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Hibberd J, Leontini J, Scott T, Pillow JJ, Miedema M, Rimensberger PC, Tingay DG. Neonatal high-frequency oscillatory ventilation: where are we now? Arch Dis Child Fetal Neonatal Ed 2024; 109:467-474. [PMID: 37726160 DOI: 10.1136/archdischild-2023-325657] [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: 04/02/2023] [Accepted: 09/04/2023] [Indexed: 09/21/2023]
Abstract
High-frequency oscillatory ventilation (HFOV) is an established mode of respiratory support in the neonatal intensive care unit. Large clinical trial data is based on first intention use in preterm infants with acute respiratory distress syndrome. Clinical practice has evolved from this narrow population. HFOV is most often reserved for term and preterm infants with severe, and often complex, respiratory failure not responding to conventional modalities of respiratory support. Thus, optimal, and safe, application of HFOV requires the clinician to adapt mean airway pressure, frequency, inspiratory:expiratory ratio and tidal volume to individual patient needs based on pathophysiology, lung volume state and infant size. This narrative review summarises the status of HFOV in neonatal intensive care units today, the lessons that can be learnt from the past, how to apply HFOV in different neonatal populations and conditions and highlights potential new advances. Specifically, we provide guidance on how to apply an open lung approach to mean airway pressure, selecting the correct frequency and use of volume-targeted HFOV.
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Affiliation(s)
- Jakob Hibberd
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Justin Leontini
- Department of Mechanical and Product Design Engineering, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - Thomas Scott
- Department of Mechanical and Product Design Engineering, Swinburne University of Technology, Hawthorn, Victoria, Australia
| | - J Jane Pillow
- School of Human Science, The University of Western Australia, Perth, Western Australia, Australia
- NCCU, King Edward Memorial Hospital Neonatal Clinical Care Unit, Subiaco, Western Australia, Australia
- Telethon Kids Institute, Perth, Western Australia, Australia
| | - Martijn Miedema
- Neonatology, Amsterdam Universitair Medische Centra, Amsterdam, The Netherlands
| | | | - David Gerald Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
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2
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Mammel MC. Evolution of mechanical ventilation of the newborn infant. Semin Perinatol 2024; 48:151884. [PMID: 38555220 DOI: 10.1016/j.semperi.2024.151884] [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: 04/02/2024]
Abstract
Artificial ventilation of the newborn infant is the foundation of neonatology. Early practitioners included pediatricians, anesthesiologists, cardiologists, respiratory therapists, and engineers. The discovery of surfactant, followed by the death of Patrick Kennedy, jump-started the new area, with investment and research rapidly expanding. The ever more complex design of mechanical ventilators necessitated a more thorough understanding of newborn pulmonary physiology in order to provide support with minimal associated injury. This piece briefly reviews and highlights this history.
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Affiliation(s)
- Mark C Mammel
- Professor of Pediatrics, University of Minnesota, Minneapolis, MN 55455, United States.
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Veneroni C, Dellacà RL, Küng E, Bonomi B, Berger A, Werther T. Oscillometry for personalizing continuous distending pressure maneuvers: an observational study in extremely preterm infants. Respir Res 2024; 25:4. [PMID: 38178216 PMCID: PMC10765834 DOI: 10.1186/s12931-023-02639-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/15/2023] [Indexed: 01/06/2024] Open
Abstract
RATIONALE Lung recruitment and continuous distending pressure (CDP) titration are critical for assuring the efficacy of high-frequency ventilation (HFOV) in preterm infants. The limitation of oxygenation (peripheral oxygen saturation, SpO2) in optimizing CDP calls for evaluating other non-invasive bedside measurements. Respiratory reactance (Xrs) at 10 Hz measured by oscillometry reflects lung volume recruitment and tissue strain. In particular, lung volume recruitment and decreased tissue strain result in increased Xrs values. OBJECTIVES In extremely preterm infants treated with HFOV as first intention, we aimed to measure the relationship between CDP and Xrs during SpO2-driven CDP optimization. METHODS In this prospective observational study, extremely preterm infants born before 28 weeks of gestation undergoing SpO2-guided lung recruitment maneuvers were included in the study. SpO2 and Xrs were recorded at each CDP step. The optimal CDP identified by oxygenation (CDPOpt_SpO2) was compared to the CDP providing maximal Xrs on the deflation limb of the recruitment maneuver (CDPXrs). RESULTS We studied 40 infants (gestational age at birth = 22+ 6-27+ 5 wk; postnatal age = 1-23 days). Measurements were well tolerated and provided reliable results in 96% of cases. On average, Xrs decreased during the inflation limb and increased during the deflation limb. Xrs changes were heterogeneous among the infants for the amount of decrease with increasing CDP, the decrease at the lowest CDP of the deflation limb, and the hysteresis of the Xrs vs. CDP curve. In all but five infants, the hysteresis of the Xrs vs. CDP curve suggested effective lung recruitment. CDPOpt_SpO2 and CDPXrs were highly correlated (ρ = 0.71, p < 0.001) and not statistically different (median difference [range] = -1 [-3; 9] cmH2O). However, CDPXrs were equal to CDPOpt_SpO2 in only 6 infants, greater than CDPOpt_SpO2 in 10, and lower in 24 infants. CONCLUSIONS The Xrs changes described provide complementary information to oxygenation. Further investigation is warranted to refine recruitment maneuvers and CPD settings in preterm infants.
