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PEDIATRICS Vol. 108 No. 1 July 2001, pp. 13-17
, and
From the Departments of * Pediatrics and Objective. To determine whether
synchronized nasal intermittent positive pressure ventilation (SNIPPV)
would decrease extubation failure compared with nasal continuous
positive airway pressure (NCPAP) in preterm infants being ventilated
for respiratory distress syndrome (RDS).
Methods. Infants who were Results. Thirty-two (94%) of 34 infants were extubated
successfully with the use of SNIPPV versus 18 (60%) of 30 with the use
of NCPAP (P < .01). There was no difference in
apnea/bradycardia episodes in the 2 groups during the 72-hour study
period. Among 55 infants who had PFT, 80% (8 of 10) with dynamic lung
compliance of Conclusions. SNIPPV is more effective than NCPAP in
weaning infants with RDS from the ventilator. PFT may be useful in
predicting successful extubation.
Respiratory Care,
Albert Einstein Medical Center, Philadelphia, Pennsylvania.
ABSTRACT
Top
Abstract
Methods
Results
Discussion
Conclusion
References
34 weeks' gestational age and
who were ventilated for RDS were randomized to either SNIPPV or NCPAP
after extubation. The criteria for extubation were peak inspiratory pressure of 16 cm H2O, positive end expiratory pressure
of 5 cm H2O, intermittent mandatory ventilation rate of
15 to 25, and fraction of inspired oxygen 0.35. Pulmonary function
tests (PFT) were obtained before extubation. After extubation, blood
gases were monitored for a minimum of 72 hours. Success was defined as
remaining in the selected mode of treatment or demonstrating improvement (switching to oxyhood/nasal cannula/room air) by 72 hours.
0.5 mL/kg/cm H2O and expiratory airway
resistance of 70 cm H2O/L/s were extubated successfully.
In infants with poor lung function (dynamic lung compliance: <0.5
mL/kg/cm H2O; expiratory airway resistance: >70 cm
H2O/L/s), successful extubation was seen in 93% (27 of 29)
in the SNIPPV group and 60% (15 of 25) in the NCPAP group. When weight
was controlled for at the time of extubation, the odds of success in
the SNIPPV group were 21.1 times higher (95% confidence interval: 3.4, 130.1) than that of the NCPAP group.
Continuous positive airway pressure (CPAP) frequently is
used to wean infants from mechanical ventilation. The common modalities of delivering CPAP are through nasal prongs
(NCPAP),1-7 nasopharyngeal tube
(NPCPAP),8 endotracheal tube,5,9 or face
mask.10 These studies have yielded conflicting results in
regard to their efficacy. Although some studies1,2,4,6 showed that NCPAP facilitates extubation as compared with oxyhood, others3,5,8 found no difference. Robertson and
Hamilton7 did not find any difference between elective versus rescue NCPAP after extubation. However, a recent meta-analysis favors the use of prophylactic NCPAP postextubation.11 Endotracheal CPAP was found to be deleterious,5,9 whereas
face mask CPAP was shown to be beneficial.10 We showed
previously that NCPAP is as efficacious as NPCPAP in weaning infants
with respiratory distress syndrome (RDS) from mechanical
ventilation.12
Nasal intermittent positive pressure ventilation (NIPPV) involves
giving CPAP to the infant in the intermittent mandatory ventilation
(IMV) mode. A number of studies have evaluated
NIPPV.13-20 Garland et al13 found increased
risk of gastrointestinal perforations in sick neonates who were on
mechanical ventilation with either nasal prongs or face mask in a
retrospective case-control study in the presurfactant era. Other
investigators14 did not find any advantage of NIPPV over
NCPAP in treating infants with apnea of prematurity. However, this
crossover study evaluated the frequency of apnea/bradycardia for only 6 hours after extubation. They did not report any significant side
effects. Two other studies15,17 were uncontrolled, whereas
Lin et al16 found decreased apnea in infants who were on
NIPPV during a 4-hour observation period.
