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Mukerji A, Keszler M. Continuous Positive Airway Pressure versus Nasal Intermittent Positive Pressure Ventilation in Preterm Neonates: What if Mean Airway Pressures Were Equivalent? Am J Perinatol 2024; 41:1616-1624. [PMID: 38211631 DOI: 10.1055/a-2242-7391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Respiratory support for preterm neonates in modern neonatal intensive care units is predominantly with the use of noninvasive interfaces. Continuous positive airway pressure (CPAP) and nasal intermittent positive pressure ventilation (NIPPV) are the prototypical and most commonly utilized forms of noninvasive respiratory support, and each has unique gas flow characteristics. In meta-analyses of clinical trials till date, NIPPV has been shown to likely reduce respiratory failure and need for intubation compared to CPAP. However, a significant limitation of the included studies has been the higher mean airway pressures used during NIPPV. Thus, it is unclear to what extent any benefits seen with NIPPV are due to the cyclic pressure application versus the higher mean airway pressures. In this review, we elaborate on these limitations and summarize the available evidence comparing NIPPV and CPAP at equivalent mean airway pressures. Finally, we call for further studies comparing noninvasive respiratory support modes at equal mean airway pressures. KEY POINTS: · Most current literature on CPAP vs. NIPPV in preterm neonates is confounded by use of higher mean airway pressures during NIPPV.. · In this review, we summarize existing evidence on CPAP vs. NIPPV at equivalent mean airway pressures.. · We call for future research on noninvasive support modes to account for mean airway pressures..
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Affiliation(s)
- Amit Mukerji
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Martin Keszler
- Department of Pediatrics, Brown University, Providence, Rhode Island
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Hemodynamic consequences of respiratory interventions in preterm infants. J Perinatol 2022; 42:1153-1160. [PMID: 35690691 PMCID: PMC9436777 DOI: 10.1038/s41372-022-01422-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 05/21/2022] [Accepted: 05/25/2022] [Indexed: 12/14/2022]
Abstract
Advances in perinatal management have led to improvements in survival rates for premature infants. It is known that the transitional period soon after birth, and the subsequent weeks, remain periods of rapid circulatory changes. Preterm infants, especially those born at the limits of viability, are susceptible to hemodynamic effects of routine respiratory care practices. In particular, the immature myocardium and cardiovascular system is developmentally vulnerable. Standard of care (but essential) respiratory interventions, administered as part of neonatal care, may negatively impact heart function and/or pulmonary or systemic hemodynamics. The available evidence regarding the hemodynamic impact of these respiratory practices is not well elucidated. Enhanced diagnostic precision and therapeutic judiciousness are warranted. In this narrative, we outline (1) the vulnerability of preterm infants to hemodynamic disturbances (2) the hemodynamic effects of common respiratory practices; including positive pressure ventilation and surfactant therapy, and (3) identify tools to assess cardiopulmonary interactions and guide management.
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Bamat N, Fierro J, Mukerji A, Wright CJ, Millar D, Kirpalani H. Nasal continuous positive airway pressure levels for the prevention of morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2021; 11:CD012778. [PMID: 34847243 PMCID: PMC8631577 DOI: 10.1002/14651858.cd012778.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Preterm infants are at risk of lung atelectasis due to various anatomical and physiological immaturities, placing them at high risk of respiratory failure and associated harms. Nasal continuous positive airway pressure (CPAP) is a positive pressure applied to the airways via the nares. It helps prevent atelectasis and supports adequate gas exchange in spontaneously breathing infants. Nasal CPAP is used in the care of preterm infants around the world. Despite its common use, the appropriate pressure levels to apply during nasal CPAP use remain uncertain. OBJECTIVES To assess the effects of 'low' (≤ 5 cm H2O) versus 'moderate-high' (> 5 cm H2O) initial nasal CPAP pressure levels in preterm infants receiving CPAP either: 1) for initial respiratory support after birth and neonatal resuscitation or 2) following mechanical ventilation and endotracheal extubation. SEARCH METHODS We ran a comprehensive search on 6 November 2020 in the following databases: CENTRAL via CRS Web and MEDLINE via Ovid. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs) and quasi-randomized trials. SELECTION CRITERIA We included RCTs, quasi-RCTs, cluster-RCTs and cross-over RCTs randomizing preterm infants of gestational age < 37 weeks or birth weight < 2500 grams within the first 28 days of life to different nasal CPAP levels. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal to collect and analyze data. We used the GRADE approach to assess the certainty of the evidence for the prespecified primary outcomes. MAIN RESULTS Eleven trials met inclusion criteria of the review. Four trials were parallel-group RCTs reporting our prespecified primary or secondary outcomes. Two trials randomized 316 infants to low versus moderate-high nasal CPAP for initial respiratory support, and two trials randomized 117 infants to low versus moderate-high nasal CPAP following endotracheal extubation. The remaining seven studies were cross-over trials reporting short-term physiological outcomes. The most common potential sources of bias were absent or unclear blinding of personnel and assessors and uncertain selective reporting. Nasal CPAP for initial respiratory support after birth and neonatal resuscitation None of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months. The remaining five outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age (PMA) (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.56 to 1.85; 1 trial, 271 participants); mortality by hospital discharge (RR 1.04, 95% CI 0.51 to 2.12; 1 trial, 271 participants); BPD at 28 days of age (RR 1.10, 95% CI 0.56 to 2.17; 1 trial, 271 participants); BPD at 36 weeks' PMA (RR 0.80, 95% CI 0.25 to 2.57; 1 trial, 271 participants), and treatment failure or need for mechanical ventilation (RR 1.00, 95% CI 0.63 to 1.57; 1 trial, 271 participants). We assessed the certainty of the evidence as very low for all five outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. Nasal CPAP following mechanical ventilation and endotracheal extubation One of the six primary outcomes prespecified for inclusion in the summary of findings was eligible for meta-analysis. On the basis of these data, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcome of treatment failure or need for mechanical ventilation (RR 1.52, 95% CI 0.92 to 2.50; 2 trials, 117 participants; I2 = 17%; risk difference 0.15, 95% CI -0.02 to 0.32; number needed to treat for an additional beneficial outcome 7, 95% CI -50 to 3). We assessed the certainty of the evidence as very low due to risk of bias, inconsistency across the studies, and imprecise effect estimates. No trials reported on moderate-severe neurodevelopmental impairment at 18 to 26 months or BPD at 28 days of age. The remaining three outcomes were reported in a single trial. On the basis of this trial, we are uncertain whether low or moderate-high nasal CPAP levels improve the outcomes of: death or BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants); mortality by hospital discharge (RR 2.94, 95% CI 0.12 to 70.30; 1 trial, 93 participants), and BPD at 36 weeks' PMA (RR 0.87, 95% CI 0.51 to 1.49; 1 trial, 93 participants). We assessed the certainty of the evidence as very low for all three outcomes due to risk of bias, a lack of consistency across multiple studies, and imprecise effect estimates. AUTHORS' CONCLUSIONS: There are insufficient data from randomized trials to guide nasal CPAP level selection in preterm infants, whether provided as initial respiratory support or following extubation from invasive mechanical ventilation. We are uncertain as to whether low or moderate-high nasal CPAP levels improve morbidity and mortality in preterm infants. Well-designed trials evaluating this important aspect of a commonly used neonatal therapy are needed.
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Affiliation(s)
- Nicolas Bamat
- Division of Neonatology and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie Fierro
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Amit Mukerji
- Paediatrics, McMaster University, Hamilton, Canada
| | - Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Millar
- Regional Neonatal Intensive Care Unit, Royal Jubilee Maternity Service, Belfast, UK
| | - Haresh Kirpalani
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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Van Wyk L, Smith J, Lawrenson J, Lombard CJ, de Boode WP. Bioreactance-derived haemodynamic parameters in the transitional phase in preterm neonates: a longitudinal study. J Clin Monit Comput 2021; 36:861-870. [PMID: 33983533 DOI: 10.1007/s10877-021-00718-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/06/2021] [Indexed: 11/26/2022]
Abstract
Bioreactance (BR) is a novel, non-invasive technology that is able to provide minute-to-minute monitoring of cardiac output and additional haemodynamic variables. This study aimed to determine the values for BR-derived haemodynamic variables in stable preterm neonates during the transitional period. A prospective observational study was performed in a group of stable preterm (< 37 weeks) infants in the neonatal service of Tygerberg Children's Hospital, Cape Town, South Africa. All infants underwent continuous bioreactance (BR) monitoring until 72 h of life. Sixty three preterm infants with a mean gestational age of 31 weeks and mean birth weight of 1563 g were enrolled. Summary data and time series graphs were drawn for BR-derived heart rate, non-invasive blood pressure, stroke volume, cardiac output and total peripheral resistance index. All haemodynamic parameters were significantly associated with postnatal age, after correction for clinical variables (gestational age, birth weight, respiratory support mode). To our knowledge, this is the first paper to present longitudinal BR-derived haemodynamic variable data in a cohort of stable preterm infants, not requiring invasive ventilation or inotropic support, during the first 72 h of life. Bioreactance-derived haemodynamic monitoring is non-invasive and offers the ability to simultaneously monitor numerous haemodynamic parameters of global systemic blood flow. Moreover, it may provide insight into transitional physiology and its pathophysiology.
