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Hirsch TI, Tsikis ST, Fligor SC, Pan AS, Wang SZ, Quigley M, Dadi S, Kishikawa H, Mitchell PD, Niaudet C, Bielenberg DR, Puder M. Systemic heparin administration impairs lung development in neonatal mice. Sci Rep 2025; 15:15273. [PMID: 40312554 PMCID: PMC12046039 DOI: 10.1038/s41598-025-99831-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 04/23/2025] [Indexed: 05/03/2025] Open
Abstract
Preterm infants born in the saccular stage of lung development are at risk for developing bronchopulmonary dysplasia (BPD). Oxygen toxicity and volutrauma are identified as major contributors of BPD. Despite mitigation of these risks preterm infants continue to be affected by chronic lung disease. Heparin is commonly administered to preterm infants and is known to interfere with angiogenesis, a critical element of lung development. We previously demonstrated, in a murine model, that compensatory lung growth after left pneumonectomy is inhibited by heparin administration. Based on these results, we hypothesized that heparin would interfere with lung development in neonatal mice, which are born during the saccular phase of lung development. Newborn C57BL/6J mice received either therapeutic unfractionated heparin (UFH), low molecular weight heparin (LMWH) or normal saline (control) for the first week of life. At one month, both UFH and LMWH produced an emphysematous lung phenotype. Late administration of heparin, after the saccular phase did not impact lung function or growth. This data establishes the negative effects of UFH and LMWH during the critical period of postnatal lung development. Based on this work, clinical studies on the impact of heparin on lung development of newborn and preterm infants are warranted.
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Affiliation(s)
- Thomas I Hirsch
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Savas T Tsikis
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Scott C Fligor
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Amy Shei Pan
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Sarah Z Wang
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Mikayla Quigley
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA
| | - Srujan Dadi
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Hiroko Kishikawa
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Paul D Mitchell
- Biostatistics and Research Design Center, Boston Children's Hospital, Boston, MA, 02115, USA
| | - Colin Niaudet
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Diane R Bielenberg
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Mark Puder
- Vascular Biology Program, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Fegan 3, Boston, MA, 02115, USA.
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Fuchs A, Disma N, Engelhardt T, Marchesini V, Riedel T, Boda K, Habre W, Riva T, Disma N, Veyckemans F, Virag K, Hansen TG, Becke-Jakob K, Harlet P, Vutskits L, Walker SM, de Graaff JC, Zielinska M, Simic D, Engelhardt T, Habre W. Ventilation strategies and risk factors for intraoperative respiratory critical events and postoperative pulmonary complications in neonates and small infants: a secondary analysis of the NECTARINE cohort ☆. Br J Anaesth 2025:S0007-0912(25)00058-3. [PMID: 39979152 DOI: 10.1016/j.bja.2024.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 11/08/2024] [Accepted: 12/10/2024] [Indexed: 02/22/2025] Open
Abstract
BACKGROUND Optimal ventilation strategies and use of neuromuscular blocking agents (NMBAs) in neonates and small infants undergoing anaesthesia remain unclear. We examined the association of perioperative ventilation strategies and administration of NMBAs on respiratory adverse events in the NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) cohort. METHODS We performed a secondary analysis of NECTARINE, which included infants up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures. The primary endpoint was the association between ventilation mode and intraoperative respiratory adverse events. Secondary endpoints were use of NMBA, and 30-day postoperative pulmonary complications (PPCs). RESULTS The dataset comprised 5609 patients undergoing 6542 procedures. Pressure-controlled ventilation was the primary ventilation modality, accounting for 52.4% (n=3428) of cases. The incidence of intraoperative respiratory critical events was 20.7% (95% confidence interval [CI] 19.7-21.7%), while PPCs were observed in 17% of cases (95% CI 16.0-18.1%). Preanaesthesia respiratory conditions and NMBA use after tracheal intubation were associated with higher incidence of PPCs. Of the children receiving NMBAs, reversal was reported in 29.8%. The absence of reversal was associated with a higher incidence of PPCs, with a relative risk of 1.50 (95% CI 1.17-1.93). Conversely, NMBA reversal was associated with a reduced relative risk of 0.43 (95% CI 0.26-0.70). CONCLUSIONS Regardless of ventilation strategy used, mechanical ventilation and baseline respiratory conditions were risk factors for a greater incidence of adverse respiratory events and PPCs. Reversal of NMBAs before tracheal extubation was significantly associated with reduced PPCs in neonates and should be routine clinical practice. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT02350348).
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Affiliation(s)
- Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Children's Hospital, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Nicola Disma
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Thomas Engelhardt
- Queen Elizabeth Hospital of Montreal Foundation, Department of Pediatric Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada
| | - Vanessa Marchesini
- Department of Anaesthesia, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Thomas Riedel
- Division of Paediatric Critical Care, Department of Paediatrics, Children's Hospital, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Krisztina Boda
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Walid Habre
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Children's Hospital, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicola Disma
- Department of Anaesthesia, Unit for Research & Innovation, Istituto Giannina Gaslini, Genova, Italy
| | - Francis Veyckemans
- Département d'Anaesthésie-Réanimation pédiatrique, Hôpital Jeanne de Flandre, CHRU de Lille, Lille, France
| | - Katalin Virag
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Tom G Hansen
- Department of Anaesthesia and Intensive Care - Paediatrics, Odense University Hospital, Department of Clinical Research - Anaesthesiology, University of Southern Denmark, Odense, Denmark
| | - Karin Becke-Jakob
- Department of Anaesthesia and Intensive Care, Cnopf Children's Hospital/Hospital Hallerwiese, Nürnberg, Germany
| | - Pierre Harlet
- Research Department, European Society of Anaesthesiology, Brussels, Belgium
| | - Laszlo Vutskits
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
| | - Suellen M Walker
- Department of Paediatric Anaesthesia, Great Ormond St Hospital NHS Foundation Trust, London, UK
| | - Jurgen C de Graaff
- Department of Anesthesia, Erasmus MC- Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marzena Zielinska
- Department of Paediatric Anaesthesiology and Intensive Care, Wroclaw Medical University, Wroclaw, Poland
| | - Dusica Simic
- Department of Pediatric Anesthesia and Intensive Care, University Children's Hospital, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Thomas Engelhardt
- Department of Anaesthesia, Montreal Children's Hospital, Montreal, QC, Canada
| | - Walid Habre
- Department of Anaesthesiology, Pharmacology, Intensive Care and Emergency Medicine, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
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De Bernardo G, Crisci V, Centanni F, Giordano M, Perrone S, Buonocore G, Mandato C. Laryngeal Mask for Minimally-invasive Surfactant Administration: A Narrative Review. Curr Pediatr Rev 2025; 21:111-117. [PMID: 39229991 DOI: 10.2174/0115733963328784240820062714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/27/2024] [Accepted: 07/12/2024] [Indexed: 09/05/2024]
Abstract
The cornerstone of treatment for respiratory distress syndrome in preterm infants is surfactant administration, traditionally performed through an invasive procedure involving tracheal intubation and mechanical ventilation. Consequently, there has been a growing interest in exploring less invasive methods of surfactant delivery to mitigate the associated risks. Currently, several techniques are under evaluation, including intratracheal instillation using a thin catheter, aerosolized or nebulized administration, and guided administration by supraglottic airway devices. One such method is surfactant administration through laryngeal or supraglottic airway, which involves placing a laryngeal mask without the need for laryngoscopy and administering surfactant through the device. The simplicity of laryngeal mask insertion could potentially streamline the surfactant delivery process, eliminating the necessity for advanced skills. This narrative review aimed to assess the current evidence in the literature regarding the benefits and risks associated with surfactant administration through a laryngeal supraglottic airway.
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Affiliation(s)
- Giuseppe De Bernardo
- Department of Woman and Child, Buon Consiglio Fatebenefratelli Hospital, Naples, Italy
| | - Valeria Crisci
- Department of Medicine and Surgery, "Scuola Medica Salernitana", Section of Pediatrics, University of Salerno, Salerno, Italy
| | - Fabio Centanni
- Division of Pediatrics, Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Maurizio Giordano
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Serafina Perrone
- Neonatology Unit, Department of Medicine and Surgery, University of Parma, Pietro Barilla Children's Hospital, Parma, Italy
| | - Giuseppe Buonocore
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Claudia Mandato
- Department of Medicine and Surgery, "Scuola Medica Salernitana", Section of Pediatrics, University of Salerno, Salerno, Italy
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Dvorsky R, Bibl K, Lietz A, Haderer M, Klebermaß-Schrehof K, Werther T, Schmölzer GM, Berger A, Wagner M. Optimization of manual ventilation quality using respiratory function monitoring in neonates: A two-phase intervention trial. Resuscitation 2024; 203:110345. [PMID: 39097079 DOI: 10.1016/j.resuscitation.2024.110345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 07/09/2024] [Accepted: 07/28/2024] [Indexed: 08/05/2024]
Abstract
OBJECTIVE The aim of this study was the evaluation of the impact of a respiratory function monitor (RFM, Neo100, Monivent AB, Gothenburg, Sweden) on the quality of ventilation in neonates. METHODS This single-center two-phase intervention study was conducted at the Neonatal Intensive Care Unit and the delivery room of the Medical University of Vienna. Patients with clinical need for positive pressure ventilation were included in either of two consecutive study phases: (i) patients were ventilated with a hidden RFM (control) or (ii) visible RFM (intervention) during manual positive pressure ventilations. The duration of each phase was approximately six months. The primary outcome was the percentage of ventilations within a tidal volume range of 4-8 ml/kg (pVTe). RESULTS A total of 90 patients (GA 22-66 weeks) were included. The primary outcome was significantly higher in the intervention group with a visible RFM (53.7%, SD 22.6) than in the control group without the monitor (37.3%, SD 20.5); (p < 0.001, mean difference [i.e., change in percentage points]: 16.95% CI: 7.4-35). In terms of secondary outcomes, excessive tidal volumes (>8ml/kg), potentially associated with an increased risk of brain injury, could be significantly reduced when a RFM was visible during ventilation (10.9% [IQR 26.4] vs. 29.5% [IQR 38.1]; p = 0.004). Furthermore, mask leakage could be significantly decreased (37.3% [SD 22.7] vs. 52.7% [SD 23.0]; p = 0.002). CONCLUSION Our results suggest that the clinical application of a RFM for manual ventilation of preterm and term infants leads to a significant improvement in ventilation parameters.
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Affiliation(s)
- Robyn Dvorsky
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katharina Bibl
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Andrea Lietz
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Moritz Haderer
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katrin Klebermaß-Schrehof
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Tobias Werther
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.
