Mechanisms of nasal high flow on ventilation during wakefulness and sleep. Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies) Work of breathing using high-flow nasal cannula in preterm infants Early weaning from CPAP to high flow nasal cannula in preterm infants is associated with prolonged oxygen requirement: a randomized controlled trial. Patient comfort during treatment with heated humidified high flow nasal cannulae versus nasal continuous positive airway pressure: a randomised cross-over trial Early CPAP versus surfactant in extremely preterm infants. Nasal high-flow therapy delivers low level positive airway pressure High-flow nasal cannula and extubation success in the premature infant: a comparison of two modalities Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective, randomized, masked, crossover trial High-flow nasal cannulae in very preterm infants after extubation. Heated, Humidified High-Flow Nasal Cannula Versus Nasal CPAP for Respiratory Support in Neonates Nasal continuous positive airway pressure from high flow cannula versus Infant Flow for preterm infants A comparison of nasal trauma in preterm infants extubated to either heated humidified high-flow nasal cannulae or nasal continuous positive airway pressure Nasal trauma due to continuous positive airway pressure in neonates A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS. High-flow nasal cannulae in the management of apnea of prematurity: a comparison with conventional nasal continuous positive airway pressure. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. A trial comparing noninvasive ventilation strategies in preterm infants. Nursing perceptions of high-flow nasal cannulae treatment for very preterm infants. Respiratory mechanics during NCPAP and HHHFNC at equal distending pressures
Nasal high flow ( NHF ) has been shown to increase expiratory pressure and reduce respiratory rate but the mechanisms involved remain unclear . Ten healthy participants [ age , 22 ± 2 yr ; body mass index ( BMI ) , 24 ± 2 kg/m(2 ) ] were recruited to determine ventilatory responses to NHF of air at 37 ° C and fully saturated with water . We conducted a r and omized , controlled , cross-over study consisting of four separate ∼60-min visits , each 1 wk apart , to determine the effect of NHF on ventilation during wakefulness ( NHF at 0 , 15 , 30 , and 45 liters/min ) and sleep ( NHF at 0 , 15 , and 30 liters/min ) . In addition , a nasal cavity model was used to compare pressure/air-flow relationships of NHF and continuous positive airway pressure ( CPAP ) throughout simulated breathing . During wakefulness , NHF led to an increase in tidal volume from 0.7 ± 0.1 liter to 0.8 ± 0.2 , 1.0 ± 0.2 , and 1.3 ± 0.2 liters , and a reduction in respiratory rate ( fR ) from 16 ± 2 to 13 ± 3 , 10 ± 3 , and 8 ± 3 breaths/min ( baseline to 15 , 30 , and 45 liters/min NHF , respectively ; P < 0.01 ) . In contrast , during sleep , NHF led to a ∼20 % fall in minute ventilation due to a decrease in tidal volume and no change in fR. In the nasal cavity model , NHF increased expiratory but decreased inspiratory resistance depending on both the cannula size and the expiratory flow rate . The mechanisms of action for NHF differ from those of CPAP and are sleep/wake-state dependent . NHF may be utilized to increase tidal breathing during wakefulness and to relieve respiratory loads during sleep Objective To determine survival and neonatal morbidity for babies born between 22 and 26 weeks ’ gestation in Engl and during 2006 , and to evaluate changes in outcome since 1995 for babies born between 22 and 25 weeks ’ gestation . Design Prospect i ve national cohort studies . Setting Maternity and neonatal units in Engl and . Participants 3133 births between 22 and 26 weeks ’ gestation in 2006 ; 666 admissions to neonatal units in 1995 and 1115 in 2006 of babies born between 22 and 25 weeks ’ gestation . Main outcome measures Survival to discharge from hospital , pregnancy and delivery outcomes , infant morbidity until discharge . Results In 2006 , survival of live born babies was 2 % ( n=3 ) for those born at 22 weeks ’ gestation , 19 % ( n=66 ) at 23 weeks , 40 % ( n=178 ) at 24 weeks , 66 % ( n=346 ) at 25 weeks , and 77 % ( n=448 ) at 26 weeks ( P<0.001 ) . At discharge from hospital , 68 % ( n=705 ) of survivors had bronchopulmonary