High-flow nasal cannula for neonatal respiratory distress: is it enough?

CPAP is the most studied form of noninvasive ventilation in neonates, and early investigations focused on the use of CPAP following surfactant administration, to minimize the need for invasive mechanical ventilation.1 Verder and colleagues demonstrated that a strategy of CPAP following brief intubation and surfactant administration (the INSURE technique: INtubation, SURfactant, Extubation) improved outcomes in patients with respiratory distress syndrome (RDS),2 and those results were replicated in multiple randomized controlled trials.3 In addition, early observational studies also suggested that preterm neonates treated with CPAP alone (without endotracheal intubation and surfactant) had less need for mechanical ventilation.4-8 The Neonatal Research Network’s SUPPORT (Surfactant, Positive Pressure, and Pulse Oximetry Randomized Trial) trial in extremely preterm infants confirmed that CPAP alone wassuperior to intubationandsurfactant administrationwithin 1 hour of birth.9 Those results, along with similar findings from the European CURPAP study, led to the general acceptance of CPAP as an alternative to intubation and surfactant administration in extremely preterm neonates.10 Despite these recognized benefits of CPAP, the optimal method for the noninvasive delivery of distending pressure is unknown. A variety of devices are currently utilized, and they differ in both the type of gas flow generated (constant vs variable flow) and patient interface.11 Regardless of the interface selected, nasal breakdown is a frequent complication associated with all infant nasal CPAP devices.12 In one study, 13% of infants treated with CPAP developed some form of nasal complication after only 10 days of support.13 These complications include skin excoriation, nasal damage, nasal obstruction, and cutaneous infection.14