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Gaertner VD, Büchler VL, Waldmann A, Bassler D, Rüegger CM. Deciphering Mechanisms of Respiratory Fetal-to-Neonatal Transition in Very Preterm Infants. Am J Respir Crit Care Med 2024; 209:738-747. [PMID: 38032260 DOI: 10.1164/rccm.202306-1021oc] [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: 06/13/2023] [Accepted: 11/30/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: The respiratory mechanisms of a successful transition of preterm infants after birth are largely unknown. Objectives: To describe intrapulmonary gas flows during different breathing patterns directly after birth. Methods: Analysis of electrical impedance tomography data from a previous randomized trial in preterm infants at 26-32 weeks gestational age. Electrical impedance tomography data for individual breaths were extracted, and lung volumes as well as ventilation distribution were calculated for end of inspiration, end of expiratory braking and/or holding maneuver, and end of expiration. Measurements and Main Results: Overall, 10,348 breaths from 33 infants were analyzed. We identified three distinct breath types within the first 10 minutes after birth: tidal breathing (44% of all breaths; sinusoidal breathing without expiratory disruption), braking (50%; expiratory brake with a short duration), and holding (6%; expiratory brake with a long duration). Only after holding breaths did end-expiratory lung volume increase: Median (interquartile range [IQR]) = 2.0 AU/kg (0.6 to 4.3), 0.0 (-1.0 to 1.1), and 0.0 (-1.1 to 0.4), respectively; P < 0.001]. This was mediated by intrathoracic air redistribution to the left and non-gravity-dependent parts of the lung through pendelluft gas flows during braking and/or holding maneuvers. Conclusions: Respiratory transition in preterm infants is characterized by unique breathing patterns. Holding breaths contribute to early lung aeration after birth in preterm infants. This is facilitated by air redistribution during braking/holding maneuvers through pendelluft flow, which may prevent lung liquid reflux in this highly adaptive situation. This study deciphers mechanisms for a successful fetal-to-neonatal transition and increases our pathophysiological understanding of this unique moment in life. Clinical trial registered with www.clinicaltrials.gov (NCT04315636).
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
- Division of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Vanessa L Büchler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Andreas Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
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2
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Belting C, Rüegger CM, Waldmann AD, Bassler D, Gaertner VD. Rescue nasopharyngeal tube for preterm infants non-responsive to initial ventilation after birth. Pediatr Res 2024:10.1038/s41390-024-03033-6. [PMID: 38273117 DOI: 10.1038/s41390-024-03033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/29/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Physiological changes during the insertion of a rescue nasopharyngeal tube (NPT) after birth are unclear. METHODS Observational study of very preterm infants in the delivery room. Data were extracted at predefined timepoints starting with first facemask placement after birth until 5 min after insertion of NPT. End-expiratory lung impedance (EELI), heart rate (HR) and SpO2/FiO2-ratio were analysed over time. Changes during the same time span of NIPPV via facemask and NIPPV via NPT were compared. RESULTS Overall, 1154 inflations in 15 infants were analysed. After NPT insertion, EELI increased significantly [0.33 AU/kg (0.19-0.57), p < 0.001]. Compared with the mask period, changes in EELI were not significantly larger during the NPT period [median difference (IQR) = 0.14 AU/kg (-0.14-0.53); p = 0.12]. Insertion of the NPT was associated with significant improvement in HR [52 (33-96); p = 0.001] and SpO2/FiO2-ratio [161 (69-169); p < 0.001] not observed during the mask period. CONCLUSIONS In very preterm infants non-responsive to initial facemask ventilation after birth, insertion of an NPT resulted in a considerable increase in EELI. This additional gain in lung volume was associated with an immediate improvement in clinical parameters. The use of a NPT may prevent intubation in selected non-responsive infants. IMPACT After birth, a nasopharyngeal tube may be considered as a rescue airway in newborn infants non-responsive to initial positive pressure ventilation via facemask. Although it is widely used among clinicians, its effect on lung volumes and physiological parameters remains unclear. Insertion of a rescue NPT resulted in a considerable increase in lung volume but this was not significantly larger than during facemask ventilation. However, insertion of a rescue NPT was associated with a significant and clinically important improvement in heart rate and oxygenation. This study highlights the importance of individual strategies in preterm resuscitation and introduces the NPT as a valid option.
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Affiliation(s)
- Carina Belting
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
- Department of Pediatric Intensive Care and Neonatology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
| | - Andreas D Waldmann
- Department of Anaesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
| | - Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland.
