Elsevier

Clinics in Perinatology

Volume 46, Issue 3, September 2019, Pages 537-551
Clinics in Perinatology

Is Nasal High Flow Inferior to Continuous Positive Airway Pressure for Neonates?

https://doi.org/10.1016/j.clp.2019.05.005Get rights and content

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Key points

  • Evidence suggests that CPAP is superior to nasal high flow for initial noninvasive support of preterm infants with respiratory distress syndrome.

  • Nasal high flow is noninferior to CPAP for postextubation support of preterm infants ≥28 weeks’ gestation.

  • Limited data are available for nasal high flow use in extremely preterm infants born less than 28 weeks’ gestation, or term infants.

  • Compared with CPAP, nasal high flow use does not increase the risk of bronchopulmonary dysplasia in very preterm

Background

Rates of preterm birth are increasing,1 and many preterm infants require respiratory support. The ultimate goal of treatment is to maintain adequate gas exchange, while minimizing short- and long-term respiratory and neurodevelopmental sequelae. In 1971, Kitchen and Campbell2 published a landmark trial of neonatal intensive care, demonstrating that supportive care, including mechanical ventilation, of very low birth weight infants improved their chances of survival. This earliest phase of

Continuous positive airway pressure for primary respiratory support in preterm infants

Three large RCTs have examined the use of CPAP as an alternative to endotracheal intubation and mechanical ventilation in very preterm infants. In the COIN trial, 610 infants born 25 to 28 weeks’ gestation were randomized to CPAP or intubation and ventilation at 5 minutes of life.9 CPAP use did not significantly reduce the primary outcome of death or BPD at 36 weeks’ corrected gestation, compared with intubation. However, fewer infants randomized to CPAP received surfactant and these infants

The evidence for continuous positive airway pressure as postextubation support

Early and successful extubation from mechanical ventilation is important in limiting the risk of BPD. Use of CPAP following extubation improves the likelihood of extubation success,16 and is the most commonly used form of postextubation respiratory support for extremely preterm infants.17 There is also some evidence that higher set CPAP pressure (7–9 cm H2O vs 4–6 cm H2O) may further improve extubation success.18

Complications of continuous positive airway pressure

Although CPAP provides effective noninvasive respiratory support for preterm infants, the inherent difficulties of delivering CPAP, along with nursing and parental preferences, have led to the use of alternative noninvasive therapies, such as nHF.

Nasal trauma is a recognized complication of nasal CPAP use in preterm infants, with a reported incidence of 20% to 100%, depending on the classification system used and gestational age of the population studied.10 Several factors increase the risk of

The increased use of nasal high flow

nHF use is widespread and increasing. Surveys have found that 77% of level II and III centers in the United Kingdom22 and 89% of tertiary centers in Canada23 used nHF in some capacity. Practice varies considerably between units. Only half of the 57 units surveyed in a UK study had a written guideline or policy regarding nHF use.22 Unit approaches to choosing the nasal cannula size also varied, often contravening current recommendations. Manufacturers recommend a prong size approximately 50% of

Perceived benefits of nasal high flow

The increased use of nHF has been prompted by several perceived advantages of this modality over CPAP. Parents and nursing staff report a preference for nHF over CPAP, particularly for older and more stable preterm infants.13, 27 Reported perceived benefits include increased parent-child interaction, improved comfort, easier skin-to-skin care, and improved oral feeding.12, 22

The available evidence suggests that nHF causes less nasal trauma than CPAP. Most RCTs of nHF have reported nasal trauma

Statistical noninferiority

RCTs are generally conducted as superiority trials. However, when a new treatment has some benefits over the current standard treatment, a noninferiority trial may be used.33 When evaluating the primary outcome, if the efficacy of the new treatment falls within a margin of noninferiority, it is deemed to be no worse than the standard treatment. The perceived importance of the new treatment’s benefits must justify this noninferiority. If a margin of noninferiority is too large, then this

Death or Bronchopulmonary Dysplasia

Several trials have evaluated the incidence of death or BPD when nHF is used for primary respiratory support, compared with CPAP. A 2016 Cochrane Review pooled the available data regarding the effect of nHF use as primary respiratory support on death or BPD.34 Four published and unpublished trials with a total of 439 preterm infants were included. There was no difference found in the primary outcomes of death (typical RR, 0.36; 95% CI, 0.01–8.73) or BPD (typical RR, 2.07; 95% CI, 0.64–6.64).

What is next for nasal high flow and continuous positive airway pressure?