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Affiliation(s)
- Chiara Veneroni
- TechRes Lab, Department of Electronics, Information and Biomedical Engineering (DEIB), Politecnico di Milano University, Via G. Colombo 40, Milan, 20133, Italy
| | - Raffaele L Dellacà
- TechRes Lab, Department of Electronics, Information and Biomedical Engineering (DEIB), Politecnico di Milano University, Via G. Colombo 40, Milan, 20133, Italy.
| | - Erik Küng
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Beatrice Bonomi
- TechRes Lab, Department of Electronics, Information and Biomedical Engineering (DEIB), Politecnico di Milano University, Via G. Colombo 40, Milan, 20133, Italy
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Tobias Werther
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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Giusto E, Sankaran D, Lesneski A, Joudi H, Hardie M, Hammitt V, Zeinali L, Lakshminrusimha S, Vali P. Neonatal resuscitation with continuous chest compressions and high frequency percussive ventilation in preterm lambs. Pediatr Res 2024; 95:160-166. [PMID: 37726545 DOI: 10.1038/s41390-023-02820-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/16/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Cerebral oxygen delivery (cDO2) is low during chest compressions (CC). We hypothesized that gas exchange and cDO2 are better with continuous CC with high frequency percussive ventilation (CCC + HFPV) compared to conventional 3:1 compressions-to-ventilation (C:V) resuscitation during neonatal resuscitation in preterm lambs with cardiac arrest induced by umbilical cord compression. METHODS Fourteen lambs in cardiac arrest were randomized to 3:1 C:V resuscitation (90CC + 30 breaths/min) per the Neonatal Resuscitation Program guidelines or CCC + HFPV (120CC + HFPV continuously). Intravenous epinephrine was given every 3 min until return of spontaneous circulation (ROSC). RESULTS There was no difference in the incidence and time to ROSC between both groups. Median (IQR) PaCO2 was significantly lower with CCC + HFPV during CC, at ROSC and 15 min post-ROSC-[104 (99-112), 83 (77-99), and 43 (40-64)], respectively compared to 3:1 C:V-[149 (139-167), 153 (143-168), and 153 (138-178) mmHg. PaO2 and cDO2 were higher with CCC + HFPV during CC and at ROSC. PaO2 was similar 15 min post-ROSC with a lower FiO2 in the CCC + HFPV group 0.4 (0.4-0.5) vs. 1 (0.6-1). CONCLUSION In preterm lambs with perinatal cardiac-arrest, continuous chest compressions with HFPV does not improve ROSC but enhances gas exchange and increases cerebral oxygen delivery compared to 3:1 C:V during neonatal resuscitation. IMPACT STATEMENT Ventilation is the most important intervention in newborn resuscitation. Currently recommended 3:1 compression-to-ventilation ratio is associated with hypercarbia and poor oxygen delivery to the brain. Providing uninterrupted continuous chest compressions during high frequency percussive ventilation is feasible in a lamb model of perinatal cardiac arrest, and demonstrates improved gas exchange and oxygen delivery to the brain. This is the first study in premature lambs evaluating high frequency percussive ventilation with asynchronous chest compressions and lays the groundwork for future clinical studies to optimize gas exchange and hemodynamics during chest compressions in newborns.
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Affiliation(s)
- Evan Giusto
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA.
- D-5 Neonatal Units, Patient Care Services, University of California, Davis Health, Sacramento, CA, USA.
| | - Deepika Sankaran
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Amy Lesneski
- Stem Cell Program, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Houssam Joudi
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Morgan Hardie
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Victoria Hammitt
- Stem Cell Program, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Lida Zeinali
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Payam Vali
- Department of Pediatrics, School of Medicine, University of California, Davis, Sacramento, CA, USA
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5
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Sett A, Rogerson SR, Foo GWC, Keene J, Thomas N, Kee PPL, Zayegh A, Donath SM, Tingay DG, Davis PG, Manley BJ. Estimating Preterm Lung Volume: A Comparison of Lung Ultrasound, Chest Radiography, and Oxygenation. J Pediatr 2023; 259:113437. [PMID: 37088185 DOI: 10.1016/j.jpeds.2023.113437] [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: 02/20/2023] [Revised: 03/25/2023] [Accepted: 03/31/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE To determine the relationship between lung ultrasound (LUS) examination, chest radiograph (CXR), and radiographic and clinical evaluations in the assessment of lung volume in preterm infants. STUDY DESIGN In this prospective cohort study LUS was performed before CXR on 70 preterm infants and graded using (1) a LUS score, (2) an atelectasis score, and (3) measurement of atelectasis depth. Radiographic diaphragm position and radio-opacification were used to determine global and regional radiographic atelectasis. The relationship between LUS, CXR, and oxygenation was assessed using receiver operator characteristic and correlation analysis. RESULTS LUS scores, atelectasis scores, and atelectasis depth did not correspond with radiographic global atelectasis (area under receiver operator characteristics curves, 0.54 [95% CI, 0.36-0.71], 0.49 [95% CI, 0.34-0.64], and 0.47 [95% CI, 0.31-0.64], respectively). Radiographic atelectasis of the right upper, right lower, left upper, and left lower quadrants was predicted by LUS scores (0.75 [95% CI, 0.59-0.92], 0.75 [95% CI, 0.62-0.89], 0.69 [95% CI, 0.56-0.82], and 0.63 [95% CI, 0.508-0.751]) and atelectasis depth (0.66 [95% CI, 0.54-0.78], 0.65 [95% CI, 0.53-0.77], 0.63 [95% CI, 0.50-0.76], and 0.56 [95% CI, 0.44-0.70]). LUS findings were moderately correlated with oxygen saturation index (ρ = 0.52 [95% CI, 0.30-0.70]) and saturation to fraction of inspired oxygen ratio (ρ = -0.63 [95% CI, -0.76 to -0.46]). The correlation between radiographic diaphragm position, the oxygenation saturation index, and peripheral oxygen saturation to fraction of inspired oxygen ratio was very weak (ρ = 0.36 [95% CI, 0.11-0.59] and ρ = -0.32 [95% CI, -0.53 to -0.07], respectively). CONCLUSIONS LUS assessment of lung volume does not correspond with radiographic diaphragm position preterm infants. However, LUS predicted radiographic regional atelectasis and correlated with oxygenation. The relationship between radiographic diaphragm position and oxygenation was very weak. Although LUS may not replace all radiographic measures of lung volume, LUS more accurately reflects respiratory status in preterm infants. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12621001119886.