dysplasia ( receiving supplemental oxygen at 36 weeks postmenstrual age ) , 13 % ( n=135 ) had evidence of serious abnormality on cerebral ultrasonography , and 16 % ( n=166 ) had laser treatment for retinopathy of prematurity . For babies born between 22 and 25 weeks ’ gestation from March to December , the number of admissions for neonatal care increased by 44 % , from 666 in 1995 to 959 in 2006 . By 2006 adherence to evidence based practice associated with improved outcome had significantly increased . Survival increased from 40 % to 53 % ( P<0.001 ) overall and at each week of gestation : by 9.5 % ( confidence interval −0.1 % to 19 % ) at 23 weeks , 12 % ( 4 % to 20 % ) at 24 weeks , and 16 % ( 9 % to 23 % ) at 25 weeks . The proportions of babies surviving in 2006 with bronchopulmonary dysplasia , major cerebral scan abnormality , or weight and /or head circumference < −2 SD were similar to those in 1995 , but the proportion treated for retinopathy of prematurity had increased from 13 % to 22 % ( P=0.006 ) . Predictors of mortality and morbidity were similar in both cohorts . Conclusion Survival of babies born between 22 and 25 weeks ’ gestation has increased since 1995 but the pattern of major neonatal morbidity and the proportion of survivors affected are unchanged . These observations reflect an important increase in the number of preterm survivors at risk of later health problems Objective : To compare the work of breathing ( WOB ) in premature neonates supported with high-flow nasal cannula ( HFNC ) and nasal continuous positive airway pressure ( NCPAP ) . Study Design : Eighteen preterm neonates < 2.0 kg on HFNC or NCPAP support were studied in a r and om order . A ventilator was used to deliver 6 cm H2O of NCPAP with nasal prongs . High-flow nasal cannula delivered with Vapotherm ( VAPO ) at 3 , 4 and 5 l/min was used . Tidal ventilation was obtained using respiratory inductance plethysmography calibrated with face-mask pneumotachography . An esophageal balloon estimated pleural pressure from which changes in end distending pressure were calculated . Inspiratory , elastic and resistive WOB and respiratory parameters were calculated . Results : No differences were found in the WOB for all setting s. Changes in end distending pressure did not vary significantly over all device setting s except VAPO at 5 l/min . Conclusion : In these preterm infants with mild respiratory illness , HFNC provided support comparable to NCPAP OBJECTIVE To determine the better approach for weaning preterm infants from nasal continuous positive airway pressure ( NCPAP ) with or without transitioning to nasal cannula ( NC ) .  DESIGN / METHODS This is a r and omized , open label , controlled trial . Preterm infants born at ≥28 weeks gestation who were clinical ly stable on NCPAP of 5 cm H(2)O with FiO(2)<0.30 for at least 24 h were r and omly assigned to one of 2 groups . The no-NC group were kept on NCPAP until they were on FiO(2)=0.21 for 24 h , and then were weaned off NCPAP completely without any exposure to NC . If they met failing criteria , NCPAP was re-instituted . The NC-group was weaned off NCPAP when FiO(2 ) was ≤0.30 to NC ( 2 L/min ) followed by gradual weaning from oxygen . Infants who failed NC were supported back with NCPAP for 24 h before making a second attempt of NC . RESULTS Sixty neonates were enrolled ; 30 in each group . The two groups were similar in birthweight , gestational age , sex , antenatal steroids , mode of delivery , use of surfactant and xanthines , and duration of mechanical ventilation . After r and omization , the no-NC group had fewer days on oxygen [ median ( interquartile range ) : 5 ( 1 - 8 ) vs 14 ( 7.5 - 19.25 ) days , p<0.001 ] and shorter duration of respiratory support [ 10.5 ( 4 - 21 ) vs 18 ( 11.5 - 29 ) days , p=0.03 ] . There were no differences between groups regarding success of weaning  from NCPAP . CONCLUSIONS Weaning preterm infants  from NCPAP to NC is associated with increased exposure to oxygen and longer duration of respiratory support Objective To compare patient comfort in preterm infants treated with heated humidified high flow nasal cannulae ( HHHFNC )  versus nasal continuous positive airway pressure ( NCPAP ) . Design R and omised cross-over trial ( 2 × 24 h ) . Setting Single tertiary neonatal unit . Patients 20 infants less than 