- Division of Neonatology, Dr von Hauner Children's Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
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3
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Monnelly V, Josephsen JB, Isayama T, de Almeida MFB, Guinsburg R, Schmölzer GM, Rabi Y, Wyckoff MH, Weiner G, Liley HG, Solevåg AL. Exhaled CO 2 monitoring to guide non-invasive ventilation at birth: a systematic review. Arch Dis Child Fetal Neonatal Ed 2023; 109:74-80. [PMID: 37558397 DOI: 10.1136/archdischild-2023-325698] [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: 04/13/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE Measuring exhaled carbon dioxide (ECO2) during non-invasive ventilation at birth may provide information about lung aeration. However, the International Liaison Committee on Resuscitation (ILCOR) only recommends ECO2 detection for confirming endotracheal tube placement. ILCOR has therefore prioritised a research question that needs to be urgently evaluated: 'In newborn infants receiving intermittent positive pressure ventilation by any non-invasive interface at birth, does the use of an ECO2 monitor in addition to clinical assessment, pulse oximetry and/or ECG, compared with clinical assessment, pulse oximetry and/or ECG only, decrease endotracheal intubation in the delivery room, improve response to resuscitation, improve survival or reduce morbidity?'. DESIGN Systematic review of randomised and non-randomised studies identified by Ovid MEDLINE, Embase and Cochrane CENTRAL search until 1 August 2022. SETTING Delivery room. PATIENTS Newborn infants receiving non-invasive ventilation at birth. INTERVENTION ECO2 measurement plus routine assessment compared with routine assessment alone. MAIN OUTCOME MEASURES Endotracheal intubation in the delivery room, response to resuscitation, survival and morbidity. RESULTS Among 2370 articles, 23 were included; however, none had a relevant control group. Although studies indicated that the absence of ECO2 may signify airway obstruction and ECO2 detection may precede a heart rate increase in adequately ventilated infants, they did not directly address the research question. CONCLUSIONS Evidence to support the use of an ECO2 monitor to guide non-invasive positive pressure ventilation at birth is lacking. More research on the effectiveness of ECO2 measurement in addition to routine assessment during non-invasive ventilation of newborn infants at birth is needed. PROSPERO REGISTRATION NUMBER CRD42022344849.
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Affiliation(s)
- Vix Monnelly
- Department of Neonatology, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Justin B Josephsen
- Department of Pediatrics, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Tetsuya Isayama
- Division of Neonatology, Center of Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation and Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Myra H Wyckoff
- Pediatrics, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Gary Weiner
- Department of Pediatrics, Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Helen G Liley
- Mater Research Institute, The University of Queensland, South Brisbane, QLD, Australia
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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Kribs A, Roberts KD, Trevisanuto D, O' Donnell C, Dargaville PA. Alternative routes of surfactant application - An update. Semin Fetal Neonatal Med 2023; 28:101496. [PMID: 38040586 DOI: 10.1016/j.siny.2023.101496] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Non-invasive modes of respiratory support have been shown to be the preferable way of primary respiratory support of preterm infants with respiratory distress syndrome (RDS). The avoidance of invasive mechanical ventilation can be beneficial for preterm infants in reduction of morbidity and even mortality. However, it is well-established that some infants managed with non-invasive respiratory support from the outset have symptomatic RDS to a degree that warrants surfactant administration. Infants for whom non-invasive respiratory support ultimately fails are prone to adverse outcomes, occurring at a frequency on par with the group intubated primarily. This raises the question how to combine non-invasive respiratory support with surfactant therapy. Several methods of less or minimally invasive surfactant therapy have been developed to address the dilemma between avoidance of mechanical ventilation and administration of surfactant. This paper describes the different methods of less invasive surfactant application, reports the existing evidence from clinical studies, discusses the limitations of each of the methods and the open and future research questions.
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Affiliation(s)
- Angela Kribs
- Division of Neonatology, Department of Paediatrics, University of Cologne, Faculty of Medicine, Cologne, Germany.
| | - Kari D Roberts
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis, MN, United States
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Colm O' Donnell
- School of Medicine, University College Dublin, Dublin, Ireland; Department of Neonatology, National Maternity Hospital, Dublin, Ireland.
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia; Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
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5
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Respiratory function monitoring during neonatal resuscitation: A systematic review. Resusc Plus 2022; 12:100327. [PMID: 36425449 PMCID: PMC9678959 DOI: 10.1016/j.resplu.2022.100327] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 11/18/2022] Open
Abstract
Aim Positive pressure ventilation via a facemask is critical in neonatal resuscitation, but frequently results in mask leak, obstruction, and inadequate respiratory support. This systematic review aimed to determine whether the display of respiratory function monitoring improved resuscitation or clinical outcomes. Methods Randomized controlled trials comparing outcomes when respiratory function monitoring was displayed versus not displayed for newborns requiring positive pressure ventilation at birth were selected and from databases (last search August 2022), and assessed for risk of bias using Cochrane Risk of Bias Tools for randomized control trials. The study was registered in the Prospective Register of Systematic Reviews. Grading of Recommendations, Assessment, Development and Evaluations was used to assess the certainty of evidence. Treatment recommendations were approved by the Neonatal Life Support Task Force of the International Liaison Committee on Resuscitation. Results reported primary and secondary outcomes and included resuscitation and clinical outcomes. Results Of 2294 unique articles assessed for eligibility, three randomized controlled trials were included (observational studies excluded) (n = 443 patients). For predefined resuscitation and clinical outcomes, these studies either did not report the primary outcome (time to heart rate ≥ 100 bpm from birth), had differing reporting methods (achieving desired tidal volumes, significant mask leak) or did not find significant differences (intubation rate, air leaks, death before hospital discharge, severe intraventricular hemorrhage, chronic lung disease). Limitations included limited sample size for critical outcomes, inconsistent definitions amongst studies and unreported long-term outcomes. Conclusion Although respiratory function monitoring has been utilized in clinical care, there is currently insufficient evidence to suggest its benefit for newborn infants receiving respiratory support for resuscitation at birth. Registration PROSPERO CRD42021278169 (registered November 27, 2021). Funding The International Liaison Committee on Resuscitation provided support that included access to software platforms and teleconferencing.