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Affiliation(s)
- Arun Sett
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Victoria, Australia; Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Melbourne, Australia.
| | - Sheryle R Rogerson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Melbourne, Australia
| | - Gillian W C Foo
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, Australia
| | - Jacqui Keene
- Department of Radiology, The Royal Women's Hospital, Melbourne, Australia
| | - Niranjan Thomas
- Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Penny P L Kee
- Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, Australia; Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Melbourne, Australia
| | - Amir Zayegh
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Susan M Donath
- Murdoch Children's Research Institute, Victoria, Australia
| | - David G Tingay
- Murdoch Children's Research Institute, Victoria, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Department of Neonatology, Royal Children's Hospital, Melbourne, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Victoria, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
| | - Brett J Manley
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Australia; Murdoch Children's Research Institute, Victoria, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia
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6
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Chen M, Xu Y, Guo X, Sun B. Efficacy of perinatal pharmacotherapeutic actions for survival of very preterm newborn rabbits at 26-day gestation. J Appl Physiol (1985) 2023; 134:558-568. [PMID: 36701481 DOI: 10.1152/japplphysiol.00606.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/28/2022] [Accepted: 01/23/2023] [Indexed: 01/27/2023] Open
Abstract
Investigation of the pathophysiology of lung impairment and protection in very preterm neonates at birth requires adequate experimental models. This study aimed to elucidate the efficacy and mechanism of perinatal pharmacotherapeutic action in postnatal survival of very preterm rabbits. Pregnant New Zealand White rabbits on 25-day gestation (term 31 days) were given dexamethasone (D), or sham injection as control (C), and cesarean delivered 24 hours later on day 26. Newborns were anesthetized, intratracheally intubated, randomly received either saline or porcine surfactant (S), allocated to four groups (C, S, D, and DS), and ventilated with low tidal volume. Under the identical protocol, another four groups were added with nitric oxide (N) inhalation (CN, SN, DN, and DSN). Survival length, lung mechanics, histopathology, and pathobiology of lung tissue were measured for benefits and injury patterns. DSN had the longest median survival time (ST50, 10.3 h), whereas C had the shortest (3.5 h), with remaining groups in-between. The survival was mainly benefited by S, when additive effects with D and/or N were discernible, by improved lung mechanics and alveolar aeration, ameliorated lung injury severity and pneumothorax, and augmented lung phospholipid pools, with DSN being the most optimal. Variable mRNA expression profiles of alveolar epithelia-associated cytokines and inflammatory mediators further characterized injury and response patterns as phenotyping conditioned in pharmacotherapeutic actions. In conclusion, the combined regimens of perinatal medications achieved remarkable survival in very preterm rabbits with lung protective ventilation strategy, offering a unique model in investigation of very preterm birth-associated respiratory physiology and morbidities.NEW & NOTEWORTHY By establishing a very preterm rabbit model with 26-day gestation (term 31 days), optimal survival length for 50% of animals in groups was achieved by comparing regimens of combined antenatal glucocorticoids, postnatal surfactant and inhaled nitric oxide, with a low tidal volume ventilation strategy. The efficacies of pharmacotherapeutic action were associated with significantly improved lung mechanics, ameliorated lung injury and pneumothorax, and enhanced surfactant phospholipid metabolism, along with variable mRNA expression profiles characterizing the response patterns.
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Affiliation(s)
- Meimei Chen
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
| | - Yaling Xu
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
| | - Xiaojing Guo
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
| | - Bo Sun
- Departments of Pediatrics and Neonatology, Children's Hospital of Fudan University, Shanghai, People's Republic of China
- National Children's Medical Center, the Laboratory of Neonatal Diseases, National Commission of Health, Shanghai, People's Republic of China
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7
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Kjellberg M, Sanchez-Crespo A, Jonsson B. First week of life respiratory management and pulmonary ventilation/perfusion matching in infants with bronchopulmonary dysplasia: a retrospective observational study. J Perinatol 2023; 43:317-323. [PMID: 36456603 PMCID: PMC9991908 DOI: 10.1038/s41372-022-01569-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/11/2022] [Accepted: 11/18/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE To investigate the association between early neonatal respiratory management in infants with bronchopulmonary dysplasia (BPD) and the degree of pulmonary ventilation perfusion-matching (V/Q) at term. METHODS 30 preterm infants with a diagnosis of BPD who were initially treated with either controlled mechanical ventilation/continuous positive airway pressure (CMV/CPAP) (n = 14) or high-frequency oscillatory ventilation (HFOV) using a high lung-volume strategy (n = 16) were retrospectively included in this study. All infants underwent pulmonary V/Q single photon emission computed tomography at a median postmenstrual age of 37 weeks. RESULTS Infants treated with HFOV had significantly larger proportion of the lung with matched V/Q as compared to infants treated with CMV/CPAP, median (interquartile range) 60.4% (55.5-66.0%) and 45.8% (37.8-53.1%) respectively (p = 0.01). CONCLUSIONS In infants who needed mechanical ventilation the first week of life and later developed BPD an association was observed between treatment with a HFOV and better pulmonary V/Q matching at near-term age.