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Affiliation(s)
- Lizelle Van Wyk
- Division Neonatology, Dept. Pediatrics & Child Health, Stellenbosch University and Tygerberg Children's Hospital, Cape Town, South Africa.
| | - Johan Smith
- Division Neonatology, Dept. Pediatrics & Child Health, Stellenbosch University and Tygerberg Children's Hospital, Cape Town, South Africa
| | - John Lawrenson
- Pediatric Cardiology Unit, Dept. Pediatrics & Child Health, Stellenbosch University, Cape Town, South Africa
| | - Carl J Lombard
- Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Willem Pieter de Boode
- Division of Neonatology, Dept. of Perinatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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Ericksen K, Alpan G, La Gamma EF. Effect of ventilator modes on neonatal cerebral and peripheral oxygenation using near-infrared spectroscopy. Acta Paediatr 2021; 110:1151-1156. [PMID: 32989810 DOI: 10.1111/apa.15600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/27/2020] [Accepted: 09/23/2020] [Indexed: 12/01/2022]
Abstract
AIM The effect of ventilator modes on regional tissue oxygenation in premature neonates with respiratory distress syndrome (RDS) has yet to be delineated. Previous studies have looked at global oxygen delivery and have not assessed the effects on regional tissue oxygenation. Our aim in this study was to assess such tissue oxygenation in premature babies with RDS in relation to differing modes of ventilation using near-infrared spectroscopy (NIRS). METHODS In 24 stable preterm infants with RDS, undergoing elective wean in ventilator mode, cerebral and muscle tissue oxygenation were assessed using NIRS. Infants were weaned from high-frequency oscillator or jet ventilator to conventional invasive ventilation (CV) or extubated from CV to non-invasive mechanical ventilation. Data at 30 minutes prior and at one hour after change in ventilator mode were compared (paired t test). RESULTS In babies changed from high-frequency oscillation to CV, jet to CV and CV to non-invasive ventilation, the differences in cerebral NIRS (mean ± SD) were 1.7 ± 9.9%, 2.3 ± 5.7% and 2.1 ± 8.4%, respectively. The concomitant changes in muscle NIRS were -2.9 ± 8.5%, 8.1 ± 9.7% and 3.6 ± 22.4%, respectively. No changes were statistically significant. CONCLUSION Our data suggest that there is no alteration in regional tissue oxygenation related to ventilator mode in stable preterm infants with improving RDS.