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6
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Gaertner VD, Minocchieri S, Waldmann AD, Mühlbacher T, Bassler D, Rüegger CM. Prophylactic surfactant nebulisation for the early aeration of the preterm lung: a randomised clinical trial. Arch Dis Child Fetal Neonatal Ed 2022; 108:217-223. [PMID: 36424125 DOI: 10.1136/archdischild-2022-324519] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The effect of prophylactic surfactant nebulisation (SN) is unclear. We aimed to determine whether prophylactic SN improves early lung aeration. DESIGN Parallel, randomised clinical trial, conducted between March 2021 and January 2022. SETTING Delivery room (DR) of a tertiary neonatal centre in Zurich, Switzerland. PATIENTS Preterm infants between 26 0/7 and 31 6/7 weeks gestation INTERVENTIONS: Infants were randomised to receive positive distending pressure alone or positive distending pressure and additional SN (200 mg/kg; poractant alfa) using a customised vibrating membrane nebuliser. SN commenced with the first application of a face mask immediately after birth. MAIN OUTCOME MEASURES Primary outcome was the difference in end-expiratory lung impedance from birth to 30 min after birth (∆EELI30min). EELI correlates well with functional residual capacity. Secondary outcomes included physiological and clinical outcomes. RESULTS Data from 35 infants were collected, and primary outcome data were analysed from 32 infants (n=16/group). Primary outcome was not different between intervention and control group (median (IQR): 25 (7-62) vs 10 (0-26) AU/kg, p=0.21). ∆EELI was slightly higher in the intervention group at 6 and 12 hours after birth, particularly in the central areas of the lung. There were no differences in cardiorespiratory and clinical parameters. Two adverse events were noted in the intervention group. CONCLUSIONS Prophylactic SN in the DR did not significantly affect ∆EELI30min and showed only minimal effects on lung physiology. Prophylactic SN in the DR was feasible. There were no differences in clinical outcomes. TRIAL REGISTRATION NUMBER NCT04315636.
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Stefan Minocchieri
- Department of Neonatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Andreas D Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Tobias Mühlbacher
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Christoph Martin Rüegger
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
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7
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van Leuteren RW, Kho E, de Waal CG, Te Pas AB, Salverda HH, de Jongh FH, van Kaam AH, Hutten GJ. Cardiorespiratory monitoring in the delivery room using transcutaneous electromyography. Arch Dis Child Fetal Neonatal Ed 2021; 106:352-356. [PMID: 33214154 DOI: 10.1136/archdischild-2020-319535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To assess feasibility of transcutaneous electromyography of the diaphragm (dEMG) as a monitoring tool for vital signs and diaphragm activity in the delivery room (DR). DESIGN Prospective observational study. SETTING Delivery room. PATIENTS Newborn infants requiring respiratory stabilisation after birth. INTERVENTIONS In addition to pulse oximetry (PO) and ECG, dEMG was measured with skin electrodes for 30 min after birth. OUTCOME MEASURES We assessed signal quality of dEMG and ECG recording, agreement between heart rate (HR) measured by dEMG and ECG or PO, time between sensor application and first HR read-out and agreement between respiratory rate (RR) measured with dEMG and ECG, compared with airway flow. Furthermore, we analysed peak, tonic and amplitude diaphragmatic activity from the dEMG-based respiratory waveform. RESULTS Thirty-three infants (gestational age: 31.7±2.8 weeks, birth weight: 1525±661 g) were included.18%±14% and 22%±21% of dEMG and ECG data showed poor quality, respectively. Monitoring HR with dEMG was fast (median 10 (IQR 10-11) s) and accurate (intraclass correlation coefficient (ICC) 0.92 and 0.82 compared with ECG and PO, respectively). RR monitoring with dEMG showed moderate (ICC 0.49) and ECG low (ICC 0.25) agreement with airway flow. Diaphragm activity started high with a decreasing trend in the first 15 min and subsequent stabilisation. CONCLUSION Monitoring vital signs with dEMG in the DR is feasible and fast. Diaphragm activity can be detected and described with dEMG, making dEMG promising for future DR studies.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands .,Amsterdam Reproduction & Development Research Institute, Amsterdam, North-Holland, Netherlands
| | - Eline Kho
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Technical Medicine, University of Twente, Enschede, Overijssel, Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Hylke H Salverda
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, Overijssel, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
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8
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Clark AR. Essentials for aerosol delivery to term and pre-term infants. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:594. [PMID: 33987292 DOI: 10.21037/atm-20-7265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Effectively delivering pharmaceutical aerosols to the lungs of preterm and term infants represents a considerable technical challenge. Small infants are obligatory nose breathers, they have small airways, low tidal volumes and rapid respiration rates. It is ethically unacceptable to investigate aerosol deposition in vivo in newborns due to ethical concerns about the radiation exposure involved in imaging studies and drug delivery and blood draws in pharmacokinetics studies. The purpose of the work reported in this article was thus to report the use of modeling to develop an understanding of the regional deposition of aerosols in neonates and to build a theoretical basis for choosing an optimum aerosol size to maximize delivery and minimize variability. Recent data on aerosol deposition in the nasal airways of newborn term and preterm infants was coupled to an established, scalable, lung deposition model to investigate the effects of age, aerosol size and ventilation on regional airway deposition. In the term newborn infant lung deposition ranged from 25% to 35% depending on Geometric Standard Deviations (GSDs). Intrasubject variability was minimized for aerosols with larger GSD. However, mean lung deposition is reduced with increasing GSD. A compromise between maximum lung deposition and increased intersubject variability appears to be in the region of GSDs of 1.75. In the 30-week GA preterm infant lung deposition is slightly higher than in the term infant despite smaller airways and lower tidal volumes. This is likely due to the lower inhaled flow rates that are concomitant with lower lung volumes. Finally, when aerosol delivery is directly to the trachea, as it would be if delivered via an endotracheal tube there is a monotonic increase in lung deposition with increasing aerosol size with peripheral deposition peaking at 2 to 3 µm. However, practical limitations of aerosol transport through endotracheal tubes, limiting delivered aerosol size, likely caps lung deposition at around 30% to 30% of the delivered dose.
