Early nasal continuous positive airway pressure versus INSURE in VLBW neonates

Saianda, Ana; Fernandes, Ricardo M.; Saldanha, Joana

doi:10.1016/S2173-5115(10)70077-4

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Abstract

Background

Evidence suggests the INSURE strategy (INtubate-SURfactant administration and Extubate to nasal continuous positive airway pressure [nCPAP]) is superior to mechanical ventilation (MV) with rescue surfactant for the management of respiratory distress syndrome (RDS) in very low birth weight (VLBW) neonates. There is limited data, however, to assess whether INSURE is superior to nCPAP alone. We aimed to compare these two strategies regarding early and late outcomes.

Methods

Retrospective cohort study from Jan/2002 to Aug/2008. We included VLBW neonateswith gestational age (GA) ≤ 30 weeks registered in the Vermont Oxford Network that used either nCPAP alone (nCPAP group, N=40), or with INSURE (INSURE group, N=56). We assessed early (RDS, need for rescue surfactant, and CPAP failure with MV) and late outcomes (chronic lung disease of prematurity (CLD), mortality, and composite outcome of mortality and/or CLD).

Results

Neonates in the INSURE group had lower mean GA, while other baseline variables were comparable. The proportion of RDS was significantly superior in the nCPAP group (53% vs. 30%; adjusted OR [95% CI] – 0.2 [0.1-0.6]). Therapeutic surfactant was administered to all cases with RDS in the nCPAP group, but to none from the INSURE group. MV was more frequently required in the nCPAP group (11/ 40, 28% vs. 9/ 56, 12%; p=0.04). No statistically significant differences were found in either of the late outcomes.

Conclusion

The use of nCPAP alone in VLBW neonates with GA ≤ 30 weeks may be associated with slightly poorer early outcomes than the INSURE strategy, but there were no significant differences in CLD or mortality.

Key-words:

Very low birth weight

nCPAP ventilation

INSURE

respiratory distress syndrome (newborn)

chronic lung disease of prematurity

mortality

Resumo

Introdução

Pretende-se determinar se a utilização do método INSURE em recém-nascidos de muito baixo peso, com idade gestacional (IG) ≤ 30 semanas se associa a menor morbilidade e mortalidade quando comparado com uso de nCPAP isolado.

Métodos

Estudo de coorte retrospectiva dos RNMBP nascidos num hospital de apoio perinatal diferenciado entre Janeiro/2002-Agosto/2008. Incluíram-se as crianças registadas na Vermont-Oxford Network com IG ≤30semanas e com uso de nCPAP logo após o nascimento (N=96). Estabeleceu-se Grupo nCPAP – uso de nCPAP isolado (N=40) e Grupo INSURE (N=56). Consideraram-se outcomes precoces: síndroma de dificuldade respiratória (SDR), necessidade de administrar surfactante com intuito terapêutico ou recurso a ventilação invasiva. Compararam-se igualmente outcomes tardios: doença pulmonar crónica da prematuridade (DPC), mortalidade e o outcome composto DPC-mortalidade.

Resultados

No grupo INSURE verificou-se menor IG, não se registando diferenças relativamente ao peso ao nascer e indução da maturação pulmonar. Verificou-se SDR em 21/40 (53%) casos do grupo nCPAP e em 17/56 (30%) casos do grupo INSURE (OR ajustado [IC 95%] – 0,2 [0,1-0,6]). No grupo nCPAP todos estes casos realizaram surfactante com intuito terapêutico, não tendo sido efectuada nenhuma dose adicional de surfactante no grupo INSURE. Verificou-se maior número de casos com necessidade de VI no grupo nCPAP do que no grupo INSURE (11/40, 28% vs 9/56, 12%). Não foram encontradas diferenças estatisticamente significativas relativamente aos outcomes tardios.

Conclusão

Em RNMBP com IG ≤30sem, o uso isolado de nCPAP poderá traduzir-se numa ligeira desvantagem em outcomes precoces, sem evidentes repercussões em termos de DPC ou mortalidade.

Palavras-chave:

Recém-nascido muito baixo peso

nCPAP

INSURE

sindroma de dificuldade respiratória neonatal

doença pulmonar crónica da prematuridade

mortalidade

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