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Al Mandhari H, Al Maawali Z, Al Saadi H, Khan A. A Retrospective Cohort Study of the Impact of Implementing Volume-Targeted Compared to Pressure-Limited Ventilation in a Single-Center, Level III Neonatal Intensive Care Unit in Oman. Cureus 2024; 16:e55731. [PMID: 38586699 PMCID: PMC10998685 DOI: 10.7759/cureus.55731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Background The use of volume-targeted ventilation (VTV) in neonatology has been introduced in the last decade. This study was performed to determine the impact of clinical implementation of volume-targeted conventional mechanical ventilation using the volume guarantee mode in mechanical ventilation of all neonates needing mechanical ventilation compared to pressure-limited ventilation (PLV) modes. The mortality rate, duration of mechanical ventilation, and bronchopulmonary dysplasia were the primary outcomes of the study. Methodology This retrospective cohort study was conducted at a level III-VI neonatal intensive care unit (NICU) within a tertiary academic hospital in Oman. All intubated neonates admitted to the NICU within two time periods, i.e., the PLV cohort: January 2011 to December 2013 (three years), and the VTV cohort: January 2017 to December 2019 (three years), were eligible for inclusion in the study. Neonates were excluded if they had multiple congenital anomalies, tracheostomy, and those with a Do Not Resuscitate status. A predetermined data set was collected retrospectively from electronic records. The PLV and VTV cohorts were compared, and SPSS version 25 (IBM Corp., Armonk, NY, USA) was used for data analysis. Results A total of 290 neonates were included (PLV: n = 138, and VTV: n = 152). The two cohorts were statistically similar in their baseline characteristics, including gestational age, birth weight, Apgar scores, indications for mechanical ventilation, age at intubation, need for surfactant therapy, and age at extubation. The VTV cohort had a significantly lower mortality rate (n (%) = 10 (6.6%) vs. 21 (15.3%), p = 0.02). An insignificant trend of lower duration of ventilation was observed in the VTV cohort (34.5 vs. 50.5 hours, p = 0.24). There was no significant difference in bronchopulmonary dysplasia (16 (21.3%) vs. 12 (17.8%), p = 0.18). VTV was associated with a significant reduction in pulmonary hemorrhage (1 (0.7%) vs. 8 (5.7%), p = 0.04), episodes of hypocapnia (2 vs. 3/patient, p = 0.04), and episodes of hypercapnia (0 vs 1/patient, p = 0.04). Conclusions The implementation of VTV in clinical practice in our level III-VI NICU was associated with significant advantages, including reduction in mortality, pulmonary hemorrhage, and episodes of hypercapnia and hypocapnia. A large prospective, randomized, and multicenter trial is recommended to confirm these findings.
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Affiliation(s)
- Hilal Al Mandhari
- Neonatal Unit, Child Health Department, Sultan Qaboos University Hospital/Sultan Qaboos University, Muscat, OMN
| | - Zainab Al Maawali
- College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, OMN
| | | | - Ashfaq Khan
- Neonatal Unit, Child Health Department, Sultan Qaboos University Hospital/Sultan Qaboos University, Muscat, OMN
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Mani S, Rawat M. Less Invasive Surfactant Administration: A Viewpoint. Am J Perinatol 2024; 41:211-227. [PMID: 36539205 PMCID: PMC10791155 DOI: 10.1055/a-2001-9139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
The standard of care in treating respiratory distress syndrome in preterm infants is respiratory support with nasal continuous positive airway pressure or a combination of continuous positive airway pressure and exogenous surfactant replacement. Endotracheal intubation, the conventional method for surfactant administration, is an invasive procedure associated with procedural and mechanical ventilation complications. The INSURE (intubation, surfactant administration, and extubation soon after) technique is an accepted method aimed at reducing the short-term complications and long-term morbidities related to mechanical ventilation but does not eliminate risks associated with endotracheal intubation and mechanical ventilation. Alternative methods of surfactant delivery that can overcome the problems associated with the INSURE technique are surfactant through a laryngeal mask, surfactant through a thin intratracheal catheter, and aerosolized surfactant delivered using nebulizers. The three alternative methods of surfactant delivery studied in the last two decades have advantages and limitations. More than a dozen randomized controlled trials have aimed to study the benefits of the three alternative techniques of surfactant delivery compared with INSURE as the control arm, with promising results in terms of reduction in mortality, need for mechanical ventilation, and bronchopulmonary dysplasia. The need to find a less invasive surfactant administration technique is a clinically relevant problem. Before broader adoption in routine clinical practice, the most beneficial technique among the three alternative strategies should be identified. This review aims to summarize the current evidence for using the three alternative techniques of surfactant administration in neonates, compare the three techniques, highlight the knowledge gaps, and suggest future directions. KEY POINTS: · The need to find a less invasive alternative method of surfactant delivery is a clinically relevant problem.. · Clinical trials that have studied alternative surfactant delivery methods have shown promising results but are inconclusive for broader adoption into clinical practice.. · Future studies should explore novel clinical trial methodologies and select clinically significant long term outcomes for comparison..
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Affiliation(s)
- Srinivasan Mani
- Department of Pediatrics, University of Toledo, Toledo, Ohio
| | - Munmun Rawat
- Department of Pediatrics, University at Buffalo, Buffalo, New York
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Dassios T, Kaltsogianni O, Saka J, Greenough A. A neonatal in-vitro study on the effect of the inflation pressure on end-tidal carbon dioxide levels. Med Eng Phys 2023; 120:104052. [PMID: 37838403 DOI: 10.1016/j.medengphy.2023.104052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Describing the association of the peak inflation pressure (PIP) with end-tidal carbon dioxide (ETCO2) is a prerequisite for the development of closed loop ventilation in neonatal intensive care. We aimed to develop an in-vitro system to study this relationship. METHODS A ventilator was connected to a test lung, supplied with a stable CO2 concentration from a cylinder. The PIP was altered and the change in ETCO2 per unit of PIP was calculated in three models mimicking respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD) and viral bronchiolitis. RESULTS The median (IQR) change in ETCO2 per unit of PIP was 0.23(0.13-0.38) kPa/cmH2O, using 138 paired measurements of PIP and ETCO2. The median (IQR) change in ETCO2 per unit of PIP, was higher when starting at an ETCO2 > 6 kPa [0.43(0.33-0.58) kPa/cmH2O] compared to starting at an ETCO2 < 6 kPa [0.14(0.08-0.20) kPa/cmH2O, p < 0.001]. The median (IQR) change in ETCO2 per unit of PIP, was larger in the model of RDS [0.33(0.13-0.51) kPa/cmH2O] compared to the BPD [0.23(0.13-0.33) kPa/cmH2O, p = 0.043] and the bronchiolitis models [0.15(0.10-0.31) kPa/cmH2O, p = 0.017]. CONCLUSIONS The change in ETCO2 in response to increasing PIP was larger for higher ETCO2 values and in a model simulating neonatal RDS, compared to BPD and bronchiolitis.
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Affiliation(s)
- Theodore Dassios
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom.
| | - Ourania Kaltsogianni
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Jonathan Saka
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anne Greenough
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
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Lemyre B, Deguise MO, Benson P, Kirpalani H, Ekhaguere OA, Davis PG. Early nasal intermittent positive pressure ventilation (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. Cochrane Database Syst Rev 2023; 7:CD005384. [PMID: 37466143 PMCID: PMC10355255 DOI: 10.1002/14651858.cd005384.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Nasal continuous positive airway pressure (NCPAP) is a strategy to maintain positive airway pressure throughout the respiratory cycle through the application of a bias flow of respiratory gas to an apparatus attached to the nose. Early treatment with NCPAP is associated with decreased risk of mechanical ventilation exposure and might reduce chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation delivered through the same nasal interface during which patients are exposed to short inflations, along with background end-expiratory pressure. OBJECTIVES To examine the risks and benefits of early (within the first six hours after birth) NIPPV versus early NCPAP for preterm infants at risk of or with respiratory distress syndrome (RDS). Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include the incidence of mortality, chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), pneumothorax, duration of respiratory support, duration of oxygen therapy, and intraventricular hemorrhage (IVH). SEARCH METHODS Searches were conducted in January 2023 in CENTRAL, MEDLINE, Embase, Web of Science, and Dissertation Abstracts. The reference lists of related systematic reviews and of studies selected for inclusion were also searched. SELECTION CRITERIA We considered all randomized and quasi-randomized controlled trials. Eligible studies compared NIPPV versus NCPAP treatment, starting within six hours after birth in preterm infants (< 37 weeks' gestational age (GA)). DATA COLLECTION AND ANALYSIS We collected and analyzed data using the recommendations of the Cochrane Neonatal Review Group. MAIN RESULTS We included 17 trials, enrolling 1958 infants in this review. NIPPV likely reduces the rate of respiratory failure (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.54 to 0.78; risk difference (RD) -0.08, 95% CI -0.12 to -0.05; 17 RCTs, 1958 infants; moderate-certainty evidence) and needing endotracheal tube ventilation (RR 0.67, 95% CI 0.56 to 0.81; RD -0.07, 95% CI -0.11 to -0.04; 16 RCTs; 1848 infants; moderate-certainty evidence) amongst infants treated with early NIPPV compared with early NCPAP. The meta-analysis demonstrated that NIPPV may reduce the risk of developing CLD compared to CPAP (RR 0.70, 95% CI 0.52 to 0.92; 12 RCTs, 1284 infants; low-certainty evidence) slightly. NIPPV may result in little to no difference in mortality (RR 0.82, 95% CI 0.62 to 1.10; 17 RCTs; 1958 infants; I2 of 0%; low-certainty evidence), the incidence of pneumothorax (RR 0.92, 95% CI 0.60 to 1.41; 16 RCTs; 1674 infants; I2 of 0%; low-certainty evidence), and rates of severe IVH (RR 0.98, 95% CI 0.53 to 1.79; 8 RCTs; 977 infants; I2 of 0%; low-certainty evidence). AUTHORS' CONCLUSIONS When applied within six hours after birth, NIPPV likely reduces the risk of respiratory failure and the need for intubation and endotracheal tube ventilation in very preterm infants (GA 28 weeks and above) with respiratory distress syndrome or at risk for RDS. It may also decrease the rate of CLD slightly. However, most trials enrolled infants with a gestational age of approximately 28 to 32 weeks with an overall mean gestational age of around 30 weeks. As such, the results of this review may not apply to extremely preterm infants that are most at risk of needing mechanical ventilation or developing CLD. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.