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Affiliation(s)
- Malin Kjellberg
- Department of Woman and Child Health, Department of Neonatology, Karolinska Institute, Stockholm, Sweden
| | - Alejandro Sanchez-Crespo
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden. .,Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden.
| | - Baldvin Jonsson
- Department of Woman and Child Health, Department of Neonatology, Karolinska Institute, Stockholm, Sweden
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8
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Sett A, Kenna KR, Sutton RJ, Perkins EJ, Sourial M, Chapman JD, Donath SM, Sasi A, Rogerson SR, Manley BJ, Davis PG, Pereira-Fantini PM, Tingay DG. Lung ultrasound of the dependent lung detects real-time changes in lung volume in the preterm lamb. Arch Dis Child Fetal Neonatal Ed 2023; 108:51-56. [PMID: 35750468 PMCID: PMC9763221 DOI: 10.1136/archdischild-2022-323900] [Citation(s) in RCA: 1] [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: 01/26/2022] [Accepted: 06/03/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Effective lung protective ventilation requires reliable, real-time estimation of lung volume at the bedside. Neonatal clinicians lack a readily available imaging tool for this purpose. OBJECTIVE To determine the ability of lung ultrasound (LUS) of the dependent region to detect real-time changes in lung volume, identify opening and closing pressures of the lung, and detect pulmonary hysteresis. METHODS LUS was performed on preterm lambs (n=20) during in vivo mapping of the pressure-volume relationship of the respiratory system using the super-syringe method. Electrical impedance tomography was used to derive regional lung volumes. Images were blindly graded using an expanded scoring system. The scores were compared with total and regional lung volumes, and differences in LUS scores between pressure increments were calculated. RESULTS Changes in LUS scores correlated moderately with changes in total lung volume (r=0.56, 95% CI 0.47-0.64, p<0.0001) and fairly with right whole (r=0.41, CI 0.30-0.51, p<0.0001), ventral (r=0.39, CI 0.28-0.49, p<0.0001), central (r=0.41, CI 0.31-0.52, p<0.0001) and dorsal (r=0.38, CI 0.27-0.49, p<0.0001) regional lung volumes. The pressure-volume relationship of the lung exhibited hysteresis in all lambs. LUS was able to detect hysteresis in 17 (85%) lambs. The greatest changes in LUS scores occurred at the opening and closing pressures. CONCLUSION LUS was able to detect large changes in total and regional lung volume in real time and correctly identified opening and closing pressures but lacked the precision to detect small changes in lung volume. Further work is needed to improve precision prior to translation to clinical practice.
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Affiliation(s)
- Arun Sett
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia .,Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Newborn Services, Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kelly R Kenna
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Rebecca J Sutton
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Translational Research Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Magdy Sourial
- Translational Research Unit, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jack D Chapman
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan M Donath
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Arun Sasi
- Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Sheryle R Rogerson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia,Paediatric Infant Perinatal Emergency Retrieval, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Brett J Manley
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter G Davis
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Prue M Pereira-Fantini
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia,Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia,Department of Neonatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
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9
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Werther T, Kueng E, Aichhorn L, Pummer L, Goeral K, Berger A, Hermon M, Klebermass-Schrehof K. Regular lung recruitment maneuvers during high-frequency oscillatory ventilation in extremely preterm infants: a randomized controlled trial. BMC Pediatr 2022; 22:710. [PMID: 36503480 PMCID: PMC9743585 DOI: 10.1186/s12887-022-03780-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Lung recruitment maneuvers (LRMs) improve lung volume at initiation of high-frequency oscillatory ventilation (HFOV), but it is unclear when to repeat LRMs. We evaluated the efficiency of scheduled LRMs. METHODS In a randomized controlled trial, extremely preterm infants on HFOV received either LRMs at 12-hour intervals and when clinically indicated (intervention) or only when clinically indicated (control). The primary outcome was the cumulative oxygen saturation index (OSI) over HFOV time, limited to 7 days. Additionally, LRMs were analyzed with respect to OSI improvement. RESULTS Fifteen infants were included in each group. The mean (SD) postmenstrual age and weight at HFOV start were 23 + 6 (0 + 5) weeks and 650 (115) g in the intervention group and 24 + 4 (0 + 6) weeks (p = 0.03) and 615 (95) g (p = 0.38) in the control group. The mean (SD) cumulative OSI amounted to 4.95 (1.72) in the intervention versus 5.30 (2.08) in the control group (p = 0.61). The mean (SD) number of LRMs in 12 h was 1.3 (0.2) in the intervention versus 1.1 (0.5) in the control group (p = 0.13). Performing LRM when FiO2 > 0.6 resulted in a mean OSI reduction of 3.6. CONCLUSION Regular versus clinically indicated LRMs were performed with equal frequency in preterm infants during HFOV, and consequently, no difference in lung volume was observed. LRMs seem to be most efficient at high FiO2. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT04289324 (28/02/2020).
