| dc.description.abstract | Optimizing non-invasive respiratory support for preterm infants
Optimizing non-invasive breathing support for preterm infants with respiratory distress syndrome (RDS) includes different treatment strategies and perspectives: Understanding the breathing effort and pattern, how to recognize respiratory distress, what respiratory support to choose and the technologies behind the ventilation mode, managing the interface, facilitating breastfeeding and comfort, optimizing growth and development, and bonding with the parents. In the care for preterm infants suffering from respiratory distress a focus on the here and now situation is needed, but also having in mind that the immature lungs easily can be damaged affecting the childhood and adult life with health-related problems and rehospitalizations.
RDS is one of the leading complications after preterm birth and is caused by surfactant deficiency and complex mechanisms of alveolar perfusion and ventilation. The disease occurs gradually the first 24 hours of life, leading to atelectasis, hypoxia and increased work of breathing. Some of the preterm infants need installation of surfactant to open the folded alveolus to overcome ventilation, while others remain with the need of continuous positive airway pressure (CPAP) and supplemental oxygen. The most immature preterm infants are at risk of respiratory insufficiency and the need for mechanical ventilation (MV). The period after stabilization and recovery from RDS can last for days, weeks or even months and there is a transition in the diagnosis of prolonged RDS and evolving chronic lung disease. From the minute the preterm infant is born, and during the stay at the neonatal intensive care unit (NICU), there is a need of various breathing modes in the adaption of the fetal transition to the life outside the womb and to support the child’s own capacity to breathe. There is international consensus to avoid invasive MV as much as possible and the recommendations for spontaneously breathing preterm infants are non-invasive modes of respiratory support.
The overall aim of this PhD project is to optimize lung protective breathing support to preterm infants with RDS. In order to reach this aim, the project comprises two single centered randomized crossover studies comparing two new non-invasive breathing support systems with standard care, and one multicenter reliability study testing a long-lasting clinical measure of respiratory distress in preterm infants.
There has been an increasingly use of high flow nasal cannula (HFNC) in preterm infants over the last 10 years in NICUs in high-income countries. CPAP has several known side effects associated with stress, pain and discomfort. HFNC is accepted as more comfortable than CPAP. The simpler interface shows reduction the incidence of nasal damage, and makes interaction with the caregivers and breastfeeding easier. In the first study, we compared CPAP and HFNC in the weaning period from CPAP. We found that there was no significant difference in diaphragm activity, respiratory vital signs and clinical scoring of respiratory distress comparing the two methods. We concluded that HFNC could replace CPAP in the weaning period from respiratory support.
Recognizing respiratory distress in preterm infants and grading the severity is important to respond with the right intervention. In the second study, we aimed to test the Silverman and Andersen index (SA index) among neonatologists and nurses in three hospitals in Norway when applied to preterm infants on various types of breathing support. We found poor interrater reliability; good intra-rater reliability and that SA index had a moderate correlation with the inspiratory diaphragm activity. In this study, we concluded that formal training measuring the fidelity of training might improve inter-rater reliability.
There is consensus to avoid MV, but the failure rates from CPAP is high with the need of MV in the most immature preterm infants. Non-invasive intermittent positive pressure ventilation is a step-up from CPAP and might be beneficial to reduce the need of MV. The importance of synchronization with the infants’ irregular breathing pattern is established, but challenging due to suboptimal technical devices. Non-invasive neurally adjusted ventilatory assist (NIV NAVA) has the potential to overcome the challenges of non-synchronized pressure transmission to the vulnerable lungs in preterm infants. The third study compared NIV NAVA and CPAP for preterm infants with prolonged respiratory insufficiency. In this study the parents were also invited to report their child‘s breathing effort and comfort comparing the two methods. We concluded that NIV NAVA improved the work of breathing and comfort compared to CPAP in preterm infants. | en_US |
