Downloaded from http://fn.bmj.com/ on February 17, 2016 - Published by group.bmj.com
ADC-FNN Online First, published on February 16, 2016 as 10.1136/archdischild-2015-309683 Original article
High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia Sandeep Shetty,1,2 Katie Hunt,2 Amy Douthwaite,2 Maria Athanasiou,2 Ann Hickey,2 Anne Greenough1,3 1
Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK 2 Neonatal Intensive Care Centre, King’s College Hospital, London, UK 3 NIHR Biomedical Centre at Guy’s and St Thomas NHS Foundation Trust and King’s College London, London, UK Correspondence to Professor Anne Greenough, NICU, 4th Floor Golden Jubilee Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK; anne.greenough@kcl. ac.uk Received 2 September 2015 Revised 18 January 2016 Accepted 22 January 2016
ABSTRACT Objective To determine whether the time to achieve full oral feeding differed between infants with bronchopulmonary dysplasia (BPD) supported by nasal continuous positive airway pressure (nCPAP) compared with those supported by nCPAP and subsequently transferred to heated, humidified, high-flow nasal cannula oxygen (HHFNC). Design Two-cohort comparison. Setting Tertiary neonatal unit. Patients –72 infants, median gestational age 27 (range 24–32) weeks in the nCPAP group, and 44 infants, median gestational age 27 (range 24–31) weeks in the nCPAP/HHFNC group. Interventions Between 2011 and 2013, infants post extubation were supported by nCPAP and from 2013 infants were supported by nCPAP and then HHFNC. Main outcome measures The postnatal age at which oral feeds were first trialled and full oral feeds established. The length of respiratory support as either nCPAP or nCPAP/HHFNC and the total length of respiratory support and hospital stay were also determined. Subanalysis was undertaken of infants requiring respiratory support beyond 34 weeks postmenstrual age (PMA). Results The postnatal age at trial of first oral feeds was earlier in the nCPAP/HHFNC group ( p=0.012), but infants were a shorter time on nCPAP compared with nCPAP/HHFNC ( p=0.003). On subgroup analysis, the age to achieve full oral feeds was earlier in the nCPAP/ HHFNC group ( p34 weeks PMA achieved full oral feeding earlier in the nCPAP/HHFNC group. swallowing usually occurred during a respiratory pause and after 35 weeks PMA swallowing occurred typically at the end of inspiration. In addition, respiratory rate reduction during intermittent sucking after 34 weeks was smaller than that at 32 or 33 weeks PMA.3–5 During humidified, high-flow nasal cannula (HHFNC), heated and humidified gas is delivered at high flow rates between 2 and 8 L/min via nasal cannulae. Infants are perceived to be more comfortable and be more easily handled on HHFNC than nasal continuous positive airways pressure (nCPAP).6 We, therefore, hypothesised that infants with BPD who were receiving HHFNC would be fully orally fed sooner than those who were supported by nCPAP. We also hypothesised any differences in feeding might be particularly marked in those who continued to require positive pressure respiratory support after 34 weeks PMA. The aim of this study was to test those hypotheses by comparing the time to full oral feeding between infants with BPD who were supported by nCPAP with those who received nCPAP and then transferred to HHFNC.
METHODS A review was undertaken of infants born prior to 33 weeks of gestational age who had developed
Shetty S, et al. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F4. doi:10.1136/archdischild-2015-309683
F1
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Downloaded from http://fn.bmj.com/ on February 17, 2016 - Published by group.bmj.com
Original article Table 1 Demographic data by respiratory rate
n Gestational age (weeks) Birth weight (g) Male gender Antenatal steroid exposure Postnatal surfactant Duration of mechanical ventilation (days)
CPAP
HHFNC/CPAP
p Value
72 27 (24–32) 865 (484–1800) 33 (46%) 68 (94%) 62 (86%) 8.5 (0–83)
44 27 (24–31) 915 (600–1740) 22 (50%) 40 (91%) 40 (91%) 13 (0–57)
0.479 0.365 0.508 0.355 0.195 0.846
Data displayed as median (range) or n (%). CPAP, continuous positive airway pressure; HHFNC, humidified high-flow nasal cannula.
