High-Frequency Ventilation as a Mode of Noninvasive Respiratory Support

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.

Use of Targeted Neonatal Echocardiography and Focused Cardiac Sonography in Tertiary Neonatal Intensive Care Units: Time to Embrace It?

Focused cardiac sonography and targeted neonatal echocardiography refer to goal-directed cardiac imaging using ultrasound, typically by noncardiologic specialists. Although the former consists of a rapid qualitative assessment of cardiac function, which is usually performed by acute care practitioners, the latter refers to detailed functional echocardiography to obtain quantitative and qualitative indexes of pulmonary and systemic hemodynamics in sick neonates and is typically performed by neonatologists. Although the use of these modalities is increasing, they still remain unavailable in most North American centers providing acute care to neonates, partly because of limited data regarding their direct impact on patient care. Here we present a series of 5 cases from a large perinatal unit in which immediate availability of relevant expertise led to important and arguably life-saving clinical interventions. In 4 of these cases, focused cardiac sonography was sufficient to make the diagnosis, whereas in 1 case, clinical integration of detailed systemic hemodynamics measured on target neonatal echocardiography was required.

Neurodevelopmental Outcomes in Preterm Infants with Intraventricular Hemorrhage in Canada

BACKGROUND: Conflicting evidence exists in regards to outcomes of infants with mild IVH [subependymal hemorrhage (SEH) and IVH without ventricular dilatation (VD)] with recent reports suggesting poor outcomes.

OBJECTIVES: To compare 1) neurodevelopmental (ND) outcomes of infants < 29 wks GA with normal head ultrasound scan findings (Group 1: no IVH/PVL/VD to those with a) Group 2: SEH or IVH without VD, b) Group 3: IVH with VD (ventricle size > 10 mm) and c) Group 4: persistent intraparenchymal echogenicity (IPE) or lucency with or without IVH and 2) composite outcome of death or ND impairment (NDI)/severe NDI (SNDI) at 18-24 months in these groups.

DESIGN/METHODS: Retrospective cohort study of data from Canadian Neonatal Network (CNN)and Canadian Neonatal Follow-up Network (CNFUN) from April 2010 to September 2011. NDI was defined as any one of Bayley III score < 85 (cognition, language or motor), cerebral palsy (CP) or visual/hearing impairment. SNDI was defined as Bayley III score < 70 for any of the 3 components, CP with GMFCS > 3, severe visual impairment <20/200 or hearing impairment needing aids/cochlear implants. Data for the 4 groups were compared using Chi-squared test or ANOVA as appropriate. Multivariable regression was conducted to obtain adusted OR (95% CI).

RESULTS: See tables on page e51.

Impact of interprofessional education on noninvasive ventilation in a tertiary neonatal intensive care unit

OBJECTIVE

To evaluate the impact and effectiveness of an experiential interprofessional education workshop on noninvasive ventilation (NIV) in the setting of a neonatal intensive care unit.

METHODS

In the present cross-sectional study, a full-day workshop, consisting of didactic and hands-on components, was developed to assess knowledge and perceptions, and to disseminate the latest evidence and practical aspects of NIV use. All health care professionals (HCPs) were asked to participate. Pre- and post-participation questionnaires and knowledge tests were used to assess the effectiveness of knowledge transfer, and to seek participants' reflections on the utility of the workshop.

RESULTS

Among 214 participants, 206 (96%) and 195 (91%) completed the pre- and post-participation questionnaires, respectively. The majority agreed (14%) or strongly agreed (75%) that NIV education was important for their role. Participants scored their perceived comfort with NIV following the workshop highly (median 5 [interquartile range (IQR) 1]) on a five-point Likert scale and 96% would recommend it to a colleague. Median knowledge scores on NIV, assessed as percent correct responses, increased from 74% (IQR 16) to 86% (IQR 11) (P<0.05).

CONCLUSIONS

A focused, context-specific workshop helped improve understanding and comfort among HCPs while reducing misconceptions about NIV. Further research to assess optimal delivery of NIV education and impact on patient outcomes is required.

Honey on oral mucositis: A Randomized controlled trial

BACKGROUND AND OBJECTIVE

The main stream of management of head and neck cancer is by radiotherapy and surgery. During radiation therapy in head and neck cancers, oral cavity is directly exposed to high dose radiation which leads to several side effects - oral mucositis being the most distressing one. This study was intended to assess the effects of applying honey on oral mucositis during radiation therapy.

MATERIAL AND METHODS

The research design used in this study was Randomized Control Trial with single blinding method in the Radiotherapy Unit of Regional Cancer Centre (RCC), at JIPMER. The study population included a total of 28 patients. Participants in experimental group were given 15ml natural honey for applying on oral mucosa and in control group 15ml plain water were given. Assessment of oral mucosa was done after every 5 doses of radiation therapy using RTOG scale and severity of oral mucositis was assessed.