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Affiliation(s)
- Tobias Werther
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Erik Kueng
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Lukas Aichhorn
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Linda Pummer
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katharina Goeral
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Angelika Berger
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Michael Hermon
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katrin Klebermass-Schrehof
- grid.22937.3d0000 0000 9259 8492Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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10
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Tang B, Ling Q, Yang Q, Li M, Shi W, Wu Q. How to survive a periviable birth baby with birth weight of 450g: A case report. Medicine (Baltimore) 2022; 101:e31356. [PMID: 36281089 PMCID: PMC9592289 DOI: 10.1097/md.0000000000031356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
RATIONALE An increasing number of periviable birth newborns (PVBs) have emerged with concurrent growing high-risk pregnancy. To date, postnatal management of PVBs remains one of the most challenging issues and limited studies have been reported. PATIENT CONCERNS A female baby born at 230/7 weeks of gestation with birth weight of 450g. DIAGNOSIS PVB baby, respiratory distress syndrome (RDS), ventilator associated pneumonia (VAP), intraventricular hemorrhage (IVH), metabolic bone disease of prematurity (MBDP), transient hypothyroxinemia of prematurity (THOP), bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP). INTERVENTIONS Individualized treatment and intensive care, including neonatal resuscitation, effective respiratory and circulatory support, venous access and nutrition, prevention and treatment of infection, management of endocrine and metabolic problems, individualized nursing such as developmental supportive care, integrated oral motor interventions, skin care, family-integrated-care, etc were performed according to existing literature. OUTCOMES The baby was discharged home after 138 days of hospitalization with body weight of 2700 g, a full oral feed achieved, and without any requirement of respiratory support or oxygen supply. Now she is 38-month-old, with no significant long-term adverse sequelae. LESSONS Our case expands the experience and knowledges of individualized and intensive management of PVB babies in their early life days, which increase PVBs' survival and improves their prognosis.
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Affiliation(s)
- Binzhi Tang
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Qiying Ling
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Qian Yang
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Maojun Li
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Wei Shi
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
| | - Qing Wu
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- Department of Pediatrics, Clinical College of University of Electronic Science and Technology of China, Chengdu, Sichuan Province, China
- *Correspondence: Qing Wu, Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, No. 32 West Second Section First Ring Road, Chengdu 610072, Sichuan Province, China (e-mail: )
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11
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Norman M, Jonsson B, Wallström L, Sindelar R. Respiratory support of infants born at 22-24 weeks of gestational age. Semin Fetal Neonatal Med 2022; 27:101328. [PMID: 35400604 DOI: 10.1016/j.siny.2022.101328] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lung immaturity and acute respiratory failure are the major problems in the care of extremely preterm infants. Most infants with gestational age (GA) 22-24 weeks will need mechanical ventilation and many will depend on some type of respiratory support, invasive and non-invasive for extended periods. There is ongoing gap in knowledge regarding optimal respiratory support and applying strategies that are effective in more mature populations is not easy or even suitable because lung maturation differs in smaller infants. Better strategies on how to avoid lung damage and to promote growth and development of the immature lung are warranted since increased survival is accompanied by increasing rates of bronchopulmonary dysplasia and concerns over long-standing reductions in lung function. This review focuses on some aspects of respiratory care of infants born at 22-24 weeks of GA.
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Affiliation(s)
- Mikael Norman
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden; Department of Neonatal Medicine, S3:03 Norrbacka, Karolinska University Hospital, SE-171 76, Stockholm, Sweden.
| | - Baldvin Jonsson
- Department of Neonatal Medicine, S3:03 Norrbacka, Karolinska University Hospital, SE-171 76, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Linda Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Pediatrics, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
| | - Richard Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Department of Pediatrics, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
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12
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Abstract
Mechanical ventilation can be life-saving for the premature infant, but is often injurious to immature and underdeveloped lungs. Lung injury is caused by atelectrauma, oxygen toxicity, and volutrauma. Lung protection must include appropriate lung recruitment starting in the delivery suite and throughout mechanical ventilation. Strategies include open lung ventilation, positive end-expiratory pressure, and volume-targeted ventilation. Respiratory function monitoring, such as capnography and ventilator graphics, provides clinicians with continuous real-time information and an adjunct to optimize lung-protective ventilatory strategies. Further research is needed to assess which lung-protective strategies result in a decrease in long-term respiratory morbidity.
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13
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Lung Deposition of Surfactant Delivered via a Dedicated Laryngeal Mask Airway in Piglets. Pharmaceutics 2021; 13:pharmaceutics13111858. [PMID: 34834273 PMCID: PMC8621675 DOI: 10.3390/pharmaceutics13111858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/20/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
It is unknown if the lung deposition of surfactant administered via a catheter placed through a laryngeal mask airway (LMA) is equivalent to that obtained by bolus instillation through an endotracheal tube. We compare the lung deposition of surfactant delivered via two types of LMA with the standard technique of endotracheal instillation. 25 newborn piglets on continuous positive airway pressure support (CPAP) were randomized into three groups: 1—LMA-camera (integrated camera and catheter channel; catheter tip below vocal cords), 2—LMA-standard (no camera, no channel; catheter tip above the glottis), 3—InSurE (Intubation, Surfactant administration, Extubation; catheter tip below end of endotracheal tube). All animals received 100 mg·kg−1 of poractant alfa mixed with 99mTechnetium-nanocolloid. Surfactant deposition was measured by gamma scintigraphy as a percentage of the administered dose. The median (range) total lung surfactant deposition was 68% (10–85), 41% (5–88), and 88% (67–92) in LMA-camera, LMA-standard, and InSurE, respectively, which was higher (p < 0.05) in the latter. The deposition in the stomach and nasopharynx was higher with the LMA-standard. The surfactant deposition via an LMA was lower than that obtained with InSurE. Although not statistically significant, introducing the catheter below the vocal cords under visual control with an integrated camera improved surfactant LMA delivery by 65%.
