1
|
Bamat NA, Orians CM, Abbasi S, Morley CJ, Ross Russell R, Panitch HB, Handley SC, Foglia EE, Posencheg MA, Kirpalani H. Use of ventilation/perfusion mismatch to guide individualised CPAP level selection in preterm infants: a feasibility trial. Arch Dis Child Fetal Neonatal Ed 2023; 108:188-193. [PMID: 36104165 DOI: 10.1136/archdischild-2022-324474] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/31/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To measure within-subject changes in ventilation/perfusion (V'/Q') mismatch in response to a protocol of individualised nasal continuous positive airway pressure (CPAP) level selection. DESIGN Single-arm, non-randomised, feasibility trial. SETTING Three centres in the Children's Hospital of Philadelphia neonatal care network. PATIENTS Twelve preterm infants of postmenstrual age 27-35 weeks, postnatal age >24 hours, and receiving a fraction of inspired oxygen (FiO2) >0.25 on CPAP of 4-7 cm H2O. INTERVENTIONS We applied a protocol of stepwise CPAP level changes, with the overall direction and magnitude guided by individual responses in V'/Q' mismatch, as determined by the degree of right shift (kilopascals, kPa) in a non-invasive gas exchange model. Best CPAP level was defined as the final pressure level at which V'/Q' improved by more than 5%. MAIN OUTCOME MEASURES Within-subject change in V'/Q' mismatch between baseline and best CPAP levels. RESULTS There was a median (IQR) within-subject reduction in V'/Q' mismatch of 1.2 (0-3.2) kPa between baseline and best CPAP levels, p=0.02. Best CPAP was observed at a median (range) absolute level of 7 (5-8) cm H2O. CONCLUSIONS Non-invasive measures of V'/Q' mismatch may be a useful approach for identifying individualised CPAP levels in preterm infants. The results of our feasibility study should be interpreted cautiously and replication in larger studies evaluating the impact of this approach on clinical outcomes is needed. TRIAL REGISTRATION NUMBER NCT02983825.
Collapse
Affiliation(s)
- Nicolas A Bamat
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA .,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Carolyn M Orians
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Soraya Abbasi
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Rob Ross Russell
- Paediatrics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Howard B Panitch
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Sara C Handley
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael A Posencheg
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
2
|
A Compartment-Based Mathematical Model for Studying Convective Aerosol Transport in Newborns Receiving Nebulized Drugs during Noninvasive Respiratory Support. Pharmaceutics 2020; 12:pharmaceutics12100936. [PMID: 33007894 PMCID: PMC7600494 DOI: 10.3390/pharmaceutics12100936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/24/2020] [Accepted: 09/28/2020] [Indexed: 12/28/2022] Open
Abstract
Nebulization could be a valuable solution to administer drugs to neonates receiving noninvasive respiratory support. Small and irregular tidal volumes and air leaks at the patient interface, which are specific characteristics of this patient population and are primarily responsible for the low doses delivered to the lung (DDL) found in this application, have not been thoroughly addressed in in vitro and in vivo studies for quantifying DDL. Therefore, we propose a compartment-based mathematical model able to describe convective aerosol transport mechanisms to complement the existing deposition models. Our model encompasses a mechanical ventilator, a nebulizer, and the patient; the model considers the gas flowing between compartments, including air leaks at the patient–ventilator interface. Aerosol particles are suspended in the gas flow and homogeneously distributed. The impact of breathing pattern variability, volume of the nebulizer, and leaks level on DDL is assessed in representative conditions. The main finding of this study is that convective mechanisms associated to air leaks and breathing patterns with tidal volumes smaller than the nebulizer dramatically reduce the DDL (up to 70%). This study provides a possible explanation to the inconsistent results of drug aerosolization in clinical studies and may provide guidance to improve nebulizer design and clinical procedures.