RESULTS

There was a statistically significant difference in degree of oral mucositis between the experimental and control group in week 4, 5 and 6 (p<0.01). During the whole course of study, 9 (64.28 percent) participants in control group developed grade III oral mucositis while only one participant (7.14%) in experimental group developed grade III oral mucositis.

CONCLUSION

The study concluded that applying natural honey on oral mucositis was effective among head and neck cancers patients receiving external beam radiation therapy.

Periventricular/Intraventricular Hemorrhage and Neurodevelopmental Outcomes: A Meta-analysis

CONTEXT

Periventricular/intraventricular hemorrhage (PIVH) is a common short-term morbidity in preterm infants, but its long-term neurodevelopmental impact, particularly with mild PIVH, remains unclear.

OBJECTIVE

To systematically review and meta-analyze the neurodevelopmental outcomes of preterm infants ≤34 weeks' gestation with mild and severe PIVH, compared with no PIVH.

DATA SOURCES

Medline, Embase, CINAHL, and PsychINFO databases from January 2000 through June 2014.

STUDY SELECTION

Studies reporting long-term neurodevelopmental outcomes based on severity of PIVH were included.

DATA EXTRACTION

Study characteristics, inclusion/exclusion criteria, exposures, and outcome assessment data extracted independently by 2 coauthors.

RESULTS

The pooled unadjusted odds ratios of the primary outcome of death or moderate-severe neurodevelopmental impairment (NDI) were higher with both mild (1.48, 95% CI 1.26-1.73; 2 studies) and severe PIVH (4.72, 4.21-5.31; 3 studies); no studies reported adjusted odds ratios. Among survivors, odds of moderate-severe NDI were higher with mild and severe PIVH in both unadjusted (1.75, 1.40-2.20; 3 studies; 3.36, 3.06-3.68; 5 studies) and adjusted (1.39, 1.09-1.77; 3 studies; 2.44, 1.73-3.42; 2 studies) pooled analyses. Adjusted odds of cerebral palsy and cognitive delay were higher with severe but not mild PIVH.

LIMITATIONS

Only observational studies were included. Fifteen of 21 included studies had a moderate-high risk of bias.

CONCLUSIONS

Mild and severe PIVH are associated with progressively higher odds of death or moderate-severe NDI compared with no PIVH, but no studies adjusted for confounders. Among survivors, mild PIVH was associated with higher odds of moderate-severe NDI compared with no PIVH.

Neonatal nasal intermittent positive pressure ventilation efficacy and lung pressure transmission

OBJECTIVE

The objective of this study was to evaluate carbon dioxide (CO2) clearance, delivered pressures and tidal volume (VT) during neonatal nasal intermittent positive pressure ventilation (NIPPV) with two commonly used interfaces.

STUDY DESIGN

A neonatal lung model, with either short binasal prongs (SBP) or a small caliber nasal cannula (RAM) interface, was tested over a range of clinically relevant settings. A fixed amount of CO2 was infused and the fraction remaining in the lung 100 s postinfusion was measured. Pressure transmission to the lung and VT was measured at the level of the trachea.

RESULT

CO2 elimination was directly proportional to the inspiratory pressure during NIPPV. At peak pressures of 22 to 34 cm H2O, CO2 clearance was greater (P<0.001) with SBP as compared with RAM. Relative to the set ventilator parameters, a substantial pressure dampening effect was documented at the lung level, which was significantly lower with RAM when compared with SBP (2.8% (0.2) versus 11.9% (1.5), P<0.0001). CO2 elimination was dependent on VT and effective despite only a small fraction of physiological VT (maximum delivered VT%: SBP 15.5 (0.7) versus RAM 6.1 (1.4), P<0.0001).

CONCLUSION

NIPPV promotes CO2 elimination even at low transmitted airway pressures, but less effective with RAM as compared with SBP. CO2 elimination despite small VT suggests that NIPPV may depend on a non-conventional gas-exchange mechanism.

Use of noninvasive high-frequency ventilation in the neonatal intensive care unit: a retrospective review

OBJECTIVE

The aim of the article is to review the effectiveness of neonatal noninvasive high-frequency ventilation (NIHFV) in preventing endotracheal mechanical ventilation.

STUDY DESIGN

Retrospective case series including all 79 instances of NIHFV use at four participating centers between July 2010 and September 2012.

