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Delivery room resuscitation and short-term outcomes of extremely preterm and extremely low birth weight infants: a multicenter survey in North China. Chin Med J (Engl) 2021; 134:1561-1568. [PMID: 34133350 PMCID: PMC8280058 DOI: 10.1097/cm9.0000000000001499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Delivery room resuscitation assists preterm infants, especially extremely preterm infants (EPI) and extremely low birth weight infants (ELBWI), in breathing support, while it potentially exerts a negative impact on the lungs and outcomes of preterm infants. This study aimed to assess delivery room resuscitation and discharge outcomes of EPI and ELBWI in China. Methods: The clinical data of EPI (gestational age [GA] <28 weeks) and ELBWI (birth weight [BW] <1000 g), admitted within 72 h of birth in 33 neonatal intensive care units from five provinces and cities in North China between 2017 and 2018, were analyzed. The primary outcomes were delivery room resuscitation and risk factors for delivery room intubation (DRI). The secondary outcomes were survival rates, incidence of bronchopulmonary dysplasia (BPD), and risk factors for BPD. Results: A cohort of 952 preterm infants were enrolled. The incidence of DRI, chest compressions, and administration of epinephrine was 55.9% (532/952), 12.5% (119/952), and 7.0% (67/952), respectively. Multivariate analysis revealed that the risk factors for DRI were GA <28 weeks (odds ratio [OR], 3.147; 95% confidence interval [CI], 2.082–4.755), BW <1000 g (OR, 2.240; 95% CI, 1.606–3.125), and antepartum infection (OR, 1.429; 95% CI, 1.044–1.956). The survival rate was 65.9% (627/952) and was dependent on GA. The rate of BPD was 29.3% (181/627). Multivariate analysis showed that the risk factors for BPD were male (OR, 1.603; 95% CI, 1.061–2.424), DRI (OR, 2.094; 95% CI, 1.328–3.303), respiratory distress syndrome exposed to ≥2 doses of pulmonary surfactants (PS; OR, 2.700; 95% CI, 1.679–4.343), and mechanical ventilation ≥7 days (OR, 4.358; 95% CI, 2.777–6.837). However, a larger BW (OR, 0.998; 95% CI, 0.996–0.999), antenatal steroid (OR, 0.577; 95% CI, 0.379–0.880), and PS use in the delivery room (OR, 0.273; 95% CI, 0.160–0.467) were preventive factors for BPD (all P < 0.05). Conclusion: Improving delivery room resuscitation and management of respiratory complications are imperative during early management of the health of EPI and ELBWI.
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Ng EH, Shah V. Guidelines for surfactant replacement therapy in neonates. Paediatr Child Health 2021; 26:35-49. [PMID: 33552321 DOI: 10.1093/pch/pxaa116] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 10/18/2019] [Indexed: 11/12/2022] Open
Abstract
Surfactant replacement therapy (SRT) plays a pivotal role in the management of neonates with respiratory distress syndrome (RDS) because it improves survival and reduces respiratory morbidities. With the increasing use of noninvasive ventilation as the primary mode of respiratory support for preterm infants at delivery, prophylactic surfactant is no longer beneficial. For infants with worsening RDS, early rescue surfactant should be provided. While the strategy to intubate, give surfactant, and extubate (INSURE) has been widely accepted in clinical practice, newer methods of noninvasive surfactant administration, using thin catheter, laryngeal mask airway, or nebulization, are being adopted or investigated. Use of SRT as an adjunct for conditions other than RDS, such as meconium aspiration syndrome, may be effective based on limited evidence.
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Affiliation(s)
- Eugene H Ng
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
| | - Vibhuti Shah
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Ng EH, Shah V. Les directives pour le traitement par surfactant exogène chez le nouveau-né. Paediatr Child Health 2021. [DOI: 10.1093/pch/pxaa117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Résumé
Le traitement par surfactant exogène joue un rôle essentiel dans la prise en charge des nouveau-nés atteints du syndrome de détresse respiratoire (maladie des membranes hyalines) parce qu’il améliore la survie et limite les troubles respiratoires. Puisque la ventilation non invasive est de plus en plus utilisée comme principal mode d’assistance respiratoire chez le nouveau-né prématuré à la naissance, l’administration prophylactique de surfactant n’est plus bénéfique. L’administration précoce de surfactant sous forme de traitement de rattrapage est préconisée chez les nouveau-nés dont le syndrome de détresse respiratoire s’aggrave. La stratégie qui consiste à intuber, administrer du surfactant, puis extuber (INSURE) est largement acceptée en pratique clinique, mais des méthodes non invasives plus récentes à l’aide d’un cathéter fin, d’un masque laryngé ou d’un nébuliseur sont en cours d’adoption ou d’exploration. Selon des données limitées, un traitement d’appoint par surfactant exogène pourrait être efficace pour traiter d’autres affections que le syndrome de détresse respiratoire, telles que le syndrome d’aspiration méconiale.
