Summary: Stabilisation of premature infants in the delivery room with nasal high flow.

Topic: Primary Support – Delivery Room

Reynolds P, Leontiadi S, Lawson T, et al. Stabilisation of premature infants in the delivery room with nasal high flow. Arch Dis Child Fetal Neonatal Ed. 2016 Jul;101(4):F284-7. doi: 10.1136/archdischild-2015-309442. Epub 2016 Jan 5. PMID: 26733541. 

Reynolds and colleagues conducted a single center pilot study to determine the feasibility of using heated humidified high-flow nasal cannula (Vapotherm’ s Precision Flow High Velocity Nasal Insufflation (HVNI) Therapy) for Delivery Room (DR)stabilization of babies born at <30 weeks gestation as respiratory support immediately after birth and upon transfer to the neonatal intensive care unit (NICU). The study demonstrated that it is feasible to use HVNI for the stabilization of premature babies without the need for routine intubation and/or surfactant prior to and during transfer to NICU in the majority of cases. 

In this study, 28 babies between 23+4 and 29+6 weeks gestation were enrolled, and the mean birth weight was 876 g (range 456–1430 g). Three babies born at 23 or 24 weeks were intubated and transferred to NICU ventilated as per protocol.  25 babies were stabilized and transferred to the NICU on HVNI. Less than half (48%) of the babies required surfactant and 60% were still on HVNI 72 h after admission but only 5 (42%) were still on HVNI at 72 h. These babies ranged from 23+4 to 29+6 weeks gestation. Of the 13 babies (24+1 to 29+5 weeks gestation) who did not require surfactant, 11 (85%) were still maintained on HVNI at 72 h. 1 baby received inotropes in the first 72 h due to a pulmonary hemorrhage after 48 h. In comparison with the pre-study routine practice for the DR management of babies born at <30 weeks gestation during the year preceding this study, of 52 babies born, 73% were intubated in the DR (100% if born at <26 weeks), with all intubated babies receiving surfactant in the DR. (One planned and three unplanned extubations occurred prior to transfer to NICU, and 15/34 (44%) were then electively extubated within 24 h on NICU. The authors report a long-standing policy of early extubation and non-invasive ventilation to HVNI.  5/52 babies were still ventilated at 72 h with only two babies receiving inotropes. 

The smallest baby stabilized successfully weighed 498 g, was still on HVNI after 72 h, and was eventually transferred back to their local hospital. Two babies developed grade 3 or 4 intraventricular hemorrhages (8%). There was one pneumothorax after 24 h, which occurred after the baby had been intubated and received IPPV before and after administration of surfactant. 

After delivery of the infant, the protocol included the application of HVNI set at 37°C with starting flow at 6-7 L/min, and a maximum flow rate up to 8 L/min. The technology in this study could be set up in 2 minutes with an additional 2-3 minutes of heating time needed to reach the 37°C level during which time the clinicians assessed the infants and performed routine checks of resuscitation equipment. Preductal pulse and oxygen saturation monitoring was initiated with values obtained after about 1 min, and oxygen given at the clinician’s discretion. Acceptable initial values were heart rate >100 bpm and SaO₂ >40%, with spontaneous respirations. No other airway interventions such as suction or inflation breaths were applied. A steady increase in SaO₂ was expected (approximately 10% per minute over the next 5 min) with SaO₂ targeted to 90%–95% after 10 min if requiring supplemental oxygen. If the baby was apneic, five normal inflation breaths were applied according to standard guidance. If the baby responded promptly to initial resuscitation measures, then stabilization on nHF could be attempted at the discretion of the senior clinician present. When stable, babies were transferred to the NICU (a one-minute transfer time). 

Reynolds et al describe a small cohort of premature babies in whom the use of intubation, ventilation, surfactant and inotropes is low, and the clinical outcomes describe a ‘well’ preterm population. The least ‘successful’ group for stabilization in this study were those born at 23–24 weeks gestation; from 25 weeks upwards, the stabilization was always successful. The authors report the belief that the use of HVNI at birth contributed to this clinical stability and conclude that preterm babies <30 weeks gestation can often be stabilized in the DR and transferred, in stable condition, to the NICU using heated humidified high-flow nasal cannula as demonstrated by the application of HVNI in this pilot study. 

There are several limitations noted for this study. This was a small pilot study designed to generate the hypothesis that using nHF for DR stabilization would be feasible. It was conducted in a single center with considerable expertise in using nHF in premature babies, potentially limiting its current generalizability. Deliveries were always attended by either an experienced neonatal registrar and/or a consultant, which may have contributed to the successful outcomes for the majority of babies. The strengths of the study are that it demonstrated that the use of nHF is feasible as measured by short-term outcomes, and the clinical protocol is easy to follow. 

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