RESULTS

In 73% of cases, NIHFV was used as rescue after another noninvasive mode, and prophylactically (postextubation) in the remainder. In 58% of cases, infants transitioned to another noninvasive mode, without requiring intubation. There were significant reductions in the mean (SD) number of apneas, bradycardias, or desaturations (over 6 hours) (3.2 [0.4] vs. 1.2 [0.3]; p < 0.001), FiO2 (48 [3] vs. 40 [2]%; p < 0.001) and CO2 levels (74 [6] vs. 62 [4] mm Hg; p = 0.025] with NIHFV. No NIHFV-related complications were noted.

CONCLUSIONS

NIHFV is a promising NIV mode that may help prevent or delay intubation and deserves further clinical research.

An observational study of the hand hygiene initiative: a comparison of preintervention and postintervention outcomes

OBJECTIVES

To evaluate the impact of implementing a simple, user-friendly eLearning module on hand hygiene (HH) compliance and infection rates.

DESIGN

Preintervention and postintervention observational study.

PARTICIPANTS

All neonates admitted to the neonatal intensive care unit (NICU) over the study period were eligible for participation and were included in the analyses. A total of 3422 patients were admitted over a 36-month span (July 2009 to June 2012).

INTERVENTIONS

In the preintervention and postintervention periods (phases I and II), all healthcare providers were trained on HH practices using an eLearning module. The principles of the '4 moments of HH' and definition of 'baby space' were incorporated using interactive tools. The intervention then extended into a long-term sustainability programme (phase III), including the requirement of an annual recertification of the module and introduction of posters and screensavers throughout the NICU.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was HH compliance rates among healthcare providers in the three phases. The secondary outcome was healthcare-associated infection rates in the NICU.

RESULTS

HH compliance rates declined initially in phase II then improved in phase III with the addition of a long-term sustainability programme (76%, 67% and 76% in phases I, II and III, respectively (p<0.01). Infection rates showed an opposing, but concomitant trend in the overall population as well as in infants <1500 g and were 4%, 6% and 4% (p=0.02), and 11%, 21% and 16% (p<0.01), respectively, during the three phases.

CONCLUSIONS

Interventions to improve HH compliance are challenging to implement and sustain with the need for ongoing reinforcement and education.

Nasal high-frequency oscillation for lung carbon dioxide clearance in the newborn

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.

Identification of single‐domain, Bax‐specific intrabodies that confer resistance to mammalian cells against oxidative‐stress‐induced apoptosis

Bax is a proapoptotic protein implicated in cell death involved in several neurodegenerative diseases. Intracellularly expressed antibody (Ab) fragments (intrabodies) inhibiting Bax function would have potential for developing therapeutics for the aforementioned diseases and can serve as research tools. We report identification, cloning, and functional characterization of several Bax-specific single-domain antibodies (sdAbs). These minimal size Ab fragments, which were isolated from a llama V(H)H phage display library by panning, inhibited Bax function in in vitro assays. Importantly, as intrabodies, these sdAbs, which were stably expressed in mammalian cells, were nontoxic to their host cells and rendered them highly resistant to oxidative-stress-induced apoptosis. The intrabodies prevented mitochondrial membrane potential collapse and apoptosis after oxidative stress in the host cells. These anti-Bax V(H)Hs could be used as tools for studying the role of Bax in oxidative-stress-induced apoptosis and for developing novel therapeutics for the degenerative diseases involving oxidative stress.

Water-soluble formulation of Coenzyme Q10 inhibits Bax-induced destabilization of mitochondria in mammalian cells

Oxidative stress leads to mitochondrial dysfunction, which triggers the opening of the permeability transition pores (PTP) and the release of pro-apoptotic factors causing apoptotic cell death. In a limited number of cell systems, anti-oxidants and free-radical scavengers have been shown to block this response. We have previously reported that coenzyme Q(10) (CoQ(10)), an electron carrier in the mitochondrial respiratory chain, is involved in the reactive oxygen species (ROS) removal and prevention of oxidative stress-induced apoptosis in neuronal cells. However, the mechanism of this protection has not been fully elucidated. In the present study we investigated the effects of CoQ(10) on the mitochondrial events characteristic to apoptosis, especially on the function of pro-apoptotic protein Bax. Our results demonstrated that following a brief exposure of two human cell lines (fibroblasts and HEK293 cells) to H(2)O(2) the intracellular levels of ROS and the association of Bax with the mitochondria significantly increased and the cells underwent apoptosis. Both of these events, as well as the release of cytochrome c from the mitochondria, were blocked by a 24 h pre-treatment with CoQ(10). It is therefore believed that CoQ(10) prevented the collapse of the mitochondrial membrane potential in response to the H(2)O(2) treatment. Recombinant Bax protein alone caused the ROS generation and release of cytochrome c from isolated mitochondria and, again, CoQ(10) inhibited these Bax-induced mitochondrial dysfunctions.