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"Latar belakang: Refluks gastroesofagus merupakan hal yang normal pada bayi prematur karena fungsi sfingter esofagus bawah belum sempurna. Penegakkan diagnosis refluks seringkali didasarkan oleh gejala klinis berupa apnea, desaturasi, dan bradikardi. Gejala-gejala tersebut sering dijadikan dasar untuk pemberian terapi proton pump inhibitor. Kondisi overdiagnosis dan overtreatment  ini bukan hanya terjadi di Indonesia, tetapi secara global.

Tujuan: Mengetahui frekuensi kejadian refluks, apnea, desaturasi, dan bradikardi pada bayi prematur. Mengetahui faktor risiko refluks pada bayi prematur terkait dengan modalitas suplementasi oksigen dan strategi pemberian susu. Mengetahui hubungan refluks dengan apnea, desaturasi, dan bradikardi.

Metode: Penelitian analitik observasional dengan desain potong lintang. Subjek adalah bayi prematur dengan postmentrual age 32-36 minggu yang memiliki riwayat apnea, desaturasi, atau bradikardi dicurigai akibat refluks. Subjek sudah mendapat susu minimal 60 mL/kg/hari. Subjek dieksklusi jika sudah mendapat obat prokinetik, penekan asam lambung, menggunakan alat bantu pernapasan yang lanjut (terintubasi, noninvasive positive pressure ventilation, atau continuous positive airway pressure dengan positive and expiratory pressure >7 cmH₂O), terdapat kelainan intrakranial, kongenital mayor, atau dalam kondisi sepsis. Posisi semua bayi adalah terlentang dengan kepala lebih tinggi 45°. Diagnosis refluks ditegakkan dengan menggunakan pemeriksaan baku emas, yaitu multipel intraluminal impedance – pHmetri, yang merekam kejadian refluks selama 24 jam. Diagnosis apnea, desaturasi, dan bradikardi ditegakkan dengan perekaman monitor hemodinamik dan pencatatan oleh perawat selama 24 jam.

Hasil: Dari total 20 subjek, terdapat 3882 refluks selama 24 jam. Dari refluks tersebut, sebanyak 331 refluks (8,5%) mencapai batas sfingter esofagus atas. Sebanyak 17 subjek (85%) mempunyai nilai indeks refluks normal (<5). Dari 2 subjek yang mempunyai indeks refluks ≥ 10, tidak ada gejala klinis esofagitis refluks yang khas. Karakteristis refluks sebagian besar merupakan jenis refluks cair (79,9%) yang bersifat asam lemah (84,6%). Tidak ada hubungan yang signifikan antara refluks dengan jenis suplementasi oksigen, jenis susu, frekuensi pemberian susu, durasi pemberian susu, ataupun volume pemberian susu. Proporsi refluks tinggi yang disertai dengan apnea dan bradikardi sangat kecil (0,3%). Secara statistik, refluks tinggi tidak berhubungan dengan kejadian desaturasi. Namun, terdapat 2 subjek (10%) yang mempunyai refluks tinggi disertai dengan desaturasi. Pada kedua subjek tersebut, tidak ada alarm symptoms yang khas.

Kesimpulan: Semua bayi prematur mengalami refluks, tetapi hanya 15% yang mengalami refluks patologis. Refluks pada bayi prematur tidak dipengaruhi oleh modalitas suplementasi oksigen ataupun strategi pemberian susu. Tidak ada hubungan antara refluks dengan kejadian apnea, desaturasi, dan bradikardi.

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Background: Gastroesophageal reflux is common in premature baby due to immature lower esophageal sphincter function. The diagnosis of reflux is often based on clinical symptoms such as apnea, desaturation, and bradycardia. Furthermore, these symptoms are often used as the basis by clinicians to provide proton pump inhibitor therapy. This condition of overdiagnosis and overtreatment does not only occur in Indonesia but globally.

Objective: To determine the frequency of reflux, apnea, desaturation, and bradycardia in preterm infants. To determine the risk of reflux in preterm infants related to oxygen supplementation and milk feeding strategy. To determine the significance of the association between reflux with apnea, desaturation, and bradycardia.

Method: Observational analytic study with a cross-sectional design. Subjects were preterm infants with postmenstrual age of 32-36 weeks who have a history of apnea, desaturation, or bradycardia suspected of reflux and have received milk at least 60 mL/kg/day. Subjects were excluded if they have received prokinetic drugs, gastric acid suppressants, are still using advanced respiratory support (intubated, non-invasive positive pressure ventilation, or continuous positive airway pressure with positive and expiratory pressure >7 cmH2O), having intracranial abnormalities, major congenital abnormalities, or sepsis condition. The position of all subjects is lying with head elevated 45°. Diagnosis of reflux was done using the gold standard examination, namely multiple intraluminal impedance – pHmetry, which records for 24 hours. Diagnoses of apnea, desaturation, and bradycardia were made with 24-hour hemodynamic monitor recording and was recorded by the attending nurse.

