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Optimising Pressure Support in Preterm Infants with Respiratory Distress Syndrome: a Randomised Clinical Trail

Presented at the Neonatal Society 2017 Summer Meeting.

Mallya P1, Gupta S1, Sinha S2, Janakiraman S1, Harikumar C1, Donn SM3

1 University Hospital of North Tees, Stockton, UK
2 James Cook University Hospital, Middlesbrough, UK
3 University of Michigan Health System, C.S. Mott Children’s Hospital, Ann Arbor, Michigan

Background: Pressure support ventilation (PSV) is widely used in children and adults but its use is relatively unexplored in preterm infants. PSV can be minimally applied to assist spontaneous breaths during synchronised intermittent mandatory ventilation (SIMV), or it can be used to fully augment spontaneous breaths with SIMV as a safety net. A hypothesis from a previous study (1) suggested Pressure Support Ventilation could be advantageous for weaning mechanical ventilation in preterm infants. We designed a clinical trial (Pressure support or SIMV Trial, POST) to compare these two applications of PSV.

Methods: This two-centre study randomised preterm infants <32 weeks gestation with RDS to either full PSV along with fixed (10 breaths/min) SIMV breaths (PSVmax) or high rate (40 breaths/min) SIMV along with minimal PSV (PSVmin). Infants were stratified in three groups based on gestation at birth. Randomised mode was commenced when infants achieved mean airway pressure <10 cm H2O, FiO2 <0.4 and had reliable respiratory drive for at least two consecutive hours. In both groups minute ventilation was maintained between 240-360 mL/kg/min. A minute ventilation test (MVT) (2) was performed to assess readiness for extubation when baby reached minimum support. The primary outcome measure was the time from trial entry until passing the MVT. Data was analysed using SPSS v.22. The study was registered with randomised controlled trial registry (ISRCTN74272142).

Results: 247 babies met eligibility criteria, 93 were randomised (47 infants in PSVmax and 46 in PSVmin). The two groups were demographically similar. There was a strong trend favouring PSVmax [31 (12.59-49.5) vs. 42 (28.2-55.7) hours, median (IQR)] for faster weaning but the difference was not statistically significant. This difference was observed across all stratified gestation groups. There were no differences in death, BPD or other secondary outcomes.

Conclusion: Pressure support ventilation can be used safely to wean preterm infants. Infants randomized to PSVmax demonstrated faster weaning across all gestational ages, suggesting better unloading of respiratory musculature.

Corresponding author: prashmallya@gmail.com

References
1. Gupta S, Sinha SK, Donn SM. The effect of two levels of pressure support ventilation on tidal volume delivery and minute ventilation in preterm infants. ADC Fetal and Neonatal 2009;94(2):F80
2. Gillespie LM, White SD, Sinha SK, Donn SM. Usefulness of the minute ventilation test in predicting successful extubation in newborn infants: a randomized controlled trial. J Perinatol 2003;23:205

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