Several new applications of nHF and CPAP, and variations in the way they are used, show promise for improving noninvasive respiratory management of neonates. For CPAP, the use of neurally adjusted ventilatory assist (NAVA) and high-frequency nasal ventilation (HFNV) may broaden the applications of the modality. Future research questions for nHF include use during neonatal endotracheal intubation, for delivery room stabilization of preterm infants, using higher gas flows, and comparing

Summary

Evidence evaluating the use of nHF in newborn infants and neonates has accumulated over recent years. nHF therapy is a reasonable alternative to CPAP for postextubation support of infants greater than 28 weeks’ gestation. There is no difference in the rate of death and BPD, and nHF is noninferior to CPAP for preventing extubation failure, provided rescue CPAP is available. In contrast, CPAP is a superior therapy to nHF for primary support of RDS and for all indications in infants less than

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References (67)

  • G.C. Liggins et al.

    A controlled trial of antepartum glucocorticoid treatment for prevention of the respiratory distress syndrome in premature infants

    Pediatrics

    (1972)
  • J.D. Horbar et al.

    Decreasing mortality associated with the introduction of surfactant therapy

    Pediatrics

    (1993)
  • M.C. Walsh et al.

    Summary proceedings from the bronchopulmonary dysplasia group

    Pediatrics

    (2006)
  • L.M. Davidson et al.

    Bronchopulmonary dysplasia: chronic lung disease of infancy and long-term pulmonary outcomes

    J Clin Med

    (2017)
  • M.S. Dunn et al.

    Randomized trial comparing 3 approaches to the initial respiratory management of preterm neonates

    Pediatrics

    (2011)
  • N.N. Finer et al.

    Early CPAP versus surfactant in extremely preterm infants

    N Engl J Med

    (2010)
  • C.J. Morley et al.

    Nasal CPAP or intubation at birth for very preterm infants

    N Engl J Med

    (2008)
  • D.I. Imbulana et al.

    Nasal injury in preterm infants receiving non-invasive respiratory support: a systematic review

    Arch Dis Child Fetal Neonatal Ed

    (2018)
  • M. Osman et al.

    Assessment of pain during application of CPAP and high flow in preterm infants

    J Perinatol

    (2015)
  • C.T. Roberts et al.

    Nursing perceptions of high-flow nasal cannulae treatment for very preterm infants

    J Paediatr Child Health

    (2014)
  • C. Klingenberg et al.

    Patient comfort during treatment with heated humidified high flow nasal cannulae versus nasal continuous positive airway pressure: a randomised cross-over trial

    Arch Dis Child Fetal Neonatal Ed

    (2014)
  • G.M. Schmolzer et al.

    Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

    BMJ

    (2013)
  • Respiratory support in preterm infants at birth

    Pediatrics

    (2014)
  • V. Shah et al.

    Golden hour management practices for infants <32 weeks gestational age in Canada

    Paediatr Child Health

    (2018)
  • H. Al-Mandari et al.

    International survey on periextubation practices in extremely preterm infants

    Arch Dis Child Fetal Neonatal Ed

    (2015)
  • P.G. Davis et al.

    Nasal continuous positive airway pressure immediately after extubation for preventing morbidity in preterm infants

    Cochrane Database Syst Rev

    (2003)
  • B.J. Manley et al.

    High-flow nasal cannulae in very preterm infants after extubation

    N Engl J Med

    (2013)
  • S. Ojha et al.

    Use of heated humidified high-flow nasal cannula oxygen in neonates: a UK wide survey

    Acta Paediatr

    (2013)
  • A. Mukerji et al.

    Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units

    Acta Paediatr

    (2017)
  • C. Milesi

    High-flow nasal cannula

    Ann Intensive Care

    (2014)
  • E.M. Sivieri et al.

    Effect of HFNC flow rate, cannula size, and nares diameter on generated airway pressures: an in vitro study

    Pediatr Pulmonol

    (2013)
  • S. Shetty et al.

    High-flow nasal cannula oxygen and CPAP and full oral feeding in infants with BPD

    Arch Dis Child Fetal Neonatal Ed

    (2016)
  • S.J. Glackin et al.

    High flow nasal cannula versus NCPAP, duration to full oral feeds in preterm infants: a randomised controlled trial

    Arch Dis Child Fetal Neonatal Ed

    (2017)
  • Cited by (16)

    • Impact of early respiratory care for extremely preterm infants

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      Citation Excerpt :

      The 2016 Cochrane review comparing initial NIPPV with initial CPAP included some EP infants and found a significantly reduced risk of intubation (RR 0.78, 95% CI 0.64, 0.94) in infants receiving NIPPV, but no difference in the rate of BPD. Nasal high-flow (nHF) has been explored as an alternative to CPAP,49 however, there are almost no data regarding first line treatment for EP infants with nHF, and caution is recommended in this population. Despite the focus on non-invasive respiratory support, many EP infants still require mechanical ventilation, particularly those born <25 weeks’ gestation.50

    View all citing articles on Scopus

    Disclosure Statement: No conflicts of interest to disclose.

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