Neonatal and Pediatric Medicine
Open Access

Preterm infants; Respiratory management; Respiratory distress syndrome

Introduction

Respiratory failure is a common and important clinical condition affecting preterm infants that is inversely related to gestational age (GA) and is associated with increased neonatal morbidity and mortality. Currently available data indicate that respiratory distress syndrome (RDS) affects approximately 80% of newborns born at 28 weeks GA, and this proportion rises to 90% at 24 weeks GA [1]. Approximately 50-60% of these newborns require surfactant administration. Extensive atelectasis, inability to achieve functional residual capacity (FRC), hypoxemia, hypercapnia, and excessive work of breathing can affect respiration in preterm infants from the first breath in the delivery room [2]. It is a clinical feature that reflects failure. According to this pathophysiology, current resuscitation guidelines identify the development of adequate lung expansion and ventilation. H. Adequate her FRC after birth as the most important goal of neonatal survival [3]. However, all types of mechanical ventilation, especially invasive mechanical ventilation (MV), have been shown to carry a high risk of lung damage and consequent bronchopulmonary dysplasia (BPD). Approaches aimed at reducing the global burden of early lung disease must therefore focus on developing lung-protective ventilation strategies. To reduce associated morbidity, recent resuscitation guidelines emphasize that noninvasive respiratory support should be a priority in the management of all airway conditions in spontaneously breathing preterm infants. It is generally accepted that the risks associated with intubation increase inversely with GA [4]. Today’s premature infants are born with increasingly early lung development, making them more susceptible to lung damage from MV. A current challenge for neonatologists is to handle both non-invasive and invasive techniques to treat a wide range of lung diseases, from acute to chronic. Respiratory management of preterm infants should begin with the first breath in the delivery room and continue throughout their stay in the neonatal intensive care unit (NICU). Each paragraph of this narrative review provided guidelines and the best available evidence, including underlying pathophysiological mechanisms [5]. The purpose of this review is to summarize the current evidence on respiratory management of preterm infants and to provide a practical guide for neonatologists, especially in the early stages of neonatal respiratory distress syndrome (RDS). Includes the following relevant sections: Respiratory management of preterm infants in the delivery room; noninvasive respiratory support for preterm infants in the NICU. Mechanical ventilation of premature infants in the neonatal intensive care unit; exogenous surfactant therapy in preterm infants [6].

Methods

We searched the literature on PubMED to identify articles that were included in the narrative review selection. This survey was conducted on English-language sources only. We restricted our search using the age filter “premature” and used the following search terms: Preterm Birth and Delivery Room Ventilation Management; Preterm Birth and Noninvasive Ventilation; Preterm Birth and Ventilation Support; ``Heat-humidified high-nasal cannula’’, ``Preterm infant AND nasal intermittent positive pressure ventilation’’, ``Preterm infant AND ventilator’’, ``Preterm infant AND high frequency oscillatory ventilation’’, ``Preterm infant AND lung protective ventilation’’, ``Preterm infant “Infants and Optimal Lung Volume Strategies”, “Preterm Infants and Volume-Controlled Ventilation”, “Prematurity and Weaning from Ventilation”, “Prematurity and Extubation from Ventilation”, “Prematurity and Exogenous Surfactant” Therapy ”.

The final search has been updated for December 2022 and has no release year restrictions. Reference lists of potential publications were also thoroughly screened for material that may have been overlooked in the literature review [7].

Respiratory executive of incomplete offspring in the delivery room

Most preterm infants breathe independently, require care only during the transition from intrauterine life, and do not require immediate intubation. This is in contrast to certain preterm infants who are clinically unwell and require resuscitation. Pulmonary fluid clearance and establishment of an adequate FRC are the main variables affecting successful transition in preterm infants. However, premature infants have difficulty maintaining adequate alveolar ventilation after the early stages of the transition process due to reduced inspiratory effort, intercostal muscle weakness, reduced diaphragmatic function, and surfactant deficiency. There are cases. To facilitate this process, neonatologists need to understand optimal ventilation and oxygenation strategies for the delivery room [8].

Ventilation in the delivery room

Continuous positive nasal airway pressure (nCPAP) initiated in the delivery room reduces mortality and BPD in very preterm infants compared with intubation. Early initiation of CPAP may shorten the duration of MV and postnatal corticosteroid therapy.

