Original Article Neonatal Resuscitation Using a Nasal Cannula: A Single-Center Experience Pedro Paz, MD, MPH 1 Rangasamy Ramanathan, MD 1,2 Richard Hernandez, RCP 2 Manoj Biniwale, MD 1 1 Division of Neonatal Medicine, LAC þ USC Medical Center, Children s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California 2 Neonatal Respiratory Therapy Department, LAC þ USC Medical Center, Los Angeles, California Address for correspondence Manoj Biniwale, MD, LAC þ USC Medical Center, Keck School of Medicine of the University of Southern California, 1200 N. State Street, IRD Building, Room 820, Los Angeles, CA 90033 (e-mail: biniwale@usc.edu). Am J Perinatol Abstract Objective The aim of the study was to describe our experience using a modified nasal cannula to deliver nasal continuous positive airway pressure and/or nasal intermittent positive pressure ventilation during primary neonatal resuscitation of preterm and term newborns. Study Design Data were collected retrospectively for all neonates resuscitated with nasal cannula in the delivery room. The primary outcome was the number of newborns intubated in the delivery room. Secondary outcomes included need for chest compressions, intubations in the first 24 hours, air-leaks, and surfactant administration. Results A total of 102 infants were resuscitated using nasal cannula. Eight (7.8%) were Keywords neonatal resuscitation nasal cannula preterm NCPAP NIPPV Currently, there has been a trend toward early use of noninvasive ventilation, as lung injury is directly related to the duration of invasive ventilation via the endotracheal tube. 1,2 Although face mask has been shown to be mostly effective in providing continuous positive airway pressure (CPAP) and positive pressure ventilation (PPV) during neonatal resuscitation, significant airway obstructions and mask leaks have been reported during this procedure, which in turn may impact the delivery of effective positive pressure breaths in compromised newborn infants. 3,4 When compared with face mask ventilation, early use of nasal CPAP (NCPAP) in the delivery room has been shown to decrease the number of delivery room intubations. 5,6 Compared with NCPAP alone, the addition of ventilator-delivered peak inspiratory pressure (PIP) during nasal intermittent positive pressure ventilation intubated in the delivery room, five (4.9%) required chest compressions, and five (4.9%) had pneumothorax noted on chest X-ray. No deaths occurred in the delivery room. Twenty-eight patients (27.5%) received early rescue surfactant after admission to the neonatal intensive care unit. Conclusion Neonatal resuscitation can be effectively performed in preterm and term newborns using a modified nasal cannula in the delivery room. (NIPPV) has been used successfully to decrease the work of breathing in premature infants. 7,8 Recently, randomized controlled trials comparing face mask to nasal tube and single nasal prong, in infants born between 24 and 29 weeks gestation and < 31 weeks gestation, respectively, failed to show a difference in intubation rates in the delivery room. 9,10 Nasal cannula, in the form of binasal prongs, has been shown to be more effective than face mask for primary neonatal resuscitation of larger preterm and term infants. 11 The 2010 European Consensus Guidelines on the management of neonatal respiratory distress syndrome (RDS) in preterm infants has acknowledged nasal prongs as an alternative way of providing respiratory support in neonatal resuscitation. 12 Nevertheless, the routine use of nasal cannula in the delivery room has not been adopted, in part due to received December 10, 2013 accepted after revision January 6, 2014 Copyright by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. DOI http://dx.doi.org/ 10.1055/s-0034-1370350. ISSN 0735-1631.