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Affiliation(s)
- Brigitte Lemyre
- Division of Neonatology, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Marc-Olivier Deguise
- Dept. of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Paige Benson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Osayame A Ekhaguere
- Division of Neonatal-Perinatal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Parkville, Australia
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Sand L, Szatkowski L, Kwok TC, Sharkey D, Todd DA, Budge H, Ojha S. Observational cohort study of changing trends in non-invasive ventilation in very preterm infants and associations with clinical outcomes. Arch Dis Child Fetal Neonatal Ed 2022; 107:150-155. [PMID: 34413093 DOI: 10.1136/archdischild-2021-322390] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 08/05/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the change in non-invasive ventilation (NIV) use over time in infants born at <32 weeks' gestation and the associated clinical outcomes. STUDY DESIGN Retrospective cohort study using routinely recorded data from the National Neonatal Research Database of infants born at <32 weeks admitted to neonatal units in England and Wales from 2010 to 2017. RESULTS In 56 537 infants, NIV use increased significantly between 2010 and 2017 (continuous positive airway pressure (CPAP) from 68.5% to 80.2% in 2017 and high flow nasal cannula (HFNC) from 14% to 68%, respectively) (p<0.001)). Use of NIV as the initial mode of respiratory support also increased (CPAP, 21.5%-28.0%; HFNC, 1%-7% (p<0.001)).HFNC was used earlier, and for longer, in those who received CPAP or mechanical ventilation. HFNC use was associated with decreased odds of death before discharge (adjusted OR (aOR) 0.19, 95% CI 0.17 to 0.22). Infants receiving CPAP but no HFNC died at an earlier median chronological age: CPAP group, 22 (IQR 10-39) days; HFNC group 40 (20-76) days (p<0.001). Among survivors, HFNC use was associated with increased odds of bronchopulmonary dysplasia (BPD) (aOR 2.98, 95% CI 2.81 to 3.15) and other adverse outcomes. CONCLUSIONS NIV use is increasing, particularly as initial respiratory support. HFNC use has increased significantly with a sevenfold increase soon after birth which was associated with higher rates of BPD. As more infants survive with BPD, we need robust clinical evidence, to improve outcomes with the use of NIV as initial and ongoing respiratory support.
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Affiliation(s)
- Laura Sand
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lisa Szatkowski
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - T'ng Chang Kwok
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Don Sharkey
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - David A Todd
- Neonatal Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Helen Budge
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK
| | - Shalini Ojha
- Academic Unit of Population and Lifespan Sciences, School of Medicine, University of Nottingham, Nottingham, UK .,Neonatal Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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10
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Liquid Ventilation in the Management of Preterm Infants. CURRENT STEM CELL REPORTS 2021. [DOI: 10.1007/s40778-021-00192-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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Peterson J, den Boer MC, Roehr CC. To Sedate or Not to Sedate for Less Invasive Surfactant Administration: An Ethical Approach. Neonatology 2021; 118:639-646. [PMID: 34628413 DOI: 10.1159/000519283] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 08/24/2021] [Indexed: 11/19/2022]
Abstract
Less invasive surfactant administration (LISA) is an effective, minimally invasive technique of administering surfactant to infants with respiratory distress syndrome. While termed less invasive, LISA still requires airway instrumentation with direct laryngoscopy, thus may be considered painful. However, the issue of whether or not to routinely sedate infants for LISA remains contentious, with significant variation in practice between centres. Proponents for giving pharmacological analgesia and/or sedation predominantly focus on patient comfort during the procedure. However, those who favour non-pharmacological measures of pain management focus on the potential for procedural success without the risk of adverse events, such as respiratory depression and potentially the need for escalation to intubation, which may occur with pharmacological agents. The neonatal population who may benefit from LISA is varied. Due to this variety in presentation type, gestational age, and unit experience, there is a need to provide an individualized, tailored approach to sedation and analgesia for these infants. Using a blanket approach to sedation will lead to infants being exposed to sedative medications on the assumption of potential distress, rather than in response to signs of actual distress. This places the infant at risk of the adverse reactions, potentially without them ever having needed the beneficial effect of the medications. This seems an unnecessary risk. This article explores the ethical arguments pertaining to analgesia and sedation during the LISA technique, concluding that a standardized approach to the usage of pharmacological sedation is undesirable. Moreover, we maintain that procedural analgesia and sedation should be based on individualized, infant-centred assessment, rather than on a rigid, standardized approach.
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Affiliation(s)
- Jennifer Peterson
- Neonatal Unit, St Mary's Maternity Hospital, Manchester Foundation Trust, Manchester, United Kingdom,
| | - Maria C den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Charles Christoph Roehr
- Neonatal Intensive Care Unit, Southmead Hospital, North Bristol Trust, Bristol, United Kingdom.,Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom.,National Perinatal Epidemiology Unit, Clinical Trials Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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12
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Zhang CY, Liu DJ, Hua SD, Guo S, Li XY, Zhang B, An LH. Caffeine versus aminophylline in combination with oxygen therapy for apnea of prematurity: A retrospective cohort study. Exp Ther Med 2020; 20:46. [PMID: 32952637 PMCID: PMC7480137 DOI: 10.3892/etm.2020.9175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 04/09/2020] [Indexed: 11/25/2022] Open
Abstract
The present study was conducted to investigate the clinical significance of caffeine and aminophylline in the treatment of premature infants with apnea under varying conditions of oxygen (O2) delivery. The clinical data of 120 premature infants with apnea treated with oxygen therapy and either caffeine citrate (20 mg/kg/day; n=77) or aminophylline (10 mg/kg/day; n=43) were retrospectively examined. The therapeutic performance of the drugs after the completion of the treatment was evaluated primarily according to the risk of recurrent episodes of apnea, the changes in the duration and concentration of inhaled O2 and the incidence of complications. In contrast to aminophylline, caffeine treatment significantly reduced the duration of O2 inhalation and the inhaled O2 concentration in the infants treated with mechanical ventilation or O2 delivery devices (P<0.05). Treatment with caffeine also decreased the incidence of recurrent apnea events and complications in the investigated population (P<0.05 or P<0.01). Caffeine performs better than aminophylline in the treatment of premature infants with apnea under different conditions of O2 delivery. The therapeutic performance of caffeine is achieved primarily via improving the efficacy of supplemental O2 and reducing the incidence of complications.
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Affiliation(s)
- Cheng-yun Zhang
- Department of Neonatology, The First People's Hospital of Zhengzhou City, Zhengzhou, Henan 450000, P.R. China
| | - Dong-jie Liu
- Department of Neonatology, The First People's Hospital of Zhengzhou City, Zhengzhou, Henan 450000, P.R. China
| | - Shao-dong Hua
- Newborn Intensive Care Unit, The Seventh Medical Center of The Chinese People's Liberation Army, Affiliated Bayi Children's Hospital, Beijing 100700, P.R. China
| | - Shan Guo
- Department of Obstetrics, The First People's Hospital of Zhengzhou City, Zhengzhou, Henan 450000, P.R. China
| | - Xiao-yan Li
- Department of Neonatology, The First People's Hospital of Zhengzhou City, Zhengzhou, Henan 450000, P.R. China
| | - Bing Zhang
- Department of Neonatology, The First People's Hospital of Zhengzhou City, Zhengzhou, Henan 450000, P.R. China
| | - Li-hua An
- Department of Neonatology, The First People's Hospital of Zhengzhou City, Zhengzhou, Henan 450000, P.R. China
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13
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Chen L, Wang L, Ma J, Feng Z, Li J, Shi Y. Nasal High-Frequency Oscillatory Ventilation in Preterm Infants With Respiratory Distress Syndrome and ARDS After Extubation: A Randomized Controlled Trial. Chest 2020; 155:740-748. [PMID: 30955572 DOI: 10.1016/j.chest.2019.01.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/09/2018] [Accepted: 01/02/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Nasal high-frequency oscillatory ventilation (NHFOV) has been described as supplying the combined advantages of nasal CPAP (NCPAP) and HFOV. However, its effect on preterm infants needs to be further elucidated. Our objective was to assess whether NHFOV could reduce intubation and Pco2 levels as compared with NCPAP during the postextubation phase in preterm infants. METHODS This was a single-center, randomized, controlled trial, and it was registered at clinicaltrials.gov (NCT03140891) and conducted between May 2017 and May 2018. Ventilated infants born at less than 37 weeks' gestational age and ready to be extubated were included and randomized to either the NHFOV or NCPAP group. Primary outcomes were the incidence of reintubation within 1 week and the Pco2 level within 6 h. RESULTS A total of 206 preterm infants were included. Of them, 127 (61.7%) were diagnosed with respiratory distress syndrome, 53 (25.7%) with ARDS, and 26 (12.6%) with both respiratory distress syndrome and ARDS. Comparing with NCPAP, NHFOV significantly reduced the reintubation rate (16:87 vs 35:68; 95% CI, 0.18-0.70; P = .002), especially in the subgroup with a gestational age of ≤ 32 weeks (12:34 vs 25:20; 95% CI, 0.12-0.68; P = .004). The Pco2 level was also significant lower in the NHFOV group (49.6 ± 8.7 vs 56.9 ± 9.9; 95% CI, -9.95 to -4.80; P = < .001). Moreover, NHFOV significantly reduced the reintubation rate in preterm infants with ARDS (10:33 vs 21:15; 95% CI, 0.08-0.57; P = .002). CONCLUSIONS NHFOV was shown to be superior to NCPAP in avoiding reintubation, especially in very preterm infants and those infants diagnosed with ARDS. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03140891; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Long Chen
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Wang
- Department of Pediatrics, Daping Hospital of the Army Medical University, Chongqing, China
| | - Juan Ma
- Department of Pediatrics, Daping Hospital of the Army Medical University, Chongqing, China
| | - Zhichun Feng
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China
| | - Jie Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China; China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China; Chongqing Key Laboratory of Pediatrics, Chongqing, China; Department of Pediatrics, Daping Hospital of the Army Medical University, Chongqing, China.
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14
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Makker K, Cortez J, Jha K, Shah S, Nandula P, Lowrie D, Smotherman C, Gautam S, Hudak ML. Comparison of extubation success using noninvasive positive pressure ventilation (NIPPV) versus noninvasive neurally adjusted ventilatory assist (NI-NAVA). J Perinatol 2020; 40:1202-1210. [PMID: 31911641 PMCID: PMC7222927 DOI: 10.1038/s41372-019-0578-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/18/2019] [Accepted: 12/18/2019] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Compare rates of initial extubation success in preterm infants extubated to NIPPV or NI-NAVA. STUDY DESIGN In this pilot study, we randomized 30 mechanically ventilated preterm infants at the time of initial elective extubation to NI-NAVA or NIPPV in a 1:1 assignment. Primary study outcome was initial extubation success. RESULTS Rates of continuous extubation for 120 h were 92% in the NI-NAVA group and 69% in the NIPPV group (12/13 vs. 9/13, respectively, p = 0.14). Infants extubated to NI-NAVA remained extubated longer (median 18 vs. 4 days, p = 0.02) and experienced lower peak inspiratory pressures (PIP) than infants managed with NIPPV throughout the first 3 days after extubation. Survival analysis through 14 days post extubation showed a sustained difference in the primary study outcome until 12 days post extubation. CONCLUSIONS Our study is the first to suggest that a strategy of extubating preterm infants to NI-NAVA may be more successful.