Optimal CPAP levels are unknown, but most studies have used levels of at least 6 cm H2O, and some studies have used levels of 9 cm H2O. The reported concentration of CPAP commonly used in the delivery room is 5 cm H2O, but infants whose FRC is not fully established may benefit from higher concentrations. Current European guidelines recommend using her CPAP of at least 6 cm H2O [9].

Noninvasive respiratory support for preterm infants in the NICU

Most extremely premature babies require ventilator support for the first few days of life. Long-term invasive MV is associated with an increased risk of developing BPD and other comorbidities.

Avoiding MV when possible and optimizing noninvasive respiratory support in preterm infants reduces lung damage and improves neonatal outcomes. Thanks to a better understanding of the pathophysiology of BPD and advances in technology, the use of non-invasive ventilation (NIV) has expanded to provide initial support immediately after birth (primary mode) and post-extubation support (secondary mode) for neonates in respiratory arrest mode are both increasing. Several non-invasive respiratory assistance techniques are currently available. They can be classified into two categories: NIV technologies that apply constant pressure to the airway throughout the respiratory cycle B. CPAP and high flow nasal cannula (HFNC); (2) NIV technologies that apply variable pressure to the airway B. Bilevel positive airway pressure (BiPAP), nasal intermittent positive pressure ventilation (NIPPV), and nasal high frequency oscillatory ventilation (NHFOV) [10].

Exogenous surfactant therapy in preterm infants

Surfactants are naturally occurring surfactant lipoproteins mixed with proteins that lower the surface tension of the alveolar fluid surface, keeping the alveoli open during exhalation and greatly reducing the work of breathing. Surfactants also improve mucociliary transport, prevent pulmonary edema formation, improve pulmonary compliance, and contribute to pulmonary defense against pathogens. For these reasons, exogenous surfactant therapy is one of the most important treatments for preterm infants. Administration of exogenous surfactant is life-saving in the management of IBS in preterm infants,especially ELGAN, and other neonatal respiratory diseases that exhibit altered surfactant homeostasis (e.g., meconium aspiration syndrome, pneumonia, pulmonary hemorrhage, acute neonatal respiratory disease). Over the past decade, new minimally invasive techniques for surfactant administration have been investigated to avoid or minimize trauma associated with endotracheal intubation and MV. These techniques are called minimally invasive surfactant administration (LISA) or minimally invasive surfactant therapy (MIST). A thin catheter or plastic tube is inserted into the trachea, either directly or under videolaryngoscope, and the patient breathes spontaneously, most commonly assisted by noninvasive respiratory support with either nasal CPAP or NIPPV, with surfactant placed in the airway.

Discussion

Respiratory failure, in contrast to GA, is one of the most significant clinical conditions affecting preterm infants. Adequate respiratory management of a preterm infant, especially her ELGAN (<28 weeks of age), ensures adequate gas exchange, reduces VILI, promotes growth and reduces overall neonatal morbidity and mortality. is essential to Beginning in the delivery room, today’s neonatologist must implement evidence-based best practices for bedside respiratory support while the patient is in her NICU. This support must be tailored to the specific characteristics and timing of the lung disease being treated. By tracing a hypothetical timeline from the first ventilator support at birth to the preterm infant’s entire stay in the NICU, this overview summarizes the major evidence currently available for ventilator management of preterm infants. We have compiled recommendations for best practices based on: Current evidence suggests the primary use of noninvasive respiratory support in spontaneously breathing preterm infants to avoid MV and reduce morbidity and mortality. However, a significant proportion of preterm infants require life-saving intubation and MV at some point in the delivery room and/or during their NICU stay. For these reasons, neonatologists must be able to treat a variety of lung conditions, ranging from acute to chronic, using both non-invasive and invasive respiratory support systems.

Conclusions

Summarizing the current knowledge about respiratory management in preterm infants, the following conclusions can be drawn. In the delivery room: Delivery room-initiated nCPAP reduces death or BPD in very preterm infants compared with intubation. Current European guidelines recommend using her CPAP with at least 6 cm H2O. Endotracheal intubation should only be considered in infants who are unable to make adequate respiratory efforts and/or who remain bradycardic and/or hypoxic despite adequate masking or nasal prongs PPV. In the NICU, NIPPV, especially sNIPPV, is the primary mode of non-invasive respiratory support. As an alternative primary support, it seems appropriate to select her nCPAP for infants born <28 weeks after GA. As post-extubation ventilation support, NIPPV seems a reasonable choice for preterm infants, especially ELGAN, who are at high risk of extubation failure. nCPAP can be selected if the risk of unsuccessful extubation is low.

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