Benefits of nasal intermittent mandatory ventilation for preterms

Anna W. Rosenquist, MD MassGeneral Hospital for Children Harvard University Boston, Massachusetts Kateri Heydon, MS Daniel J. Licht, MD Ron Keren, MD, MPH Theoklis Zaoutis, MD, MSCE Richard L. Hodinka, PhD Susan E. Coffin, MD, MPH Children’s Hospital of Philadelphia University of Pennsylvania Philadelphia, Pennsylvania Barbara Watson, MBChB Philadelphia Department of Public Health Philadelphia, Pennsylvania

higher initial ventilatory settings but spent less time on mechanical ventilation than the NCPAP group. Tolerating higher initial ventilatory settings and early extubation from mechanical ventilation might have helped decrease the incidence of BPD. There is a group of VLBW infants in the preterm population who, despite all efforts, will inevitably need mechanical ventilation; strategies to decrease BPD in this group need to be identified.3 Our neonatal unit has been using NIMV for initial respiratory support in preterm infants with RDS. As part of an ongoing study, we are finding that NIMV does reduce the need for mechanical ventilation compared with NCPAP, especially in conjunction with surfactant therapy. Further analysis of the data will show whether this trend will appear in the group of infants with birth weight ⬍1000 g and, if so, whether it will influence the incidence of BPD. Jucille Meneses, MD Neonatal Unit Maternal-Infant Institute of Pernambuco (IMIP) Recife, PE Brazil

10.1016/j.jpeds.2007.07.049

REFERENCE 1. Chung BHY, Tsang AMC, Wong VCN. Neurologic complications in children hospitalized with influenza: Comparison between USA and Hong Kong. J Pediatr 2007;151:e17-8.

10.1016/j.jpeds.2007.07.027

REFERENCES Benefits of nasal intermittent mandatory ventilation for preterms To the Editor: We read with interest the report by Kugelman et al1 that demonstrated that preterm infants with respiratory distress syndrome (RDS) treated initially with nasal intermittent mandatory ventilation (NIMV) needed less mechanical ventilation and had a decreased incidence of bronchopulmonary dysplasia (BPD) compared with preterm infants treated with nasal continuous positive airway pressure (NCPAP). Observational studies have shown that surfactant administration followed by extubation to NCPAP or NIPPV decreases the need for mechanical ventilation in preterm infants.2 Kugelman et al reported that surfactant was given as a rescue therapy in their study. This leads us to determine the rate of surfactant use in each group and to evaluate whether surfactant use was higher in the NIMV group. There was a 50% reduction in the need for mechanical ventilation and a significant decrease in the incidence of BPD (33% vs 5%; P ⫽ 0.04) in the very low birth weight (VLBW) infants in the NIMV group. This substantially decreased incidence of BPD is very surprising even when the lower need for mechanical ventilation is taken into account, because BPD is such a complex disorder. However, as the authors point out, the study does not have statistical power for these outcome measures. In addition, the number of infants with birth weight ⬍1000 g in each group was small. It is important to determine whether these ventilatory strategies to decrease mechanical ventilation and BPD would be effective with in the extremely preterm infants, who are more vulnerable. An important finding was that the VLBW infants in the NIMV group that failed nasal support had significantly Letters to the Editor

1. Kugelman A, Feferkorn I, Riskin A, Chistyakov I, Kaufman B, Bader D. Nasal intermittent mandatory ventilation versus nasal continuous positive airway pressure for respiratory distress syndrome: a randomized, controlled, prospective study. J Pediatr 2007;150:521-6. 2. Ramanathan R. Early surfactant therapy and noninvasive ventilation. J Perinatol 2007;27:S33-37. 3. Booth C, Premkumar M, Yannoulis A, Thomson M, Edwards A. Sustainable use of continuous positive airway pressure in extremely preterm infants during the first week after delivery. Arch Dis Child Fetal Neonatal Ed 2006;91:F398-402.

Reply To the Editor: We appreciate the comments of Dr Meneses on our recent article.1 It is true that surfactant was not administered to infants in whom nasal respiratory support was successful and was given only as rescue therapy. On the other hand, our policy was that those infants who failed nasal respiratory support for respiratory distress syndrome (RDS) and needed endotracheal ventilation got surfactant. Because this policy was similar in those infants treated initially with nasal continuous positive airway pressure (NCPAP) and those treated initially with nasal intermittent mandatory ventilation (NIMV), the rate or surfactant administration did not differ between the failing infants in the 2 methods. Individualized intubation strategy in delivery room was found to be safe.2 Several centers administer surfactant, immediately extubate the infants, and then use NCPAP to shorten the course of mechanical ventilation.3-6 The best option for treatment of RDS in respect to gestational age and RDS severity should be investigated further.5 The significant decrease in bronchopulmonary dysplasia (BPD) in infants treated initially with NIMV was surprising when taking into account the complexity of causes leading to e19