limitations in the standard nasal cannula interfaces, such as high resistance and longer time constants. In addition, studies showing the efficacy of nasal cannula for the resuscitation of extremely low birth weight (ELBW, < 1,000 g birth weight) and very low birth weight (VLBW, < 1,500 g birth weight) infants are lacking. The purpose of this study was to describe our experience using a modified nasal cannula (Neotech RAM Cannula, Valencia, CA) to deliver NCPAP and/or NIPPV using a T-piece resuscitator, during primary neonatal resuscitation of preterm and term infants of different gestational ages. Materials and Methods Study Setting This retrospective study was performed at the LAC þ USC Medical Center. Institutional Review Board approval was obtained to review the records of all patients resuscitated with the nasal cannula in the delivery room. We have experience using nasal cannula for NCPAP and NIPPV in our neonatal intensive care units (NICUs) and we have presented results from our experience. 13 Our center also published the first randomized, controlled trial comparing NCPAP versus NIPPV using long nasopharyngeal prongs in 1999. 14 On the basis of our experience using the modified nasal cannula to deliver NCPAP and/or NIPPV in all four of our divisional NICUs, we began using the nasal cannula to provide neonatal resuscitation in the delivery room. We introduced this mode of resuscitation with the purpose of evaluating potentially better practice and outcomes. All patients resuscitated with a modified nasal cannula in the delivery room, between June 2011 and October 2012, were included in the study. This study period was based on the dates approved for review of the data by the Institutional Review Board. Patients who were resuscitated by any of the coauthors who had an affiliation with Neotech products were excluded from the final analysis. Resuscitation Protocol Using Nasal Cannula The 2011 American Academy of Pediatrics Neonatal Resuscitation Program (NRP) algorithm was followed except for the nasal interface used. 15 An integrated T-piece infant resuscitation system on a Panda Warmer (GE Healthcare, Fairfield, CT) was used to provide respiratory support. Initial settings were positive end expiratory pressure (PEEP) of 5 cm H 2 O, PIP of 20 cm H 2 O, FiO 2 of 0.30, and a flow rate of 10 L/min. After initial evaluation, patients with respiratory distress, apnea, hypopnea, or a heart rate of less than 100 beats per minute were given NCPAP through an appropriately sized nasal cannula based on estimated birth weight or gestational age. Positive pressure breaths were delivered at a rate of 40 to 60 breaths per minute to infants who had continued apnea or bradycardia after 30 seconds of adequate NCPAP. PIP was increased to a maximum of 30 cm H 2 O in infants with continued respiratory distress and poor response to resuscitation. PIP and FiO 2 were adjusted when needed, based on each patient s response (i.e., chest rise, changes in heart rate, or oxygen saturations). Flow rate was not adjusted during the resuscitation procedure. Decisions to intubate, start chest compressions, and the response to resuscitation were based on current NRP guidelines. 15 If there was no response, or poor response to the initial resuscitation with the nasal cannula such as low heart rate or oxygen saturation, the resuscitation team had the option to intubate or use a standard face mask interface as a rescue strategy. Once stabilized, patients were transported to the NICU while receiving NCPAP, NIPPV, or no respiratory support, unless intubated. Stable infants of more than 35 weeks gestational age were left with their mothers for bonding and normal transition per our unit guidelines. For patients with RDS, surfactant was administered using the INSURE (INtubation, SURfactant, Extubation) approach 16,17 upon admission to the NICU. A chest X-ray was obtained on all patients requiring any respiratory support upon admission to the NICU. Patients intubated in the delivery room were extubated to nasal cannula intermittent mandatory ventilation (NC-IMV) or NCPAP when deemed ready by the attending neonatologists or by the healthcare team. Data Collection Data were collected retrospectively using our neonatal database. Charts were reviewed and checked for any inconsistencies. The patient characteristics collected included birth weight, gestational age, and sex. The primary outcome was the number of patients intubated (including failed intubation attempts) in the delivery room. Intubation for suctioning of meconium only, in depressed infants, was not included unless the patients required reintubation due to failure of PPV. Secondary outcomes recorded included intubation during the first 24 hours after birth, number of patients requiring chest compressions in the delivery room, number of patients who developed pneumothorax or other air-leaks based on first admission chest X-ray, number of deaths in the delivery room, Apgar scores 7 at 5 minutes, and surfactant administration in the NICU. Patients who were intubated for surfactant administration alone were not included in the combined total, unless they remained intubated after surfactant administration. Results A total of 102 infants were resuscitated in the delivery room during the study period using the modified nasal cannula. The patient characteristics of the study subjects are summarized in Table 1. Patients who received NCPAP and NIPPV are shown in Table 2. Sixty-three (61.8%) patients were transported to the NICU while receiving PPV with the modified nasal cannula and T-piece resuscitator, after initial stabilization with either NCPAP or NIPPV in the delivery room. The number of intubations attempted in the delivery room and the total number of patients who were intubated in the first 24 hours after birth are shown in Table 2. Four of the eight patients who were intubated in the delivery room were extubated within 24 hours to NC-IMV or NCPAP. The other four patients who remained intubated were all ELBW infants who had significant respiratory distress, along with
