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ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 102-105

Comparison of efficacy of nasal continuous positive airway pressure and heated humidified high-flow nasal cannula as a primary mode of respiratory support in preterm infants


Department of Paediatrics, Santokba Durlabhji Memorial Hospital, Jaipur, Rajasthan, India

Date of Web Publication25-Apr-2019

Correspondence Address:
Dr. Anil Kumar Poonia
Department of Paediatrics, Santokba Durlabhji Memorial Hospital, Jaipur - 302 002, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_116_18

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  Abstract 


Background: Nasal continuous positive airway pressure (NCPAP) is a well-recognized mode of noninvasive respiratory support (NIV) for newborns with respiratory distress. Evidence for the heated humidified high-flow nasal cannula (HHHFNC) as an alternative mode of respiratory support is scarce. The aim of this work was to evaluate whether HHHFNC is equally efficacious to NCPAP as providing primary respiratory support in the first 6 h of life for preterm neonates with respiratory distress. Methods: Preterm infants (gestation 26–34 weeks) with respiratory distress were randomized to either HHHFNC or NCPAP. The primary outcomes of the study were inferred in terms of total duration of NIV support (in hours) and total duration of oxygen supplementation (NIV + oxyhood/oxygen by nasal prongs) required. The secondary outcomes measured and compared between the two study groups were total time taken to reach full feeds; incidence and severity of nasal trauma; incidence of air leaks, bronchopulmonary dysplasia, patent ductus arteriosus, and retinopathy of prematurity. Results: The mean duration of NIV support in NCPAP and HHHFNC group was 69.1 ± 37.75 and 67.57 ± 45.48 h, respectively (P = 0.867). The mean durations of total oxygen supplementation in NCPAP and HHHFNC groups were 96.88 ± 100 and 83.73 ± 107 h, respectively (P = 0.062). The failure rate was similar in both the study groups (P = 1.000). Conclusions: We conclude from the present study that HHHFNC is equally efficacious to NCPAP as a primary mode of respiratory support for respiratory distress in preterm infants.

Keywords: Heated humidified high-flow nasal cannula, nasal continuous positive airway pressure, noninvasive ventilation, preterm, respiratory distress


How to cite this article:
Sharma PK, Poonia AK, Bansal RK. Comparison of efficacy of nasal continuous positive airway pressure and heated humidified high-flow nasal cannula as a primary mode of respiratory support in preterm infants. J Clin Neonatol 2019;8:102-5

How to cite this URL:
Sharma PK, Poonia AK, Bansal RK. Comparison of efficacy of nasal continuous positive airway pressure and heated humidified high-flow nasal cannula as a primary mode of respiratory support in preterm infants. J Clin Neonatol [serial online] 2019 [cited 2019 Jul 22];8:102-5. Available from: http://www.jcnonweb.com/text.asp?2019/8/2/102/257133




  Introduction Top


Among the various causes of neonatal intensive care unit (NICU) admission in infants, respiratory distress is the most common one.[1] Approximately 15% of term neonates and 34% of late preterm infants require NICU admission after birth due to significant respiratory problems; this is even higher for preterm infants born before 34 weeks of gestation.[2] Respiratory distress syndrome (RDS) is by far the most common cause of respiratory distress in preterm infants (50.8%), followed by transient tachypnea of the newborn (4.3%) and pneumonia/sepsis (1.9%).[3]

There has been an increased use of nasal continuous positive airway pressure (CPAP), and avoidance of intubation and mechanical ventilation due to its complications, as a primary mode of the treatment for respiratory distress in neonates.[4],[5]

However, the use of nasal CPAP (NCPAP) in neonates is also associated with some problems such as difficulty in maintaining the nasal prongs in the nostrils, difficulty in positioning the neonate, poor tolerance of the infant to the apparatus, and nasal trauma (ulceration, necrosis, and nasal vestibular stenosis).[6],[7]

To avoid these problems with NCPAP, a newer modality is being used in the NICUs across the world, the use of heated and humidified HFNC to provide positive pressure support in infants with respiratory distress.[8]

Thus, we conducted this randomized controlled trial to compare the efficacy between NCPAP and heated humidified high-flow nasal cannula (HHHFNC) as a primary mode of respiratory support in preterm infants with respiratory distress.


  Materials and Methods Top


We conducted a prospective, double-blinded, randomized controlled trial at a tertiary care hospital in Jaipur and enrolled total 100 infants in the study, randomly and equally divided into two groups, i.e., 50 infants in NCPAP group and 50 infants in HHHFNC group. Infants between 26 and 34 weeks of gestation, who developed mild-to-moderate respiratory distress within the first 6 h of birth and required noninvasive ventilation, were included in the study. Infants having <26 weeks and more than 34 weeks of gestational age, APGAR score <5 at 5 min, any nasopharyngeal pathology/associated surgical illness (e.g., cleft lip, cleft palate, and choanal atresia), any major congenital malformations, or congenital heart disease were excluded from the study.