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Affiliation(s)
- Kristina Ericksen
- Division of Perinatal‐Neonatal Medicine Maria Fareri Children’s Hospital at Westchester Medical Center New York Medical College Valhalla, New York NY USA
| | - Gad Alpan
- Division of Perinatal‐Neonatal Medicine Maria Fareri Children’s Hospital at Westchester Medical Center New York Medical College Valhalla, New York NY USA
| | - Edmund F. La Gamma
- Division of Perinatal‐Neonatal Medicine Maria Fareri Children’s Hospital at Westchester Medical Center New York Medical College Valhalla, New York NY USA
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Zhou H, Hou X, Cheng R, Zhao Y, Qiu J. Effects of Nasal Continuous Positive Airway Pressure on Cerebral Hemodynamics in Preterm Infants. Front Pediatr 2020; 8:487. [PMID: 32974250 PMCID: PMC7472537 DOI: 10.3389/fped.2020.00487] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/13/2020] [Indexed: 11/24/2022] Open
Abstract
Background: To evaluate the effects of pressure levels on cerebral hemodynamics in premature infants receiving nasal continuous positive airway pressure (nCPAP) during the first 3 days of life. Methods: Forty-four preterm infants treated with nCPAP were divided into two groups: very preterm infants [gestational age 1 (GA1), GA < 32 weeks, n = 24] and moderate/late preterm infants (GA2 group, GA 32-37 weeks, n = 20). During monitoring, pressure levels were set at 4 → 6 → 8 → 4 cmH2O, and cerebral hemodynamics was assessed by near-infrared spectroscopy (NIRS). Vital signs, peripheral oxygen saturation (SpO2) and transcutaneous carbon dioxide pressure (TcPCO2) were simultaneously recorded. Results: Pressures of 4-8 cmH2O had no significant influence on cerebral hemodynamics, TcPCO2, SpO2 or other vital signs. The tissue oxygenation index (TOI), the difference between oxygenated hemoglobin (ΔHbO2) and deoxygenated hemoglobin (ΔHHb) (ΔHbD), and cerebral blood volume (ΔCBV) were all significantly positively correlated with gestational and post-natal age, with fluctuations being greater in the GA1 group. ΔHbD and ΔCBV were also significantly positively correlated with TcPCO2. Conclusions: No significant differences were observed in cerebral hemodynamics when the nCPAP pressure was set to 4-8 cmH2O.
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Affiliation(s)
- Han Zhou
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, China.,Department of Paediatrics, Nantong First People's Hospital, Nantong, China
| | - Xuewen Hou
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Rui Cheng
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Youyan Zhao
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Qiu
- Department of Newborn Infants, Children's Hospital of Nanjing Medical University, Nanjing, China
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Fiorenzano DM, Leal GN, Sawamura KSS, Lianza AC, Carvalho WBD, Krebs VLJ. Respiratory distress syndrome: influence of management on the hemodynamic status of ≤ 32-week preterm infants in the first 24 hours of life. Rev Bras Ter Intensiva 2019; 31:312-317. [PMID: 31618349 PMCID: PMC7005966 DOI: 10.5935/0103-507x.20190056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/09/2019] [Indexed: 11/21/2022] Open
Abstract
Objective To investigate the influence of respiratory distress syndrome management on clinical and echocardiographic parameters used for hemodynamic evaluation in ≤ 32- week newborns. Methods Thirty-three ≤ 32-week newborns were prospectively evaluated and subjected to invasive mechanical ventilation. The need for exogenous surfactant and clinical and echocardiographic parameters in the first 24 hours of life was detailed in this group of patients. Results The mean airway pressure was significantly higher in newborn infants who required inotropes [10.8 (8.8 - 23) cmH2O versus 9 (6.2 - 12) cmH2O; p = 0.04]. A negative correlation was found between the mean airway pressure and velocity-time integral of the pulmonary artery (r = -0.39; p = 0.026), right ventricular output (r = -0.43; p = 0.017) and measurements of the tricuspid annular plane excursion (r = -0.37; p = 0.036). A negative correlation was found between the number of doses of exogenous surfactant and the right ventricular output (r = -0.39; p = 0.028) and pulmonary artery velocity-time integral (r = -0.35; p = 0.043). Conclusion In ≤ 32-week newborns under invasive mechanical ventilation, increases in the mean airway pressure and number of surfactant doses are correlated with the worsening of early cardiac function. Therefore, more aggressive management of respiratory distress syndrome may contribute to the hemodynamic instability of these patients.
