For extremely low birth weight infants in resource-limited hospitals, nasal continuous positive airway pressure (NCPAP) plus intubation, surfactant, and extubation (InSurE) improves survival after respiratory distress syndrome (RDS), a new study shows.
"Survival at discharge increased from 43% for similar infants treated with oxygen by hood in 1994 (departmental data) and 55% in infants treated with NCPAP only in 2004 (departmental data) to almost 75% with InSurE," the researchers note.
"Limited resources (no back-up ventilatory facilities) are not an excuse for a poor outcome in ELBW infants," said Dr. Gerhardus Francois Kirsten, who led the study at Tygerberg Children's Hospital.
Infants with RDS receive nasal CPAP
"Neonatal intensive care is extremely expensive and requires highly specialised physicians and nurses and will not become the norm in developing countries," he continued. "Good antenatal care, including antenatal steroids, gentle resuscitation with CPAP, early nasal CPAP and InSurE when indicated combined with breast milk feeding and kangaroo mother care outside an intensive care unit improves the survival of these infants significantly."
"At our institution all infants with RDS with birth weights >500 g and gestational age >25 weeks receive nasal CPAP," Dr. Kirsten said. "Those >750 g and >26 weeks who fail nasal CPAP are given InSurE."
When resources permit, RDS treatment includes NCPAP, early surfactant use, and ventilatory assistance when NCPAP fails.
In the journal Pediatrics, Dr Kirsten and colleagues report on 318 extremely low birth weight (ELBW) infants with RDS who were treated with NCPAP and InSurE in a neonatal high care ward in a tertiary state hospital with limited NICU resources (including limited back-up ventilatory facilities).
Gestational age not associated with survival
Ninety percent of the infants were alive at day three, and 87% were alive at day seven. Just over a quarter of the infants (78, 25.2%) died during the hospital stay.
InSurE failed in 33 infants, including 15 who were admitted to the NICU. Five of these 15 infants died, as did all 18 who were not admitted to the NICU.
The best rates of survival to hospital discharge were for infants with a birth weight of at least 750 g (79.3%) and a gestational age beyond 26 weeks (79.7%).
In logistic regression analyses, increasing birth weight, NCPAP, and antenatal steroids were significantly associated with increased survival at days 3 and 7 and at hospital discharge. Gestational age was not significantly associated with survival in these analyses.
Survival of infants in Sub-Sahara Africa dismal
Two infants who had received InSurE had chronic lung disease at 36 weeks' corrected age, and two infants developed pneumothorax.
Dr Kirsten said a study of the infants' long term neurodevelopment is in progress.
"Survival of infants between 1000 and 1500 g in sub-Saharan Africa is dismal," Dr Kirsten added. "Although infants in this weight category did not form part of the current study, this treatment modality has significantly improved their survival at our institution. These infants will benefit the most from nCPAP and InSurE and they should be the immediate target group to decrease the neonatal mortality."
(Will Boggs MD, Reuters Health, March 2012)
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