After taking written consent from parents, enrolled infants were randomly assigned to either NCPAP or HHHFNC by simple randomization using computer-generated random numbers. The study was double-blinded; fixed and standard protocols for initiation, identification of intervention failure, and weaning of noninvasive respiratory support (NIV) support was used.

The primary outcomes of the study were inferred in terms of total duration of NIV support (in hours) and total duration of oxygen supplementation (NIV + oxyhood/oxygen by nasal prongs) required. The secondary outcomes measured and compared between the two study groups were total time taken to reach full feeds; incidence and severity of nasal trauma; incidence of air leaks, BPD, patent ductus arteriosus (PDA), and retinopathy of prematurity (ROP).

The enrolled infants who failed the primary NIV support during the study were excluded from the main study. However, data for NIV failure rate were analyzed separately for those infants who required mechanical ventilation within the first 72 h of initiation of NIV support. Med Calc 12.2.1.0 version software was used for all statistical calculations. Data on ratio and interval scale were summarized as mean and standard deviation and were analyzed using Chi-square test/Fischer's exact test. Ordinal scale variables were summarized as median and interquartile range and were analyzed by doing Mann–Whitney U-test. P < 0.05 was considered statistically significant.


  Results Top


During the study, a total of 126 preterm infants between 26 and 34 weeks of gestation were admitted to our NICU with mild-to-moderate respiratory distress within the first 6 h of birth. Of these, 26 infants met exclusion criteria and thus excluded out of the study. As shown in [Figure 1], a total of 100 infants were enrolled for the study and divided equally into two groups by randomization, i.e., 50 infants in NCPAP group and 50 infants in HHHFNC group.
Figure 1: Participants CONSORT flow diagram

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The baseline demographic characteristics of enrolled infants were similar between the two study groups in terms of gestational age, birth weight, gender, mode of delivery, risk of early-onset sepsis, antenatal steroids given to mother, resuscitation requirement at birth, and need for surfactant after birth [Table 1].
Table 1: Comparison of baseline characteristics between heated, humidified, high-flow nasal cannula, and nasal continuous positive airway pressure groups

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There was no statistically significant difference between the study groups when primary outcomes were measured and compared, i.e., total duration of NIV support (in hours) and total duration of supplemental oxygen required (in hours) were similar in both NCPAP and HHHFNC groups [Table 2].
Table 2: Comparison of primary outcomes between nasal continuous positive airway pressure and heated, humidified, high-flow nasal cannula group

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  Discussion Top


Respiratory distress is the most common cause of neonatal morbidity and mortality across the world, especially in preterm infants.[1],[2] There is now a concerted effort in many practices to avoid the use of prolonged invasive ventilator support when treating acute respiratory distress in preterm infants with early application of NCPAP either immediately after birth or following a brief period of intubation, mechanical ventilation, and dosing with surfactant.[4],[5]

An alternative to the use of NCPAP as a noninvasive modality for respiratory support in premature infants has been the recent introduction of HHHFNC devices in many units. Few studies have proved HHHFNC to be equally efficacious to NCPAP for respiratory support in preterm infants.[9],[10],[11],[12]

HHHFNC has many effects on respiratory mechanics, by which it improves clinical outcomes such as washout of anatomic dead space and improved gas mixing in large airways; heating and humidification of inhaled gas; high nasal inspiratory flow; generation of positive airway pressure that results in increased end-expiratory lung volume; and increased alveolar Po2.[13]

This study was designed to compare the efficacy between NCPAP and HHHFNC as a primary mode of respiratory support in preterm infants in view of total duration of NIV support required and total duration of oxygen support required. Other outcomes related to efficacy and safety such as failure rate, time taken to reach full feed, and complications such as incidence of nasal trauma, BPD, ROP, PDA, and air leak were also measured.

The mean duration of NIV support in NCPAP and HHHFNC group was 69.1 ± 37.75 and 67.57 ± 45.48 h, respectively. Although the duration of NIV support was lesser in HHHFNC group, the difference was not statistically significant between the two groups (P = 0.867). Therefore, both the modalities were equally efficacious in view of the duration of NIV support required. The similar result was obtained in the study by Hegde et al.[14] in which the mean duration of NIV support was 67.15 and 66.9 h in HHHFNC and NCPAP groups, respectively, and the difference was not statistically significant (P = 0.46) between the two groups.

Other primary outcome in our study was the total duration of oxygen supplementation (via NIV + oxyhood/simple nasal prongs) required in both the study groups. The mean durations of total oxygen supplementation in NCPAP and HHHFNC groups were 96.88 ± 100 and 83.73 ± 107 h, respectively. The total duration of oxygen supplementation was slightly less in HHHFNC group as compared to NCPAP group, but the difference was not statistically significant (P = 0.062). Therefore, in this study, both NCPAP and HHHFNC groups were found equally efficacious in view of total duration of oxygen support required. Similar results were obtained in the studies by Hegde et al.,[14] Yoder et al.,[15] and Kadiver et al.[16] where the mean durations of oxygen supplementation were similar in both the study groups with P = 0.62, 0.357, and 0.545, respectively.

