Objective: To evaluate the clinical course, respiratory outcomes and markers of inflammation in preterm infants with moderate respiratory distress syndrome (RDS) assigned from birth to nasal continuous positive airway pressure (NCPAP) or bi-level NCPAP. Methods: A total of 40 infants with a gestational age (GA) of 28–34 weeks (<35 weeks' GA), affected by moderate RDS, were considered eligible and were randomised to NCPAP (group A; n=20, CPAP level=6 cm H₂O) or to bi-level NCPAP (group B; n=20, lower CPAP level=4.5 cm H₂O, higher CPAP level=8 cm H₂O), provided with variable flow devices. Inflammatory response was the primary outcome; serum cytokines were measured on days 1 and 7 of life. Length of ventilation, oxygen dependency, need for intubation and occurrence of air leaks were considered as secondary outcomes. Results: Infants showed similar characteristics at birth (group A vs group B: GA 30.3±2 vs 30.2±2 weeks, birth weight 1429±545 vs 1411±560 g) and showed similar serum cytokine levels at all times. Group A underwent longer respiratory support (6.2±2 days vs 3.8±1 days, p=0.025), longer O₂ dependency (13.8±8 days vs 6.5±4 days, p=0.027) and was discharged later (GA at discharge 36.7±2.5 weeks vs 35.6±1.2 weeks, p=0.02). All infants survived. No bronchopulmonary dysplasia (BPD) or neurological disorders occurred. Conclusions: Bi-level NCPAP was associated with better respiratory outcomes versus NCPAP, and allowed earlier discharge, inducing the same changes in the cytokine levels. It was found to be well tolerated and safe in the study population.

Background: Sustained lung inflation (SLI) applied at birth has been demonstrated to lead to clearance of lung fluid and achievement of a precocious functional residual capacity in animal studies. Objectives: To verify if the application of SLI in preterm infants at birth may reduce the need for mechanical ventilation and improve their respiratory outcome. Methods: We prospectively studied 89 infants with respiratory distress (gestational age (GA) 28.1 ± 2.2 weeks) treated at birth with a SLI (25 cm H₂O, sustained for 15 s) in addition to AAP recommendations versus a historical control group (n = 119; GA 28.1 ± 2.0 weeks) treated without SLI with the same device (controlled positive end-expiratory pressure of 5 cm H₂O). Results: The SLI group had less need for (51 vs. 76%, p < 0.0001) and shorter duration of mechanical ventilation (5 ± 11 vs. 11 ± 19 days, p = 0.008), a more frequent occurrence of exclusive nasal continuous airway pressure support (49 vs. 24%, p < 0.0001) and INtubation-SURfactant-Extubation (INSURE) treatment (16 vs. 3%, p = 0.01), less need for surfactant (45 vs. 61%, p = 0.027) and postnatal steroids (10 vs. 25%, p = 0.01), a shorter duration of oxygen therapy (21 ± 27 vs. 31 ± 31 days, p = 0.016), and, finally, a lower occurrence of bronchopulmonary dysplasia in survivors (7 vs. 25%, p = 0.004). Multiple regression analysis showed that 23–27 weeks of GA and birth weight <750 g increased the risk of mechanical ventilation, while a clinical risk index for babies (CRIB) score <3 as well as INSURE strategy and SLI treatment in the delivery room decreased it. Conclusions: The application of a SLI at birth in preterm infants with respiratory distress may decrease the need for mechanical ventilation without inducing evident adverse effects.