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9
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Baixauli-Alacreu S, Padilla-Sánchez C, Hervás-Marín D, Lara-Cantón I, Solaz-García A, Alemany-Anchel MJ, Vento M. Expired Tidal Volume and Respiratory Rate During Postnatal Stabilization of Newborn Infants Born at Term via Cesarean Delivery. THE JOURNAL OF PEDIATRICS: X 2021. [DOI: 10.1016/j.ympdx.2020.100063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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10
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King A, Blank D, Bhatia R, Marzbanrad F, Malhotra A. Tools to assess lung aeration in neonates with respiratory distress syndrome. Acta Paediatr 2020; 109:667-678. [PMID: 31536658 DOI: 10.1111/apa.15028] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 08/26/2019] [Accepted: 09/17/2019] [Indexed: 12/31/2022]
Abstract
AIM Respiratory distress syndrome is a common condition among preterm neonates, and assessing lung aeration assists in diagnosing the disease and helping to guide and monitor treatment. We aimed to identify and analyse the tools available to assess lung aeration in neonates with respiratory distress syndrome. METHODS A systematic review and narrative synthesis of studies published between January 1, 2004, and August 26, 2019, were performed using the OVID Medline, PubMed, Embase and Scopus databases. RESULTS A total of 53 relevant papers were retrieved for the narrative synthesis. The main tools used to assess lung aeration were respiratory function monitoring, capnography, chest X-rays, lung ultrasound, electrical impedance tomography and respiratory inductive plethysmography. This paper discusses the evidence to support the use of these tools, including their advantages and disadvantages, and explores the future of lung aeration assessments within neonatal intensive care units. CONCLUSION There are currently several promising tools available to assess lung aeration in neonates with respiratory distress syndrome, but they all have their limitations. These tools need to be refined to facilitate convenient and accurate assessments of lung aeration in neonates with respiratory distress syndrome.
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Affiliation(s)
- Arrabella King
- Department of Paediatrics Monash University Melbourne Vic. Australia
| | - Douglas Blank
- Monash Newborn Monash Children's Hospital Melbourne Vic. Australia
- The Ritchie Centre Hudson Institute of Medical Research Melbourne Vic. Australia
| | - Risha Bhatia
- Department of Paediatrics Monash University Melbourne Vic. Australia
- Monash Newborn Monash Children's Hospital Melbourne Vic. Australia
| | - Faezeh Marzbanrad
- Department of Electrical and Computer Systems Engineering Monash University Melbourne Vic. Australia
| | - Atul Malhotra
- Department of Paediatrics Monash University Melbourne Vic. Australia
- Monash Newborn Monash Children's Hospital Melbourne Vic. Australia
- The Ritchie Centre Hudson Institute of Medical Research Melbourne Vic. Australia
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11
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Dekker J, Martherus T, Lopriore E, Giera M, McGillick EV, Hutten J, van Leuteren RW, van Kaam AH, Hooper SB, Te Pas AB. The Effect of Initial High vs. Low FiO 2 on Breathing Effort in Preterm Infants at Birth: A Randomized Controlled Trial. Front Pediatr 2019; 7:504. [PMID: 31921719 PMCID: PMC6927294 DOI: 10.3389/fped.2019.00504] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Infants are currently stabilized at birth with initial low FiO2 which increases the risk of hypoxia and suppression of breathing in the first minutes after birth. We hypothesized that initiating stabilization at birth with a high O2 concentration, followed by titration, would improve breathing effort when compared to a low O2 concentration, followed by titration. Methods: In a bi-center randomized controlled trial, infants <30 weeks gestation were stabilized at birth with an initial O2 concentration of 30 or 100%, followed by oxygen titration. Primary outcome was minute volume of spontaneous breathing. We also assessed tidal volumes, mean inspiratory flow rate (MIFR) and respiratory rate with a respiratory function monitor in the first 5 min after birth, and evaluated the duration of mask ventilation in the first 10 min after birth. Pulse oximetry was used to measure heart rate and SpO2 values in the first 10 min. Hypoxemia was defined as SpO2 < 25th percentile and hyperoxemia as SpO2 >95%. 8-iso-prostaglandin F2α (8iPGF2α) was measured to assess oxidative stress in cord blood and 1 and 24 h after birth. Results: Fifty-two infants were randomized and recordings were obtained in 44 infants (100% O2-group: n = 20, 30% O2-group: n = 24). Minute volumes were significantly higher in the 100% O2-group (146.34 ± 112.68 mL/kg/min) compared to the 30% O2-group (74.43 ± 52.19 mL/kg/min), p = 0.014. Tidal volumes and MIFR were significantly higher in the 100% O2-group, while the duration of mask ventilation given was significantly shorter. Oxygenation in the first 5 min after birth was significantly higher in infants in the 100% O2-group [85 (64-93)%] compared to the 30% O2-group [58 (46-67)%], p < 0.001. The duration of hypoxemia was significantly shorter in the 100% O2-group, while the duration of hyperoxemia was not different between groups. There was no difference in oxidative stress marker 8iPGF2α between the groups. Conclusion: Initiating stabilization of preterm infants at birth with 100% O2 led to higher breathing effort, improved oxygenation, and a shorter duration of mask ventilation as compared to 30% O2, without increasing the risk for hyperoxia or oxidative stress. Clinical Trial Registration: This study was registered in www.trialregister.nl, with registration number NTR6878.