Infants who failed the given NIV support within 72 h of initiating support were labeled as NIV failure in our study and were excluded out of the study. Seven (14%) infants out of total 50 infants enrolled to NCPAP by randomization failed the NIV support, while in HHHFNC group, 6 (12%) infants out of total 50 infants enrolled in group after randomization failed the given NIV support and needed mechanical ventilation. The failure rate was similar in both the study groups (P = 1.000). Thus, we found out that both NCPAP and HHHFNC groups were equally efficacious in view of NIV failure rate.

The overall incidence of nasal trauma was more in NCPAP group in comparison to HHHFNC group in our study. About 34.9% of infants in NCPAP group and 11.4% of infants in HHHFNC group had some form of nasal trauma (P = 0.019). Incidences of other complications such as PDA, BPD, ROP, and air leak were similar in both groups.


  Conclusion Top


We conclude from the present study that HHHFNC is equally efficacious to NCPAP as a primary mode of respiratory support for mild-to-moderate respiratory distress in preterm infants. Furthermore, HHHFNC is safer modality than NCPAP in terms of nasal trauma. Hence, HHHFNC can be used as a primary modality to treat preterm infants with mild-to-moderate respiratory distress.

Limitations of study

  1. The sample size was small in this study
  2. Some of the secondary outcomes such as incidence of sepsis, necrotizig enterocolitis (NEC), and intraventricular hemorrhage (IVH) were not measured.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Edwards MO, Kotecha SJ, Kotecha S. Respiratory distress of the term newborn infant. Paediatr Respir Rev 2013;14:29-36.  Back to cited text no. 1
    
2.
Consortium on Safe Labor, Hibbard JU, Wilkins I, Sun L, Gregory K, Haberman S, et al. Respiratory morbidity in late preterm births. JAMA 2010;304:419-25.  Back to cited text no. 2
    
3.
Jackson JC. Respiratory distress in the preterm infant. In: Gleason CA, Devaskar SU, editors. Avery's Diseases of the Newborn. 9th ed. Philadelphia: Elsevier Saunders; 2012. p. 633-46.  Back to cited text no. 3
    
4.
Diblasi RM. Neonatal noninvasive ventilation techniques: Do we really need to intubate? Respir Care 2011;56:1273-94.  Back to cited text no. 4
    
5.
Diblasi RM. Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant. Respir Care 2009;54:1209-35.  Back to cited text no. 5
    
6.
Bonner KM, Mainous RO. The nursing care of the infant receiving bubble CPAP therapy. Adv Neonatal Care 2008;8:78-95.  Back to cited text no. 6
    
7.
McCoskey L. Nursing care guidelines for prevention of nasal breakdown in neonates receiving nasal CPAP. Adv Neonatal Care 2008;8:116-24.  Back to cited text no. 7
    
8.
Mathai SS, Raju U, Kanitkar M. Management of respiratory distress in the newborn. Med J Armed Forces India 2007;63:269-72.  Back to cited text no. 8
    
9.
Manley BJ, Dold SK, Davis PG, Roehr CC. High-flow nasal cannulae for respiratory support of preterm infants: A review of the evidence. Neonatology 2012;102:300-8.  Back to cited text no. 9
    
10.
Wilkinson D, Anderson C, O'Donnell CP, De Paoli AG, Manley BJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 2011;5:CD006405.  Back to cited text no. 10
    
11.
Dani C, Pratesi S, Migliori C, Bertini G. High flow nasal cannula therapy as respiratory support in the preterm infant. Pediatr Pulmonol 2009;44:629-34.  Back to cited text no. 11
    
12.
Davis RP, Mychaliska GB. Neonatal pulmonary physiology. Semin Pediatr Surg 2013;22:179-84.  Back to cited text no. 12
    
13.
Goligher EC, Slutsky AS. Not just oxygen? mechanisms of benefit from high-flow nasal cannula in hypoxemic respiratory failure. Am J Respir Crit Care Med 2017;195:1128-31.  Back to cited text no. 13
    
14.
Hegde D, Mondkar J, Panchal H, Manerkar S, Jasani B, Kabra N. Heated Humidified High Flow Nasal Cannula versus Nasal Continuous Positive Airway Pressure as primary mode of respiratory support for respiratory distress in preterm infants. Indian Pediatr 2016;53:129-33.  Back to cited text no. 14
    
15.
Yoder BA, Stoddard RA, Li M, King J, Dirnberger DR, Abbasi S. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics 2013;131:1482-90.  Back to cited text no. 15
    
16.
Kadivar M, Mosayebi Z, Razi N, Nariman S, Sangsari R. High Flow Nasal Cannulae versus Nasal Continuous Positive Airway Pressure in Neonates with Respiratory Distress Syndrome Managed with INSURE Method: A Randomized Clinical Trial. Iran J Med Sci 2016;41:494-500.  Back to cited text no. 16
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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