So, although most studies support the notion that CPAP is beneficial
compared with oxyhood1,2,4,6,10,11 and NCPAP is as
efficacious as NPCPAP12 in weaning infants from mechanical
ventilation, there is scant information available in the postsurfactant
era to suggest the benefit of nasal ventilation over NCPAP.
In addition, most studies that evaluated NIPPV had a small number of
infants,14-16,18,20 only looked at short-term
effects,14-20 or did not evaluate lung
function.14-16,19 Thus, we hypothesized that synchronized
NIPPV (SNIPPV) would decrease extubation failure as compared with NCPAP
in preterm infants. Specifically, we conducted a prospective,
randomized, controlled study comparing the efficacy of SNIPPV versus
NCPAP in the weaning of premature infants ( The size of the prongs to be used for each infant was determined
by the infants' weight as follows: large, for infants weighing 1500 g; small, for infants 1000 to 1500 g; and X-small, for
infants weighing 1000 g and under. The Argyle CPAP Nasal Cannula
Kit (Sherwood Medical, St Louis, MO) was used.
The ventilators used were either the Bear Cub (Model BP 2001; Bear
Medical Systems, Inc, Riverside, CA) or the Infant Star 500/950
(Infrasonics, Inc, San Diego CA), with synchronized IMV box (Star Sync;
Infrasonics). The Infant Star was used in the infants who were assigned
to the SNIPPV mode. PFT were obtained with the use of the Bicore CP-100
Neonatal Pulmonary Monitor (Bicore Monitoring Systems, Irvine, CA).
Patients
All neonates ( Definitions
Pregnancy-induced hypertension was defined as a maternal
systolic blood pressure of >140 mm Hg and a diastolic pressure of >90
mm Hg in the presence of proteinuria (>300 mg/24 hours) and nondependent edema. A positive culture from the amniotic fluid was
defined as chorioamnionitis. In the absence of the above, chorioamnionitis was defined in the presence of organisms on Gram stain, sheets of leukocytes, or low glucose in the amniotic fluid in
the presence of any 2 of the following clinical symptomatology: maternal fever, leukocytosis, uterine tenderness, pus from the cervix,
and fetal tachycardia. RDS was defined in the presence of clinical
features and a positive chest x-ray. Air leaks were documented by
positive evidence of pneumothorax, pneumomediastinum, or pulmonary
interstitial emphysema on the chest radiograph. PPV was inclusive of
endotracheal tube ventilation, SNIPPV, and NCPAP. Patent ductus
arteriosus was documented by echocardiography. Intraventricular hemorrhage was determined according to Papile's classification of
cranial ultrasound findings of blood in the germinal matrix or
ventricular system with or without ventricular dilation and parenchymal
extension.21 Periventricular leukomalacia was defined as
cerebral ultrasound findings of increased echogenicity and cystic
lesions in the periventricular white matter.22 Chronic
lung disease (CLD) was defined as the need for oxygen supplementation
at 36 weeks' postconceptional age in association with characteristic
radiograph changes.23 Sepsis was diagnosed by a positive
blood culture. Necrotizing enterocolitis was defined as Management of RDS
Infants were treated as per nursery standards for RDS. Initial
ventilator settings of infants with RDS included peak inspiratory pressure (PIP) at 16 to 20 cm H2O, positive end
expiratory pressure (PEEP) at 4 to 6 cm H2O, an
inspiratory time of 0.35 to 0.45 seconds, a rate of 40 to 60/min, and
fraction of inspired oxygen (FIO2) adjusted to keep saturations at 90% to 96%. Exogenous surfactant (Survanta; Ross Laboratories, Columbus, OH) was used only as rescue therapy. The infant was weaned as clinically tolerated and monitored by
serial blood gas analyses. The criteria for extubation were PIP Once the infants fulfilled the criteria for extubation, PFT were
conducted by the neonatal respiratory therapist. PFT included dynamic
lung compliance (CDYN) and expiratory airway
resistance (RAWE) measurements. PFT were
considered reliable for analyses only if air leak was <20% and
reproducible optimal flow-volume and pressure-volume loops were
obtained.
