Antonio G De Paoli

Minimally-invasive surfactant therapy in preterm infants on continuous positive airway pressure

Objective To evaluate the applicability and potential effectiveness of a technique of minimally-invasive surfactant therapy (MIST) in preterm infants on continuous positive airway pressure (CPAP). Methods An open feasibility study of MIST was conducted at two sites. Infants were eligible for MIST if needing CPAP pressure ≥7 cm H2O and FiO2 ≥0.3 (25–28 weeks gestation, n=38) or ≥0.35 (29–32 weeks, n=23). Without premedication, a narrow-bore catheter was inserted through the vocal cords under direct vision. Surfactant (100 or 200 mg/kg Curosurf) was then instilled, followed by reinstitution of CPAP. Outcomes were compared between surfactant-treated infants and historical controls achieving the same CPAP and FiO2 thresholds. Results Surfactant was successfully administered via MIST in all cases, with a rapid and sustained reduction in FiO2 thereafter. For infants at 25–28 weeks gestation, need for intubation <72 h was diminished after MIST compared with controls (32% vs 68%; OR 0.21, 95% CI 0.083 to 0.55), with a similar trend at 29–32 weeks (22% vs 45%; OR 0.34, 95% CI 0.11 to 1.1). Duration of ventilation and incidence of bronchopulmonary dysplasia were similar, but infants receiving MIST had a shorter duration of oxygen therapy. Conclusion Surfactant delivery via a narrow-bore tracheal catheter is feasible and potentially effective, and deserves further investigation in clinical trials.

Incidence and Outcome of CPAP Failure in Preterm Infants

BACKGROUND AND OBJECTIVES: Data from clinical trials support the use of continuous positive airway pressure (CPAP) for initial respiratory management in preterm infants, but there is concern regarding the potential failure of CPAP support. We aimed to examine the incidence and explore the outcomes of CPAP failure in Australian and New Zealand Neonatal Network data from 2007 to 2013. METHODS: Data from inborn preterm infants managed on CPAP from the outset were analyzed in 2 gestational age ranges (25–28 and 29–32 completed weeks). Outcomes after CPAP failure (need for intubation <72 hours) were compared with those succeeding on CPAP using adjusted odds ratios (AORs). RESULTS: Within the cohort of 19 103 infants, 11 684 were initially managed on CPAP. Failure of CPAP occurred in 863 (43%) of 1989 infants commencing on CPAP at 25–28 weeks’ gestation and 2061 (21%) of 9695 at 29–32 weeks. CPAP failure was associated with a substantially higher rate of pneumothorax, and a heightened risk of death, bronchopulmonary dysplasia (BPD) and other morbidities compared with those managed successfully on CPAP. The incidence of death or BPD was also increased: (25–28 weeks: 39% vs 20%, AOR 2.30, 99% confidence interval 1.71–3.10; 29–32 weeks: 12% vs 3.1%, AOR 3.62 [2.76–4.74]). The CPAP failure group had longer durations of respiratory support and hospitalization. CONCLUSIONS: CPAP failure in preterm infants is associated with increased risk of mortality and major morbidities, including BPD. Strategies to promote successful CPAP application should be pursued vigorously.

Cooling for Newborns with Hypoxic Ischemic Encephalopathy

adverse effects of cooling and ‘early’ indicators of neurodevelopmental outcome. Data Collection and Analysis: Four review authors independently selected, assessed the quality of and extracted data from the included studies. Study authors were contacted for further information. Meta-analyses were performed using risk ratios (RR) and risk differences (RD) for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals (CI). Main Results: We included 11 randomized controlled trials in this updated review, comprising 1,505 term and late preterm infants with moderate/severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age (typical RR 0.75 (95% CI 0.68–0.83); typical RD –0.15, 95% CI –0.20 to –0.10); number needed to treat for an additional beneficial outcome (NNTB) 7 (95% CI 5–10) (8 studies, 1,344 infants). Cooling also resulted in statistically significant reductions in mortality (typical RR 0.75 (95% CI 0.64–0.88), typical RD –0.09 (95% CI –0.13 to –0.04); NNTB 11 (95% CI 8–25) (11 studies, 1,468 infants) and in neurodevelopmental disability in survivors (typical RR 0.77 (95% CI 0.63–0.94), typical RD –0.13 (95% CI –0.19 to –0.07); NNTB 8 (95% CI 5–14) (8 studies, 917 infants). Some adverse effects of hypothermia included an increase sinus bradycardia and a significant increase in thrombocytopenia. Cochrane Abstract

Massive hepatic congenital haemangioma: Clinical dilemmas

Abstract:  A case of massive hepatomegaly secondary to a hepatic congenital haemangioma in a preterm neonate is described. This infant died after withdrawal of neonatal intensive care support, following massive intracerebral haemorrhage. There remains considerable uncertainty regarding the classification of, and therapy for, hepatic vascular anomalies.

