no difference in the incidence of other common neonatal morbidities. There were no differences in the Mental or Psychomotor Developmental Index scores on follow-up between the two groups.
Conclusion: Infants of BW 600 to 1250 g with RDS receiving surfactant with early extubation to SNIPPV had a significantly lower incidence of BPD/death. Primary mode SNIPPV is a feasible method of ventilation in small premature infants.

Introduction

Respiratory distress syndrome (RDS) and its sequelae, bronchopulmonary dysplasia (BPD) are both frequent complications of prematurity, and account for 21% of infant deaths each year due to complications of prematurity.[1] Despite the advent of antenatal steroids and surfactant replacement therapy for management of RDS, the incidence of BPD has not changed significantly in the last decade.[2] The pathogenesis of BPD is multifactorial.[3] Although chorioamnionitis is an important factor implicated in the pathogenesis of BPD, the roles of hyperoxia, ventilator-induced injury, pulmonary edema, late-onset sepsis and genetic predisposition are also major contributors. There appears to be a major role for inflammation causing significant lung damage and interfering with the normal development of airways and alveoli, culminating in BPD.[3]

In an effort to decrease ventilator-induced lung injury, alternative techniques of invasive ventilation have been employed.[4,5,6,7] Recent studies have shown little or no difference in outcomes when these methods have been used as a primary mode of ventilation for infants with RDS.[5,6,7] This has led to suggestions for a non-invasive approach to the ventilation of the newborn with RDS.[8,9] Although use of nasal continuous positive airway pressure (NCPAP) post-surfactant (InSUrE, intubation, surfactant and extubation) has met with some success,[9,10,11,12] some infants have failed that approach.[13,14]

Nasal intermittent positive pressure ventilation (NIPPV) is a form of non-invasive respiratory support that combines NCPAP with intermittent ventilator breaths. The use of synchronized NIPPV (SNIPPV) for supporting infants who are extubated has been advocated by many investigators.[8,15,16] SNIPPV has been found to be more effective than NCPAP in weaning infants with RDS from mechanical ventilation and has been recommended as the modality of choice for extubation, especially for extremely low birth weight (ELBW) infants.[8] A decrease in BPD and retinopathy of prematurity (ROP) had also been noted in the same study.[8] In view of benefits noted when SNIPPV was used in the secondary mode (that is, for extubation after a prolonged weaning phase of mechanical ventilation in the 'recovery' phase of RDS), we hypothesized that SNIPPV use in the primary mode (that is, in the 'acute' phase of RDS) would be safe and useful in preterm infants. The prospective observational study in the use of SNIPPV as a primary mode of ventilation in infants of 28 to 34 weeks of gestational age (GA) with RDS requiring surfactant, reported that babies with an early extubation to SNIPPV had a shorter duration of intubation, and decreased need for oxygen as compared to conventional ventilation (CV).[17] There was also a significant decrease in the duration of parenteral nutrition and hospitalization. It was concluded that SNIPPV was feasible as a primary mode of ventilation in larger premature infants.[17]

In the present study, we hypothesized that primary mode SNIPPV (defined as its use in the acute phase of RDS, following the administration of the first dose of surfactant) initiated shortly after birth would decrease the incidence of BPD or death in smaller premature babies when compared to conventional endotracheal mode of ventilation. The purpose of this study was to conduct a randomized controlled trial (RCT) to test the feasibility of comparing SNIPPV versus CV in infants (BW=600 to 1250 g) with RDS requiring at least one dose of surfactant.

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