Infants were assigned randomly either to SNIPPV or to NCPAP with the
use of sealed envelopes and 3 birth weight blocks as follows: 500 to
749 g, 750 to 999 g, and >1000 g. Infants who were
randomized to NCPAP were put on CPAP of 4 to 6 cm
H2O. Infants who were randomized to SNIPPV
received synchronized IMV at the same rate as they were receiving
before extubation, PIP was increased by 2 to 4 cm
H2O, and the PEEP was kept at After careful evaluation of the infant's respiratory status, the
infant was weaned from SNIPPV/NCPAP to nasal cannula, oxyhood, or room
air. This was done by the attending neonatologist with the use of the
following guidelines: in the SNIPPV group, once the infants had
ventilator settings of PIP/PEEP 14/4 cm H2O, rate of Extubation failure was defined as the need for reintubation and
mechanical ventilation. Reintubation was performed in the presence of
any of the following (within 72 hours of extubation): a pH <7.25,
PaCO2 >60 mm Hg, a single episode of apnea
needing bag and mask resuscitation, frequent (>2-3/hour)
apnea/bradycardia spells (cessation of respiration for >20 s
associated with a heart rate of <100/min) not responding to
theophylline therapy, frequent desaturations (<85%) Infants were monitored as per standard nursing protocols in our NICU.
Cranial ultrasound was done on all infants at days 1 to 3 and 7 to 10, at discharge, and as indicated. X-rays, cardiac echocardiography, blood
cultures, and pH probe tests were conducted when clinically indicated.
Eye examinations were performed on the infants by pediatric
ophthalmologists at 4 to 6 weeks of age and repeated every 1 to 2 weeks
as indicated. Specialist physicians who performed the cranial
ultrasound, echocardiographic, and eye examinations were not aware of
the child's grouping status. The rest of the medical treatment of
these infants was as per the attending neonatologist.
Statistical Analysis
We calculated our sample size to detect a 50% reduction in the
number of reintubations with SNIPPV compared with NCPAP, with Between September 1998 and September 1999, 119 infants who were
TABLE 134 weeks' gestational age
[GA]) from mechanical ventilation with RDS. Furthermore, we
determined whether pulmonary function tests (PFT) obtained on these
infants before extubation would help us to identify infants with the
best chance of success (ie, remaining extubated). In addition, neonatal
intensive care (NICU) outcome (up to patient discharge from hospital)
was analyzed.
METHODS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
34 weeks' GA) who were admitted to the NICU
with the diagnosis of RDS and required mechanical ventilation formed the study group. Infants with major congenital malformations were excluded. The study was approved by the Institutional Review Board of
the Albert Einstein Healthcare Network, and signed consent was obtained
from 1 or both parents. Data were collected as per the following
definitions.
stage 2 as
per modified Bells criteria.24 Gastroesophageal reflux was
diagnosed by a positive pH probe test. Retinopathy of prematurity (ROP)
was defined as per the international classification.25
16 cm
H2O, PEEP 5 cm H2O, IMV
rate of 15 to 25, FIO2 of .35,
aminophylline level of 8 mg/L, and hematocrit of 40%.
5 cm
H2O; FIO2 was adjusted in all infants to maintain oxygen saturations at 90% to 96%
on pulse oximetry. The flow rate was kept at 8 to 10 L/min in both
modes of respiratory support. A blood gas was obtained 1 to 3 hours
after extubation as is routine in our NICU. Blood gas analyses were
conducted from samples that were obtained from indwelling arterial
lines (in 35 [55%] of 64 infants) or arterialized capillary blood
that was obtained from a warmed heel. Thereafter, blood gases were
conducted as clinically indicated, but at least once every 8 hours in
the first 24 hours postextubation, then every 12 hours for 48 hours as
long as the infant was on the NCPAP/SNIPPV mode. Ventilator rates could
be increased to 25/min in the SNIPPV mode, if needed, to maintain
normal blood gases (vide infra).