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Affiliation(s)
- Kartikeya Makker
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL, USA.
| | - Josef Cortez
- 0000 0004 0625 1409grid.413116.0Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
| | - Kanishk Jha
- 0000 0004 0625 1409grid.413116.0Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
| | - Sanket Shah
- 0000 0004 0625 1409grid.413116.0Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
| | - Padma Nandula
- 0000 0004 0625 1409grid.413116.0Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
| | - David Lowrie
- 0000 0004 0625 1409grid.413116.0Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
| | - Carmen Smotherman
- 0000 0004 0625 1409grid.413116.0Center for Health Equity and Research (CHEQR), University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
| | - Shiva Gautam
- 0000 0004 0625 1409grid.413116.0Center for Health Equity and Research (CHEQR), University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
| | - Mark L. Hudak
- 0000 0004 0625 1409grid.413116.0Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine—Jacksonville, Jacksonville, FL USA
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15
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How to ventilate preterm infants with lung compliance close to circuit compliance: real-time simulations on an infant hybrid respiratory simulator. Med Biol Eng Comput 2019; 58:357-372. [PMID: 31853776 PMCID: PMC7223676 DOI: 10.1007/s11517-019-02089-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 11/25/2019] [Indexed: 11/02/2022]
Abstract
Circuit compliance close to lung compliance can create serious problems in effective and safe mechanical ventilation of preterm infants. We considered what ventilation technique is the most beneficial in this case. A hybrid (numerical-physical) simulator of infant respiratory system mechanics, the Bennett Ventilator and NICO apparatus were used to simulate pressure-controlled ventilation (PC) and volume-controlled ventilation with constant flow (VCVCF) and descending flow (VCVDF), under permissive hypercapnia (PHC) (6 ml kg-1) and normocapnia (SV) (8 ml kg-1) conditions. Respiratory rate (RR) was 36 or 48 min-1 and PEEP was 0.3 or 0.6 kPa. Peak inspiratory pressure (PIP), mean airway pressure (MAP), and work of breathing by the ventilator (WOB) were lower (P < 0.01, 1 - β = 0.9) using the PHC strategy compared to the SV strategy. The WOB increased (P < 0.01; 1 - β = 0.9) when the RR increased. The PC, VCVCF, and VCVDF modes did not differ in minute ventilation produced by the ventilator (MVV), but the PC mode delivered the highest minute ventilation to the patient (MVT) (P < 0.01; 1 - β = 0.9) at the same PIP, MAP, and WOB. The most beneficial ventilation technique appeared to be PC ventilation with the PHC strategy, with lower RR (36 min-1). Graphical abstract The effectiveness of an infant ventilation depending on circuit compliance to lung compliance ratio (Cv CL -1) and inspiration time (Ti). VV, VT, tidal volume set on the ventilator and delivered to patient, respectively.
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16
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Atkins WK, McDougall R, Perkins EJ, Pereira-Fantini PM, Tingay DG. A dedicated respiratory function monitor to improve tidal volume delivery during neonatal anesthesia. Paediatr Anaesth 2019; 29:920-926. [PMID: 31318466 DOI: 10.1111/pan.13707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 07/07/2019] [Accepted: 07/12/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tight control of tidal volume using accurate monitoring may improve neonatal outcomes. However, respiratory function monitors incorporated in current anesthetic workstations are generally inaccurate at tidal volumes used for infants. AIMS To determine if a specific respiratory function monitor for neonatal infants improved expired tidal volume delivery during anesthesia. METHOD Infants <3 months old requiring intubation for surgery in the operating theater were studied. After intubation a Phillips NM3, Acutronic Florian, or Novametrix Ventcheck Respiratory Function Monitor was integrated into the circuit, and clinicians given access to the display for the duration of anesthesia. Breath-to-breath expired tidal volume delivery, leak, and delivered pressure were recorded, with cardiorespiratory parameters. These were compared with a matched control group with clinicians blinded to respiratory function monitor display. RESULTS A total of 10 055 and 2569 inflations were measured in the respiratory function monitor visible (n = 32) and masked (n = 33) groups, respectively, with mean (standard deviation) delivered expired tidal volume 7.5 (2.4) mL/kg and 7.7 (3.0) mL/kg, respectively; mean difference (95% confidence interval) -0.2 (-1.1, 0.8) mL/kg (Welch's t test). In the visible group, 55.6% of expired tidal volumes were between 4 and 8 mL/kg compared to 51.7% in the masked group; relative benefit (95% confidence interval), 1.08 (1.03, 1.12). Expired tidal volume was less likely to be <4 mL/kg in the visible group compared to masked group; 6.4% vs 9.8%, 1.53 (1.33, 1.76). The use of a respiratory function monitor also reduced the number of inflations >10 mL/kg; 13.0% vs 22.0%, 1.11 (1.09, 1.14). CONCLUSION Tidal volumes <4 mL/kg and >10 mL/kg are frequently delivered during neonatal anesthesia. The inclusion of an accurate respiratory function monitor may reduce the risk of exposure to potentially harmful tidal volumes.
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Affiliation(s)
- William K Atkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia
| | - Rob McDougall
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Department of Anaesthesia, The Royal Children's Hospital, Parkville, Vic., Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Neonatology, The Royal Children's Hospital, Parkville, Vic., Australia
| | - Prue M Pereira-Fantini
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Vic., Australia.,Department of Paediatrics, University of Melbourne, Parkville, Vic., Australia.,Department of Neonatology, The Royal Children's Hospital, Parkville, Vic., Australia
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17
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Lee BK, Shin SH, Jung YH, Kim EK, Kim HS. Comparison of NIV-NAVA and NCPAP in facilitating extubation for very preterm infants. BMC Pediatr 2019; 19:298. [PMID: 31462232 PMCID: PMC6712684 DOI: 10.1186/s12887-019-1683-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/21/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Various types of noninvasive respiratory modalities that lead to successful extubation in preterm infants have been explored. We aimed to compare noninvasive neurally adjusted ventilatory assist (NIV-NAVA) and nasal continuous positive airway pressure (NCPAP) for the postextubation stabilization of preterm infants. METHODS This retrospective study was divided into two distinct periods, between July 2012 and June 2013 and between July 2013 and June 2014, because NIV-NAVA was applied beginning in July 2013. Preterm infants of less than 30 weeks GA who had been intubated with mechanical ventilation for longer than 24 h and were weaned to NCPAP or NIV-NAVA after extubation were enrolled. Ventilatory variables and extubation failure were compared after weaning to NCPAP or NIV-NAVA. Extubation failure was defined when infants were reintubated within 72 h of extubation. RESULTS There were 14 infants who were weaned to NCPAP during Period I, and 2 infants and 16 infants were weaned to NCPAP and NIV-NAVA, respectively, during Period II. At the time of extubation, there were no differences in the respiratory severity score (NIV-NAVA 1.65 vs. NCPAP 1.95), oxygen saturation index (1.70 vs. 2.09) and steroid use before extubation. Several ventilation parameters at extubation, such as the mean airway pressure, positive end-expiratory pressure, peak inspiratory pressure, and FiO2, were similar between the two groups. SpO2 and pCO2 preceding extubation were comparable. Extubation failure within 72 h after extubation was observed in 6.3% of the NIV-NAVA group and 37.5% of the NCPAP group (P = 0.041). CONCLUSIONS The data in the present showed promising implications for using NIV-NAVA over NCPAP to facilitate extubation.
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Affiliation(s)
- Byoung Kook Lee
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-769 South Korea
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18
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Nurse Decision Making and Attitudes About Circuit Disconnection During Ventilator Therapy at a Swedish Neonatal Intensive Care Unit. Adv Neonatal Care 2018; 18:E13-E20. [PMID: 30299284 DOI: 10.1097/anc.0000000000000564] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND There are many challenges to providing care to infants in need of ventilator therapy. Yet, few studies describe the practical handling of the ventilator circuit during nursing care. PURPOSE To describe neonatal intensive care unit (NICU) nurses' decision making regarding whether or not to disconnect the ventilator circuit when changing the infant's position and to investigate the grounds for their decisions. METHODS A descriptive questionnaire study with both quantitative and qualitative elements was conducted. In 2015, a convenience sample of nurses working in an NICU completed a questionnaire including both closed-ended and open-ended, free-text questions. Answers to the closed-ended questions were analyzed with descriptive statistics, whereas answers to the free-text questions were analyzed using qualitative content analysis. RESULTS Nurses' decisions on whether to disconnect or keep the ventilator circuit closed were based on the infant's needs for ventilator support. The nurses gave several reasons and motivations both for why they disconnected the circuit and for why they did not. The handling of the circuit and the reasons and motivations given were inconsistent among the nurses. IMPLICATIONS FOR PRACTICE This study highlights the need for continuous, repetitive education and training for NICU nurses, as well as demonstrating the importance of clear and distinct guidelines and working methods regarding the care of infants on ventilator support. IMPLICATIONS FOR RESEARCH Future research should continue to find ways of working and handling an infant on ventilator support that are least harmful to the infant.
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19
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Smitthimedhin A, Whitehead MT, Bigdeli M, Nino G, Perez G, Otero HJ. MRI determination of volumes for the upper airway and pharyngeal lymphoid tissue in preterm and term infants. Clin Imaging 2018; 50:51-56. [DOI: 10.1016/j.clinimag.2017.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 11/28/2017] [Accepted: 12/14/2017] [Indexed: 10/18/2022]
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20
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Zhu XW, Zhao JN, Tang SF, Yan J, Shi Y. Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with moderate-severe respiratory distress syndrome: A preliminary report. Pediatr Pulmonol 2017; 52:1038-1042. [PMID: 28672094 DOI: 10.1002/ppul.23755] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effect of noninvasive high-frequency oscillatory ventilation (nHFOV) with nasal continuous positive airway pressure (nCPAP) in preterm infants with moderate-severe respiratory distress syndrome (RDS) after surfactant administration via INSURE (intubation, surfactant, extubation) method on the need for invasive mechanical ventilation (IMV). METHODS A total of 81 infants with a gestational age (GA) of 28-34 weeks were eligible and were randomized to nCPAP (n = 42) or to nHFOV (n = 39). The need for IMV was the primary outcome. The incidence of bronchopulmonary dysplasia (BPD), occurrence of intraventricular hemorrhage (IVH), and air leaks, and mortality were considered as secondary outcomes. RESULT A total 76 infants finally completed the study. The need for IMV was significantlylower in the nHFOV group compared with the nCPAP group(24.3% vs 56.4%, P < 0.01). The incidence of IVH, air leaks or BPD was similar between the two groups. In addition, the mortality rate was not statistically different. CONCLUSION In this prospective, randomized controlled study, nHFOV significantly reduced the need for IMV as compared with nCPAP in preterm infants with moderate-severe RDS without increase in adverse effects.
