The use of low flow nasal prongs therapy versus self ventilation in weaning neonates from nasal continuous positive airway pressure (NCPAP). The NOFLO trial

Background: Acute cardiogenic pulmonary edema (ACPE) is characterized by acute breathlessness and hypoxia and is associated with poor prognosis. Standard pre-hospital management of ACPE includes high-flow oxygen, nitroglycerin and, in severe cases, assisted ventilation. Patients with ACPE can be supported with newer modalities of non-invasive ventilation, specifically continuous positive airway pressure (CPAP). The aim of this study was to determine whether patients with ACPE treated with CPAP plus low-flow oxygen pre-hospitally have a lower mortality rate than those treated conventionally. Methods: This study was a pre-hospital randomised, non-blinded controlled trial conducted July 2009–July 2010. Included were all participants transported by ambulance and admitted to the Royal Hobart Hospital, Tasmania, Australia. The study population was consecutive persons ≥18 years of age with sudden onset of severe respiratory distress, diagnosed as ACPE. Patients were included if they required ventilatory assistance. Patients required a GCS >12 and blood pressure >90 mmHg systolic to safely receive CPAP. The primary outcome was pre- or in-hospital mortality. Results: In total, 50 patients were enrolled with mean age of 79.8 (±11.9) years. There were two deaths (8.3%) in the CPAP arm and nine (34.6%) in the control arm (RR, −0.24; 95% CI, 0.06–1.00; p=0.051) with a number needed to treat of 4. CPAP plus low-flow oxygen was significantly less likely to result in respiratory acidosis (mean difference in pH, −0.11; 95% CI, −0.04–−0.17; p=0.002), with elevated pCO2 (mean difference, −10.0 mmHg; 95% CI, −19.2–−0.78; p=0.026). The length of hospital stay was significantly shorter in the surviving patients who received CPAP (ratio of means, 0.45; 95% CI, 0.29–0.70; p≤0.001). Discussion: This study, which provides interim results due to early termination of the trial, shows CPAP in the pre-hospital setting for ACPE is practicable and is associated with improved patient outcomes.

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Helmet Continuous Positive Airway Pressure versus High-Flow Nasal Cannula in COVID-19: A pragmatic randomised clinical trial (COVID HELMET)

10.21203/rs.3.rs-38453/v2 ◽

2020 ◽

Author(s):

Jonas Tverring ◽

Anna Åkesson ◽

Niklas Nielsen

Keyword(s):

Continuous Positive Airway Pressure ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Invasive Mechanical Ventilation ◽

Randomised Trial ◽

High Flow ◽

Nasal Cannula ◽

Low Flow ◽

High Flow Nasal Cannula ◽

Significance Level

Abstract Background: Patients with COVID-19 and hypoxemia despite conventional low-flow oxygen therapy are often treated with High-flow Nasal Cannula (HFNC) in line with international guidelines. Oxygen delivery by Helmet Continuous Positive Airway Pressure (CPAP) is a feasible option that enables a higher positive end-expiratory pressure (PEEP) and may theoretically reduce the need for intubation compared to HFNC but direct comparative evidence is lacking. Methods: We plan to perform an investigator-initiated, pragmatic, randomised trial at an intermediate-level COVID-19 cohort ward in Helsingborg Hospital, southern Sweden. We have estimated a required sample size of 120 patients randomised 1:1 to HFNC or Helmet CPAP to achieve 90% power to detect superiority at a 0.05 significance level regarding the primary outcome of ventilator free days (VFD) within 28 days using a Mann-Whitney U test. Patient recruitment is planned to being June 2020 and be completed in the first half of 2021.Discussion: We hypothesize that the use of Helmet CPAP will reduce the need for invasive mechanical ventilation compared to the use of HFNC without having a negative effect on survival. This could have important implications during the current COVID-19 epidemic. Trial registration: ClinicalTrials.gov, NCT04395807, Registered 20 May 2020, https://clinicaltrials.gov/ct2/show/NCT04395807

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To Bubble or Not? A Systematic Review of Bubble Continuous Positive Airway Pressure in Children in Low- and Middle-Income Countries

Journal of Tropical Pediatrics ◽

10.1093/tropej/fmz069 ◽

2019 ◽

Vol 66 (3) ◽

pp. 339-353 ◽

Cited By ~ 1

Author(s):

Mathilde Nørgaard ◽

Cecilie Stagstrup ◽

Stine Lund ◽

Anja Poulsen

Keyword(s):

Continuous Positive Airway Pressure ◽

Respiratory Distress ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Age Groups ◽

Low Flow ◽

Middle Income ◽

Middle Income Countries ◽

Technical Specifications ◽

Low And Middle Income

Abstract Background Bubble-continuous positive airway pressure (bCPAP) is a simple, low-cost ventilation therapy with the potential to lower morbidity and mortality in children in low- and middle-income countries (LMICs). Aim To examine (i) whether bCPAP is a safe and effective treatment for children in all age-groups presenting with respiratory distress from any cause, (ii) LMIC-implemented bCPAP devices including their technical specifications and costs and (iii) the setting and level of health care bCPAP has been implemented in. Method A systematic search was performed of Embase, PubMed and Web of Science. Inclusion criteria: bCPAP for children with respiratory distress in all age groups in LMICs. Database searches were performed up to 1 November 2018. Results A total of 24 publications were eligible for the review. For neonates bCPAP was superior in improving survival and clinical progression compared with oxygen therapy and mechanical ventilation (MV). In two studies bCPAP was superior to low flow oxygen in reducing mortality in children 29 days to 13 months. Respiratory rate reductions were significant across all ages. Only three of six studies in children of all ages evaluated serious adverse events. In 12 studies comprising 1338 neonates treated with bCPAP, pneumothorax was reported 27 times. The majority of studies were carried out at tertiary hospitals in middle-income countries and 50% implemented the most expensive bCPAP-device. Conclusion In neonates and children below 13 months bCPAP is a safe treatment improving clinical outcomes and reducing the need for MV, without an increase in mortality. High-quality studies from non-tertiary settings in low-income countries are needed.