20/min, and FIO2 0.3 with
normal blood gases; in the NCPAP group, once CPAP reached 4 cm
H2O and FIO2
0.3 with normal blood gases. Success was defined as remaining in the
selected mode of treatment or demonstrating improvement (switching to
nasal cannula/oxyhood/room air) by 72 hours.
3 episodes/hour
not responding to increased ventilatory settings or an increase in
FIO2 to 1.0, or a
PaO2 <50 mm Hg despite an
FIO2 of 1.0.
= 0.05 and a power of 80%, and estimated that 25 infants were needed
in each group. Statistical analyses were performed with the use of SPSS
9.0 for Windows (SPSS, Inc, Chicago, IL). SNIPPV and NCPAP groups were
compared with the use of student's t test, 
2, or Mann-Whitney U analyses, as
appropriate. Mantel-Haenszel 2 was used for
the subgroup analyses. Logistic regression was used to examine factors
that influenced successful extubation. P < .05 was
considered statistically significant.
RESULTS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
34 weeks' GA were admitted to the NICU. Sixty-eight percent (81 of
119) had RDS and hence were eligible for enrollment in this study.
Consent was obtained for 64 patients. Infants (N = 17)
who were not randomized had demographic characteristics similar to the
study patients (data not shown). Thirty-four infants were randomized to
SNIPPV, and 30 infants were randomized to NCPAP. The mean birth weight
was 1088 versus 1032 g, respectively; the GA was 28 weeks for both
SNIPPV and NCPAP groups. Study infants also were similar in other
characteristics as shown in Table 1.
Demographic Data
The median age and weight at study were similar in both groups (Table 2). Before extubation, the mean airway pressure, FIO2, RAWE, and CDYN were similar in both groups (Table 2). Postextubation blood gases also were similar in the 2 groups for 72 hours (data in Table 2 indicates the pH, PCO2 of the first gas).
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However, 32 (94%) of 34 infants who were randomized to receive SNIPPV were extubated successfully as compared with 18 (60%)of 30 on NCPAP (P < .01; Table 2). Two infants failed SNIPPV, both of them on day 2 of the study. One was reintubated because of frequent apnea, the other because of an increase in PaCO2. Twelve infants who were randomized to NCPAP failed extubation because of multiple desaturations/frequent or significant apnea; 8 infants failed on day 1, and 4 infants failed on day 2. Ten infants were reintubated. Although crossover was not part of the study design, the remaining 2 infants were placed on SNIPPV (at the discretion of the attending neonatologist) and remained extubated successfully. Even when these 2 infants were excluded from analyses, the success rate of SNIPPV over NCPAP (32 [94%] of 34 vs 16 [57%] of 28) remained significant (P = .001).
We also looked at "late failures" (ie, infants who required reintubation after 72 hours of the study period). There were 4 infants in the SNIPPV compared with 1 infant in the NCPAP who were reintubated after the designated study period; this was not significantly different (P = .4). Even after the late failures were taken into account, more infants on SNIPPV remained successfully extubated as compared with infants on NCPAP (28 [82%] of 34 vs 17 [57%] of 30; P = .03).
We analyzed the data regarding PFT (55 [86%] of 64). Cutoff points
for RAWE and for CDYN were
chosen by the use of normative data (as per the study manual of the
Bicore CP-100 pulmonary monitor) in predicting successful extubation.