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Affiliation(s)
- Janneke Dekker
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Tessa Martherus
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Enrico Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Martin Giera
- Center Proteomics Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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12
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Dekker J, Hooper SB, Giera M, McGillick EV, Hutten GJ, Onland W, van Kaam AH, Te Pas AB. High vs. Low Initial Oxygen to Improve the Breathing Effort of Preterm Infants at Birth: Study Protocol for a Randomized Controlled Trial. Front Pediatr 2019; 7:179. [PMID: 31134170 PMCID: PMC6514187 DOI: 10.3389/fped.2019.00179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/17/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Although most preterm infants breathe at birth, their respiratory drive is weak and supplemental oxygen is often needed to overcome hypoxia. This could in turn lead to hyperoxia. To reduce the risk of hyperoxia, currently an initial low oxygen concentration (21-30%) is recommended during stabilization at birth, accepting the risk of a hypoxic period. However, hypoxia inhibits respiratory drive in preterm infants. Starting with a higher level of oxygen could lead to a shorter duration of hypoxia by stimulating breathing effort of preterm infants, and combined with subsequent titration based on oxygen saturation, prolonged hyperoxia might be prevented. Study design: This multi-center randomized controlled trial will include 50 infants with a gestational age between 24 and 30 weeks. Eligible infants will be randomized to stabilization with an initial FiO2 of either 1.0 or 0.3 at birth. Hereafter, FiO2 will be titrated based on the oxygen saturation target range. In both groups, all other interventions during stabilization and thereafter will be similar. The primary outcome is respiratory effort in the first 5 min after birth expressed as average minute volume/kg. Secondary outcomes include inspired tidal volumes/kg, rate of rise to maximum tidal volume/kg, percentage of recruitment breaths with tidal volumes above 8 mL/kg, duration of hypoxia and hyperoxia and plasma levels of markers of oxidative stress (8-iso-prostaglandin F2α). Discussion: Current resuscitation guidelines recommend oxygen titration if infants fail to achieve the 25th percentile of the SpO2 reference ranges. It has become clear that, using this approach, most preterm infants are at risk for hypoxia in the first 5 min after birth, which could suppress the breathing effort. In addition, for compromised preterm infants who need respiratory support at birth, higher SpO2 reference ranges in the first minutes after birth might be needed to prevent prolonged hypoxia. Enhancing breathing effort by achieving an adequate level of oxygenation could potentially lead to a lower incidence of intubation and mechanical ventilation in the delivery room, contributing to a lower risk on lung injury in high-risk preterm infants. Measuring 8-iso-prostaglandin F2α could lead to a reflection of the true amount of oxygen exposure in both study groups.
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Affiliation(s)
- Janneke Dekker
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Martin Giera
- Center Proteomics Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - W Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Arjan B Te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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13
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Dekker J, Hooper SB, Martherus T, Cramer SJE, van Geloven N, Te Pas AB. Repetitive versus standard tactile stimulation of preterm infants at birth - A randomized controlled trial. Resuscitation 2018; 127:37-43. [PMID: 29580959 DOI: 10.1016/j.resuscitation.2018.03.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/19/2018] [Accepted: 03/22/2018] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the direct effect of repetitive tactile stimulation on breathing effort of preterm infants at birth. METHODS This randomized controlled trial compared the effect of repetitive stimulation on respiratory effort during the first 4 min after birth with standard stimulation based on clinical indication in preterm infants with a gestational age of 27-32 weeks. All details of the stimulation performed were noted. The main study parameter measured was respiratory minute volume, other study parameters assessed measures of respiratory effort; tidal volumes, rate of rise to maximum tidal volumes, percentage of recruitment breaths, and oxygenation of the infant. RESULTS There was no significant difference in respiratory minute volume in the repetitive stimulation group when compared to the standard group. Oxygen saturation was significantly higher (87.6 ± 3.3% vs 81.7 ± 8.7%, p = .01) while the amount of FiO2 given during transport to the NICU was lower (28.2 (22.8-35.0)% vs 33.6 (29.4-44.1)%, p = .04). There was no significant difference in administration of positive pressure ventilation (52% vs 78%, p = .13), or the duration of ventilation (median (IQR) time 8 (0-118)s vs 35 (13-131)s, p = .23). Caregivers decided less often to administer caffeine in the delivery room to stimulate breathing in the repetitive stimulation group (10% vs 39%, p = .036). CONCLUSION Although the increase in respiratory effort during repetitive stimulation did not reach significance, oxygenation significantly improved with a lower level of FiO2 at transport to the NICU. Repetitive tactile stimulation could be of added value to improve breathing effort at birth.