Table 1 Characteristics of patients resuscitated with nasal cannula in the delivery room (n ¼ 102) Birth weight (g) Mean SD (range) 2,106 1,094 (270 4,675) < 1,000 g, n (%) 20 (19.6%) 1,001 1,500 g, n (%) 20 (19.6%) 1,501 2,000 g, n (%) 9 (8.8%) 2,001 2,500 g, n (%) 10 (9.8%) 2,501 3,000 g, n (%) 18 (17.6%) > 3,000 g, n (%) 25 (24.5%) Gestational age (wk) Mean SD (range) 32.8 5.3 (23 41) 28 wk, n (%) 29 (28.4%) 29 32 wk, n (%) 18 (17.6%) 33 36 wk, n (%) 22 (21.5%) 37 wk, n (%) 33 (32.4%) Sex female, n (%) 48 (47%) Table 2 Outcomes of patients resuscitated with nasal cannula in the delivery room (n ¼ 102) Apgar score at 5 7, n (%) 88 (86.2%) Stabilized with NCPAP, n (%) 29 (28.4%) Stabilized with NCPAP þ NIPPV, n (%) 73 (71.6%) Intubation attempt in delivery room, n (%) 11 (10.7%) Intubated by first 24 h, n (%) 13 (12.7%) Chest compressions, n (%) 5 (4.9%) Pneumothorax, n (%) 5 (4.9%) Deathindeliveryroom,n (%) 0 (0%) Abbreviations: NCPAP, nasal continuous positive airway pressure; NIPPV, nasal intermittent positive pressure ventilation. hemodynamic instability. There were also three (2.9%) failed intubations in the delivery room. All three infants who failed intubation in the delivery room were ELBW infants. These three patients were effectively stabilized using NIPPV via the nasal cannula in the delivery room, and were safely transferred to the NICU while receiving NIPPV. Twenty-eight patients (27.5%) received early rescue surfactant after admission to NICU. Five (4.9%) patients had pneumothorax noted on the first chest X-ray, obtained upon admission to the NICU. All of the patients who had pneumothorax were more than 35 weeks gestational age, and all the pneumothoraces were small and resolved spontaneously without any intervention. Five (4.9%) patients received chest compressions in the delivery room. Of the five patients who received chest compressions in the delivery room, two were secondary to bradycardia during intubation attempts, and the other three were born with severe perinatal depression at birth (all depressed infants had a 1 minute Apgar score of 1). Overall study population and immediate outcomes are shown in Fig. 1. Discussion This study describes a single-center s experience using a modified nasal cannula as a nasal interface for providing NCPAP or PPV during primary neonatal resuscitation of a varying range of infants, which included VLBW and ELBW infants. Previously, nasal cannula, in the form of a CPAP nasal prong device, was shown to be more effective than face mask in neonatal resuscitation, but the patients in that study were larger, with mean birth weight of 2,780 1,133 g. 11 The rate of intubation following initial resuscitation was 10.7% in the delivery room after NCPAP and/or NIPPV and a total intubation rate of 12.7% during the first 24 hours of life. None of the patients who were intubated in the delivery room had received NCPAP alone, and all the patients had received PPV via the nasal cannula before intubation. The study by Capasso et al reported an intubation rate of 0.6% for patients who were resuscitated with NCPAP prongs compared with 6.3% in the mask group; however, that study did not include sick ELBW or many VLBW infants. 11 Patients in our study who required intubation were predominantly ELBW and VLBW infants. Five (4.9%) patients had pneumothorax noted on the first chest X-ray, obtained within 2 hours of admission to the NICU. This is higher than the pneumothorax rate of 2.2% in the group using NCPAP prongs reported by Capasso et al. 11 We speculate that our pneumothorax rate could have been higher because we obtained chest X-rays on all infants admitted to the NICU for respiratory distress within the first 2 hours of life. Furthermore, all of the pneumothoraces reported were small incidental findings on chest X-ray, and all resolved spontaneously without intervention. Also, none of the ELBW and VLBW infants in our study developed pneumothorax after receiving NIPPV in the delivery room. It is difficult to discern whether these pneumothoraces were a direct result of using nasal cannula in the delivery room, from the initial ventilator support in the NICU, or from incidental spontaneous pneumothoraces. Five (4.9%) patients received chest compressions in the delivery room. The study by Capasso et al showed a rate of chest compressions in larger, less sick infants to be 1.6% in the NCPAP prong group and 8.28% in the face mask group. 11 In the study by McCarthy et al comparing single nasal prong with face mask, 1 and 7% of the infants who were < 31 weeks gestation needed chest compressions, respectively. 10 In two of our patients, chest compressions were performed after bradycardia from unsuccessful intubation attempts. In these two patients, intubation was attempted solely because of extreme prematurity with birth weights < 500 g, despite stable heart rate, respiratory effort, and oxygen saturation before intubation. The other three cases of bradycardia were in patients born with severe perinatal
