Summary: Nasal high-flow therapy as primary respiratory support for preterm infants without the need for rescue with nasal continuous positive airway pressure, Neonatology.

Topic: Primary Support – NICU

Zivanovic S, Scrivens A, Panza R, et al, Nasal high-flow therapy as primary respiratory support for preterm infants without the need for rescue with nasal continuous positive airway pressure, Neonatology. 2019;115:175–181. doi: 10.1159/000492930. 

Zivanovic and colleagues conducted a retrospective analysis at two tertiary neonatal units in the United Kingdom (UK) analyzing the outcomes of 381 preterm infants who were stabilized with continuous positive airway pressure (CPAP) in the delivery room and then transitioned to High Velocity Nasal Insufflation (HVNI) for primary respiratory support. The authors concluded that HVNI provides effective primary respiratory support for premature neonates without use of nasal continuous positive airway pressure as “rescue” treatment.  

The analysis included infants with respiratory distress syndrome (RDS) born between 28+0 and 36+6 weeks gestational age (GA). The primary outcome was intubation rate within 72 hours of starting HVNI The recorded reasons for intubation were increased FiO2 (> 0.4), pH ≤7.2 and/or partial pressure of CO2 > 60 mm Hg, recurring episodes of apnea, urgent need for intubation and mechanical ventilation (MV), or clinician’s decision.  

Post-delivery stabilization, the neonates were started on HVNI with an initial flow rate of 6–7 L/min and FiO2 for targeting peripheral oxygen saturation 88–93%. Both flow rate and FiO2 were then adjusted accordingly. Targeted surfactant (200 mg/kg) was considered for neonates showing clinical signs of RDS. Intravenous caffeine citrate (20 mg/kg loading dose and maintenance dose of 10 mg/kg/day) was routinely commenced for prevention and treatment of apnea of prematurity in all neonates < 32 weeks within 4 h of birth and discontinued at 34 weeks corrected GA in the absence of ongoing apnea at both centers. There were no significant differences in intubation rates or other secondary outcomes, concluding that HVNI appears to have similar efficacy and safety as nCPAP when used as primary treatment of mild to moderate RDS. 

The findings are consistent with those of Lavizzari et al. who randomized 316 premature infants (29+0 to 36+6 weeks GA) to receive either HVNI of 4–6 L/min or nCPAP/bilevel nCPAP of 4–6 cm H2O1. Conversely, the study findings differ from those reported by Roberts et al., who found HFNC (Optiflow Junior, Fisher &Paykel) with the primary outcome of treatment failure within 72 hours to be not noninferior to CPAP because more infants in the nHFT group (71 of 278 infants [25.5%]) had reached the prespecified treatment failure criteria compared to the nCPAP group (38 of 286 infants [13.3%]) and therefore, as per protocol, were given “rescue” by nCPAP to prevent intubation2

The study noted several limitations. Due to the retrospective data collection, the authors were not able to explore the indications for intubation in the subgroup of intubated infants and were not able to compare the use of HVNI with other noninvasive ventilation (NIV) modes either. In addition, as the study describes outcomes in two centers that have been using HVNI without the use of nCPAP in this GA group for more than a decade, it is not possible to exclude bias of the nursing and medical staff towards this mode of NIV. The exclusive use of HVNI makes a center well versed in its use, and therefore it might not be possible to replicate these outcomes in a different center with, for instance, a long-standing history of nCPAP use. 

Zivanovic and colleague authors concluded that the “use of nHFT for primary respiratory support, without use of nasal continuous positive airway pressure as “rescue” treatment, resulted in intubation rates lower or comparable to published data from randomized controlled trials.” 

1.) Lavizzari A, Colnaghi M, Ciuffini F, et al. Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity: a randomized clinical noninferiority trial. JAMA Pediatr. 2016 Aug 8. doi: 10.1001/jamapediatrics.2016.1243. 
2.) Roberts, CT, et al. “Nasal high-flow therapy for primary respiratory support in preterm infants.” New England Journal of Medicine 375.12 (2016): 1142-1151. 

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