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EBNEO COMMENTARY: NONINVASIVE HIGH-FREQUENCY OSCILLATORY VENTILATION VS NASAL CONTINUOUS POSITIVE AIRWAY PRESSURE VS NASAL INTERMITTENT POSITIVE PRESSURE VENTILATION AS POSTEXTUBATION SUPPORT FOR PRETERM NEONATES

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EBNEO review of the study Zhu X, et al on Nasal Oscillation Post-Extubation (NASONE) Study Group. Noninvasive High-Frequency Oscillatory Ventilation vs Nasal Continuous Positive Airway Pressure vs Nasal Intermittent Positive Pressure Ventilation as Postextubation Support for Preterm Neonates in China: A Randomized Clinical Trial. JAMA Pediatr. 2022 Jun 1;176(6):551-559. PMID: 35467744 reviewed for EBNeo by Faeq Almudares and Bheru Gandhi from College of Medicine/Division of Neonatology, Texas Children’s Hospital.

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Acta Paediatrica commentary by Faeq Almudares and Bheru Gandhi:
 
 

COMMENTARY:

Invasive mechanical ventilation (IMV) while life-saving in neonates with severe respiratory failure, is often associated with worsened neonatal outcomes, including bronchopulmonary dysplasia (BPD), lower neurodevelopmental scores and death.1 In order to reduce complications of IMV, various non-invasive ventilation (NIV) strategies have been studied to evaluate improvement in extubation success. Nasal high-frequency oscillatory ventilation (NHFOV) is a newer NIV mode. NHFOV generates high mean airway pressure with superimposed oscillations, thus decreasing air trapping seen with high nasal continuous positive airway pressure (NCPAP) pressures.2 It can also eliminate the need for synchronisation with nasal intermittent positive pressure ventilation (NIPPV).2

The NASONE (Nasal Oscillation Post-Extubation) study is the largest randomised control trial to assess NHFOV's superiority over NCPAP in preventing reintubation and reducing IMV duration. NHFOV's effectiveness was not significantly different than NIPPV.3 This study was unique in its direct comparison of the three NIV modes: NHFOV, NCPAP and NIPPV. It was well-designed and adequately powered to investigate the primary outcomes. Its design enhances that generalizability of the approach, although the effectiveness of the intervention may vary in certain patient populations. The analysis was conducted via an intention-to-treat basis, with no crossover between groups permitted. However, in clinical practice, different NIV modes may be attempted before intubation.

Although NHFOV showed greater effectiveness than NCPAP in preventing re-intubation, it did not impact BPD incidence. Using a pragmatic approach with a range of gestational ages, the paper assumes 31–32 week infants would have the same severity of lung disease as 25–26-week infants, and that NHFOV would have a similar effect. Upon limiting the analysis to extremely premature neonates or infants with severe respiratory failure, the secondary analysis showed NHFOV was associated with a decreased incidence of moderate to severe BPD.4

Limitations include lack of diversity in ethnicity and racial backgrounds of the cohort and the absence of NIPPV synchronisation. Given the overall limited availability of NIPPV synchronisation, the study's approach was appropriate. The lower rates of antenatal steroid use in the study cohort may have influenced the measured outcomes, but those rates were similar between intervention groups. Nevertheless, caution is needed when implementing the trial results in different hospitals and regions.

There were no reported adverse outcomes associated with higher pressures experienced by neonates in the NHFOV group compared to the NCPAP and NIPPV groups. This aligns with previously reported results.5 However, it is important to acknowledge that the assessment of feeding intolerance was limited and did not include the rates of feeding interruptions or abdominal distension. Nonetheless, infants in the NHFOV group had statistically significantly higher weight gain than the NCPAP group. The difference in weight gain, 13 g versus 12 g, may be clinically insignificant but does show that HFOV did not compromise growth.

This trial contributes to the evidence supporting the efficacy and safety of NHFOV in preterm infants, underscoring its potential advantages over NCPAP.67 Further trials are warranted to confirm the short-term benefits of NHFOV and to investigate its long-term efficacy and safety in preterm infants.

 

This is one of the future topics that we have to wait until results in other studies, but physiologically it can promise good results

Verey interesting study. I'm interested in obtaining information on the regulations regarding the parameters of nasal high frequency, particularly for very preterm infants."

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