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Affiliation(s)
- Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Stuart B Hooper
- The Ritchie Center, MIMR-PHI Institute of Medical Research, Melbourne, Australia
| | - Tessa Martherus
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie J E Cramer
- Department of Instrumental Affairs, Leiden University Medical Center, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Medical Statistics and Bio-informatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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14
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Huberts TJP, Foglia EE, Narayen IC, van Vonderen JJ, Hooper SB, Te Pas AB. The Breathing Effort of Very Preterm Infants at Birth. J Pediatr 2018; 194:54-59. [PMID: 29336795 DOI: 10.1016/j.jpeds.2017.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/23/2017] [Accepted: 11/01/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the respiratory effort of very preterm infants receiving positive pressure ventilation (PPV) with infants breathing on continuous positive airway pressure (CPAP), directly after birth. STUDY DESIGN Recorded resuscitations of very preterm infants receiving PPV or CPAP after birth were analyzed retrospectively. The respiratory effort (minute volume and recruitment breaths [>8 mL/kg], heart rate, oxygen saturation, and oxygen requirement were analyzed for the first 2 minutes and in the fifth minute after birth. RESULTS Respiratory effort was analyzed in 118 infants, 87 infants receiving PPV and 31 infants receiving CPAP (median gestational age, 28 weeks [IQR, 26-29] vs 29 weeks [IQR, 29-30; P < .001); birth weight, 1059 g [IQR, 795-1300] vs 1205 g [IQR, 956-1418; P = .06]). The minute volume of spontaneous breaths of infants receiving PPV was lower at 2 minutes (37 mL/kg/minute [IQR, 15-69] vs 188 mL/kg/minute [IQR, 128-297; P < .001]) and at 5 minutes (112 mL/kg/minute [IQR, 46-229] vs 205 mL/kg/minute [IQR, 174-327; P < .001]). Recruitment breaths occurred less in the PPV group at 2 minutes (0 breaths/minute [IQR, 0-1] vs 4 breaths/minute [IQR, 1-8; P < .001]) and 5 minutes (0 breaths/minute [IQR, 0-3] vs 2 breaths/minute [IQR, 0-11; P = .01). The heart rate was lower in the PPV group (94 beats/minute [IQR, 68-128] vs 124 beats/minute [IQR, 100-144; P = .02]) as was oxygen saturation (50% [IQR, 35%-66%] vs 67% [IQR, 34%-80%; P = .04]), but not different at 5 minutes (heart rate, 149 beats/minute [IQR, 131-162] vs 150 beats/minute [IQR, 132-160; P = NS]; oxygen saturation , 91% [IQR, 80%-95%] vs 92% [IQR, 89%-97%; P = NS]). The oxygen requirement was higher (at 2 minutes, 30% [IQR, 21%-53%] vs 21% [IQR, 21%-29%; P = .05]; at 5 minutes, 39% [IQR, 22%-91%] vs 22% [IQR, 21%-31%; P = .003]). CONCLUSION Very preterm infants breathe at birth when receiving PPV, but the respiratory effort was significantly lower when compared with infants receiving CPAP only. The reduced breathing effort observed likely justified applying PPV in most infants.
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Affiliation(s)
- Tom J P Huberts
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth E Foglia
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ilona C Narayen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia; Department of Obstetrics and Gynecology, Monash University, Melbourne, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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15
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Ngan AY, Cheung PY, Hudson-Mason A, O'Reilly M, van Os S, Kumar M, Aziz K, Schmölzer GM. Using exhaled CO 2 to guide initial respiratory support at birth: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2017; 102:F525-F531. [PMID: 28596379 DOI: 10.1136/archdischild-2016-312286] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 03/21/2017] [Accepted: 03/26/2017] [Indexed: 11/04/2022]
Abstract
IMPORTANCE A sustained inflation (SI) provided at birth might reduce bronchopulmonary dysplasia (BPD). OBJECTIVE This study aims to examine whether an SI-guided exhaled carbon dioxide (ECO2) compared with positive pressure ventilation (PPV) alone at birth decreases BPD. DESIGN Randomised controlled trial. Infants were randomly allocated to either SI (SI group) or PPV (PPV group). PARTICIPANTS Participants of this study include infants between 23+0 and 32+6 weeks gestation with a need for PPV at birth. INTERVENTION Infants randomised into the SI group received an initial SI with a peak inflation pressure (PIP) of 24 cmH2O over 20 s. The second SI was guided by the amount of ECO2. If ECO2 was ≤20 mm Hg, a further SI of 20 s was delivered. If ECO2 was >20 mm Hg the second SI was 10 s. Infants randomised into the PPV group received mask PPV with an initial PIP of 24 cmH2O. PRIMARY OUTCOMES Reduction in BPD defined as the need for respiratory support or supplemental oxygen at corrected gestational age of 36 weeks. RESULTS SI (n=76) and PPV (n=86) group had similar rates of BPD (23% vs 33%, p=0.090, not statistically significant). The duration of mechanical ventilation was significantly reduced with SI versus PPV (63 (10-246) hours versus 204 (17-562) hours, respectively (p=0.045)). No short-term harmful effects were identified from two SI lasting up to 40 s (eg, pneumothorax, intraventricular haemorrhage or patent ductus arteriosus). CONCLUSION Preterm infants <33 weeks gestation receiving SI at birth had lower duration of mechanical ventilation and similar incidence of BPD compared with PPV. Using ECO2 to guide length of SI is feasible. TRIAL REGISTRATION NUMBER NCT01739114; Results.