34 weeks postmenstrual age treated with NCPAP due to mild respiratory illness . Interventions After parental consent , infants were r and omised to 24 h of treatment with NCPAP or HHHFNC followed by 24 h of the alternate therapy . Main outcome measures Primary outcome was patient comfort assessed by the EDIN ( neonatal pain and discomfort ) scale . Secondary outcomes were respiratory parameters ( respiratory rate , FiO2 , SpO2 , TcPCO2 ) , ambient noise , salivary cortisol and parental assessment s of their child . Results We found no differences between HHHFNC and NCPAP  in mean cumulative EDIN score ( 10.7 vs 11.1 , p=0.25 ) or ambient noise ( 70 vs 74 dBa , p=0.18 ) . Parents assessed HHHFNC treatment as significantly better in the three domains , 1 ) child satisfied , 2 ) parental contact and interaction and 3 ) possibility to take part in care . Mean respiratory rate over 24 h was lower during HHHFNC than CPAP ( 41 vs 46 , p=0.001 ) . Other respiratory parameters were similar . Conclusions Using EDIN scale , we found no difference in patient comfort with HHHFNC versus NCPAP . However , parents preferred HHHFNC , and during HHHFNC respiratory rate was lower than during NCPAP . Clinical Trials.gov , number NCT01526226 BACKGROUND There are limited data to inform the choice between early treatment with continuous positive airway pressure ( CPAP ) and early surfactant treatment as the initial support for extremely-low-birth-weight infants . METHODS We performed a r and omized , multicenter trial , with a 2-by-2 factorial design , involving infants who were born between 24 weeks 0 days and 27 weeks 6 days of gestation . Infants were r and omly assigned to intubation and surfactant treatment ( within 1 hour after birth ) or to CPAP treatment initiated in the delivery room , with subsequent use of a protocol -driven limited ventilation strategy . Infants were also r and omly assigned to one of two target ranges of oxygen saturation . The primary outcome was death or bronchopulmonary dysplasia as defined by the requirement for supplemental oxygen at 36 weeks ( with an attempt at withdrawal of supplemental oxygen in neonates who were receiving less than 30 % oxygen ) . RESULTS A total of 1316 infants were enrolled in the study . The rates of the primary outcome did not differ significantly between the CPAP group and the surfactant group ( 47.8 % and 51.0 % , respectively ; relative risk with CPAP , 0.95 ; 95 % confidence interval [ CI ] , 0.85 to 1.05 ) after adjustment for gestational age , center , and familial clustering . The results were similar when bronchopulmonary dysplasia was defined according to the need for any supplemental oxygen at 36 weeks ( rates of primary outcome , 48.7 % and 54.1 % , respectively ; relative risk with CPAP , 0.91 ; 95 % CI , 0.83 to 1.01 ) . Infants who received CPAP treatment , as compared with infants who received surfactant treatment , less frequently required intubation or postnatal corticosteroids for bronchopulmonary dysplasia ( P<0.001 ) , required fewer days of mechanical ventilation ( P=0.03 ) , and were more likely to be alive and free from the need for mechanical ventilation by day 7 ( P=0.01 ) . The rates of other adverse neonatal outcomes did not differ significantly between the two groups . CONCLUSIONS The results of this study support consideration of CPAP as an alternative to intubation and surfactant in preterm infants . ( Clinical Trials.gov number , NCT00233324 . Background The aim of this prospect i ve study was to determine whether a level of positive airway pressure was generated in participants receiving nasal high flow ( NHF ) delivered by the Optiflow ™ system ( Fisher and Paykel Healthcare Ltd , Auckl and , New Zeal and ) in a cardiothoracic and vascular intensive care unit ( ICU ) . Methods Nasopharyngeal airway pressure was measured in 15 postoperative cardiac surgery adult patients who received both NHF and st and ard facemask therapy  at a flow rate of 35 litre min−1 . Measurements were repeated in the open mouth and closed mouth positions . Mean airway pressure was determined by averaging the pressures at the peak of inspiration of each breath within a 1 min period , allowing the entire pressure profile of each breath to be included within the calculation . Results Low level positive pressure was demonstrated with NHF at 