The normal value for CDYN was 0.5 to 1.0 mL/kg/cm
H2O, whereas it was 35 to 70 cm
H2O/L/s for RAWE. Among all
infants (SNIPPV and NCPAP) with RAWE of 70, 10 (83%) of 12 were extubated successfully. With the use of a cutoff
value of 0.5 for CDYN, 33 (77%) of 43 of the
infants were extubated successfully. In infants (SNIPPV and NCPAP
together) with good lung function (by combining the above 2 cutoff
values), 8 (80%) of 10 were extubated successfully. Thus, the
sensitivity, specificity, positive predictive value, and negative
predictive value were 86%, 16%, 80%, and 22%, respectively. In
infants with poor lung function (RAWE >70 cm
H2O/L/s and CDYN <0.5
mL/kg/cm H2O), successful extubation was seen in
27 (93%) of 29 infants on SNIPPV versus 15 (40%) of 25 on NCPAP
(P < .01).
There were no differences between infants who were or were not extubated successfully except that success was associated with a higher weight at the time of extubation (1.24 ± 0.04 vs 4.95 ± 0.08 kg; P = .001). However, by logistic regression analysis, both mode of extubation (P = .001) and weight (P = .006) predicted successful extubation. When weight was controlled for, the odds of successful extubation in the SNIPPV group were 21.1 times higher (95% confidence interval: 3.4, 130.1) than that of the NCPAP group.
There were no deaths in either group. Days on PPV, oxygen days, neonatal sepsis, air leaks, patent ductus arteriosus, use of postnatal steroids, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, ROP, CLD, and length of stay were not significantly different in the 2 groups (Table 3).
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We also did a subgroup analysis of the successful extubation within the SNIPPV and NCPAP groups on the basis of birth weight categories as per the randomization protocol. In all 3 birth weight categories, more infants on SNIPPV remained successfully extubated: in infants with birth weight of <750 g, 5 (100%) of 5 on SNIPPV versus 4 (57%) of 7 on NCPAP (P = .2); in infants with birth weight of 750 to 999 g, 10 (83%) of 12 on SNIPPV versus 3 (27%) of 11 on NCPAP (P = .01); and for those weighing >999 g, 17 (100%) of 17 on SNIPPV versus 11 (92%) of 12 on NCPAP (P = .41). We evaluated further the NICU outcome in the 3 birth weight categories. The groups were similar; however, the number of infants in each birth weight category were too small for definite conclusions. No adverse effects of either therapy (SNIPPV or NCPAP) were noted during the hospital stay of the infants.
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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In this prospective, randomized, controlled study, we showed that infants who were extubated to the SNIPPV mode had a significantly higher success rate compared with the NCPAP group (94% vs 60%; P < .01) at 72 hours postextubation. The study patients were well matched in terms of birth weight, GA, and severity of RDS (using doses of surfactant as a surrogate marker) as shown in Table 1. The age and the weight at study as well as preextubation parameters were not significantly different (Table 2).
With increased survival of very low birth weight (VLBW) infants, the number of VLBW infants who require prolonged mechanical ventilation has increased. Increasingly, the pulmonary management of these infants is directed at minimizing the need for prolonged mechanical ventilation to reduce ventilator-induced trauma and oxygen toxicity. Nevertheless, early extubation often presents difficulties because of upper-airway instability, poor respiratory drive, alveolar atelectasis, and residual lung damage.11,26,27 CPAP, by various means, commonly is used to wean premature infants from mechanical ventilation.
Numerous investigators have shown that NCPAP is better than oxyhood,1,2,4,6,10,11 and we showed previously12 that NCPAP is as efficacious as NPCPAP for successful weaning from the ventilator. Potential benefits of NCPAP include prevention of atelectasis,1 improved oxygenation,10 and decreased apnea.10 Miller et al28 speculated that NCPAP decreases supraglottic resistance directly through mechanical splinting of the airway and that this might be the primary mechanism for reduction of obstructive apnea in premature infants. It has been shown that NCPAP improves thoracoabdominal motion synchrony, and this is suggestive of an improved breathing strategy.29 Recently, Kiciman et al18 showed a decrease in thoracoabdominal motion asynchrony in newborns who were ventilated with nasal IMV and that nasal IMV decreased flow resistance through the nasal prongs and improved the stability of the chest wall, resulting in improved pulmonary mechanics. We support the notion that the addition of a PIP above PEEP by using SNIPPV not only adds intermittent distending pressure above PEEP but also increases flow delivery in the upper airway as suggested by Friedlich et al.30 Furthermore, Moretti et al20 found that application of SNIPPV was associated with an increase in tidal and minute volumes as compared with NCPAP in the same infant. Furthermore, SNIPPV could be creating an inadvertent PEEP that would allow recruitment of alveoli and improved functional residual capacity. All of the above factors probably account for the success of SNIPPV over NCPAP in our study.