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Affiliation(s)
- Xing-Wang Zhu
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China.,Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neonatology, Jiulongpo People's Hospital, Chongqing, China
| | - Jin-Ning Zhao
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China
| | - Shi-Fang Tang
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China
| | - Jun Yan
- Department of Neonatology, Jiulongpo People's Hospital, Chongqing, China
| | - Yuan Shi
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China.,Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
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Stankiewicz B, Pałko KJ, Darowski M, Zieliński K, Kozarski M. A new infant hybrid respiratory simulator: preliminary evaluation based on clinical data. Med Biol Eng Comput 2017; 55:1937-1948. [PMID: 28343335 DOI: 10.1007/s11517-017-1635-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 03/13/2017] [Indexed: 11/28/2022]
Abstract
A new hybrid (numerical-physical) simulator of the respiratory system, designed to simulate spontaneous and artificial/assisted ventilation of preterm and full-term infants underwent preliminary evaluation. A numerical, seven-compartmental model of the respiratory system mechanics allows the operator to simulate global and peripheral obstruction and restriction of the lungs. The physical part of the simulator is a piston-based construction of impedance transformer. LabVIEW real-time software coordinates the work of both parts of the simulator and its interaction with a ventilator. Using clinical data, five groups of "artificial infants" were examined: healthy full-term infants, very low-birth-weight preterm infants successfully (VLBW) and unsuccessfully extubated (VLBWun) and extremely low-birth-weight preterm infants without (ELBW) and with bronchopulmonary dysplasia (ELBW_BPD). Pressure-controlled ventilation was simulated to measure peak inspiratory pressure, mean airway pressure, total (patient + endotracheal tube) airway resistance (R), total dynamic compliance of the respiratory system (C), and total work of breathing by the ventilator (WOB). The differences between simulation and clinical parameters were not significant. High correlation coefficients between both types of data were obtained for R, C, and WOB (γ R = 0.99, P < 0.0005; γ C = 0.85, P < 0.005; γWOB = 0.96, P < 0.05, respectively). Thus, the simulator accurately reproduces infant respiratory system mechanics.
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Affiliation(s)
- Barbara Stankiewicz
- Department of Biomedical Systems and Technologies, Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 4 Trojdena Street, Warsaw, Poland.
| | - Krzysztof J Pałko
- Department of Biomedical Systems and Technologies, Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 4 Trojdena Street, Warsaw, Poland
| | - Marek Darowski
- Department of Biomedical Systems and Technologies, Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 4 Trojdena Street, Warsaw, Poland
| | - Krzysztof Zieliński
- Department of Biomedical Systems and Technologies, Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 4 Trojdena Street, Warsaw, Poland
| | - Maciej Kozarski
- Department of Biomedical Systems and Technologies, Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, 4 Trojdena Street, Warsaw, Poland
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Binmanee A, El Helou S, Shivananda S, Fusch C, Mukerji A. Use of high noninvasive respiratory support pressures in preterm neonates: a single-center experience. J Matern Fetal Neonatal Med 2017; 30:2838-2843. [PMID: 27892756 DOI: 10.1080/14767058.2016.1265931] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To describe the incidence, indications and clinical outcomes following high pressures on noninvasive respiratory support (NRS) in preterm neonates. STUDY DESIGN Retrospective cohort study of all neonates with BW <1.500 g admitted from July 2012 to June 2014 and placed on high noninvasive respiratory support (NRS), defined as mean airway pressure ≥10 cm H2O for at least 12 continuous hours using nasal continuous positive airway pressure (NCPAP) and/or nasal high-frequency ventilation (NIHFV). Clinical and physiological outcomes following high NRS were ascertained. Median (IQR) and percentages were used to describe continuous and categorical data, respectively. RESULTS There were 131 instances of high NRS use in 70 of 315 eligible infants. Most common indication was post-extubation, observed in 37% (49/131) of high NRS instances. Intubation was avoided in 71% (93/131) of instances in the first 7 days following high NRS initiation. There were no physiological perturbations in heart rate, blood pressure or oxygen requirement. Furthermore, there were no instances of lung hyperinflation, pneumothoraces or spontaneous intestinal perforation following high NRS. CONCLUSION The use of high NRS pressure was followed by avoidance of intubation in the majority of cases without adverse effects. Further research on high NRS use including its indications, clinical outcomes and safety profile is warranted.
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Affiliation(s)
| | - Salhab El Helou
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
| | | | - Christoph Fusch
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
| | - Amit Mukerji
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
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Joseph RA. Prolonged Mechanical Ventilation: Challenges to Nurses and Outcome in Extremely Preterm Babies. Crit Care Nurse 2017; 35:58-66. [PMID: 26232802 DOI: 10.4037/ccn2015396] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Worldwide, about 15 million infants are born prematurely each year. Technological advances, including invasive mechanical ventilation, play a major role in the survival of extremely preterm babies. Those who survive may have prolonged morbid conditions that result in long-term sequelae. Nurses face several challenges during the hospitalization of these infants. Vigilant care, monitoring, and careful handling of the infants can prevent infections and long-term complications. Newer, less invasive technologies are promising for improved outcomes in extremely preterm infants.
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Affiliation(s)
- Rachel A Joseph
- Rachel A. Joseph is an assistant professor, West Chester University of Pennsylvania, West Chester, Pennsylvania, and a clinical nurse in the neonatal intensive care unit, Christiana Care Health Systems, Newark, Delaware.
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Mukerji A, Sarmiento K, Lee B, Hassall K, Shah V. Non-invasive high-frequency ventilation versus bi-phasic continuous positive airway pressure (BP-CPAP) following CPAP failure in infants <1250 g: a pilot randomized controlled trial. J Perinatol 2017; 37:49-53. [PMID: 27684415 DOI: 10.1038/jp.2016.172] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Non-invasive high-frequency ventilation (NIHFV), a relatively new modality, is gaining popularity despite limited data. We sought to evaluate the effectiveness of NIHFV versus bi-phasic continuous positive airway pressure (BP-CPAP) in preterm infants failing CPAP. STUDY DESIGN Infants with BW<1250 g on CPAP were randomly assigned to NIHFV or BP-CPAP if they met pre-determined criteria for CPAP failure. Infants were eligible for randomization after 72 h age and until 2000 g. Guidelines for adjustment of settings and criteria for failure of assigned mode were implemented. The primary aim was to assess feasibility of a larger trial. In addition, failure of assigned non-invasive respiratory support (NRS) mode, invasive mechanical ventilation (MV) 72 h and 7 days post-randomization, and bronchopulmonary dysplasia (BPD) were assessed. RESULTS Thirty-nine infants were randomized to NIHFV (N=16) or BP-CPAP (N=23). There were no significant differences in mean (s.d.) postmenstrual age (28.6 (1.5) versus 29.0 (2.3) weeks, P=0.47), mean (s.d.) weight at randomization (965.0 (227.0) versus 958.1 (310.4) g, P=0.94) or other baseline demographics between the groups. Failure of assigned NRS mode was lower with NIHFV (37.5 versus 65.2%, P=0.09), although not statistically significant. There were no differences in rates of invasive MV 72 h and 7 days post-randomization or BPD. CONCLUSION NIHFV was not superior to BP-CPAP in this pilot study. Effectiveness of NIHFV needs to be proven in larger multi-center, appropriately powered trials before widespread implementation.
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Affiliation(s)
- A Mukerji
- Department of Paediatrics, McMaster University, Hamilton, ON, Canada
| | - K Sarmiento
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - B Lee
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - K Hassall
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - V Shah
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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Mowes A, de Jongh BE, Cox T, Zhu Y, Shaffer TH. A translational cellular model to study the impact of high-frequency oscillatory ventilation on human epithelial cell function. J Appl Physiol (1985) 2017; 122:198-205. [PMID: 27834669 PMCID: PMC5283848 DOI: 10.1152/japplphysiol.00400.2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 11/03/2016] [Accepted: 11/03/2016] [Indexed: 12/27/2022] Open
Abstract
High-frequency oscillatory ventilation (HFOV) has been proposed as gentle ventilation strategy to prevent lung injury in the preterm infant. High-frequency jet ventilation leads to dimensional and mechanical airway deformation in animal airway models, which is consistent with translational studies demonstrating the impact of oxygen and biophysical stresses on normal airway cellular function. There is an overall paucity of clinical and cellular data on the impact of HFOV on the conducting airway. We developed an innovative method to test the impact of the clinical HFO Ventilator (SensorMedics 3100A) on human epithelial cell function. In this translational model, we were able to study the differential effects of biophysical stress due to HFOV independently and in combination with hyperoxia on a direct cellular level of the conducting airway system. Additionally, we could demonstrate that hyperoxia and pressure by HFOV independently resulted in significant cell dysfunction and inflammation, while the combination of HFOV and hyperoxia had a synergistic effect, resulting in greater cell death. NEW & NOTEWORTHY Traditionally, large-animal models are used to analyze the impact of clinical ventilators on lung cellular function. In our dual-chamber model, we interface high-frequency oscillatory ventilation (HFOV) directly with airway cells to study the effects of HFOV independently and combined with hyperoxia. Therefore, it is possible to study the preclinical impact of interventional factors without the high cost of animal models, thus reducing staff, time, as well as animal sparing.
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Affiliation(s)
- Anja Mowes
- Department of Neonatology, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania;
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Beatriz E de Jongh
- Department of Neonatology, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
- Department of Pediatrics, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Timothy Cox
- Nemours Research Lung Center, Alfred I. duPont Children's Hospital, Wilmington, Delaware
| | - Yan Zhu
- Nemours Research Lung Center, Alfred I. duPont Children's Hospital, Wilmington, Delaware
| | - Thomas H Shaffer
- Nemours Research Lung Center, Alfred I. duPont Children's Hospital, Wilmington, Delaware
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, Pennsylvania; and
- Department of Pediatrics, Temple University, Philadelphia, Pennsylvania
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Abstract
High-frequency ventilation (HFV) as a mode of noninvasive respiratory support (NRS) in preterm neonates is gaining popularity. Benefits may accrue from combining the ventilatory efficiency of HFV delivered through a noninvasive interface, enhancing respiratory support while potentially limiting lung injury. Current evidence suggests that noninvasive HFV (NIHFV) may be superior to other NRS modes in eliminating carbon dioxide and preventing endotracheal ventilation after failure of other NRS modes. Animal data suggest NIHFV may promote improved alveolar development compared to endotracheal ventilation. However, adequately powered large-scale controlled trials are required to evaluate efficacy and safety prior to widespread use of NIHFV.
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Affiliation(s)
- Amit Mukerji
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, 1280 Main Street West, HSC-4F1E, Hamilton, Ontario L8S 4K1, Canada.
| | - Michael Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Room M4-222, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
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27
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Wright CJ, Kirpalani H. When should we start continuous positive airway pressure in the delivery room and how high should we go? Acta Paediatr 2016; 105:868-70. [PMID: 27383516 DOI: 10.1111/apa.13459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA.
