Differential effects of pancuronium bromide on cardiopulmonary function in the neonatal lamb

Quantitative Assessment of Tracheal Collapsibility in Infants with Tracheomalacia

Infantile tracheomalacia is a potentially life-threatening disease requiring prolonged artificial respiratory support. Diagnosis and management of this disease may be further improved by establishing a suitable objective and quantitative assessment protocol for tracheal collapsibility. It is our hypothesis that tracheal collapsibility can be represented by the relationship between intraluminal pressure and the cross-sectional area of the trachea. To test this hypothesis, static pressure/area relationships of the trachea were obtained from anesthetized and paralyzed infants, who were diagnosed as having tracheomalacia by endoscopic observation. These relationships were fitted on a linear regression model, followed by calculation of the estimated closing pressure. The tracheal closing pressure ranged from -8 to -27 cm H(2)O, suggesting easy collapsibility of the trachea during crying or coughing and noncollapsibility during the spontaneous respiratory cycle, which coincided with the infants' symptoms. It is our conclusion that tracheal collapsibility of infants with tracheomalacia can be quantitatively assessed by the static pressure/area relationship of the trachea obtained under general anesthesia and paralysis.

High-frequency oscillation and paralysis stabilize surfactant protein-B--deficient infants

OBJECTIVE

To determine if high-frequency oscillatory ventilation and neuromuscular blockade improve oxygenation and chest radiographic appearance more effectively than high-frequency oscillation alone for surfactant protein-B (SP-B)--deficient infants.

STUDY DESIGN

We reviewed medical records and chest radiographs of five SP-B--deficient infants awaiting lung transplantation. Changes in FiO2 and radiographic scores were analyzed with respect to neuromuscular blockade status.

RESULTS

FiO2 consistently increased 0.20 (SD 0.11) during high-frequency ventilation without neuromuscular blockade (p = 0.02) and decreased 0.14 (SD 0.11) during high-frequency ventilation with neuromuscular blockade (p = 0.05). Chest radiographic appearance, quantified by an expansion/aeration index, consistently deteriorated without neuromuscular blockade (p = 0.01) and consistently improved with neuromuscular blockade (p = 0.03). Changes in FiO2 correlated with changes in radiograph scores (r = 0.7, p < 0.001).

CONCLUSIONS

High-frequency ventilation with neuromuscular blockade optimizes oxygenation for SP-B--deficient infants. This ventilatory strategy should be considered while awaiting the diagnosis of SP-B deficiency or lung transplantation.

[Physiological basis for the use of muscarine antagonists in bronchopulmonary dysplasia]

The rationale for the use of muscarinic antagonists in bronchopulmonary dysplasia (BPD) is based on the physiology and pharmacology of airway smooth muscle, the pathology of BPD, and the response of infants with BPD to bronchodilators, in vivo and in vitro studies of airway smooth muscle of newborn animals and humans indicate that vagal efferent airway innervation and/or muscarinic receptors are functional at birth, as well as early in gestation. Current concepts regarding muscarinic receptor subtypes suggest that M3 receptors mediate airway smooth muscle contraction, M2 receptors are autoinhibitory and limit vagally-mediated bronchoconstriction, and M1 receptors may play a facilitatory role in ganglionic transmission. Muscarinic receptor subtypes appear to be functionally expressed at birth but may undergo developmental regulation. Infants with BPD have an elevated pulmonary resistance that is accompanied by hypertrophy of airway smooth muscle, b2-agonists cause bronchodilation in BPD as does atropine in infants recovering from severe BPD. The synthetic congener of atropine, ipratropium bromide (IPB) causes bronchodilation in ventilator-dependent infants with BPD in a dose-dependent fashion. Nebulized IPB causes a decrease in respiratory resistance that reaches a maximum of 20% at 175 mg. The bronchodilation seen with muscarinic antagonists suggests that part of the elevated resistance associated with BPD is due to increased muscarinic tone, presumably vagal in origin. When IPB is combined with salbutamol (0.04 mg) the response is increased in magnitude and duration; reaching a slightly larger decreases in resistance (26%) that is now accompanied by an increase in compliance (20%).(ABSTRACT TRUNCATED AT 250 WORDS)

Maturation affects the maximal pulmonary response to methacholine in rabbits

Maximal bronchoconstriction in normal adults produces only small reductions in pulmonary function; however, in normal infants severe airway obstruction limits testing to low agonist concentrations. In this study, maximal pulmonary response to methacholine was evaluated in 5 immature (1 month old) and 5 mature (6 months old) rabbits. Animals were anesthetized, paralyzed, and mechanically ventilated via a tracheostomy tube. Changes in pulmonary function were assessed from maximal deflation flow volume curves following inhalation of doubling concentrations of methacholine between 0.6 and 320 mg/mL. Following 320 mg/mL methacholine, the immature rabbits had a greater percent decline in forced vital capacity (FVC) than the mature animals (55 +/- 15% vs. 36 +/- 10%; P < 0.05). At 50% FVC, isovolume flows were measurable in the 5 mature rabbits, and 4 of 5 had plateaus in their dose-response curves. At the higher methacholine doses, only 1 of 5 immature animals had measurable isovolume flows because of the decrease in FVC. There was no significant difference between immature and mature animals in the methacholine dose required to decrease baseline flows by 50%. We conclude that in rabbits maturation affects maximal pulmonary response but not the sensitivity to methacholine.

Caffeine potentiates airway responsiveness in the neonatal lamb

In contrast to its effect on airway smooth muscle in the adult, in vitro studies have shown that caffeine significantly increases active tension in airway smooth muscle in the neonatal lamb. To determine if caffeine has a physiological effect on airway function during early development, we studied the effect of caffeine on acetylcholine-induced bronchoconstriction in two groups of neonatal lambs. The animals were anesthetized, paralyzed, and maintained normoxic and normocapnic with mechanical ventilation. Pulmonary mechanics were evaluated as indices of airway tone, and functional residual capacity was used as an index of lung volume; heart rate and mean arterial pressure were used to assess cardiovascular status. Acetylcholine-induced bronchoconstriction was evaluated as percentage changes of airway conductance and lung compliance from baseline, before and 1 hour after administration of normal saline or caffeine, and it was further analyzed with respect to the dose that produced a 20% change in those values (PD20). There were no significant alterations in baseline lung mechanics, lung volume, or mean arterial pressure following saline or caffeine infusion. However, caffeine produced a left shift in the acetylcholine dose-response curve for conductance and compliance and a significant decrease (-52%; P less than 0.001) in PD20 for conductance. There were no significant alterations in any parameter following saline administration. Since caffeine is used commonly for the treatment of apnea of prematurity, it is noteworthy that caffeine increases airway reactivity at clinically relevant doses. These findings raise important issues regarding the use of caffeine for the treatment of apnea of prematurity.