Ryan et al,14 in a crossover study that evaluated the frequency of apnea/bradycardia for 6 hours after extubation, did not find any advantage of NIPPV over NCPAP. Similarly, we found no difference in the incidence of apnea in both of our study groups during 72 hours. Lin et al,16 in their study of 34 infants, concluded that NIPPV is more effective than NCPAP in reducing the frequency of apneic episodes during a 4-hour observation period. In the present study, overall, only 41% of infants had apnea (14 and 11 infants in the NCPAP and SNIPPV groups, respectively), and we had a low frequency of apnea in both groups (Table 2) during the study period (72 hours). Lin et al14 themselves pointed out that they had a higher incidence of apnea as compared with Ryan et al.16 Our lower incidence of apnea could be attributable to a different patient population, therapeutic levels of aminophylline, higher hematocrit, or better respiratory support.
Recently, Derleth15 reported his clinical experience with NIPPV in 7 premature infants. Five of the 7 infants were treated successfully with NIPPV and avoided reintubation. Barrington et al19 in their trial found that nasal synchronized IMV was more effective than NCPAP in preventing extubation failure in 54 VLBW infants in the first 72 hours after extubation. Our results support those of previous studies15,17,19,20 in that nasal ventilation can be beneficial to preterm neonates. Similarly, Friedlich et al30 also concluded that nasal synchronized IMV is more effective than NPCPAP in decreasing extubation failure.
Visveshwara et al,17 in a nonrandomized trial, reported
that using expiratory resistance of <225 cm
H2O/L/s as a cutoff value could predict
successful weaning to SNIPPV with a sensitivity of 87% and a
specificity of 71%. Using the same cutoff value as the above mentioned
study,17 we found a sensitivity of 71% and a specificity
of 54%. In the present study, with the use of a combination of
RAWE of 70 cm H2O/L/s and
CDYN of .5 mL/kg/cm H2O,
the sensitivity was 86% and the specificity was 16%. Interestingly,
even with poor lung function (RAWE >70 cm H2O/L/s and CDYN <0.5
mL/kg/cm H2O), successful extubation was seen in
27 of 29 (93%) infants on SNIPPV versus 15 of 25 (40%) on NCPAP
(P < .01). As was true in the present trial, PFT alone may not be useful in determining optimal timing of extubation in
premature infants.31
There were no adverse effects of therapy noted or differences in NICU
outcome in both groups. It is intriguing to note that infants who were
on SNIPPV (vs NCPAP) had less ROP (stage II; 32% vs 57%;
P = .08) and decreased CLD (35% vs 53%;
P = .2) (Table 3). Because our study was not designed
to evaluate specifically whether SNIPPV could decrease ROP or CLD, we
can only speculate that infants who were on SNIPPV had decreased
ventilator-induced trauma and oxygen toxicity.
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CONCLUSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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We found SNIPPV to be more effective than NCPAP in weaning infants with RDS from mechanical ventilation. PFT may be used to aid in predicting successful extubation. In concurrence with the results of other investigators,12,14,17,19 we recommend that SNIPPV be used as the primary mode of extubation, even in infants with poor lung function. Furthermore, a prospective randomized trial should be conducted to ascertain whether SNIPPV has an impact in decreasing ROP and CLD.
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FOOTNOTES |
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Received for publication May 31, 2000; accepted Oct 16, 2000.