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14
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Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Clinicians have little guidance on the time needed before assessing the effect of a mean airway pressure change during high-frequency oscillatory ventilation. We aimed to determine: 1) time to stable lung volume after a mean airway pressure change during high-frequency oscillatory ventilation and 2) the relationship between time to volume stability and the volume state of the lung. DESIGN: Prospective observational study. SETTING: Regional quaternary teaching hospital neonatal ICU. PATIENTS: Thirteen term or near-term infants receiving high-frequency oscillatory ventilation and muscle relaxants. INTERVENTIONS: One to two cm H2O mean airway pressure changes every 10 minutes as part of an open lung strategy based on oxygen response. MEASUREMENTS AND MAIN RESULTS: Continuous lung volume measurements (respiratory inductive plethysmography) were made during the mean airway pressure changes. Volume signals were analyzed with a biexponential model to calculate the time to stable lung volume if the model R2 was greater than 0.6. If volume stability did not occur within 10 minutes, the model was extrapolated to maximum 3,600 s. One-hundred ninety-six mean airway pressure changes were made, with no volume change in 33 occurrences (17%). One-hundred twenty-five volume signals met modeling criteria for inclusion; median (interquartile range) R2, 0.96 (0.91–0.98). The time to stable lung volume was 1,131 seconds (718–1,959 s) (mean airway pressure increases) and 647 seconds (439–1,309 s) (mean airway pressure decreases), with only 17 (14%) occurring within 10 minutes and time to stability being longer when the lung was atelectatic. CONCLUSIONS: During high-frequency oscillatory ventilation, the time to stable lung volume after a mean airway pressure change is variable, often requires more than 10 minutes, and is dependent on the preceding volume state.
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15
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Li HX, Gao CJ, Cheng S, Mao ZL, Wang HY. Risk factors for respiratory assistance in premature infants. Exp Ther Med 2021; 21:237. [PMID: 33603845 PMCID: PMC7851612 DOI: 10.3892/etm.2021.9668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 12/10/2020] [Indexed: 11/06/2022] Open
Abstract
Premature infants are prone to dyspnea after birth due to immature development, and some infants require respiratory assistance. However, the risk factors for respiratory assistance in premature infants are rarely reported. The present study enrolled 3,394 premature infants (665 infants had been provided with respiratory assistance and 2,729 had not used respiratory assistance) to retrospectively analyze the risk factors associated with respiratory aid. The multivariate logistic regression analysis demonstrated that placental abnormality [odds ratio (OR)=1.284; P=0.048], the male sex (OR=0.696; P=0.001), delivery via cesarean section (OR=1.538; P<0.001), low 1-min Apgar score (OR=0.727; P<0.001), low birth weight (OR=0.999; P=0.005) and low gestational age (OR=0.616; P<0.001) were independent risk factors for respiratory assistance in premature infants. Overall, a number of risk factors, including placental abnormality, cesarean section, low 1-min Apgar score, low birth weight and small gestational age, were identified for respiratory assistance in premature infants. By conducting a risk assessment of risk factors at birth and using this information to provide timely respiratory assistance, the survival rates of premature infants may increase.
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Affiliation(s)
- Hai-Xin Li
- Department of Child Healthcare, Changzhou Women and Children Health Care Hospital, Changzhou, Jiangsu 213000, P.R. China
| | - Cai-Jie Gao
- Department of Infectious Disease, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
| | - Shan Cheng
- Department of Infectious Disease, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu 210008, P.R. China
| | - Zhi-Lei Mao
- Department of Child Healthcare, Changzhou Women and Children Health Care Hospital, Changzhou, Jiangsu 213000, P.R. China
| | - Huai-Yan Wang
- Department of Child Healthcare, Changzhou Women and Children Health Care Hospital, Changzhou, Jiangsu 213000, P.R. China
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16
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Özkan H, Arsan S, Shi Y. Editorial: Respiratory Management of Extremely Preterm Infants. Front Pediatr 2021; 9:756819. [PMID: 34604145 PMCID: PMC8485023 DOI: 10.3389/fped.2021.756819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hasan Özkan
- Department of Neonatology, Dokuz Eylül University, Izmir, Turkey
| | - Saadet Arsan
- Department of Neonatology, Ankara University, Ankara, Turkey
| | - Yuan Shi
- Department of Neonatology, Chongqing Medical University, Chongqing, China
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17
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Synchronized Inflations Generate Greater Gravity-Dependent Lung Ventilation in Neonates. J Pediatr 2021; 228:24-30.e10. [PMID: 32827530 DOI: 10.1016/j.jpeds.2020.08.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/05/2020] [Accepted: 08/14/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe the regional distribution patterns of tidal ventilation within the lung during mechanical ventilation that is synchronous or asynchronous with an infant's own breathing effort. STUDY DESIGN Intubated infants receiving synchronized mechanical ventilation at The Royal Children's Hospital neonatal intensive care unit were studied. During four 10-minute periods of routine care, regional distribution of tidal volume (VT; electrical impedance tomography), delivered pressure, and airway flow (Florian Respiratory Monitor) were measured for every inflation. Post hoc, each inflation was then classified as synchronous or asynchronous from video data of the ventilator screen, and the distribution of absolute VT and delivered ventilation characteristics determined. RESULTS In total, 2749 inflations (2462 synchronous) were analyzed in 19 infants; mean (SD) age 28 (30) days, gestational age 35 (5) weeks. Synchronous inflations were associated with a shorter respiratory cycle (P = .004) and more homogenous VT (center of ventilation) along the right (0%) to left (100%) lung plane; 45.3 (8.6)% vs 48.8 (9.4)% (uniform ventilation 46%). The gravity-dependent center of ventilation was a mean (95% CI) 2.1 (-0.5, 4.6)% toward the dependent lung during synchronous inflations. Tidal ventilation relative to anatomical lung size was more homogenous during synchronized inflations in the dependent lung. CONCLUSIONS Synchronous mechanical ventilator lung inflations generate more gravity-dependent lung ventilation and more uniform right-to-left ventilation than asynchronous inflations.