35 litre min−1 with mouth closed when compared with a facemask . NHF generated a mean nasopharyngeal airway pressure of mean ( sd ) 2.7 ( 1.04 ) cm H2O with the mouth closed . Airway pressure was significantly higher when breathing with mouth closed compared with mouth open ( P≤0.0001 ) . Conclusions This study demonstrated that a low level of positive pressure was generated with NHF at 35 litre min−1 of gas flow . This is consistent with results obtained in healthy volunteers . Australian Clinical Trials Registry www.actr.org.au ACTRN012606000139572 Objective : To compare the effectiveness of Fisher and Paykel ( FP ) and Vapotherm ( VT ) high-flow nasal cannula ( HFNC ) in preventing reintubation either within 72 h or < 7 days after extubation of premature infants . The primary outcome was the rate of extubation failure defined as reintubation within 72 h. Secondary outcomes included reintubation after ⩽7 days . Study Design : This was a prospect i ve , r and omized pilot study comparing the extubation success of 40 infants born between 26 and 29 weeks of gestation . Result : The rate of extubation failure at 72 h was 18 % for FP and 9 % for VT . The failure rate ⩽7 days after extubation was 30 % for FP and 27 % for VT . None of these differences were statistically significant . Conclusion : There was no difference between FP and VT in the extubation success of infants born between 26 and 29 weeks Objective : We compared two methods of delivering high-flow gas therapy by nasal cannula , applied immediately after planned endotracheal extubations of NICU patients . Study design and methods : Thirty NICU patients who were about to be extubated from mechanical ventilation were r and omized into two groups ; Group 1 received Vapotherm ® for the first 24 h after extubation , then st and ard high-flow nasal cannula for the next 24 h , and Group 2 received st and ard high-flow therapy for the first 24 h , then Vapotherm ® for the next 24 h. At 24 h after extubation and again 48 h after extubation , a neonatologist who was not aware which modality the patient had been receiving examined the nasal mucosa and applied a scoring system . A research nurse who was unaware of the modality abstract ed respiratory rates and respiratory effort scores from a specific study -bedside record . The experimental design was such that a patient could ‘ fail ’ extubation either by reintubation for mechanical ventilation , or by rescue to the opposite modality before completing the 24-h test period . Results : Fifteen patients were r and omized to Group 1 and 15 to Group 2 . No differences were apparent between the groups in birth weight , gestational age , age at study entry , gender or underlying pulmonary disorder . Respiratory rates were similar while on Vapotherm ® ( 52±13 breaths/min , mean±s.d . ) and high-flow ( 54±14/min ) . At 24 h after starting the modality , those on Vapotherm ® had more normal examinations of the nasal mucosa ( 2.7±1.2 vs 7.8±1.7 , P<0.0005 ) and lower respiratory effort scores ( 1.2±0.6 vs 2.0±0.9 , P<0.05 ) than did those on high-flow . No patients failed while on Vapotherm ® , but seven failed while on high-flow ( two reintubations and five rescue switches to Vapotherm ® , P<0.005 ) . Conclusions : Among NICU patients immediately following extubation , Vapotherm ® performed better than a st and ard high-flow nasal cannula in maintaining a normal appearing nasal mucosa , a lower respiratory effort score , and averting reintubation BACKGROUND The use of high-flow nasal cannulae is an increasingly popular alternative to nasal continuous positive airway pressure ( CPAP ) for noninvasive respiratory support of very preterm infants ( gestational age , < 32 weeks ) after extubation . However , data on the efficacy or safety of such cannulae in this population are lacking . METHODS In this multicenter , r and omized , noninferiority trial , we assigned 303 very preterm infants to receive treatment with either  high-flow nasal cannulae ( 5 to 6 liters per minute ) or nasal CPAP ( 7 cm of water ) after extubation . The primary outcome was treatment failure within 7 days . Noninferiority was determined by calculating the absolute difference in the risk of the primary outcome ; the margin of noninferiority was 20 percentage points . Infants in whom treatment with high-flow nasal cannulae