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Affiliation(s)
- Daniela Matos Fiorenzano
- Disciplina de Neonatologia, Departamento de Pediatria, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Gabriela Nunes Leal
- Serviço de Ecocardiografia Neonatal e Pediátrica, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Karen Saori Shiraishi Sawamura
- Serviço de Ecocardiografia Neonatal e Pediátrica, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Alessandro Cavalcanti Lianza
- Serviço de Ecocardiografia Neonatal e Pediátrica, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Werther Brunow de Carvalho
- Disciplina de Neonatologia, Departamento de Pediatria, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | - Vera Lúcia Jornada Krebs
- Disciplina de Neonatologia, Departamento de Pediatria, Instituto da Criança, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Mukerji A, Wahab MGA, Mitra S, Mondal T, Paterson D, Beck J, Fusch C. High continuous positive airway pressure in neonates: A physiological study. Pediatr Pulmonol 2019; 54:1039-1044. [PMID: 30859756 DOI: 10.1002/ppul.24312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We sought to evaluate physiological cardiorespiratory implications of high pressures (>8 cmH2 O) on continuous positive airway pressure (CPAP) in preterm neonates. METHODS Fifteen preterm neonates at postmenstrual age ≥32 weeks on CPAP 5 cmH2 O were enrolled. Pressures were increased by 2 cmH 2 O increments until 13 cmH 2 O. At each increment, cardiac output, electrical diaphragmatic (Edi) activity, and clinical cardiorespiratory parameters were measured. Predefined cut-off values for changes in cardiorespiratory parameters were used as termination criteria. Data, presented as mean (SD), were compared using repeated measures analysis of variance. RESULTS The mean GA, age at study, and weight of subjects were 27.4 (2.6) weeks, 58.5 (35.5) days, and 2.3 (0.6) kg, respectively. The median (IQR) time at each CPAP increment was 10 (5, 20) min. Cardiac output (mL/kg/min) at 5, 7, 9, 11, and 13 cmH 2 O were not different at 295 (75), 290 (66), 281 (69), 286 (73), and 292 (58), respectively (P = 0.99). Edi values demonstrated a trend towards decline at 9 cmH 2 O before rising again. No other cardiorespiratory parameter was different across CPAP levels; no subject met termination criteria. CONCLUSION High CPAP levels were well tolerated for short durations. Further physiological and clinical research is required on safety/efficacy in neonates with more severe lung disease, as well as its impact over longer durations.
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Affiliation(s)
- Amit Mukerji
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | | | - Souvik Mitra
- Department of Paediatrics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tapas Mondal
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Debie Paterson
- Respiratory Therapy, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jennifer Beck
- Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christoph Fusch
- Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada.,Department of Pediatrics, Nuernberg General Hospital, Paracelsus Medical School, Nuremberg, Germany
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Zhong J, Lui K, Schindler T. The Effect of Continuous Positive Airway Pressure on Cerebral and Splanchnic Oxygenation in Preterm Infants. Neonatology 2019; 116:363-368. [PMID: 31536981 DOI: 10.1159/000501936] [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: 04/06/2019] [Accepted: 07/04/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite the known clinical benefits of continuous positive airway pressure (CPAP) to support preterm infants breathing, there are limited studies that have examined its effect on regional oxygenation. OBJECTIVES This study aimed to investigate how the application of CPAP affects cerebral and splanchnic tissue oxygenation in preterm infants. METHODS A pilot observational study was conducted in infants using near-infrared spectroscopy while off CPAP and on CPAP. Regional cerebral and splanchnic saturations and variability (coefficient of variability; CV) were evaluated. RESULTS Twenty-six infants (25-37 weeks gestational age at birth) were studied. The mean cerebral oxygenation did not differ with the application of CPAP (80 ± 4.2% without CPAP; 80 ± 1.9% with CPAP), but variability around the mean was less with CPAP (CV 5 vs. 2%, respectively). Mean cerebral fractional oxygen extraction (FOE) increased with CPAP from 0.13 ± 0.06 to 0.17 ± 0.04% (p = 0.002). Splanchnic oxygenation increased significantly from 66 ± 11.6 to 75 ± 9.1% with CPAP (p < 0.001) and also became more stable (CV 13 vs. 7%, respectively). Splanchnic FOE decreased with CPAP from 0.28 ± 0.13 to 0.22 ± 0.10% (p = 0.002). CONCLUSION The application of CPAP did not affect mean cerebral oxygenation in this group of preterm and term infants; however, it led to a significant increase in splanchnic oxygenation. These findings highlight the important role that respiratory support may play in maintaining adequate and stable oxygen delivery to vital organs.