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18
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Chakkarapani AA, Adappa R, Mohammad Ali SK, Gupta S, Soni NB, Chicoine L, Hummler HD. "Current concepts in assisted mechanical ventilation in the neonate" - Part 2: Understanding various modes of mechanical ventilation and recommendations for individualized disease-based approach in neonates. Int J Pediatr Adolesc Med 2020; 7:201-208. [PMID: 33319021 PMCID: PMC7729247 DOI: 10.1016/j.ijpam.2020.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 06/12/2023]
Abstract
Mechanical ventilation is a lifesaving intervention in critically ill preterm and term neonates. However, it has the potential to cause significant damage to the lungs resulting in long-term complications. Understanding the pathophysiological process and having a good grasp of the basic concepts of conventional and high-frequency ventilation is essential for any medical or allied healthcare practitioner involved in the neonates' respiratory management. This review aims to describe the various types and modes of ventilation usually available in neonatal units. It also describes recommendations of an individualized disease-based approach to mechanical ventilation strategies implemented in the authors' institutions.
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Affiliation(s)
- Aravanan Anbu Chakkarapani
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Roshan Adappa
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
| | | | - Samir Gupta
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
- Durham University, United Kingdom
| | - Naharmal B. Soni
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
| | - Louis Chicoine
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
| | - Helmut D. Hummler
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
- University of Ulm, Germany
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19
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Management of Tracheoesophageal Fistula Repair With Cardiac Dextroposition and Right Lung Agenesis: A Case Report. A A Pract 2020; 14:e01255. [PMID: 32633924 DOI: 10.1213/xaa.0000000000001255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tracheoesophageal fistulae (TEF) commonly occur as part of the vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula, renal, and limb abnormalities (VACTERL) association. However, pulmonary agenesis is not typically seen with TEF. We report the anesthetic management of a TEF repair in a 33-week-old, 1.6-kg, monochorionic diamniotic twin with right lung agenesis, intrauterine growth restriction, and cardiac dextroposition. Due to the unique position of the heart, the patient periodically lost complete cardiac output during the exposure and repair of the esophagus.
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20
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Yang MJ, Fenton S, Russell K, Yost CC, Yoder BA. Left-sided congenital diaphragmatic hernia: can we improve survival while decreasing ECMO? J Perinatol 2020; 40:935-942. [PMID: 32066841 DOI: 10.1038/s41372-020-0615-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/21/2020] [Accepted: 02/04/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND Mortality and ECMO rates for congenital diaphragmatic hernia (CDH) remain ~30%. In 2016, we changed our CDH guidelines to minimize stimulation while relying on preductal oxygen saturation, lower mean airway pressures, stricter criteria for nitric oxide (iNO), and inotrope use. We compared rates of ECMO, survival, and survival without ECMO between the two epochs. DESIGN/METHODS Retrospective review of left-sided CDH neonates at the University of Utah/Primary Children's Hospital NICUs during pre (2003-2015, n = 163) and post (2016-2019, n = 53) epochs was conducted. Regression analysis controlled for defect size and intra-thoracic liver. RESULTS Following guideline changes, we identified a decrease in ECMO (37 to 13%; p = 0.001) and an increase in survival without ECMO (53 to 79%, p = 0.0001). Overall survival increased from 74 to 89% (p = 0.035). CONCLUSION(S) CDH management guideline changes focusing on minimizing stimulation, using preductal saturation and less aggressive ventilator/inotrope support were associated with decreased ECMO use and improved survival.
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Affiliation(s)
- Michelle J Yang
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA.
| | - Stephen Fenton
- Division of Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Katie Russell
- Division of Pediatric Surgery, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Christian Con Yost
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
| | - Bradley A Yoder
- Division of Neonatology, University of Utah School of Medicine and Primary Children's Hospital, Intermountain Health, Salt Lake City, UT, USA
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21
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Glaser K, Speer CP, Wright CJ. Fine Tuning Non-invasive Respiratory Support to Prevent Lung Injury in the Extremely Premature Infant. Front Pediatr 2020; 7:544. [PMID: 31998672 PMCID: PMC6966957 DOI: 10.3389/fped.2019.00544] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/13/2019] [Indexed: 12/31/2022] Open
Abstract
Within the last decades, therapeutic advances, such as antenatal corticosteroids, surfactant replacement, monitored administration of supplemental oxygen, and sophisticated ventilatory support have significantly improved the survival of extremely premature infants. In contrast, the incidence of some neonatal morbidities has not declined. Rates of bronchopulmonary dysplasia (BPD) remain high and have prompted neonatologists to seek effective strategies of non-invasive respiratory support in high risk infants in order to avoid harmful effects associated with invasive mechanical ventilation. There has been a stepwise replacement of invasive mechanical ventilation by early continuous positive airway pressure (CPAP) as the preferred strategy for initial stabilization and for early respiratory support of the premature infant and management of respiratory distress syndrome. However, the vast majority of high risk babies are mechanically ventilated at least once during their NICU stay. Adjunctive therapies aiming at the prevention of CPAP failure and the support of functional residual capacity have been introduced into clinical practice, including alternative techniques of administering surfactant as well as non-invasive ventilation approaches. In contrast, the strategy of applying sustained lung inflations in the delivery room has recently been abandoned due to evidence of higher rates of death within the first 48 h of life.