Preterm infants need the achievement of adequate lung volume. Lung recruitment maneuver (LRM) is applied during high-frequency oscillatory ventilation. We investigated the effect of an LRM with positive end-expiratory pressure (PEEP) on oxygenation and outcomes in infants conventionally ventilated for respiratory distress syndrome (RDS). Preterm infants in assisted controlled ventilation + volume guarantee for RDS after surfactant randomly received an LRM (group A) or did not (group B). LRM entailed increments of 0.2 cm H₂O PEEP every 5 minutes, until fraction of inspired oxygen (Fio ₂) = 0.25. Then PEEP was reduced and the lung volume was set on the deflation limb of the pressure/volume curve. When saturation of peripheral oxygen fell and Fio ₂ rose, we reincremented PEEP until Spo ₂ became stable. Group A (n = 10) and group B (n = 10) infants were similar: gestational age 25 ± 2 versus 25 ± 2 weeks; body weight 747 ± 233 versus 737 ± 219 g; clinical risk index for babies 9.8 versus 8.1; initial Fio ₂ 56 ± 24 versus 52 ± 21, respectively. LRM began at 86 ± 69 minutes of age and lasted for 61 ± 18 minutes. Groups A and B showed different max PEEP during the first 12 hours of life (6.1 ± 0.3 versus 5.3 ± 0.3 cm H₂O, p = 0.00), time to lowest Fio ₂ (94 ± 24 versus 435 ± 221 minutes; p = 0.000) and O₂ dependency (29 ± 12 versus 45 ± 17 days; p = 0.04). No adverse events and no differences in the outcomes were observed. LRM led to the earlier lowest Fio ₂ of the first 12 hours of life and a shorter O₂ dependency.

Background: Appropriate ventilation together with improvement of clinical care of premature babies can contribute to reducing lung inflammation, known to represent the “primum movens” of bronchopulmonary dysplasia (BPD). High-frequency oscillatory ventilation (HFOV) and volume-guarantee (VG) ventilation are effective in the treatment of neonatal respiratory distress syndrome (RDS). Objective: To assess the potential of HFOV and VG to prevent BPD in the acute phase of RDS, by a randomised clinical study evaluating lung inflammation in premature infants. Study design: Forty infants (gestational age 25–32 weeks) with RDS were assigned to assist-control ventilation plus VG (Vt = 5 ml/kg) or HFOV (both with a Dräger Babylog 8000 plus ventilator). Levels of interleukin (IL) 6, IL8 and tumour necrosis factor were determined in tracheal aspirate on days 1, 3 and 7 of life. Results: In the HFOV group IL6 levels were significantly higher on day 3 (0.5 (0.2) vs assisted-control ventilation plus VG group 0.1 (0.2) ng/ml) and oxygen dependency was significantly longer (36 (23) vs assisted-control ventilation plus VG group 19 (11) days). Conclusion: VG ventilation is an effective lung-protective strategy to be used in acute RDS, inducing a lower expression of early inflammation markers than HFOV. Whether the use of this initial ventilatory strategy contributes to the prevention of BPD requires further studies.

Objective: To measure tidal volume, plethysmography changes and gas exchange during respiratory support at birth. Design: The following parameters were measured: (1) expired tidal volumes (Vte (mL/kg)) using respiratory function monitoring, (2) changes in plethysmography (AU/kg) per breath using respiratory inductance plethysmography (bands placed around rib cage (RC) and abdomen (AB)) and (3) expired CO₂ (ECO₂) levels using a volumetric CO₂ monitor. For respiratory support, a T-piece resuscitator and facemask were used with peak inspiratory pressure (PIP) 25 cm H₂O and positive end expiratory pressure 5 cm H₂O. Data were analysed during the sustained inflation (SI), positive pressure ventilation (PPV) and breathing on continuous positive airway pressure (CPAP). Setting: The delivery rooms of the Leiden University Medical Center, Leiden, and V. Buzzi, Milan. Patients: 15 preterm infants with a gestational age 28 (27–31) weeks and a birth weight of 1080 (994–1300) g. Results: Vte for PPV inflations, PPV inflations with breathing and spontaneous breathing were significantly different (4.4 (2.5–8.6) vs 8.8 (5.7–11.4) vs 5.7 (3.3–9.8); p<0.0001)). Spontaneous breathing led to the highest ECO₂ levels and during PPV, ECO₂ levels were higher when the inflations coincided with breathing (32 (23–38) vs 20 (13–25) vs 2 (3–11) mm Hg; p<0.0001). Little change in plethysmography amplitude occurred during the SI, PPV and breathing at the RC. There was gain in plethysmography amplitude at the AB during the SI, PPV, but most with breathing. Conclusions: While Vte during breathing on CPAP was lower compared with PPV coinciding with breathing, breathing on CPAP was most effective in gas exchange and plethysmography amplitude gain compared with PPV and PPV coinciding with breathing.