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Affiliation(s)
- Ashley Y Ngan
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Ann Hudson-Mason
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Sylvia van Os
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Manoj Kumar
- Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Khalid Aziz
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - Georg M Schmölzer
- Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Alberta, Canada.,Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Canada
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16
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Nosherwan A, Cheung PY, Schmölzer GM. Management of Extremely Low Birth Weight Infants in Delivery Room. Clin Perinatol 2017; 44:361-375. [PMID: 28477666 DOI: 10.1016/j.clp.2017.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Extremely low birth weight (ELBW) infants are particularly vulnerable at birth, and stabilization in the delivery room (DR) remains challenging. After birth, ELBW infants are at high risk for the development of thermal dysregulation, respiratory insufficiency, and hemodynamic instability due to their immature physiology and anatomy. Although successful stabilization facilitates the transition and reduces acute morbidity, suboptimal care in the DR could cause long-term sequelae. This review addresses the challenges in stabilization in the DR and current neonatal resuscitation guidelines and recommendations.
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Affiliation(s)
- Asma Nosherwan
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada.
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17
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Oxygen Saturation and Heart Rate Ranges in Very Preterm Infants Requiring Respiratory Support at Birth. J Pediatr 2017; 182:41-46.e2. [PMID: 27939259 DOI: 10.1016/j.jpeds.2016.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 09/20/2016] [Accepted: 11/03/2016] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the changes in preductal oxygen saturation (SpO2) and heart rate in preterm infants receiving continuous positive airway pressure (CPAP) and/or positive-pressure ventilation (PPV) at birth. STUDY DESIGN A prospective observational study at birth of infants aged <32 weeks separated into 2 gestational age (GA) groups: 230/7-276/7 weeks (group 1) and 280/7-316/7 weeks (group 2). Infants received delayed cord clamping (DCC) in accordance with institutional protocol. CPAP and/or PPV was applied at the clinical team's discretion. SpO2 and heart rate were recorded every minute for 10 minutes. Preductal SpO2 was targeted according to published nomograms. For heart rate, the goal was to maintain a stable heart rate >100 bpm. RESULTS The study cohort comprised 96 group 1 infants (mean GA, 26 ± 1 weeks; mean birth weight, 818 ± 208 g) and 173 group 2 infants (mean GA, 30 ± 1 weeks; mean birth weight, 1438 ± 374 g). In general, infants requiring respiratory support reached target values for heart rate and SpO2 more slowly than the published nomograms for spontaneously breathing preterm infants without respiratory support. Infants receiving CPAP reached SpO2 and heart rate targets faster than infants receiving PPV. In group 1, but not group 2 infants, DCC resulted in higher SpO2 and heart rate. CONCLUSION SpO2 and heart rate do not quickly and reliably reach the values achieved by spontaneously breathing preterm infants not requiring respiratory support.
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18
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Forsberg D, Horn Z, Tserga E, Smedler E, Silberberg G, Shvarev Y, Kaila K, Uhlén P, Herlenius E. CO2-evoked release of PGE2 modulates sighs and inspiration as demonstrated in brainstem organotypic culture. eLife 2016; 5. [PMID: 27377173 PMCID: PMC4974055 DOI: 10.7554/elife.14170] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Accepted: 06/21/2016] [Indexed: 12/20/2022] Open
Abstract
Inflammation-induced release of prostaglandin E2 (PGE2) changes breathing patterns and the response to CO2 levels. This may have fatal consequences in newborn babies and result in sudden infant death. To elucidate the underlying mechanisms, we present a novel breathing brainstem organotypic culture that generates rhythmic neural network and motor activity for 3 weeks. We show that increased CO2 elicits a gap junction-dependent release of PGE2. This alters neural network activity in the preBötzinger rhythm-generating complex and in the chemosensitive brainstem respiratory regions, thereby increasing sigh frequency and the depth of inspiration. We used mice lacking eicosanoid prostanoid 3 receptors (EP3R), breathing brainstem organotypic slices and optogenetic inhibition of EP3R+/+ cells to demonstrate that the EP3R is important for the ventilatory response to hypercapnia. Our study identifies a novel pathway linking the inflammatory and respiratory systems, with implications for inspiration and sighs throughout life, and the ability to autoresuscitate when breathing fails. DOI:http://dx.doi.org/10.7554/eLife.14170.001 Humans and other mammals breathe air to absorb oxygen into the body and to remove carbon dioxide. We know that in a part of the brain called the brainstem, several regions work together to create breaths, but it is not clear precisely how this works. These regions adjust our breathing to the demands placed on the body by different activities, such as sleeping or exercising. Sometimes, especially in newborn babies, the brainstem’s monitoring of oxygen and carbon dioxide does not work properly, which can lead to abnormal breathing and possibly death. In the brain, cells called neurons form networks that can rapidly transfer information via electrical signals. Here, Forsberg et al. investigated the neural networks in the brainstem that generate and control breathing in mice. They used slices of mouse brainstem that had been kept alive in a dish in the laboratory. The slice contained an arrangement of neurons and supporting cells that allowed it to continue to produce patterns of electrical activity that are associated with breathing. Over a three-week period, Forsberg et al. monitored the activity of the cells and calculated how they were connected to each other. The experiments show that the neurons responsible for breathing were organized in a “small-world” network, in which the neurons are connected to each other directly or via small numbers of other neurons. Further experiments tested how various factors affect the behavior of the network. For example, carbon dioxide triggered the release of a small molecule called prostaglandin E2 from cells. This molecule is known to play a role in inflammation and fever. However, in the carbon dioxide sensing region of the brainstem it acted as a signaling molecule that increased activity. Therefore, inflammation could interfere with the body’s normal response to carbon dioxide and lead to potentially life-threatening breathing problems. Furthermore, prostaglandin E2 induced deeper breaths known as sighs, which may be vital for newborn babies to be able to take their first deep breaths of life. Future challenges include understanding how the brainstem neural networks generate breathing and translate this knowledge to improve the treatment of breathing difficulties in babies. DOI:http://dx.doi.org/10.7554/eLife.14170.002