failed could be treated with nasal CPAP ; infants in whom nasal CPAP failed were reintubated . RESULTS The use of high-flow nasal cannulae was noninferior to the use of nasal CPAP , with treatment failure occurring in 52 of 152 infants ( 34.2 % ) in the nasal-cannulae group and in 39 of 151 infants ( 25.8 % ) in the CPAP group ( risk difference , 8.4 percentage points ; 95 % confidence interval , -1.9 to 18.7 ) . Almost half the infants in whom treatment with high-flow nasal cannulae failed were successfully treated with CPAP without reintubation . The incidence of nasal trauma was significantly lower in the nasal-cannulae group than in the CPAP group ( P=0.01 ) , but there were no significant differences in rates of serious adverse events or other complications . CONCLUSIONS Although the result for the primary outcome was close to the margin of noninferiority , the efficacy of high-flow nasal cannulae was similar to that of CPAP as respiratory support for very preterm infants after extubation . ( Funded by the National Health and Medical Research Council ; Australian New Zeal and Clinical Trials Network number , ACTRN12610000166077 . ) BACKGROUND AND OBJECTIVE : Heated , humidified high-flow nasal cannula ( HHHFNC ) is commonly used as a noninvasive mode of respiratory support in the NICU . The safety and efficacy of HHHFNC have not been compared with other modes of noninvasive support in large r and omized trials . The objective was to assess the efficacy and safety of HHHFNC compared with nasal continuous positive airway pressure ( nCPAP ) for noninvasive respiratory support in the NICU . METHODS : R and omized , controlled , unblinded noncrossover trial in 432 infants ranging from 28 to 42 weeks ’ gestational age with planned nCPAP support , as either primary therapy or postextubation . The primary outcome was defined as a need for intubation within 72 hours of applied noninvasive therapy . RESULTS : There was no difference in early failure for HHHFNC ( 23/212 [ 10.8 % ] ) versus nCPAP ( 18/220 [ 8.2 % ] ; P = .344 ) , subsequent need for any intubation ( 32/212 [ 15.1 % ] vs 25/220 [ 11.4 % ] ; P = .252 ) , or in any of several adverse outcomes analyzed , including air leak . HHHFNC infants remained on the study mode significantly longer than nCPAP infants ( median : 4 vs 2 days , respectively ; P < .01 ) , but there were no differences between study groups for days on supplemental oxygen ( median : 10 vs 8 days ) , bronchopulmonary dysplasia ( 20 % vs 16 % ) , or discharge from the hospital on oxygen ( 19 % vs 18 % ) . CONCLUSIONS : Among infants ≥28 weeks ’ gestational age , HHHFNC appears to have similar efficacy and safety to nCPAP when applied immediately postextubation or early as initial noninvasive support for respiratory dysfunction Objective : To compare the feasibility of continuous positive airway pressure ( CPAP ) support generated by high flow nasal cannula with conventional CPAP for prevention of reintubation among preterm infants with a birth weight of ⩽1250 g. Study Design : Preterm infants were r and omized to CPAP generated via high flow cannula or the Infant Flow Nasal CPAP System  ( VIASYS , Conshohocken , PA , USA ) at extubation . Primary outcome was incidence of reintubation within 7 days . Secondary outcomes included change in oxygen use and frequency of apnea and bradycardias postextubation . Results : Forty neonates were r and omized . Twelve of 20 infants r and omized to high flow cannula CPAP  were reintubated compared to three of 20 using Infant Flow ( P=0.003 ) . The high flow cannula group had increased oxygen use and more apneas and bradycardias postextubation . Conclusions : CPAP delivered by high flow nasal cannula failed to maintain extubation status among preterm infants ⩽1250 g as effectively as Infant Flow CPAP The objectives of this study were ( 1 ) to devise a nasal trauma score for preterm infants receiving non-invasive respiratory support , ( 2 ) to compare the incidence of nasal trauma in preterm infants < 32 weeks gestation r and omised to either nasal continuous positive airway pressure ( NCPAP ) or heated humidified high-Flow nasal cannulae ( HHHFNC )  , in the first 7 days post-extubation and ( 3 ) to assess the effect of two different nasal dressings in those assigned to NCPAP . We r and omly assigned preterm ventilated infants