BPD (oxygen dependency at 28 days7). Between July 2011 and February 2013, infants with BPD post extubation were supported by nCPAP, initially at 6 cm H2O. From March 2013, infants were extubated onto nCPAP (6 cm H2O) and then transferred to HHFNC if they continued to require nCPAP for >2 weeks and their supplementary oxygen requirement fell to
ADC-FNN Online First, published on February 16, 2016 as 10.1136/archdischild-2015-309683 Original article
High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia Sandeep Shetty,1,2 Katie Hunt,2 Amy Douthwaite,2 Maria Athanasiou,2 Ann Hickey,2 Anne Greenough1,3 1
Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King’s College London, London, UK 2 Neonatal Intensive Care Centre, King’s College Hospital, London, UK 3 NIHR Biomedical Centre at Guy’s and St Thomas NHS Foundation Trust and King’s College London, London, UK Correspondence to Professor Anne Greenough, NICU, 4th Floor Golden Jubilee Wing, King’s College Hospital, Denmark Hill, London SE5 9RS, UK; anne.greenough@kcl. ac.uk Received 2 September 2015 Revised 18 January 2016 Accepted 22 January 2016
ABSTRACT Objective To determine whether the time to achieve full oral feeding differed between infants with bronchopulmonary dysplasia (BPD) supported by nasal continuous positive airway pressure (nCPAP) compared with those supported by nCPAP and subsequently transferred to heated, humidified, high-flow nasal cannula oxygen (HHFNC). Design Two-cohort comparison. Setting Tertiary neonatal unit. Patients –72 infants, median gestational age 27 (range 24–32) weeks in the nCPAP group, and 44 infants, median gestational age 27 (range 24–31) weeks in the nCPAP/HHFNC group. Interventions Between 2011 and 2013, infants post extubation were supported by nCPAP and from 2013 infants were supported by nCPAP and then HHFNC. Main outcome measures The postnatal age at which oral feeds were first trialled and full oral feeds established. The length of respiratory support as either nCPAP or nCPAP/HHFNC and the total length of respiratory support and hospital stay were also determined. Subanalysis was undertaken of infants requiring respiratory support beyond 34 weeks postmenstrual age (PMA). Results The postnatal age at trial of first oral feeds was earlier in the nCPAP/HHFNC group ( p=0.012), but infants were a shorter time on nCPAP compared with nCPAP/HHFNC ( p=0.003). On subgroup analysis, the age to achieve full oral feeds was earlier in the nCPAP/ HHFNC group ( p34 weeks PMA achieved full oral feeding earlier in the nCPAP/HHFNC group. swallowing usually occurred during a respiratory pause and after 35 weeks PMA swallowing occurred typically at the end of inspiration. In addition, respiratory rate reduction during intermittent sucking after 34 weeks was smaller than that at 32 or 33 weeks PMA.3–5 During humidified, high-flow nasal cannula (HHFNC), heated and humidified gas is delivered at high flow rates between 2 and 8 L/min via nasal cannulae. Infants are perceived to be more comfortable and be more easily handled on HHFNC than nasal continuous positive airways pressure (nCPAP).6 We, therefore, hypothesised that infants with BPD who were receiving HHFNC would be fully orally fed sooner than those who were supported by nCPAP. We also hypothesised any differences in feeding might be particularly marked in those who continued to require positive pressure respiratory support after 34 weeks PMA. The aim of this study was to test those hypotheses by comparing the time to full oral feeding between infants with BPD who were supported by nCPAP with those who received nCPAP and then transferred to HHFNC.
METHODS A review was undertaken of infants born prior to 33 weeks of gestational age who had developed
Shetty S, et al. Arch Dis Child Fetal Neonatal Ed 2016;0:F1–F4. doi:10.1136/archdischild-2015-309683
F1
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.
Downloaded from http://fn.bmj.com/ on February 17, 2016 - Published by group.bmj.com
Original article Table 1 Demographic data by respiratory rate
n Gestational age (weeks) Birth weight (g) Male gender Antenatal steroid exposure Postnatal surfactant Duration of mechanical ventilation (days)
CPAP
HHFNC/CPAP
p Value
72 27 (24–32) 865 (484–1800) 33 (46%) 68 (94%) 62 (86%) 8.5 (0–83)
44 27 (24–31) 915 (600–1740) 22 (50%) 40 (91%) 40 (91%) 13 (0–57)
0.479 0.365 0.508 0.355 0.195 0.846
Data displayed as median (range) or n (%). CPAP, continuous positive airway pressure; HHFNC, humidified high-flow nasal cannula.
BPD (oxygen dependency at 28 days7). Between July 2011 and February 2013, infants with BPD post extubation were supported by nCPAP, initially at 6 cm H2O. From March 2013, infants were extubated onto nCPAP (6 cm H2O) and then transferred to HHFNC if they continued to require nCPAP for >2 weeks and their supplementary oxygen requirement fell to