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Affiliation(s)
- David Forsberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden
| | - Zachi Horn
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden
| | - Evangelia Tserga
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden
| | - Erik Smedler
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Gilad Silberberg
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Yuri Shvarev
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden
| | - Kai Kaila
- Department of Biosciences and Neuroscience Center, University of Helsinki, Helsinki, Finland
| | - Per Uhlén
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Eric Herlenius
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Karolinska University Hospital, Stockholm, Sweden
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19
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Nicoll J, Cheung PY, Aziz K, Rajani V, O'Reilly M, Pichler G, Schmölzer GM. Exhaled Carbon Dioxide and Neonatal Breathing Patterns in Preterm Infants after Birth. J Pediatr 2015; 167:829-833.e1. [PMID: 26227435 DOI: 10.1016/j.jpeds.2015.06.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/10/2015] [Accepted: 06/26/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To examine the amount of exhaled carbon dioxide (ECO2) with different breathing patterns in spontaneously breathing preterm infants after birth. STUDY DESIGN Preterm infants had a facemask attached to a combined carbon dioxide/flow sensor placed over their mouth and nose to record ECO2 and gas flow. A breath-by-breath analysis of the first 5 minutes of the recording was performed. RESULTS Thirty spontaneously breathing preterm infants, gestational age (mean ± SD) 30 ± 2 weeks and birth weight 1635 ± 499 g were studied. ECO2 from normal breaths and slow expirations was significantly larger than with other breathing patterns (P < .001). ECO2 per breath also increased with gestational age P < .001. The expiratory hold pattern was the most prevalent breathing pattern both during the first minute of recording and overall. Breathing pattern proportions also varied by gestational age. Finally, ECO2 from the fifth minute of recording was significantly greater than that produced during the first 4 minutes of recording (P ≤ .029). CONCLUSIONS ECO2 varies with different breathing patterns and increases with gestational age and over time. ECO2 may be an indicator of lung aeration and that postnatal ECO2 monitoring may be useful in preterm infants in the delivery room.
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Affiliation(s)
- Jessica Nicoll
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Po-Yin Cheung
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Khalid Aziz
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Vishaal Rajani
- Neuroscience and Mental Health Institute, Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
| | - Megan O'Reilly
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Gerhard Pichler
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, Medical University, Graz, Austria
| | - Georg M Schmölzer
- Center for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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20
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Barton SK, Tolcos M, Miller SL, Roehr CC, Schmölzer GM, Davis PG, Moss TJM, LaRosa DA, Hooper SB, Polglase GR. Unraveling the Links Between the Initiation of Ventilation and Brain Injury in Preterm Infants. Front Pediatr 2015; 3:97. [PMID: 26618148 PMCID: PMC4639621 DOI: 10.3389/fped.2015.00097] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Accepted: 10/26/2015] [Indexed: 11/13/2022] Open
Abstract
The initiation of ventilation in the delivery room is one of the most important but least controlled interventions a preterm infant will face. Tidal volumes (V T) used in the neonatal intensive care unit are carefully measured and adjusted. However, the V Ts that an infant receives during resuscitation are usually unmonitored and highly variable. Inappropriate V Ts delivered to preterm infants during respiratory support substantially increase the risk of injury and inflammation to the lungs and brain. These may cause cerebral blood flow instability and initiate a cerebral inflammatory cascade. The two pathways increase the risk of brain injury and potential life-long adverse neurodevelopmental outcomes. The employment of new technologies, including respiratory function monitors, can improve and guide the optimal delivery of V Ts and reduce confounders, such as leak. Better respiratory support in the delivery room has the potential to improve both respiratory and neurological outcomes in this vulnerable population.
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Affiliation(s)
- Samantha K Barton
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia
| | - Mary Tolcos
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia ; Department of Obstetrics and Gynecology, Monash University , Melbourne, VIC , Australia
| | - Suzie L Miller
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia ; Department of Obstetrics and Gynecology, Monash University , Melbourne, VIC , Australia
| | - Charles C Roehr
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia ; Newborn Services, John Radcliffe Hospital, Oxford University Hospitals , Oxford , UK
| | - Georg M Schmölzer
- Department of Pediatrics, University of Alberta , Edmonton, AB , Canada ; Centre for the Study of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Alberta Health Services , Edmonton, AB , Canada
| | - Peter G Davis
- Neonatal Services, Newborn Research Centre, The Royal Women's Hospital , Melbourne, VIC , Australia
| | - Timothy J M Moss
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia ; Department of Obstetrics and Gynecology, Monash University , Melbourne, VIC , Australia
| | - Domenic A LaRosa
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia ; Department of Obstetrics and Gynecology, Monash University , Melbourne, VIC , Australia
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research , Melbourne, VIC , Australia ; Department of Obstetrics and Gynecology, Monash University , Melbourne, VIC , Australia
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