Thesis of care taking of prematures
Evidence basedclinicalpractice

• Prematures are the most heterogenic cohort of infant patients
• Individualized care
• References of minimally invasive procedures
• Comfort for patients together with parents

PPV and intubation in the delivery room
 

Respiratory support and intubation in the delivery roomGT 28+0 – 31+6 weeks

The effect of INTERFACE on the respiratory status and support of premature newborns in the delivery room

Respiratory support and surfactant on JIRP GT 28+0 – 31+6 weeks

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update


Recommendations
CPAP should be started from birth in all babies at risk of RDS, such as those <30 weeks' gestation who do not need intubation for stabilisation (A1).

CPAP with early rescue surfactant is considered optimal management for babies with RDS (A1).
During weaning, HFNC can be used as an alternative to CPAP for some babies with the advantage of less nasal trauma (B2).

Summary -  HFNC primary use 

• CPAP is superior of HFNC in RDS primary treatment in > 28 week infants
• HFNC fails in 25% (CPAP 15%) without previous surfactant administration  (FiO2 ≥   0.4) (HIPSTER and HUNTER trial. NEJM 2016, NEJM 2019)
• The use of  30/30 rule“  may reduce the risk of failure. Manley 2018
• No difference between CPAP and HFNC in primary use when surfactant is administered before filling of failure criteria.  Systematic review and Meta-analysis Fleeman N 2019, Hong H 2018 
• Pharyngeal pressures fluctuated and are significantly influenced by mouth position, flow and nares/prongs ratio. Liew Z et al 2019, Mazmanyan P 2020
• The data about the use of HFNC use in DR are limited. Reynolds P 2015

Pall Mall

• The clinical use of HFNC has been increasing. There is a great variety in use of HFNC: indications, flows, cannulas.   Eklund WM 2018
• Vapotherm HFNC generates higher level of noise (approx.>5-10 dB) than continuous flow CPAP (continuous flow) Konig K 2013
• HFNC is better tolerate by parents and nurse staff. Klingenberg C 2015
• Positive effect on GIT has been unclear.

  

• High VT delivery during mask PPV at birth was associated with brain injury. Strategies to limit VT delivery during mask PPV should be used to prevent high VT delivery. (Quaasim M 2019)

  

Summary:  HFNC 2-8l/min 

• The clinical use of HFNC has been increasing.
• HFNC can be use as a primary respiratory support of premature infants ≥ 28 weeks suffered from mild-moderate RDS.
• The rule 30/30 can decrease HFNC failure.
• Crossover to CPAP earlier is superior to later (FiO2 >0.35, flow 8l) 
• HFNC seems to be safe and effective respiratory support even in the delivery room however further investigation is required.