to receive Vapotherm ® HHHFNC or NCPAP post-extubation . Infants receiving HHHFNC were treated with Sticky Whiskers ® and infants receiving NCPAP received either Sticky Whiskers ® or Cannualaide ® nasal dressings . Bedside nursing staff scored six sites on each infant ’s nose for erythema , bleeding or ulceration . Scores were recorded three times daily for the first 7 days post-extubation . The sum of these 21 scores was used as the summary measure of nasal trauma . The mean nasal trauma score for infants assigned HHHFNC was 2.8 ( SD 5.7 ) compared to 11.7 for NCPAP ( SD 10.4 ) , p < 0.001 . There was no difference in mean trauma score between infants on NCPAP assigned Sticky Whiskers ® 14.4 ( SD 12.5 ) or Cannualaide ® 9.5 ( SD 7.3 ) , p = 0.06 . Conclusion : HHHFNC result ed in significantly less nasal trauma in the first 7 days post-extubation than NCPAP and was most significant in infants < 28 weeks of gestation . The use of protective dressings was not associated with decreased nasal trauma for infants on NCPAP Objective To evaluate the incidence and severity of nasal trauma secondary to nasal continuous positive airway pressure ( nCPAP ) in neonates . Design Prospect i ve observational study . Setting Neonatal intensive care unit ( NICU ) of the University Hospital of Lausanne , Switzerl and . Patients All neonates admitted between January 2002 and December 2007 treated by nCPAP were eligible . Methods Patients ' noses were monitored during nCPAP .  Nasal trauma was reported into three stages : ( I ) persistent erythema ; ( II ) superficial ulceration ; and ( III ) necrosis . Results 989 neonates were enrolled . Mean gestational age was 34 weeks ( SD 4 ) , mean birth weight 2142 g ( SD 840 ) . Nasal trauma was reported in 420 ( 42.5 % ) patients and it was of stage I , II and III in 371 ( 88.3 % ) , 46 ( 11 % ) and 3 ( 0.7 % ) patients , respectively . Incidence and severity of trauma were inversely correlated with gestational age and birth weight . The risk of nasal trauma was greater in neonates < 32 weeks of gestational age ( OR 2.48 , 95 % CI 1.59 to 3.86 ) , weighing < 1500 g at birth ( OR 2.28 , 95 % CI 1.43 to 3.64 ) , treated > 5 days by nCPAP ( OR 5.36 , 95 % CI 3.82 to 7.52 ) , or staying > 14 days in the NICU ( OR 1.67 , 95 % CI 1.22 to 2.28 ) . Most cases of nasal trauma ( 90 % ) appeared during the first 6 days of nCPAP . Persistent visible scars were present in two cases . Conclusions Nasal trauma is a frequent complication of nCPAP , especially in preterm neonates , but long-term cosmetic sequelae are very rare . This study provides a description of nasal trauma and proposes a simple staging system . This could serve as a basis to develop strategies of prevention and treatment of this iatrogenic event OBJECTIVE To compare the requirement for endotracheal ventilation  in preterm infants treated with heated , humidified high-flow nasal cannula ( HHHFNC )  with those treated with nasal intermittent positive pressure ventilation ( NIPPV ) for the primary treatment of respiratory distress syndrome ( RDS ) . STUDY DESIGN R and omized , controlled , prospect i ve , single-center pilot study . Infants ( gestational age [ GA ] < 35 weeks , birth weight [ BW ] > 1,000 g ) with RDS were r and omly assigned to receive  HHHFNC ( 38 infants ) delivered by Vapotherm ® device ( Precision Flow ™ or 2000 i , Vapotherm Inc. , Stevensville , MD ) , at flows between 1.0 and 5.0 L/min , or NIPPV ( 38 infants ) delivered by the SLE 2000 or 5000 . Surfactant was administered as rescue therapy . Analysis was done by intention-to-treat . RESULTS Infant 's characteristics ( [ mean ± SD ] GA 31.8 ± 2.3 vs. 32.0 ± 2.3 weeks )  and cardio-respiratory status at study entry ( FiO2 0.25 ± 0.05 vs. 0.26 ± 0.07 ; SpO2 90 ± 6 % vs. 87 ± 12 ; PCO2 54.4 ± 10.4 vs. 52.6 ± 8.0 mmHg ) were comparable for the HHHFNC and NIPPV groups . There was no significant difference in the need for endotracheal ventilation ( 28.9 % vs. 34.2 % ) between HHHFNC and NIPPV groups . One infant failed HHHFNC and succeeded on NIPPV . The rate of neonatal morbidities ( pneumothorax , bronchopulmonary dysplasia , intra-ventricular hemorrhage , necrotizing enterocolitis , patent ductus arteriosus , and nasal trauma ) was comparable in both groups . Duration of nasal support was longer with HHHFNC compared with NIPPV ( 5.4 ± 