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Affiliation(s)
- Jiayue Zhong
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia,
| | - Kei Lui
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
| | - Timothy Schindler
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Department of Newborn Care, Royal Hospital for Women, Sydney, New South Wales, Australia
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Kluckow M. The Pathophysiology of Low Systemic Blood Flow in the Preterm Infant. Front Pediatr 2018; 6:29. [PMID: 29503814 PMCID: PMC5820306 DOI: 10.3389/fped.2018.00029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/31/2018] [Indexed: 11/13/2022] Open
Abstract
Assessment and treatment of the VLBW infant with cardiovascular impairment requires understanding of the underlying physiology of the infant in transition. The situation is dynamic with changes occurring in systemic blood pressure, pulmonary pressures, myocardial function, and ductal shunt in the first postnatal days. New insights into the role of umbilical cord clamping in the transitional circulation have been provided by large clinical trials of early versus later cord clamping and a series of basic science reports describing the physiology in an animal model. Ultrasound assessment is invaluable in assessment of the physiology of the transition and can provide information about the size and shunt direction of the ductus arteriosus, the function of the myocardium and its filling as well as measurements of the cardiac output and an estimate of the state of peripheral vascular resistance. This information not only allows more specific treatment but it will often reduce the need for treatment.
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Affiliation(s)
- Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
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Chen TI, Tu WC. Exercise Attenuates Intermittent Hypoxia-Induced Cardiac Fibrosis Associated with Sodium-Hydrogen Exchanger-1 in Rats. Front Physiol 2016; 7:462. [PMID: 27790155 PMCID: PMC5064604 DOI: 10.3389/fphys.2016.00462] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 09/26/2016] [Indexed: 12/22/2022] Open
Abstract
Purpose: To investigate the role of sodium–hydrogen exchanger-1 (NHE-1) and exercise training on intermittent hypoxia-induced cardiac fibrosis in obstructive sleep apnea (OSA), using an animal model mimicking the intermittent hypoxia of OSA. Methods: Eight-week-old male Sprague–Dawley rats were randomly assigned to control (CON), intermittent hypoxia (IH), exercise (EXE), or IH combined with exercise (IHEXE) groups. These groups were randomly assigned to subgroups receiving either a vehicle or the NHE-1 inhibitor cariporide. The EXE and IHEXE rats underwent exercise training on an animal treadmill for 10 weeks (5 days/week, 60 min/day, 24–30 m/min, 2–10% grade). The IH and IHEXE rats were exposed to 14 days of IH (30 s of hypoxia—nadir of 2–6% O2—followed by 45 s of normoxia) for 8 h/day. At the end of 10 weeks, rats were sacrificed and then hearts were removed to determine the myocardial levels of fibrosis index, oxidative stress, antioxidant capacity, and NHE-1 activation. Results: Compared to the CON rats, IH induced higher cardiac fibrosis, lower myocardial catalase, and superoxidative dismutase activities, higher myocardial lipid and protein peroxidation and higher NHE-1 activation (p < 0.05 for each), which were all abolished by cariporide. Compared to the IH rats, lower cardiac fibrosis, higher myocardial antioxidant capacity, lower myocardial lipid, and protein peroxidation and lower NHE-1 activation were found in the IHEXE rats (p < 0.05 for each). Conclusion: IH-induced cardiac fibrosis was associated with NHE-1 hyperactivity. However, exercise training and cariporide exerted an inhibitory effect to prevent myocardial NHE-1 hyperactivity, which contributed to reduced IH-induced cardiac fibrosis. Therefore, NHE-1 plays a critical role in the effect of exercise on IH-induced increased cardiac fibrosis.
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Affiliation(s)
- Tsung-I Chen
- Center of Physical Education, Office of General and Basic Education, Tzu Chi University Hualien, Taiwan
| | - Wei-Chia Tu
- Master program in Physiological and Anatomical Medicine, School of Medicine, Tzu Chi University Hualien, Taiwan
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Chang HY, Cheng KS, Lung HL, Li ST, Lin CY, Lee HC, Lee CH, Hung HF. Hemodynamic Effects of Nasal Intermittent Positive Pressure Ventilation in Preterm Infants. Medicine (Baltimore) 2016; 95:e2780. [PMID: 26871833 PMCID: PMC4753929 DOI: 10.1097/md.0000000000002780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP) have proven to be effective modes of noninvasive respiratory support in preterm infants. Although they are increasingly used in neonatal intensive care, their hemodynamic consequences have not been fully evaluated. The aim of this study was to investigate the hemodynamic changes between NIPPV and NCPAP in preterm infants.This prospective observational study enrolled clinically stable preterm infants requiring respiratory support received NCPAP and nonsynchronized NIPPV at 40/minute for 30 minutes each, in random order. Cardiac function and cerebral hemodynamics were assessed by ultrasonography after each study period. The patients continued the study ventilation during measurements.Twenty infants with a mean gestational age of 27 weeks (range, 25-32 weeks) and birth weight of 974 g were examined at a median postnatal age of 20 days (range, 9-28 days). There were no significant differences between the NCPAP and NIPPV groups in right (302 vs 292 mL/kg/min, respectively) and left ventricular output (310 vs 319 mL/kg/min, respectively), superior vena cava flow (103 vs 111 mL/kg/min, respectively), or anterior cerebral artery flow velocity.NIPPV did not have a significant effect on the hemodynamics of stable preterm infants. Future studies assessing the effect of NIPPV on circulation should focus on less stable and very preterm infants.