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Continuous positive airway pressure for children in resource-limited settings, effect on mortality and adverse events: systematic review and meta-analysis

Archives of Disease in Childhood ◽

10.1136/archdischild-2021-323041 ◽

2021 ◽

pp. archdischild-2021-323041

Author(s):

Kristen L Sessions ◽

Andrew G Smith ◽

Peter J Holmberg ◽

Brian Wahl ◽

Tisungane Mvalo ◽

...

Keyword(s):

Systematic Review ◽

Continuous Positive Airway Pressure ◽

Adverse Events ◽

Respiratory Distress ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Meta Analysis ◽

Low Flow ◽

Close Monitoring ◽

Meta Analyses

ObjectiveDetermine non-invasive ventilation with continuous positive airway pressure (CPAP) outcomes for paediatric respiratory distress in low-income and middle-income countries (LMICs).DesignSystematic review and meta-analysis.SettingLMIC hospitals.PatientsOne month to 15 year olds with respiratory distress.InterventionsWe searched Medline, Embase, LILACS, Web of Science and Scopus on 7 April 2020. Included studies assessed CPAP safety, efficacy or effectiveness. All study types were included; neonatal only studies were excluded. Data were extracted by two reviewers and bias was assessed. Certainty of evidence was evaluated, and risk ratios (RR) were produced for meta-analyses. (PROSPERO protocol CRD42018084278).Results2174 papers were screened, 20 were included in the systematic review and 3 were included in two separate meta-analyses of mortality and adverse events. Studies suitable for meta-analysis were randomised controlled trials (RCTs) from Bangladesh, Ghana and Malawi. For meta-analyses comparing death or adverse events between CPAP and low-flow oxygen recipients, we found no clear CPAP effect on mortality (RR 0.75, 95% CI 0.33 to 1.72) or adverse events (RR 1.52, CI 0.71 to 3.26). We downgraded the certainty of evidence for both death and adverse events outcomes to ‘low’ due to design issues and results discrepancies across RCTs.ConclusionsEvidence for CPAP efficacy against mortality and adverse events has low certainty and is context dependent. Hospitals introducing CPAP need to have mechanisms in place to optimise safety in the context it is being used; this includes the location (a high dependency or intensive care area), adequate numbers of staff trained in CPAP use, close monitoring and mechanisms for escalation, daily direct physician supervision, equipment that is age appropriate and user-friendly and continuous monitoring of outcomes and quality of care.

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Helmet Continuous Positive Airway Pressure versus High-Flow Nasal Cannula in COVID-19: A pragmatic randomised clinical trial (COVID HELMET)

10.21203/rs.3.rs-38453/v1 ◽

2020 ◽

Author(s):

Jonas Tverring ◽

Anna Åkesson ◽

Niklas Nielsen

Keyword(s):

Continuous Positive Airway Pressure ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Invasive Mechanical Ventilation ◽

Randomised Trial ◽

High Flow ◽

Nasal Cannula ◽

Low Flow ◽

High Flow Nasal Cannula ◽

Significance Level

Abstract Background: Patients with COVID-19 and hypoxemia despite conventional low-flow oxygen therapy are often treated with High-flow Nasal Cannula (HFNC) in line with international guidelines. Oxygen delivery by Helmet Continuous Positive Airway Pressure (CPAP) is a feasible option that enables a higher positive end-expiratory pressure (PEEP) and may theoretically reduce the need for intubation compared to HFNC but direct comparative evidence is lacking. Methods: We plan to perform an investigator-initiated, pragmatic, randomised trial at an intermediate-level COVID-19 cohort ward in Helsingborg Hospital, southern Sweden. We have estimated a required sample size of 120 patients randomised 1:1 to HFNC or Helmet CPAP to achieve 90% power to detect superiority at a 0.05 significance level regarding the primary outcome of ventilator free days (VFD) within 28 days using a Mann-Whitney U test. Patient recruitment is planned to being June 2020 and be completed in the first half of 2021. Discussion: We hypothesize that the use of Helmet CPAP will reduce the need for invasive mechanical ventilation compared to the use of HFNC without having a negative effect on survival. This could have important implications during the current COVID-19 epidemic. Trial registration: ClinicalTrials.gov, NCT04395807, Registered 20 May 2020, https://clinicaltrials.gov/ct2/show/NCT04395807

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The use of Low Flow Nasal Prongs Therapy in weaning nasal Continuous Positive Airway Pressure (nCPAP) in neonates. Anecdotal or Evidence Based?

http://isrctn.org/> ◽

10.1186/isrctn02529072 ◽

2013 ◽

Author(s):

Jan Miletin

Keyword(s):

Continuous Positive Airway Pressure ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Low Flow ◽

Evidence Based

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