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Affiliation(s)
- Eugene H Ng
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
| | - Vibhuti Shah
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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Sivieri EM, Eichenwald EC, Rub DM, Abbasi S. An in-line high frequency flow interrupter applied to nasal CPAP: Improved carbon dioxide clearance in a premature infant lung model. Pediatr Pulmonol 2019; 54:1974-1981. [PMID: 31469253 DOI: 10.1002/ppul.24505] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/15/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Noninvasive respiratory support continues to have high failure rates in small preterm infants. We previously demonstrated significantly improved in vitro CO2 washout by applying oscillations to a high flow nasal cannula system. OBJECTIVE To develop a high frequency flow interrupter that could be applied to commonly used nasal continuous positive airway pressure (NCPAP) devices and to determine the effect of oscillations on end-tidal carbon dioxide (EtCO2 ) levels in an infant lung model. DESIGN/METHODS NCPAP was applied to a premature infant lung simulator using either bubble (BCPAP) or variable-flow (VCPAP) CPAP. Supply gas was interrupted with a solenoid pinch valve. EtCO2 was measured before and during oscillation and repeated at 4, 6, 8, 10, and 12 Hz oscillation and CPAP pressures of 4, 6, and 8 cm H 2 O. RESULTS BCPAP and VCPAP EtCO2 levels decreased with oscillation (P < .001). BCPAP EtCO2 was significantly dependent on oscillation frequency (P < .001) with decreases of 18% to 47% and maximum effect at 10 Hz. Optimum VCPAP CO2 clearance occurred at 6 Hz with reductions of 30% and 39% at 6 and 8 cm H2 O CPAP respectively. BCPAP and VCPAP mean airway pressures remained unchanged transitioning from nonoscillation to oscillation. Oscillated BCPAP and VCPAP average amplitudes were 8.3 ± 0.5 and 8.4 ± 2.3 SD cm H2 O, respectively. Power spectrum analysis of non-oscillated BCPAP showed bubbling-only dominant peaks at 10 to 12 Hz corresponding with the maximum BCPAP EtCO2 reductions. CONCLUSION Application of high frequency oscillation to NCPAP improves CO2 clearance in a premature infant lung model. This simple modification to NCPAP delivery devices may prove to be an effective enhancement of this mode of noninvasive respiratory support.
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Affiliation(s)
- Emidio M Sivieri
- Division of Neonatology, Children's Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eric C Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David M Rub
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Soraya Abbasi
- Division of Neonatology, Children's Hospital of Philadelphia Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Sivieri EM, Eichenwald E, Bakri SM, Abbasi S. Effect of high frequency oscillatory high flow nasal cannula on carbon dioxide clearance in a premature infant lung model: A bench study. Pediatr Pulmonol 2019; 54:436-443. [PMID: 30549451 DOI: 10.1002/ppul.24216] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 11/13/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This study compared CO2 clearance in a premature infant lung model connected to a high flow nasal cannula (HFNC) system supplied with oscillatory versus non-oscillatory flow. DESIGN/METHODS The lung model was set to compliance 1.0 mL/cmH2 O, RR 60 breaths/min, and 6 mL tidal volume. A 100% CO2 was injected at a constant 15 mL/min. To create oscillation, HFNC flow was interrupted at rates of 4-6-8 and 10 Hz. equilibrated end-tidal CO2 (ETCO2 ) was recorded with and without oscillation at set flows of 2-8 L/min and repeated for each oscillation frequency. RESULTS Overall ETCO2 decreased significantly (P < 0.001) during both non-oscillatory and oscillatory HFNC as set flow increased from 2 to 8 L/min by 26.3% and 60.8%, respectively. Oscillatory ETCO2 levels decreased linearly compared to non-oscillatory HFNC with negligible difference at 2 L/min and a 48.4% difference at 8 L/min (P < 0.001). There were no differences in ETCO2 levels between oscillation frequencies at any flow except at 6 Hz for which ETCO2 was significantly lower (P < 0.01) than at 4, 8, and 10 Hz for 5-8 L/min HFNC flows. Amplitude of volume oscillations increased with increasing flow from 0.5 mL at 2 L/min to 4.0 mL at 8 L/min (P < 0.001), and decreased with increasing oscillation frequency. CONCLUSION Oscillatory HFNC as compared to non-oscillatory was associated with significantly improved CO2 clearance in this premature infant lung model. This simple modification of the HFNC system may prove to be a useful enhancement to this mode of non-invasive respiratory support for preterm infants at high risk for respiratory failure.