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Affiliation(s)
- Hung-Yang Chang
- From the Department of Pediatrics, MacKay Memorial Hospital, Hsinchu Branch, Hsinchu City (H-YC, K-SC, H-LL, S-TL, C-YL, H-CL); and Department of Medical Technology, Jen-Teh Junior College of Medicine, Nursing and Management (H-YC, C-HL, H-FH), Miaoli, Taiwan
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Greenough A, Lingam I. Invasive and non-invasive ventilation for prematurely born infants - current practice in neonatal ventilation. Expert Rev Respir Med 2016; 10:185-92. [PMID: 26698269 DOI: 10.1586/17476348.2016.1135741] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Non-invasive techniques, include nasal continuous positive airways pressure (nCPAP), nasal intermittent positive pressure ventilation (NIPPV) and heated, humidified, high flow cannula (HHFNC). Randomised controlled trials (RCTs) of nCPAP versus ventilation have given mixed results, but one demonstrated fewer respiratory problems during infancy. Meta-analysis demonstrated NIPPV rather than nCPAP provided better support post extubation. After extubation or initial support HHFNC has similar efficacy to CPAP. Invasive techniques include those that synchronise inflations with the patient's respiratory efforts. Assist control/ synchronised intermittent mandatory ventilation compared to non triggered modes only reduce the duration of ventilation. Further data are required to determine the efficacy of proportional assist ventilation and neurally adjusted ventilatory assist. Other techniques aim to minimise volutrauma. RCTs of volume targeted ventilation demonstrated reductions in BPD and respiratory medication usage at follow-up. Prophylactic high frequency oscillatory ventilation does not reduce BPD, but is associated with superior lung function at school age.
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Affiliation(s)
- Anne Greenough
- a Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic, Mechanisms of Asthma , King's College London , London , UK.,b NIHR Biomedical Research Centre , Guy's and St Thomas' NHS Foundation Trust and King's College London , London , UK
| | - Ingran Lingam
- c Neonatal Intensive Care Centre , King's College Hospital NHS Foundation Trust , London , UK
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Bembich S, Travan L, Cont G, Bua J, Strajn T, Demarini S. Cerebral oxygenation with different nasal continuous positive airway pressure levels in preterm infants. Arch Dis Child Fetal Neonatal Ed 2015; 100:F165-8. [PMID: 25336677 DOI: 10.1136/archdischild-2014-306356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES This study evaluates the effect of varying nasal continuous positive airway pressure (NCPAP) level on cerebral blood flow (CBF) and oxygenation in preterm infants. METHODS Oxy-haemoglobin (HbO2) and total haemoglobin (HbTot), as CBF estimates, and the ratio between HbO2 and HbTot (HbO2/HbTot), as cerebral oxygenation estimate, were assessed by near-infrared spectroscopy in 26 stable preterm newborns at a postmenstrual age between 26 and 33 weeks. Baseline HbO2, HbTot and HbO2/HbTot values were initially collected with NCPAP at 5 cm H2O and then compared with values obtained with NCPAP levels at both 3 and 8 cm H2O. RESULTS Compared with 5 cm H2O, cerebral HbO2, HbTot and HbO2/HbTot remained unchanged both after increasing (to 8 cm H2O) and decreasing (to 3 cm H2O) the NCPAP level. This result was observed both in regional areas (24 sites) and in the overall monitored area (frontal and parietal cortex). Compared with 8 cm H2O, peripheral oxygen saturation significantly decreased at 3 cm H2O (p=0.021). Heart rate did not change. CONCLUSIONS No differences in CBF and cerebral oxygenation were observed with NCPAP levels in the range 3-8 cm H2O despite a decrease in peripheral oxygenation with 3 cm H2O.