Fig. 1 Distribution of measured outcomes based on birth weight for patients resuscitated with nasal cannula in the delivery room. NC, nasal cannula; BW, birth weight; g, grams; n, number. depression at birth, and thus were intubated before receiving adequate duration of CPAP or PPV. Therefore, in these patients, bradycardia was not secondary to a failure of nasal cannula resuscitation. Given the high failure rates reported with early NCPAP use in the delivery room needing intubation, 6,18 it has been our practice to begin NIPPV after initial stabilization in the delivery room for the patients with continued respiratory distress. As soon as patients are clinically stable, with improvement in heart rate and oxygen saturation, they are weaned to NCPAP and then to flow nasal cannula (< 2 L/min) using the same nasal interface. Our study design is different from that of Kirpalani et al. 19 In that study, there were two groups of infants at the time of randomization after admission to the NICU. The nonintubated group consisted of patients recruited within the first 7 days of life and were intubated for 24 hours. The second group included patients who were recruited in the first 28 days of life and were intubated for > 24 hours. Study centers were allowed to select any device (binasal prongs or mask) to deliver NCPAP and NIPPV after randomization. There was no difference in the primary outcome of bronchopulmonary dysplasia (BPD) or death in infants randomized to NIPPV (191 of 497; 38%) versus NCPAP (180 of 490; 37%). Our center recently reported in a multicenter randomized controlled trial that early surfactant administration (within 60 minutes of life) followed by extubation to NIPPV compared with extubation to NCPAP reduced the need for mechanical ventilation via the endotracheal tube at 7 days of age, and also decreased physiological or clinical BPD. 20 Limitations of our study include the retrospective collection of the data, the lack of a comparison group, lack of blinding the intervention, and the lack of in vivo measurements showing the pressure transmission to the hypopharynx from PPV delivered using the modified nasal cannula. We did not include all patients resuscitated in the delivery room during the study period because patients who received any form of face mask ventilation were excluded. This was done intentionally, as the intent of this study was to describe our experience using nasal cannula as a primary nasal interface for neonatal resuscitation, and inclusion of any face mask use would have potentially confounded the outcomes measured. We do acknowledge that this is a major limitation of our study. Although our study is the first to describe the use of a modified nasal cannula for the resuscitation of ELBW infants, we do acknowledge that our study included only a small number of patients in this category. Also, because of the potential conflicts of interest, we do acknowledge the potential for bias. However, Neotech products did not have any influence in the design of the study, data collection, or in our decision to submit the study for publication. Also, to further help minimize bias or potential conflict of interest, we did not include data on any patients who were resuscitated by any of the coauthors who had affiliations with Neotech products. In summary, this study describes a single-center experience using nasal cannula for the resuscitation of preterm and term infants of various gestational ages and disease states. This is the first study to describe the use of nasal cannula for the resuscitation of ELBW infants. Whether the Neotech RAM Cannula is a more effective, safer, and simpler interface than face mask for neonatal resuscitation remains to be determined, particularly in the ELBW and VLBW population in whom face mask leaks and airway obstructions are very common. Prospective, randomized controlled studies comparing nasal cannula to face mask for primary neonatal resuscitation of extremely preterm infants are needed to confirm or refute our study findings. Our group is currently designing a prospective, randomized controlled trial comparing the use of nasal cannula to face mask in the resuscitation of newborn infants 32 weeks gestation. Conflict of Interest Rangasamy Ramanathan, MD, has a licensing agreement with Neotech products. Richard Hernandez, RCP, serves as a consultant for Neotech products. Pedro Paz, MD, MPH, and Manoj Biniwale, MD, have no conflicts of interest to disclose. Neotech products did not have any influence in the design of the study, data collection, and or in our decision to submit the study for publication. References 1 De Paoli AG, Morley C, Davis PG. Nasal CPAP for neonates: what do we know in 2003? Arch Dis Child Fetal Neonatal Ed 2003;88(3): F168 F172
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