Reprint requests to (V.B.) Division of Neonatology, 2601 Lifter, Department of Pediatrics, Albert Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141. E-mail: bhandarv{at}aehn2.einstein.edu
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ABBREVIATIONS |
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CPAP, continuous positive airway pressure; NCPAP, nasal continuous positive airway pressure; NPCPAP, nasopharyngeal tube positive airway pressure; RDS, respiratory distress syndrome; NIPPV, nasal intermittent positive pressure ventilation; IMV, intermittent mandatory ventilation; SNIPPV, synchronized nasal intermittent positive pressure ventilation; GA, gestational age; PFT, pulmonary function tests; NICU, neonatal intensive care unit; CLD, chronic lung disease; ROP, retinopathy of prematurity; PIP, peak inspiratory pressure; PEEP, positive end expiratory pressure; FIO2, fraction of inspired oxygen; CDYN, dynamic lung compliance; RAWE, expiratory airway resistance; VLBW, very low birth weight.
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REFERENCES |
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Methods
Results
Discussion
Conclusion
References
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This article has been cited by other articles:
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  A A Hutchison and S Bignall Non-invasive positive pressure ventilation in the preterm neonate: reducing endotrauma and the incidence of bronchopulmonary dysplasia Arch. Dis. Child. Fetal Neonatal Ed., January 1, 2008; 93(1): F64 - F68. [Full Text] [PDF]
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N. Claure and E. Bancalari New modes of mechanical ventilation in the preterm newborn: evidence of benefit Arch. Dis. Child. Fetal Neonatal Ed., November 1, 2007; 92(6): F508 - F512. [Full Text] [PDF]
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L. S Owen, C. J Morley, and P. G Davis Neonatal nasal intermittent positive pressure ventilation: what do we know in 2007? Arch. Dis. Child. Fetal Neonatal Ed., September 1, 2007; 92(5): F414 - F418. [Abstract] [Full Text] [PDF]
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 F. Moreau-Bussiere, N. Samson, M. St-Hilaire, P. Reix, J. R. Lafond, E. Nsegbe, and J.-P. Praud Laryngeal response to nasal ventilation in nonsedated newborn lambs J Appl Physiol, June 1, 2007; 102(6): 2149 - 2157. [Abstract] [Full Text] [PDF]
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 F. van Griensven, S. Naorat, P. H. Kilmarx, S. Jeeyapant, C. Manopaiboon, S. Chaikummao, R. A. Jenkins, W. Uthaivoravit, P. Wasinrapee, P. A. Mock, et al. Palmtop-assisted Self-Interviewing for the Collection of Sensitive Behavioral Data: Randomized Trial with Drug Use Urine Testing Am. J. Epidemiol., February 1, 2006; 163(3): 271 - 278. [Abstract] [Full Text] [PDF]
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 H. Christou and D. Brodsky Lung Injury and Bronchopulmonary Dysplasia in Newborn Infants J Intensive Care Med, March 1, 2005; 20(2): 76 - 87. [Abstract] [PDF]
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 B. M. Stefanescu, W. P. Murphy, B. J. Hansell, M. Fuloria, T. M. Morgan, and J. L. Aschner A Randomized, Controlled Trial Comparing Two Different Continuous Positive Airway Pressure Systems for the Successful Extubation of Extremely Low Birth Weight Infants Pediatrics, November 1, 2003; 112(5): 1031 - 1038. [Abstract] [Full Text] [PDF]
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A G De Paoli, C Morley, and P G Davis Nasal CPAP for neonates: what do we know in 2003? Arch. Dis. Child. Fetal Neonatal Ed., May 1, 2003; 88(3): F168 - F172. [Abstract] [Full Text] [PDF]
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J. K. Jackson, J. Vellucci, P. Johnson, and H. W. Kilbride Evidence-Based Approach to Change in Clinical Practice: Introduction of Expanded Nasal Continuous Positive Airway Pressure Use in an Intensive Care Nursery Pediatrics, April 1, 2003; 111(4): e542 - 547. [Abstract] [Full Text] [PDF]
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