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Affiliation(s)
- Stefano Bembich
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo" - Trieste, Italy
| | - Laura Travan
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo" - Trieste, Italy
| | - Gabriele Cont
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo" - Trieste, Italy
| | - Jenny Bua
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo" - Trieste, Italy
| | - Tamara Strajn
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo" - Trieste, Italy
| | - Sergio Demarini
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo" - Trieste, Italy
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Beker F, Rogerson SR, Hooper SB, Sehgal A, Davis PG. Hemodynamic effects of nasal continuous positive airway pressure in preterm infants with evolving chronic lung disease, a crossover randomized trial. J Pediatr 2015; 166:477-9. [PMID: 25454930 DOI: 10.1016/j.jpeds.2014.10.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/25/2014] [Accepted: 10/03/2014] [Indexed: 11/26/2022]
Abstract
Previous studies suggest that high airway pressure may compromise cardiac output. We investigated the effect of 3 nasal continuous positive airway pressure levels on cardiac output in preterm infants with evolving chronic lung disease. We found that brief changes in continuous positive airway pressure did not affect cardiac output.
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Affiliation(s)
- Friederike Beker
- The Royal Women's Hospital, Parkville, Victoria, Australia; The Mercy Hospital for Women, Heidelberg, Victoria, Australia; Monash Medical Centre, Clayton, Victoria, Australia
| | | | - Stuart B Hooper
- The Ritchie Centre, Monash Institute for Medical Research, Clayton, Victoria, Australia
| | | | - Peter G Davis
- The Royal Women's Hospital, Parkville, Victoria, Australia
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Aquilano G, Galletti S, Aceti A, Vitali F, Faldella G. Bi-level CPAP does not change central blood flow in preterm infants with respiratory distress syndrome. Ital J Pediatr 2014; 40:60. [PMID: 24952579 PMCID: PMC4122055 DOI: 10.1186/1824-7288-40-60] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 06/11/2014] [Indexed: 11/16/2022] Open
Abstract
Background Current literature provides limited data on the hemodynamic changes that may occur during bi-level continuous positive airway pressure (CPAP) support in preterm infants. However, the application of a positive end-expiratory pressure may be transmitted to the heart and the great vessels resulting in changes of central blood flow. Objective To assess changes in central blood flow in infants with respiratory distress syndrome (RDS) during bi-level CPAP support. Design A prospective study was performed in a cohort of 18 Very-Low-Birth-Weight Infants who were put on nasal CPAP support (4–5 cmH2O) because they developed RDS within the first 24–72 hours of life. Each subject was switched to bi-level CPAP support (Phigh 8 cmH2O, Plow 4–5 cmH2O, Thigh 0.5-0.6 seconds, 20 breaths/min) for an hour. An echocardiographic study and a capillary gas analysis were performed before and after the change of respiratory support. Results No differences between n-CPAP and bi-level CPAP in left ventricular output (LVO, 222.17 ± 81.4 vs 211.4 ± 75.3 ml/kg/min), right ventricular output (RVO, 287.8 ± 96 vs 283.4 ± 87.4 ml/kg/min) and superior vena cava flow (SVC, 135.38 ± 47.8 vs 137.48 ± 46.6 ml/kg/min) were observed. The hemodynamic characteristics of the ductus arteriosus were similar. A significant decrease in pCO2 levels after bi-level CPAP ventilation was observed; pCO2 variations did not correlate with modifications of central blood flow (LVO: ρ = 0.11, p = 0,657; RVO: ρ = −0.307, p = 0.216; SVC: ρ = −0.13, p = 0.197). Conclusions Central blood flow doesn’t change during bi-level CPAP support, which could become a hemodinamically safe tool for the treatment of RDS in preterm infants.
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Affiliation(s)
| | - Silvia Galletti
- Neonatology and Neonatal Intensive Care Unit, Department of Medical and Surgical Sciences, St, Orsola-Malpighi Hospital - University of Bologna, Via Massarenti, 11 40138 Bologna, Italy.
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Bedside hemodynamic evaluation for neonates receiving respiratory support. J Pediatr 2014; 164:683-4. [PMID: 24461791 DOI: 10.1016/j.jpeds.2013.12.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Accepted: 12/13/2013] [Indexed: 11/20/2022]
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