4.0 vs. 2.6 ± 1.9 days , P = 0.006 ) but the duration of endotracheal ventilation , time to full feeds , and length of stay were comparable . CONCLUSIONS Our pilot study suggests that HHHFNC maybe as effective as NIPPV in preventing endotracheal ventilation in the primary treatment of RDS in premature infants ( < 35 weeks GA and BW > 1,000 g ) Apnea of prematurity ( AOP ) is frequently managed with nasal continuous positive airway pressure ( NCPAP ) . Nasal cannula ( NC ) are used at low flows ( < 0.5 L/min ) to deliver supplemental oxygen to neonates . A number of centers use high-flow nasal cannula ( HFNC ) in the management of AOP without measuring the positive distending pressure ( PDP ) generated . Objective . To determine the NC flow required to generate PDP equal to that provided by NCPAP at 6 cm H(2)O and to assess the effectiveness of  HFNC as compared NCPAP in the management of AOP . Method . Forty premature infants , gestation 28.7 + /- 0.4 weeks ( mean + /- st and ard error of mean ) , postconceptual age at study 30.3 + /- 0.6 weeks , birth weight 1256 + /- 66 g , study weight 1260 + /- 63 g who were being managed with conventional NCPAP for at least 24 hours for clinical ly significant apnea of prematurity , were enrolled in a trial of ventilator-generated conventional NCPAP versus infant NC at flows of up to 2.5 L/min . End expiratory esophageal pressure was measured on NCPAP and on NC , and the gas flow on NC was adjusted to generate an end expiratory esophageal pressure equal to that measured on NCPAP . Two 6-hour periods were continuously recorded and the data were stored on computer . Results . The flow required to generate a comparable PDP with NC varied with the infant 's weight and was represented by the equation : flow ( L/min ) = 0.92 + 0.68x , x = weight in kg , R = 0.72 . There was no difference in the frequency and duration of apnea , bradycardia or desaturation per recording between the 2 systems . Conclusion . NC at flows of 1 to 2.5 L/min can deliver PDP in premature neonates . HFNC is as effective as NCPAP in the management of AOP OBJECTIVE To determine whether postextubation respiratory support via heated , humidified , high-flow nasal cannulae ( HHHFNC ) results in a greater proportion of infants younger than 32 weeks ' gestation being successfully extubated after a period of endotracheal positive pressure ventilation compared with conventional nasal continuous positive airway pressure ( NCPAP ) . STUDY DESIGN We r and omly assigned preterm ventilated infants to Vapotherm HHHFNC or NCPAP after extubation . The primary outcome , extubation failure , was defined by prespecified failure criteria in the 7 days after extubation . RESULTS A total of 132 ventilated infants younger than 32 weeks ' gestation were r and omized to receive either HHHFNC ( n = 67 ) or NCPAP ( n = 65 ) . Extubation failure occurred in 15 ( 22 % ) of the HHHFNC group compared with 22 ( 34 % ) of the NCPAP group . There was no difference in the number of infants reintubated in the first week . Treatment with HHHFNC reduced the nasal trauma score 3.1 ( SD 7.2 ) versus NCPAP 11.8 ( SD 10.7 ) , P < .001 . CONCLUSIONS HHHFNC and NCPAP produced similar rates of extubation failure BACKGROUND To reduce the risk of bronchopulmonary dysplasia in extremely-low-birth-weight infants , clinicians attempt to minimize the use of endotracheal intubation by the early introduction of less invasive forms of positive airway pressure . METHODS We r and omly assigned 1009 infants with a birth weight of less than 1000 g and a gestational age of less than 30 weeks to one of two forms of noninvasive respiratory support -- nasal intermittent positive-pressure ventilation ( IPPV ) or nasal continuous positive airway pressure (CPAP)--at the time of the first use of noninvasive respiratory support during the first 28 days of life . The primary outcome was death before 36 weeks of postmenstrual age or survival with bronchopulmonary dysplasia . RESULTS Of the 497 infants assigned to nasal IPPV for whom adequate data were available , 191 died or survived with bronchopulmonary dysplasia ( 38.4 % ) , as compared with 180 of 490 infants assigned to nasal CPAP ( 36.7 % ) ( adjusted odds ratio , 1.09 ; 95 % confidence interval , 0.83 to 1.43 ; P=0.56 ) . The frequencies of air leaks and necrotizing enterocolitis , the