Surfactant therapy via brief tracheal catheterization in preterm infants with or at risk of respiratory distress syndrome

This is the protocol for a review and there is no abstract. The objectives are as follows: In non-intubated preterm infants with, or at risk of, RDS to compare surfactant administration via brief tracheal catheterization with: continuation of non-invasive respiratory support (CPAP) or high flow nasal cannulae (HFNC) without surfactant administration; intubation and surfactant administration through an ETT with or without intent to remove the ETT immediately after the procedure; Additionally: to compare different methods of surfactant administration via brief tracheal catheterization with each other.

Metilxantina profiláctica para la prevención de la apnea en lactantes prematuros

Resumen Antecedentes La apnea recurrente es frecuente en lactantes prematuros. Estos episodios pueden llevar a la aparicion de hipoxemia y bradicardia, que pueden ser lo suficientemente graves como para necesitar el uso de ventilacion con presion positiva. En los lactantes con apnea, el tratamiento con metilxantina se ha usado de forma exitosa para prevenir episodios adicionales. Es posible que el tratamiento profilactico administrado a todos los lactantes muy prematuros poco despues del nacimiento prevenga la apnea y la necesidad de asistencia respiratoria adicional. Objetivos Determinar el efecto del tratamiento profilactico con metilxantina en la apnea, la bradicardia, los episodios de hipoxemia, el uso de ventilacion mecanica y la morbilidad en lactantes prematuros en riesgo de apnea del prematuro. Estrategia de busqueda La estrategia de busqueda estandar del Grupo de Revision de Neonatalogia (Neonatal Review Group) se actualizo en agosto 2010. Este procedimiento incluyo busquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials), la Oxford Database of Perinatal Trials, MEDLINE, CINAHL y EMBASE. Criterios de seleccion Se incluyeron todos los ensayos que utilizaban la asignacion aleatoria o cuasialeatoria de los pacientes y en los que se comparo la metilxantina profilactica (cafeina o teofilina) con placebo o ningun tratamiento en lactantes prematuros. Obtencion y analisis de los datos Se utilizaron los metodos estandar de la Colaboracion Cochrane (Cochrane Collaboration) y de su Grupo Cochrane de Neonatologia (Neonatal Review Group). Resultados principales Tres estudios fueron elegibles para su inclusion en la revision. Dos estudios pequenos (que asignaron al azar a un total de 104 lactantes) evaluaron el efecto de la cafeina profilactica sobre los resultados a corto plazo. No hubo diferencias significativas entre los grupos de cafeina y de placebo en el numero de lactantes con apnea, bradicardia, episodios de hipoxemia, uso de VPPI o efectos secundarios en ninguno de los estudios. Solo dos resultados (uso de VPPI y taquicardia) fueron comunes a los dos estudios y el metanalisis no mostro diferencias considerables entre los grupos. Un ensayo amplio del tratamiento con cafeina (CAP 2006), en un grupo heterogeneo de lactantes en riesgo de apnea del prematuro o que la padecian, demostro una mejoria en la tasa de supervivencia sin discapacidad evolutiva a los 18 a 21 meses de edad corregida. Los informes del subgrupo de lactantes tratados con cafeina profilactica no demostraron ninguna diferencia significativa en los resultados clinicos excepto por una disminucion en el riesgo de ligadura del CAP. Conclusiones de los autores Los resultados de esta revision no apoyan el uso de cafeina profilactica para los lactantes prematuros en riesgo de apnea. Cualquier estudio futuro necesita examinar los efectos de las metilxantinas profilacticas en los lactantes prematuros en alto riesgo de apnea. Este procedimiento debe incluir el examen de resultados clinicos importantes, como la necesidad de VPPI, la morbilidad neonatal, la duracion de la estancia hospitalaria y el desarrollo a largo plazo.