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA
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28
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Wright CJ, Polin RA, Kirpalani H. Continuous Positive Airway Pressure to Prevent Neonatal Lung Injury: How Did We Get Here, and How Do We Improve? J Pediatr 2016; 173:17-24.e2. [PMID: 27025910 DOI: 10.1016/j.jpeds.2016.02.059] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/25/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Richard A Polin
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia at the University of Pennsylvania, Philadelphia, PA
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30
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Mayer CA, Martin RJ, MacFarlane PM. Increased airway reactivity in a neonatal mouse model of continuous positive airway pressure. Pediatr Res 2015; 78:145-51. [PMID: 25950451 PMCID: PMC4506702 DOI: 10.1038/pr.2015.90] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 02/11/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is a primary form of respiratory support used in the intensive care of preterm infants, but its long-term effects on airway (AW) function are unknown. METHODS We developed a neonatal mouse model of CPAP treatment to determine whether it modifies later AW reactivity. Unanesthetized spontaneously breathing mice were fitted with a mask to deliver CPAP (6 cmH2O, 3 h/day) for 7 consecutive days starting at postnatal day 1. AW reactivity to methacholine was assessed using the in vitro living lung slice preparation. RESULTS One week of CPAP increased AW responsiveness to methacholine in male, but not female mice, compared to untreated control animals. The AW hyper-reactivity of male mice persisted for 2 wk (at P21) after CPAP treatment ended. Four days of CPAP, however, did not significantly increase AW reactivity. Females also exhibited AW hyper-reactivity at P21, suggesting a delayed response to early (7 d) CPAP treatment. The effects of 7 d of CPAP on hyper-reactivity to methacholine were unique to smaller AWs whereas larger ones were relatively unaffected. CONCLUSION These data may be important to our understanding of the potential long-term consequences of neonatal CPAP therapy used in the intensive care of preterm infants.
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Affiliation(s)
- Catherine A. Mayer
- Department of Pediatrics, Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH, USA 44106
| | - Richard J. Martin
- Department of Pediatrics, Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH, USA 44106
| | - Peter M. MacFarlane
- Department of Pediatrics, Division of Neonatology, Rainbow Babies & Children’s Hospital, Case Western Reserve University, Cleveland, OH, USA 44106,Corresponding Author: Peter MacFarlane. Department of Pediatrics, Case Western Reserve University, Rainbow Babies & Children’s Hospital, 11100 Euclid Avenue, Cleveland, Ohio 44106-6010. USA, Phone: 216-368-4628/Fax: 216-844-3380,
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31
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Narchi H, Chedid F. Neurally adjusted ventilator assist in very low birth weight infants: Current status. World J Methodol 2015; 5:62-67. [PMID: 26140273 PMCID: PMC4482823 DOI: 10.5662/wjm.v5.i2.62] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 03/07/2015] [Accepted: 04/14/2015] [Indexed: 02/07/2023] Open
Abstract
Continuous improvements in perinatal care have resulted in increased survival of premature infants. Their immature lungs are prone to injury with mechanical ventilation and this may develop into chronic lung disease (CLD) or bronchopulmonary dysplasia. Strategies to minimize the risk of lung injury have been developed and include improved antenatal management (education, regionalization, steroids, and antibiotics), exogenous surfactant administration and reduction of barotrauma by using exclusive or early noninvasive ventilatory support. The most frequently used mode of assisted ventilation is pressure support ventilation that may lead to patient-ventilator asynchrony that is associated with poor outcome. Ventilator-induced diaphragmatic dysfunction or disuse atrophy of diaphragm fibers may also occur. This has led to the development of new ventilation modes including neurally adjusted ventilatory assist (NAVA). This ventilation mode is controlled by electrodes embedded within a nasogastric catheter which detect the electrical diaphragmatic activity (Edi) and transmit it to trigger the ventilator in synchrony with the patient’s own respiratory efforts. This permits the patient to control peak inspiratory pressure, mean airway pressure and tidal volume. Back up pressure control (PC) is provided when there is no Edi signal and no pneumatic trigger. Compared with standard conventional ventilation, NAVA improves blood gas regulation with lower peak inspiratory pressure and oxygen requirements in preterm infants. NAVA is safe mode of ventilation. The majority of studies have shown no significant adverse events in neonates ventilated with NAVA nor a difference in the rate of intraventricular hemorrhage, pneumothorax, or necrotizing enterocolitis when compared to conventional ventilation. Future large size randomized controlled trials should be established to compare NAVA with volume targeted and pressure controlled ventilation in newborns with mature respiratory drive. Most previous studies and trials were not sufficiently large and did not include long-term patient oriented outcomes. Multicenter, randomized, outcome trials are needed to determine whether NAVA is effective in avoiding intubation, facilitating extubation, decreasing time of ventilation, reducing the incidence of CLD, decreasing length of stay, and improving long-term outcomes such as the duration of ventilation, length of hospital stay, rate of pneumothorax, CLD and other major complications of prematurity. In order to prevent barotrauma, next generations of NAVA equipment for neonatal use should enable automatic setting of ventilator parameters in the backup PC mode based on the values generated by NAVA. They should also include an upper limit to the inspiratory time as in conventional ventilation. The manufacturers of Edi catheters should produce smaller sizes available for extreme low birth weight infants. Newly developed ventilators should also include leak compensation and high frequency ventilation. A peripheral flow sensor is also essential to the proper delivery of all modes of conventional ventilation as well as NAVA.
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Stefanescu BM, Frewan N, Slaughter JC, O'Shea TM. Volume guarantee pressure support ventilation in extremely preterm infants and neurodevelopmental outcome at 18 months. J Perinatol 2015; 35:419-23. [PMID: 25569681 DOI: 10.1038/jp.2014.228] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 11/05/2014] [Accepted: 11/18/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Compared with pressure-controlled ventilation (PCV), volume-targeted ventilation is associated with decreased neonatal complications, including the combined outcome of death or bronchopulmonary dysplasia. However, little is known about its effect on neurodevelopmental outcome. We evaluated the hypothesis that as compared with PCV, volume-targeted ventilation reduces the risk of the combined outcome of neurodevelopmental impairment or death in very low birth weight infants. STUDY DESIGN We studied a cohort of extremely preterm infants managed with either volume guarantee pressure support ventilation (VGPSV; n=135) or PCV (n=135). Infants were evaluated at 18 months adjusted age with a standardized neurological examination and the Bayley Scales of Infant and Toddler Development-third edition. Logistic regression models were used to evaluate the association of ventilation mode and neurodevelopmental outcome. RESULT Rates of pulmonary interstitial emphysema (odds ratio 0.6; 95% confidence limits: 0.4, 0.8), hypotension (odds ratio: 0.7; 95% confidence limits: 0.5, 0.9) and mortality (odds ratio 0.45; 95% confidence limits: 0.22, 0.9) were lower among infants treated with VGPSV. The infants in the VGPSV group had a significantly shorter duration on mechanical ventilation compared with infants in the PCV group (log-rank test P<0.01). Seventy percent (155/221) of survivors were evaluated at 18 months adjusted age. A trend towards benefit for the combined outcome of death or neurodevelopmental impairment was seen in the VGPSV group but did not reach statistical significance (odds ratio: 0.59; 95% confidence limits: 0.32, 1.08). CONCLUSION VGPSV was associated with a decreased risk of short-term complications but not long-term developmental impairment in this modest-sized cohort.
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Affiliation(s)
- B M Stefanescu
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - N Frewan
- Department of Pediatrics, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - J C Slaughter
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - T M O'Shea
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Acute Neonatal Respiratory Failure. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7193706 DOI: 10.1007/978-3-642-01219-8_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Acute respiratory failure requiring assisted ventilation is one of the most common reasons for admission to the neonatal intensive care unit. Respiratory failure is the inability to maintain either normal delivery of oxygen to the tissues or normal removal of carbon dioxide from the tissues. It occurs when there is an imbalance between the respiratory workload and ventilatory strength and endurance. Definitions are somewhat arbitrary but suggested laboratory criteria for respiratory failure include two or more of the following: PaCO2 > 60 mmHg, PaO2 < 50 mmHg or O2 saturation <80 % with an FiO2 of 1.0 and pH < 7.25 (Wen et al. 2004).
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Rimensberger PC. Surfactant. PEDIATRIC AND NEONATAL MECHANICAL VENTILATION 2015. [PMCID: PMC7175631 DOI: 10.1007/978-3-642-01219-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Exogenous pulmonary surfactant, widely used in neonatal care, is one of the best-studied treatments in neonatology, and its introduction in the 1990s led to a significant improvement in neonatal outcomes in preterm infants, including a decrease in mortality. This chapter provides an overview of surfactant composition and function in health and disease and summarizes the evidence for its clinical use.
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Affiliation(s)
- Peter C. Rimensberger
- Service of Neonatology and Pediatric Intensive Care, Department of Pediatrics, University Hospital of Geneva, Geneve, Switzerland
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35
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Work of breathing indices in infants with respiratory insufficiency receiving high-flow nasal cannula and nasal continuous positive airway pressure. J Perinatol 2014; 34:27-32. [PMID: 24071905 PMCID: PMC4141486 DOI: 10.1038/jp.2013.120] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 08/12/2013] [Accepted: 08/21/2013] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To compare work of breathing (WOB) indices between two nCPAP settings and two levels of HFNC in a crossover study. STUDY DESIGN Infants with a CGA 28-40 weeks, baseline of HFNC 3-5 lpm or nCPAP 5-6 cmH2O and fraction of inspired oxygen ≤40% were eligible. WOB was analyzed using respiratory inductive plethysmography (RIP) for each of the four modalities: HFNC 3 and 5 lpm, nCPAP 5 and 6 cmH2O. N=20; Study weight 1516 g (±40 g). RESULT Approximately 12,000 breaths were analyzed indicating a high degree of asynchronous breathing and elevated WOB indices at all four levels of support. Phase angle values (means) (P<0.01): HFNC 3 lpm (114.7°), HFNC 5 lpm (96.7°), nCPAP 5 cmH2O (87.2°), nCPAP 6 cmH2O (80.5°). The mean phase relation of total breath (PhRTB) (means) (P<0.01): HFNC 3 lpm (63.2%), HFNC 5 lpm (55.3%), nCPAP 5 cmH2O (49.3%), nCPAP 6 cmH2O (48.0%). The relative labored breathing index (LBI) (means) (P≤0.001): HFNC 3 lpm (1.39), HFNC 5 lpm (1.31), nCPAP 5 cmH2O (1.29), nCPAP 6 cmH2O (1.26). Eighty-two percent of the study subjects-respiratory mode combinations displayed clustering, in which a proportion of breaths either occurred predominantly out-of-phase (relative asynchrony) or in-phase (relative synchrony). CONCLUSION In this study, WOB indices were statistically different, yet clinically similar in that they were elevated with respect to normal values. These infants with mild-to-moderate respiratory insufficiency demonstrate a meaningful elevation in WOB indices and continue to require non-invasive respiratory support. Patient variability exists with regard to biphasic clustered breathing patterns and the level of supplemental fraction of inspired oxygen ≤40% alone does not provide guidance to the optimal matching of WOB indices and non-invasive respiratory support.