Collapse
|
3
|
Gomo ØH, Eilevstjønn J, Holte K, Yeconia A, Kidanto H, Ersdal HL. Delivery of Positive End-Expiratory Pressure Using Self-Inflating Bags during Newborn Resuscitation Is Possible Despite Mask Leak. Neonatology 2020; 117:341-348. [PMID: 32610333 DOI: 10.1159/000507829] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/08/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ventilation is the key intervention to resuscitate non-breathing newborns. Positive end-expiratory pressure (PEEP) may facilitate lung-liquid clearance and help establish functional residual capacity. OBJECTIVES The aim of this study was to describe how mask leak and ventilation rates affect delivered PEEP and tidal volumes during newborn resuscitations using a self-inflating bag with an integrated PEEP valve. METHODS This was an observational study including near-term/term newborns who received bag-mask ventilation (BMV) with a new self-inflating bag with a novel 6 mbar PEEP valve, without external gas flow, between October 1, 2016 and June 30, 2018 in rural Tanzania. Helping Babies Breathe-trained midwives performed most of the resuscitations. Pressures and flow were continuously measured and recorded by resuscitation monitors. RESULTS In total, 198 newborns with a median gestation of 39 weeks (25th, 75th percentiles 37, 40) and birth weight of 3,100 g (2,580, 3,500) were included. The median delivered PEEP and expired (tidal) volume at different levels of mask leak were 6.0 mbar and 11.3 mL/kg at 0-20% mask leak, 5.5 mbar and 9.3 mL/kg at 20-40%, 5.2 mbar and 7.8 mL/kg at 40-60%, 4.6 mbar and 5.0 mL/kg at 60-80%, and 1.0 mbar and 0.6 mL/kg at 80-100% mask leak. A high ventilation rate (>60/min) nearly halved expired volumes compared to <60/min for 0-60% leak. The BMV rate had a negligible effect on peak inflation pressure (PIP) and PEEP. CONCLUSIONS Mask leak up to 80% did not impair the provision of recommended PEEP or tidal volumes during BMV with a self-inflating bag. High or low ventilation rates did not significantly affect PIP or PEEP. Expired volumes were reduced at ventilation rates >60/min.
Collapse
Affiliation(s)
| | - Joar Eilevstjønn
- Research and Development Department, Laerdal Medical, Stavanger, Norway
| | - Kari Holte
- Neonatal Department, Østfold Hospital Trust, Grålum, Norway
| | - Anita Yeconia
- Research Department, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Hussein Kidanto
- Medical College, Aga Khan University, Dar es Salaam, Tanzania.,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Hege Langli Ersdal
- Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| |
Collapse
|
4
|
Loughlin CE, Muston HN, Pena MA, Ren CL, Yilmaz O, Noah TL. Pediatric Pulmonology year in review 2018: Asthma, physiology/pulmonary function testing, and respiratory infections. Pediatr Pulmonol 2019; 54:1508-1515. [PMID: 31237426 DOI: 10.1002/ppul.24420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
Pediatric Pulmonology publishes original research, reviews, and case reports related to a wide range of children's respiratory disorders. In our "Year in Review" series, we summarize publications in our major topic areas from 2018, in the context of selected literature in these areas from other journals relevant to our discipline. This review covers selected articles on asthma, physiology/lung function testing, and respiratory infections.
Collapse
Affiliation(s)
- Ceila E Loughlin
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Heather N Muston
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael A Pena
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Clement L Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ozge Yilmaz
- Department of Pediatrics, Pediatric Allergy and Pulmonology, Celal Bayar University, Manisa, Turkey
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| |
Collapse
|
5
|
van Leuteren RW, Hutten GJ, de Waal CG, Dixon P, van Kaam AH, de Jongh FH. Processing transcutaneous electromyography measurements of respiratory muscles, a review of analysis techniques. J Electromyogr Kinesiol 2019; 48:176-186. [PMID: 31401341 DOI: 10.1016/j.jelekin.2019.07.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/23/2019] [Accepted: 07/27/2019] [Indexed: 11/28/2022] Open
Abstract
Transcutaneous electromyography (tc-EMG) has been used to measure the electrical activity of respiratory muscles during inspiration in various studies. Processing the raw tc-EMG signal of these inspiratory muscles has shown to be difficult as baseline noise, cardiac interference, cross-talk and motion artefacts can influence the signal quality. In this review we will discuss the most important sources of signal noise in tc-EMG of respiratory muscles and the various techniques described to suppress or reduce this signal noise. Furthermore, we will elaborate on the options available to develop or improve an algorithm that can be used to guide the approach for analysis of tc-EMG signals of inspiratory muscles in future research.
Collapse
Affiliation(s)
- R W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| | - G J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - C G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - P Dixon
- Vyaire Medical, Basingstoke, United Kingdom
| | - A H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - F H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Faculty of Science and Technology, University of Twente, Enschede, the Netherlands
| |
Collapse
|
6
|
Auten RL. 2018 year in review: Part 2 of 4: Neonatal lung disease. Pediatr Pulmonol 2019; 54:765-769. [PMID: 30809976 DOI: 10.1002/ppul.24285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Accepted: 01/29/2019] [Indexed: 11/05/2022]
Abstract
Pediatric Pulmonology publishes original research, reviews and case reports related to a wide range of children's respiratory disorders. This review (Part 2 of a 4-part series) summarizes the past year's publications in the topic area of neonatal lung diseases, in the context of selected literature from other journals relevant to the discipline.
Collapse
Affiliation(s)
- Richard L Auten
- Cone Health System, Greensboro, North Carolina.,Duke University, Durham, North Carolina
| |
Collapse
|