duration of respiratory support , and the time to full feedings did not differ significantly between treatment groups . CONCLUSIONS Among extremely-low-birth-weight infants , the rate of survival to 36 weeks of postmenstrual age without bronchopulmonary dysplasia did not differ significantly after noninvasive respiratory support with nasal IPPV as compared with nasal CPAP . ( Funded by the Canadian Institutes of Health Research ; NIPPV Clinical Trials.gov number , NCT00433212 ; Controlled-Trials.com number , IS RCT N15233270 . ) AIM This study aims to assess nursing perceptions of high-flow nasal cannulae ( HFNC ) in comparison with nasal continuous positive airway pressure ( NCPAP ) as post-extubation respiratory support for very preterm infants . METHODS A st and ardised question naire form was distributed in person to nursing staff in The Royal Women 's Hospital neonatal unit , where HFNC had been recently introduced in the context of a clinical trial . Nursing staff were eligible to participate if they routinely cared for infants receiving respiratory support . RESULTS The survey was completed by 99/144 eligible nurses . The majority of the 99 nurses surveyed felt that HFNC was less likely than NCPAP to prevent re-intubation of infants 24 - 26 weeks ' gestation but equally likely to prevent re-intubation of infants 28 - 30 weeks ' gestation . Nurses preferred NCPAP for post-extubation support of 24- and 26-week infants , and HFNC for 28- and 30-week infants , despite being less experienced with HFNC . Perceptions of HFNC compared with NCPAP included increased ease-of-use , improved infant comfort and reduced nasal trauma . CONCLUSIONS Neonatal nurses preferred NCPAP for post-extubation support of infants < 28 weeks ' gestation and HFNC for infants of 28 or 30 weeks ' gestation . Nurses accurately predicted varying efficacy of HFNC across different gestational ages , consistent with the findings of a contemporaneous r and omised trial . In the context of clinical non-inferiority , as shown in the r and omised trial , nursing preference for HFNC over NCPAP in preterm infants ≥28 weeks ' gestation supports the use of HFNC as post-extubation support in this population Objective To compare the effect of heated , humidified , high-flow nasal cannula ( HHHFNC ) and nasal continuous positive airways pressure ( NCPAP ) on lung function and mechanics in preterm infants with respiratory distress syndrome ( RDS ) at the same level of retropharyngeal pressure ( Prp ) . Design R and omised crossover trial . Setting Neonatal intensive care unit , Ospedale Maggiore Policlinico , Milan , Italy . Patients 20 preterm infants ( gestational age : 31±1 wks ) with mild-moderate RDS requiring non-invasive respiratory support within 96 h after birth . Interventions Infants were exposed to a r and omised sequence of NCPAP and HHHFNC at different setting s ( 2 , 4 and 6 cmH2O for NCPAP and 2 , 4 , 6 L/min for HHHFNC ) to enable comparison at the same level of Prp . Main outcome measures Tidal volume by respiratory inductance plethysmography , pleural pressure estimated by oesophageal pressure , and gas exchange were evaluated at each setting and used to compute breathing pattern parameters , lung mechanics and work of breathing ( WOB ) . Results A poor linear regression between flow and Prp was found during HHHFNC ( Prp=0.3 + 0.7*flow ; r2=0.37 ) . Only in 15 out of 20 infants it was possible to compare HHHFNC and NCPAP at a Prp of 2 and 4 cmH2O . No statistically significant differences were found in breathing pattern , gas exchange , lung mechanics and total WOB . Resistive WOB in the upper airways was slightly but significantly higher during HHHFNC ( 0.65 ( 0.49;1.09 ) vs 1.57 ( 0.85;2.09 ) cmH2O median ( IQR ) ) . Conclusions Despite differing mechanisms for generating positive airway pressure , when compared at the same Prp , NCPAP and HHHFNC provide similar effects on all the outcomes explored
BACKGROUND AND OBJECTIVE : High-flow therapy is the most recent , and popular , mode of respiratory support in neonates .
However , the evidence supporting its efficacy and safety has not yet been established .
We conducted a systematic review and meta- analysis of clinical trials comparing efficacy and safety of high-flow therapy compared with other modes of noninvasive ventilation ( NIV ) in preterm infants .