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Mukerji A, Finelli M, Belik J. Nasal high-frequency oscillation for lung carbon dioxide clearance in the newborn. Neonatology 2013; 103:161-5. [PMID: 23258368 DOI: 10.1159/000345613] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Accepted: 11/06/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Noninvasive ventilation has been used increasingly in recent years to minimize the duration of endotracheal mechanical ventilation in neonates due to its association with lung injury. Nasal high-frequency oscillation (nHFO) is a relatively new noninvasive modality but evidence for its use is limited. OBJECTIVE The goal of this study was to compare the CO2 clearance efficacy of nHFO and noninvasive positive pressure ventilation (NIPPV) in a neonatal lung model. DESIGN/METHODS A newborn mannequin with dimensions and anatomy similar to a term infant was utilized. It was connected to a commercially available neonatal mechanical ventilator using a manufacturer-provided nasal adaptor. Various modes of noninvasive ventilation were compared as CO2 clearance was measured at the oropharynx by an end-tidal CO2 analyzer following the addition of a known amount of CO2 into the lung. Measurements were obtained at two different lung compliances using nHFO and compared with nCMV and nasal continuous positive airway pressure (nCPAP) as a control. Pressures near the nasal adaptor and the larynx were simultaneously measured with in-line pressure transducers. RESULTS Whereas no CO2 elimination was observed under nCPAP, its clearance with nHFO was 3-fold greater as compared to NIPPV. On nHFO, CO2 clearance was inversely proportional to frequency and maximal at 6 and 8 Hz. At a lower lung compliance, CO2 clearance was significantly higher at 6 Hz as compared to 10 Hz. During nHFO set to deliver a MAP of 10.0, we documented pressures of 7.2 ± 0.3 at the nasal adaptor and only 2.3 ± 0.3 cm H2O at the larynx. CONCLUSIONS Nasal HFO is effective and superior to NIPPV at lung CO2 elimination in a newborn mannequin model. The use of nHFO as the preferred mode of noninvasive ventilation warrants further clinical studies.
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Affiliation(s)
- Amit Mukerji
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ont., Canada
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Vellanki H, Antunes M, Locke RG, McGreevy T, Mackley A, Eubanks JJ, Western M, Emberger J, Paul DA. Decreased incidence of pneumothorax in VLBW infants after increased monitoring of tidal volumes. Pediatrics 2012; 130:e1352-8. [PMID: 23045561 DOI: 10.1542/peds.2011-2611] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Pneumothorax is common in very low birth weight (VLBW) infants. In our NICU, we noted an above average incidence of pneumothorax compared with similar NICUs based on Vermont Oxford Network benchmarking. The quality improvement project was designed to decrease the incidence of pneumothorax in VLBW infants in a tertiary care NICU. METHODS The project was divided into 2 periods. During period 1, all VLBW infants were followed for 6 months for the presence of pneumothorax. A multidisciplinary team met regularly to review cases of pneumothorax and identify potential causes. High tidal volumes (VT) (>6 mL/kg) were noted around the time of occurrence of pneumothorax. Guidelines were developed for improved monitoring and rapid feedback of VT and peak inspiratory pressure between nursing staff and clinicians. During period 2, these guidelines were implemented and VLBW infants were again followed for 6 months. The incidence of pneumothorax was tracked. Run charts were used to monitor changes. RESULTS The incidence of pneumothorax in VLBW infants decreased from 10.4% to 2.6% after the intervention (P = .04). By using process control, a reduction in pneumothorax was achieved in period 2. CONCLUSIONS Increased vigilance and real-time monitoring of VT and peak inspiratory pressure decreased the incidence of pneumothorax in our population of VLBW infants. These interventions can be considered in other NICUs with an above-average risk adjusted incidence of pneumothorax in VLBW infants. Our data illustrate the benefits of comparative benchmarking and organized quality improvement in advancing patient care outcomes.
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Affiliation(s)
- Haritha Vellanki
- Department of Pediatrics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Automated respiratory cycles selection is highly specific and improves respiratory mechanics analysis. Pediatr Crit Care Med 2012; 13:e234-9. [PMID: 22067983 DOI: 10.1097/pcc.0b013e318238b162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Selected optimal respiratory cycles should allow calculation of respiratory mechanic parameters focusing on patient-ventilator interaction. New computer software automatically selecting optimal breaths and respiratory mechanics derived from those cycles are evaluated. DESIGN Retrospective study. SETTING University level III neonatal intensive care unit. SUBJECTS Ten mins synchronized intermittent mandatory ventilation and assist/control ventilation recordings from ten newborns. INTERVENTION The ventilator provided respiratory mechanic data (ventilator respiratory cycles) every 10 secs. Pressure, flow, and volume waves and pressure-volume, pressure-flow, and volume-flow loops were reconstructed from continuous pressure-volume recordings. Visual assessment determined assisted leak-free optimal respiratory cycles (selected respiratory cycles). New software graded the quality of cycles (automated respiratory cycles). Respiratory mechanic values were derived from both sets of optimal cycles. We evaluated quality selection and compared mean values and their variability according to ventilatory mode and respiratory mechanic provenance. To assess discriminating power, all 45 "t" values obtained from interpatient comparisons were compared for each respiratory mechanic parameter. MEASUREMENTS AND MAIN RESULTS A total of 11,724 breaths are evaluated. Automated respiratory cycle/selected respiratory cycle selections agreement is high: 88% of maximal κ with linear weighting. Specificity and positive predictive values are 0.98 and 0.96, respectively. Averaged values are similar between automated respiratory cycle and ventilator respiratory cycle. C20/C alone is markedly decreased in automated respiratory cycle (1.27 ± 0.37 vs. 1.81 ± 0.67). Tidal volume apparent similarity disappears in assist/control: automated respiratory cycle tidal volume (4.8 ± 1.0 mL/kg) is significantly lower than for ventilator respiratory cycle (5.6 ± 1.8 mL/kg). Coefficients of variation decrease for all automated respiratory cycle parameters in all infants. "t" values from ventilator respiratory cycle data are two to three times higher than ventilator respiratory cycles. CONCLUSIONS Automated selection is highly specific. Automated respiratory cycle reflects most the interaction of both ventilator and patient. Improving discriminating power of ventilator monitoring will likely help in assessing disease status and following trends. Averaged parameters derived from automated respiratory cycles are more precise and could be displayed by ventilators to improve real-time fine tuning of ventilator settings.
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Rigo V, Graas E, Rigo J. Precision of continuous neonatal ventilator respiratory mechanics is improved with selected optimal respiratory cycles. Eur J Pediatr 2012; 171:689-96. [PMID: 22139322 DOI: 10.1007/s00431-011-1623-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/08/2011] [Indexed: 11/29/2022]
Abstract
UNLABELLED Given their high apparent variability, bedside continuous respiratory mechanics (RM) parameters [excepting tidal volume (V (T))] remain infrequently used for adjustment of neonatal ventilatory settings. RM parameters provided by ventilator (VRC) from ten recordings of newborns [10 min in synchronised intermittent mandatory ventilation and 10 min in assist/control (A/C)] were compared to those computed from visually selected assisted leak-free optimal respiratory cycles (SRC). Mean values, variability and ability to distinguish patients were compared between VRC and SRC. Dynamic resistances were more correlated (r(2) = 0.95) than compliances (r (2) = 0.42). V (T)s were correlated only in A/C (r(2) = 0.78). C20/C was significantly higher in VRC (1.81 ± 0.67) than in SRC (1.23 ± 0.36) and frequently out of neonatal reference range. In A/C ventilation, V(T) was higher in VRC (5.6 ± 1.8 ml/kg) than in SRC (4.8 ± 1.0 ml/kg) (p < 0.05). Displayed V (T)s do not reflect those found in optimal assisted breaths and therefore have incomplete value in assessing adequacy of ventilator settings. The variability of RM parameters provided by the ventilator is large, and coefficients of variation were significantly lower with optimal respiratory cycles (for resistance, compliance, V (T) and C20/C; 27%, 26%, 18%, 24% in SRC and 36%, 35%, 40% and 33% in VRC). Selecting optimal cycles yields RM with two to three times higher discriminating power between patients. CONCLUSION Current ventilator's RM parameters have limited clinical use. Using optimal breaths to calculate RM parameters improves precision and discriminating power. For integration to ventilatory care, automation of this selection must be implemented first.
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Affiliation(s)
- Vincent Rigo
- Neonatology Department, University of Liège, CHU de Liège (CHR), Boulevard du Douzième de Ligne, 1, B4000, Liège, Belgium.
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Colnaghi M, Pierro M, Migliori C, Ciralli F, Matassa PG, Vendettuoli V, Mercadante D, Consonni D, Mosca F. Nasal continuous positive airway pressure with heliox in preterm infants with respiratory distress syndrome. Pediatrics 2012; 129:e333-8. [PMID: 22291116 DOI: 10.1542/peds.2011-0532] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the therapeutic effects of breathing a low-density helium and oxygen mixture (heliox, 80% helium and 20% oxygen) in premature infants with respiratory distress syndrome (RDS) treated with nasal continuous positive airway pressure (NCPAP). METHODS Infants born between 28 and 32 weeks of gestational age with radiologic findings and clinical symptoms of RDS and requiring respiratory support with NCPAP within the first hour of life were included. These infants were randomly assigned to receive either standard medical air (control group) or a 4:1 helium and oxygen mixture (heliox group) during the first 12 hours of enrollment, followed by medical air until NCPAP was no longer needed. RESULTS From February 2008 to September 2010, 51 newborn infants were randomly assigned to two groups, 24 in the control group and 27 in the heliox group. NCPAP with heliox significantly decreased the risk of mechanical ventilation in comparison with NCPAP with medical air (14.8% vs 45.8%). CONCLUSIONS Heliox increases the effectiveness of NCPAP in the treatment of RDS in premature infants.
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Affiliation(s)
- Mariarosa Colnaghi
- NICU, Fondazione IRCCS Cà Granda - Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy.
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Gupta S, Sinha SK, Donn SM. Myth: mechanical ventilation is a therapeutic relic. Semin Fetal Neonatal Med 2011; 16:275-8. [PMID: 21621495 DOI: 10.1016/j.siny.2011.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Non-invasive respiratory support techniques such as continuous positive airway pressure (CPAP) have been increasingly used for management of surfactant-deficient lung disease in preterm infants. The successful use of this approach depends upon the condition of the baby at birth and requires the establishment of spontaneous breathing at birth. The reported advantages of CPAP in observational studies demonstrating a reduction in chronic lung disease have not been substantiated in recently reported well-designed randomised trials. This approach is now more established in larger and more mature preterm infants, and proper patient selection with close observation should be exercised when used in extremely low gestational age infants.
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Affiliation(s)
- Samir Gupta
- Department of Neonatal Paediatrics, University Hospital of North Tees, Stockton, UK.