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Affiliation(s)
- Emidio M Sivieri
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eric Eichenwald
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Salma M Bakri
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Soraya Abbasi
- CHOP Newborn Care at Pennsylvania Hospital, Philadelphia, Pennsylvania.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Allegaert K, Simons S, Van Den Anker J. Research on medication use in the neonatal intensive care unit. Expert Rev Clin Pharmacol 2019; 12:343-353. [PMID: 30741041 DOI: 10.1080/17512433.2019.1580569] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Research on medication use aims at assessing how much of current pharmacotherapy is rational. In neonates, this is hampered by extensive off-label drug use and limited knowledge. Areas covered: We report on medication use research and have conducted a systematic review of observational studies on medication use to provide an updated overview on characteristics, objectives, methods, and patterns in hospitalized neonates. Moreover, a review on aspects of medication use for opioids, anti-epileptics, gastric acid-related disorders and respiratory stimulants with emphasis on trends and impact of interventions is presented, illustrating how research on medication use can contribute to improved neonatal pharmacotherapy and more focused research. Medication use reports describe patterns and provide signals on irrational use, benchmarking, or can guide research priorities. Moreover, this may generate information on how neonatal health topics and their pharmacotherapy are handled over time or across regions. Expert opinion: Research on medicine utilization is relevant, since it will inform us on aspects like trends, variability, or about the impact and pattern of implementation of guidelines in neonates. Further progress necessitates to merge datasets on medication use with clinical characteristics, and perinatal drug use remains an area in need of additional research.
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Affiliation(s)
- Karel Allegaert
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Sinno Simons
- a Department of Pediatrics, Division of Neonatology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - John Van Den Anker
- c Division of Clinical Pharmacology, Department of Pediatrics , Children's National Health System , Washington , DC , USA.,d Division of Paediatric Pharmacology and Pharmacometrics , University of Basel Children's Hospital , Basel , Switzerland.,e Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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Raghuram K, Dunn M, Jangaard K, Reilly M, Asztalos E, Kelly E, Vincer M, Shah V. Inhaled corticosteroids in ventilated preterm neonates: a non-randomized dose-ranging study. BMC Pediatr 2018; 18:153. [PMID: 29734948 PMCID: PMC5938808 DOI: 10.1186/s12887-018-1134-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 04/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) offer targeted treatment for bronchopulmonary dysplasia (BPD) with minimal systemic effects compared to systemic steroids. However, dosing of ICS in the management of infants at high-risk of developing BPD is not well established. The objective of this study was to determine an effective dose of ICS for the treatment of ventilator-dependent infants to facilitate extubation or reduce fractional inspired oxygen concentration. Methods Forty-one infants born at < 32 weeks gestational age (GA) or < 1250 g who were ventilator-dependent at 10–28 days postnatal age were included. A non-randomized dose-ranging trial was performed using aerosolized inhaled beclomethasone with hydrofluoralkane propellant (HFA-BDP). Four dosing groups (200, 400, 600 and 800 μg twice daily for 1 week) with 11, 11, 10 and 9 infants in each group, respectively, were studied. The primary outcome was therapeutic efficacy (successful extubation or reduction in FiO2 of > 75% from baseline) in ≥60% of infants in the group. Oxygen requirements, complications and long-term neurodevelopmental outcomes were also assessed. Results The median age at enrollment was 22 (10–28) postnatal days. The primary outcome, therapeutic efficacy as defined above, was not achieved in any group. However, there was a significant reduction in post-treatment FiO2 at a dose of 800 μg bid. No obvious trends were seen in long-term neurodevelopmental outcomes. Conclusions Therapeutic efficacy was not achieved with all studied doses of ICS. A significant reduction in oxygen requirements was noted in ventilator-dependent preterm infants at 10–28 days of age when given 800 μg of HFA-BDP bid. Larger randomized trials of ICS are required to determine efficacy for the management of infants at high-risk for development of BPD. Trial registration This clinical trial was registered retrospectively on clinicaltrials.gov. The registration number is NCT03503994.
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Affiliation(s)
- Kamini Raghuram
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Michael Dunn
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Newborn Medicine and Developmental Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Krista Jangaard
- Department of Paediatrics, Izaak Walton Killam (IWK) Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Maureen Reilly
- Department of Newborn Medicine and Developmental Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Elizabeth Asztalos
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Newborn Medicine and Developmental Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Edmond Kelly
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Department of Paediatrics, Mount Sinai Hospital, 600 University Avenue, Rm 19-231, Toronto, ON, M5G 1X5, Canada
| | - Michael Vincer
- Department of Paediatrics, Izaak Walton Killam (IWK) Health Centre, Dalhousie University, Halifax, NS, Canada
| | - Vibhuti Shah
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada. .,Department of Paediatrics, Mount Sinai Hospital, 600 University Avenue, Rm 19-231, Toronto, ON, M5G 1X5, Canada.
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