When Air Leaks Meet Innovation: Obturator-Assisted Non-invasive Ventilation in a Preterm Infant With a Unilateral Cleft Lip and Palate.

Preterm infants often have respiratory distress requiring non-invasive respiratory support. Those born with a cleft lip and palate pose significant challenges in maintaining positive pressure due to anatomic differences that can cause substantial air leak when using typical mask/cannula interfaces. This leads to difficulties with ventilation and oxygenation for these infants whose lung disease would otherwise not necessitate invasive ventilation. The purpose of this case report is to provide a multidisciplinary approach to a preterm infant with a unilateral cleft lip and palate for innovative solutions in respiratory support, allowing the best possible patient outcomes by minimizing the days requiring endotracheal intubation. A 28+1-week male infant with a birth weight of 1540 g and prenatally diagnosed left-sided cleft lip and palate was born prematurely for maternal reasons. There were difficulties supporting the infant via non-invasive ventilatory methods, and multiple intubation attempts were required due to underlying anatomic airway anomalies. Upon literature review and discussion with the maxillofacial prosthetics team at our institution, a custom oral obturator was developed to provide a pseudo-palate for this infant. This allowed for decreased air leak and facilitated successful extubation to non-invasive positive pressure ventilation (NIPPV) with a RAM cannula interface (Neotech Products LLC, Valencia, CA, USA). Three evolving versions of the obturator were developed, with the final version that provided the best seal, reduced dislodgement rates, decreased oral ulcerations, and overall improved infant comfort. Use of a custom oral obturator in preterm infants to facilitate extubation to NIPPV is feasible early in the clinical course. A multidisciplinary care team is required that includes maxillofacial prosthetics or a similar specialty that can mold this type of device. This can provide a framework for future design and use of an oral obturator to facilitate earlier extubation and minimize long-term complications associated with prolonged intubation in the neonatal period.