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Czernik C, Schmalisch G, Bührer C, Proquitté H. Weaning of neonates from mechanical ventilation by use of nasopharyngeal high-frequency oscillatory ventilation: a preliminary study. J Matern Fetal Neonatal Med 2011; 25:374-8. [DOI: 10.3109/14767058.2011.580401] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Saccomandi P, Schena E, Silvestri S. A novel target-type low pressure drop bidirectional optoelectronic air flow sensor for infant artificial ventilation: measurement principle and static calibration. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2011; 82:024301. [PMID: 21361616 DOI: 10.1063/1.3549624] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
An optoelectronic target-type volumetric air flow-rate transducer for bidirectional measurements is presented. The sensor is composed of a T-shaped target and two nominally identical LED-photodiode couples which are operated in differential mode. The sensitive surfaces of the photodiodes are differentially shadowed by the deflection of the target, which in turn depends on the gas flow-rate. The principle of operation is described in mathematical terms and the design parameters have been optimized in order to obtain the highest sensitivity along with minimal pressure drop and reduced dimensions. The sensor is placed in a 20 mm diameter hose and was tested with air flow-rate in the typical temperature range of mechanical ventilation between 20 and 40 °C. The theoretical model was validated through experiments carried out in the volumetric flow range from -7.0 to +7.0 l min(-1). The nonlinear behavior allows sensitivities equal to 0.6 V l(-1) min for flow rates ranging from -2.0 to +2.0 l min(-1), equal to 2.0 V l(-1) min for flow rates ranging from -3.0 to -2.0 l min(-1) and from +2.0 to +3.0 l min(-1), up to 5.7 V l(-1) min at higher flow rates ranging from -7.0 to -3.0 l min(-1) and from +3.0 to +7.0 l min(-1). The linear range extends from 3.0 to 7.0 l min(-1) with constant sensitivity equal to 5.7 V l(-1) min. The sensor is able to detect a flow-rate equal to 1.0 l min(-1) with a sensitivity of about 400 mV l(-1) min. The differential nature of the output minimizes the influence of the LEDs' power supply variations and allows to obtain a repeatability in the order of 3% of full scale output. The small pressure drop produced by the sensor placed in-line the fluid stream, of about 2.4 Pa at 7 l min(-1), corresponds to a negligible fluid dynamic resistance lower than 0.34 Pa l(-1) min.
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Affiliation(s)
- Paola Saccomandi
- Faculty of Biomedical Engineering, University Campus Bio-Medico, Rome, Italy
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Schulzke SM, Pillow J, Ewald B, Patole SK. Flow-cycled versus time-cycled synchronized ventilation for neonates. Cochrane Database Syst Rev 2010:CD008246. [PMID: 20614468 DOI: 10.1002/14651858.cd008246.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Synchronized ventilation of neonates is standard care in industrialized countries. Both flow-cycled and time-cycled modes of synchronized ventilation are in widespread use for assisted ventilation of neonates. OBJECTIVES To determine the effect of flow-cycled versus time-cycled synchronized ventilation on the risk of bronchopulmonary dysplasia (BPD) at 36 weeks postmenstrual age (PMA) in neonates requiring assisted ventilation. SEARCH STRATEGY We used the standard methods of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 4, 2009, PubMed (January 1966 to October 2009), EMBASE (January 1974 to October 2009) and CINAHL (January 1982 to October 2009). We checked references and cross-references from identified studies. Abstracts from the proceedings of the Pediatric Academic Societies Meetings (from January 1990 to October 2009) were handsearched. We placed no restrictions on language. SELECTION CRITERIA Randomized or quasi-randomized clinical trials comparing flow-cycled with time-cycled synchronized endotracheal ventilation in neonates, reporting on at least one outcome of interest were eligible for inclusion in the review. DATA COLLECTION AND ANALYSIS One author (SMS) searched the literature as described above. Selection of studies and data extraction were done separately by two authors (SMS and SKP). Any disagreements were resolved by discussion involving all authors. MAIN RESULTS Only two small, short-term, randomized, individual cross-over trials involving a total of 19 preterm neonates met the inclusion criteria of this review. Both trials reported on lung mechanics and short-term respiratory physiology outcomes but not on clinical morbidities or mortality. AUTHORS' CONCLUSIONS There is insufficient evidence to determine the safety and efficacy of flow-cycled compared to time-cycled synchronized ventilation in neonates. Large randomized clinical trials using a parallel-group design and reporting on clinically important outcomes are warranted.
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Affiliation(s)
- Sven M Schulzke
- Department of Neonatology, University of Basel Children's Hospital (UKBB), Spitalstrasse 21, Basel, Switzerland, 4031
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Rose MJ, Stenger MR, Joshi MS, Welty SE, Bauer JA, Nelin LD. Inhaled nitric oxide decreases leukocyte trafficking in the neonatal mouse lung during exposure to >95% oxygen. Pediatr Res 2010; 67:244-9. [PMID: 19915514 PMCID: PMC2829761 DOI: 10.1203/pdr.0b013e3181ca0d93] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chronic lung injury in the neonate is termed bronchopulmonary dysplasia (BPD). These patients generally require supplemental oxygen therapy, and hyperoxia has been implicated in the pathogenesis of BPD. The concomitant use of oxygen and inhaled NO (iNO) may result in the generation of reactive nitrogen species or may have an anti-inflammatory effect in the neonatal lung. We tested the hypothesis that exposure to >95% O2 in neonatal mice would increase trafficking of leukocytes into the lung and that the addition of iNO to >95% O2 would decrease this leukocyte trafficking. Hyperoxia resulted in fewer alveoli, increased presence of neutrophils and macrophages, and decreased number of mast cells within the lung parenchyma. Adding iNO to hyperoxia prevented the hyperoxia-induced changes and resulted in the numbers of alveoli, neutrophils, macrophages, and mast cells approximating those found in controls (room air exposure). Intercellular adhesion molecule (ICAM) and monocyte chemotactic protein-1 (MCP-1), two factors responsible for leukocyte recruitment, were up-regulated by hyperoxic exposure, but the addition of iNO to the hyperoxic exposure prevented the hyperoxia-induced up-regulation of ICAM and MCP-1. These data demonstrate that iNO alters the hyperoxia-induced recruitment of leukocytes into the lung.
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Affiliation(s)
- Melissa J Rose
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio 43205, USA
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A randomized controlled trial of post-extubation bubble continuous positive airway pressure versus Infant Flow Driver continuous positive airway pressure in preterm infants with respiratory distress syndrome. J Pediatr 2009; 154:645-50. [PMID: 19230906 DOI: 10.1016/j.jpeds.2008.12.034] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Revised: 11/07/2008] [Accepted: 12/12/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of bubble continuous positive airway pressure (CPAP) and Infant Flow Driver (IFD) CPAP for the post-extubation management of preterm infants with respiratory distress syndrome (RDS). STUDY DESIGN A total of 140 preterm infants at 24 to 29 weeks' gestation or with a birth weight of 600 to 1500 g who were ventilated at birth for RDS were randomized to receive either IFD CPAP (a variable-flow device) or bubble CPAP (a continuous-flow device). A standardized protocol was used for extubation and CPAP. No crossover was allowed. The primary outcome was successful extubation maintained for at least 72 hours. Secondary outcomes included successful extubation maintained for 7 days, total duration of CPAP support, chronic lung disease, and complications of prematurity. RESULTS Seventy-one infants were randomized to bubble CPAP, and 69 were randomized to IFD CPAP. Mean gestational age and birth weight were similar in the 2 groups, as were the proportions of infants who achieved successful extubation for 72 hours and for 7 days. However, the median duration of CPAP support was 50% shorter in the infants on bubble CPAP. Moreover, in the subset of infants who were ventilated for less than 14 days, the infants on bubble CPAP had a significantly lower extubation failure rate. There was no difference in the incidence of chronic lung disease or other complications between the 2 study groups. CONCLUSIONS Bubble CPAP is as effective as IFD CPAP in the post-extubation management of infants with RDS; however, in infants ventilated for < or = 14 days, bubble CPAP is associated with a significantly higher rate of successful extubation. Bubble CPAP also is associated with a significantly reduced duration of CPAP support.
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Asistencia respiratoria neonatal, tendencia actual. An Pediatr (Barc) 2009; 70:107-10. [DOI: 10.1016/j.anpedi.2008.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Accepted: 10/12/2008] [Indexed: 11/23/2022] Open
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Abstract
AIM To assess the use of nasal high-frequency ventilation (HFV) to provide noninvasive ventilatory support for very low birthweight (VLBW) infants. STUDY DESIGN VLBW infants, >7 days of age on nasal continuous positive airway pressure (CPAP), were placed on nasal HFV for 2 h using the Infant Star high-frequency ventilator (Mallinckrodt, Inc., St. Louis, MO, USA). Mean airway pressure was set to equal the previous level of CPAP, and amplitude was adjusted to obtain chest wall vibration. Capillary blood was sampled before starting HFV and after 2 h to determine change in pH and partial pressure of carbon dioxide (pCO(2)). RESULTS Fourteen subjects were studied, 10 males and 4 females. Gestational age was 26-30 weeks (median 27). Age at study was 18-147 days (median 30). Median birth weight was 955 g; median weight at study was 1605 g. Nasal CPAP pressure was 4-7 cm H(2)O (mean 5). Amplitude was 30-60 (median 50). After 2 h, PCO(2) (mean 45 torr) was significantly lower than initial PCO(2) (mean 50 torr) (p = 0.01), and pH had increased significantly (7.40 vs. 7.37, p = 0.04). CONCLUSIONS Nasal HFV is effective in decreasing pCO(2) in stable premature infants requiring nasal CPAP support. Long-term use of nasal HFV requires further study.
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Affiliation(s)
- Tarah T Colaizy
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa 52242, USA.
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Abstract
AIM To assess the use of nasal high-frequency ventilation (HFV) to provide noninvasive ventilatory support for very low birthweight (VLBW) infants. STUDY DESIGN VLBW infants, >7 days of age on nasal continuous positive airway pressure (CPAP), were placed on nasal HFV for 2 h using the Infant Star high-frequency ventilator (Mallinckrodt, Inc., St. Louis, MO, USA). Mean airway pressure was set to equal the previous level of CPAP, and amplitude was adjusted to obtain chest wall vibration. Capillary blood was sampled before starting HFV and after 2 h to determine change in pH and partial pressure of carbon dioxide (pCO(2)). RESULTS Fourteen subjects were studied, 10 males and 4 females. Gestational age was 26-30 weeks (median 27). Age at study was 18-147 days (median 30). Median birth weight was 955 g; median weight at study was 1605 g. Nasal CPAP pressure was 4-7 cm H(2)O (mean 5). Amplitude was 30-60 (median 50). After 2 h, PCO(2) (mean 45 torr) was significantly lower than initial PCO(2) (mean 50 torr) (p = 0.01), and pH had increased significantly (7.40 vs. 7.37, p = 0.04). CONCLUSIONS Nasal HFV is effective in decreasing pCO(2) in stable premature infants requiring nasal CPAP support. Long-term use of nasal HFV requires further study.
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Affiliation(s)
- Tarah T Colaizy
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa 52242, USA.
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Abstract
Although life saving, mechanical ventilation can cause complications such as ventilator-induced lung injury and bronchopulmonary dysplasia in very preterm babies. The ventilator-induced lung injury is multi-factorial. There has been an introduction of a number of newer forms of mechanical ventilation, which are aimed to reduce such complications. These are based on sound physiologic principles and clinicians should familiarize themselves with these advances.
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Affiliation(s)
- Sunil K Sinha
- University of Durham and James Cook University Hospital, Middlesbrough, TS4 3BW, United Kingdom.
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