Results: From a total of 20 subjects, there were 3,882 refluxes over 24 hours. Of these refluxes, 331 refluxes (8.5%) reached the upper esophageal sphincter. A total of 17 subjects (85%) had normal reflux index values (<5). Of the 2 subjects who had a reflux index ≥ 10, there were no typical clinical symptoms of reflux esophagitis. Reflux characteristics were mostly liquid reflux (79.9%) and weak acid reflux (84.6%). There is no significant relationship between reflux with modes of oxygen supplementation, types of milk, frequency of feeding, duration of feeding, and milk volume. The proportion of high reflux accompanied by apnea and bradycardia was very small (0.3%). Statistically, high reflux was not associated with the incidence of desaturation. However, there was two subjects (10%) with refluxes accompanied by desaturation. There was no specific alarm symptoms in both subjects.

Conclusion: Reflux occurs in all preterm infants, but only 15% of them have pathological reflux. Reflux in preterm infants is not affected by oxygen supplementation modes or milk feeding strategy. There is no association between reflux and the incidence of apnea, desaturation, and bradycardia."

"Latar belakang: Intubasi endotrakeal merupakan tindakan yang cukup rumit dan memiliki risiko tinggi. Intubasi endotrakeal neonatus memiliki angka keberhasilan yang rendah pada percobaan pertama (first attempt) yaitu 20,3% dikarenakan kondisi desaturasi atau bradikardia. Angka mortalitas dan gangguan neurodevelopmetal meningkat pada neonatus yang gagal pada percobaan pertama intubasi. Penggunaan teknik HFN sebagai oksigenasi tambahan saat percobaan intubasi terbukti meningkatkan keberhasilan intubasi endotrakeal neonatus akan tetapi teknik tersebut memerlukan perangkat tambahan yang tidak selalu tersedia di fasilitas kesehatan. Teknik oksigenasi tambahan berupa VTP nasal dengan kanula RAM belum pernah diteliti. Tujuan: Untuk mengetahui efikasi ventilasi tekanan positif nasal dengan kanula RAM terhadap keberhasilan intubasi endotrakeal bayi prematur. Metode: Uji klinis terbuka yang dilaksanakan pada bulan Januari hingga Juni 2024. Sampel penelitian adalah bayi prematur usia gestasi ≥ 25 minggu sampai 34 minggu dengan asfiksia berat atau distres napas berat atau apnea yang memenuhi kriteria inklusi. Dilakukan randomisasi dan dibagi menjadi 2 kelompok yaitu kelompok kontrol (VTP standar) dan kelompok perlakuan (VTP standar yang ditambahkan VTP nasal dengan kanula RAM). Hasil: Terdapat 78 sampel yang terdiri dari 39 kelompok perlakuan dan 39 kelompok kontrol. Keberhasilan intubasi pada kelompok perlakuan adalah 84,6% dibandingkan kelompok kontrol 41% dengan nilai Absolute Risk Reduction (ARR) 44% dan Number Need to Treat (NNT) 2. Kejadian desaturasi pada kelompok perlakuan adalah 10,3% dibandingkan kelompok kontrol 59% dengan nilai Absolute Risk Reduction (ARR) 49% dan Number Need to Treat (NNT) 2. Rerata rentang waktu sampai terjadi desaturasi pada kelompok perlakuan sebesar 46 detik dibandingkan kelompok kontrol 29,74 (p=0,142).

Kesimpulan: VTP nasal dengan kanula RAM meningkatkan keberhasilan intubasi endotrakeal neonatus dan mengurangi desaturasi. Rerata rentang waktu sampai terjadi desaturasi secara klinis bermakna antara kedua kelompok penelitian.

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Background: Endotracheal intubation in neonates is a complex and risky procedure, with a low initial success rate of 20.3% primarily due to desaturation or bradycardia. Neonates who fail in the first attempt of endotracheal intubation are at increased risk of mortality and neurodevelopmental disorders. High-flow nasal (HFN) techniques have been shown to enhance the success of neonatal endotracheal intubation, but their implementation may be limited by the availability of necessary equipment in healthcare settings. Additional oxygenation techniques such as Nasal Positive Pressure Ventilation (PPV) through a RAM cannula in neonatal endotracheal intubation has not been studied.

Objective: To evaluate the efficacy of nasal positive pressure ventilation with ram cannula compared to the outcomes of endotracheal intubation in preterm neonates.

Methods: Open clinical trials conducted from January to June 2023. The research sample consists of preterm neonates with a gestational age of ≥ 25 weeks to 34 weeks with severe asphyxia or severe respiratory distress or apnea that meet the inclusion criteria. Randomization was performed and divided into 2 groups, namely the control group (standard PPV) and the treatment group (standard PPV with the addition of nasal PPV with RAM cannula).

Results: The study sample included 78 neonates consisting of 39 in the treatment groups and 39 in the control groups. The intubation success rate in the treatment group was 84.6%, significantly higher than the 41% success rate observed in the control group. This discrepancy resulted in an Absolute Risk Reduction (ARR) of 44% and a Number Needed to Treat (NNT) of 2. Furthermore, the occurrence of desaturation in the treatment group was notably lower at 10.3% compared to 59% in the control group, leading to an Absolute Risk Reduction (ARR) of 49% and a Number Needed to Treat (NNT) of 2. The mean time to desaturation in the treatment group was 46 seconds compared to 29.74 seconds in the control group (p=0.142).

Conclusion: Nasal PPV with RAM canula improves the success of neonatal endotracheal intubation and decrease desaturation episodes. There is a clinically significant difference in the mean time interval until desaturation occurs between the two research groups."