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Affiliation(s)
- Kirsten Glaser
- University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Christian P. Speer
- University Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
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22
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Han T, Liu H, Zhang H, Guo M, Zhang X, Duan Y, Sun F, Liu X, Zhang X, Zhang M, Liu F, Bao L, Xiao M, Liu W, Jiang R, Zheng J, Tian X, Gao Q, Zhang W, Guo W, Li L, Tong X. Minimally Invasive Surfactant Administration for the Treatment of Neonatal Respiratory Distress Syndrome: A Multicenter Randomized Study in China. Front Pediatr 2020; 8:182. [PMID: 32457854 PMCID: PMC7221055 DOI: 10.3389/fped.2020.00182] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Background/Aims: Nasal continuous positive airway pressure (nCPAP) was recommended as the initial respiratory support for spontaneous breathing in infants with very low birth weight and neonatal respiratory distress syndrome (NRDS). Less invasive surfactant administration (LISA) and minimally invasive surfactant therapy (MIST) have been reported to reduce the incidence of bronchopulmonary dysplasia (BPD). This study aimed to explore the applicability of minimally invasive surfactant administration (MISA) in China. Materials and Methods: MISA was a randomized controlled study conducted at eight level III neonatal intensive care units (NICUs) in China. Spontaneously breathing infants born at 25+0 to 31+6 weeks' gestation who progressively developed respiratory distress during the first 6 h after birth were randomly assigned to receive MISA or endotracheal intubation surfactant administration (EISA). The primary outcome was the difference in the morbidity of BPD between two groups of infants with MISA and EISA at 36 weeks corrected gestational age. Results: Demographic and clinical characteristics of the 151 infants in the MISA group were similar to the 147 infants in the EISA group. The comparison showed no clear benefits in the MISA group in the incidence of BPD, while infants from the EISA group had higher rates of patent ductus arteriosus (PDA) (60.5 vs. 41.1%, p = 0.001). The duration of surfactant infusion and the total time of surfactant administration in the MISA group were significantly longer than in the EISA group. A slightly increased heart rate was noted 1 h post surfactant administration in the EISA group. In subgroup analysis, the comparison of 51 smaller (<30 weeks) preterm infants, named MISAs (n = 31) and EISAs (n = 20), showed a significant reduction of BPD (29.0 vs. 70.0%, p = 0.004) and PDA (29.0 vs. 65.0%, p = 0.011). In the subgroup analysis of blood gas, arterial oxygen saturation (SaO2) value at 1 and 12 h and partial pressure of arterial oxygen (PaO2) at 12 h were all higher in the EISA group compared to the MISA group. Conclusion: MISA had no clear benefit on the incidence of BPD, but it was related to a reduction in PDA. It is an appropriate therapy for spontaneous breathing in infants with extremely low birth weight and NRDS.
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Affiliation(s)
- Tongyan Han
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Huiqiang Liu
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Hui Zhang
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
| | - Ming Guo
- Department of Neonatology, Fifth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Xuefeng Zhang
- Department of Neonatology, Fifth Medical Center, General Hospital of the Chinese People's Liberation Army, Beijing, China
| | - Yang Duan
- Department of Neonatology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Fuqiang Sun
- Department of Neonatology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xinjian Liu
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, China
| | - Xiang Zhang
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, China
| | - Mingtao Zhang
- Department of Neonatology, Hebei PetroChina Central Hospital, Langfang, China
| | - Fang Liu
- Department of Neonatology, Bethune International Peace Hospital, Shijiazhuang, China
| | - Lisha Bao
- Department of Neonatology, Bethune International Peace Hospital, Shijiazhuang, China
| | - Min Xiao
- Department of Neonatology, Cangzhou Central Hospital of Hebei Province, Cangzhou, China
| | - Weili Liu
- Department of Neonatology, Cangzhou Central Hospital of Hebei Province, Cangzhou, China
| | - Rui Jiang
- Department of Neonatology, Cangzhou Central Hospital of Hebei Province, Cangzhou, China
| | - Jun Zheng
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Xiuying Tian
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Qi Gao
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Wanxian Zhang
- Department of Neonatology, Tianjin Central Hospital of Obstetrics and Gynecology, Tianjing, China
| | - Wei Guo
- Department of Neonatology, Xingtai People's Hospital, Xingtai, China
| | - Ling Li
- Department of Neonatology, Xingtai People's Hospital, Xingtai, China
| | - Xiaomei Tong
- Department of Pediatrics, Peking University Third Hospital, Beijing, China
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Ventilation strategies in transition from neonatal respiratory distress to chronic lung disease. Semin Fetal Neonatal Med 2019; 24:101035. [PMID: 31759915 DOI: 10.1016/j.siny.2019.101035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the advance in neonatal care over the past few decades, preventing preterm infants with respiratory distress syndrome progress to bronchopulmonary dysplasia remained challenging. In this review, we will discuss the respiratory support strategies in preterm infants with RDS evolving into BPD based on the changes in pulmonary mechanics and pathophysiology as well as currently available evidence.
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24
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Petrillo F, Gizzi C, Maffei G, Matassa PG, Ventura ML, Ricci C, Pastorino R, Vento G. Neonatal respiratory support strategies for the management of extremely low gestational age infants: an Italian survey. Ital J Pediatr 2019; 45:44. [PMID: 30971298 PMCID: PMC6458627 DOI: 10.1186/s13052-019-0639-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/29/2019] [Indexed: 11/20/2022] Open
Abstract
Background We aimed to survey Delivery Room and Neonatal Intensive Care Unit (NICU) respiratory strategies dedicated to the extremely low gestational age newborn (ELGAN – GA < 28 wks) in Italy. Methods A questionnaire was sent to 113 Italian level III centres. A lead physician and a nurse with expertise in mechanical ventilation (MV) were identified in each unit to answer. Information about those aspects of ventilatory support considered by center’s staff as needing improvement was also collected. Results A 100% response rate was obtained. In the Delivery Room, sustained lung inflation was performed in 74.8% of centres, and 89.2% used NCPAP. For ELGANs who need invasive MV, conventional MV was the most used strategy. Volume-targeted ventilation and High-frequency oscillatory ventilation (HFOV) were considered as primary mode in < 30% of centres. Among non-invasive strategies, NCPAP was the most utilized, followed by BiPAP, High-flow nasal cannula and nasal intermittent positive pressure ventilation. Nurses more commonly recorded in the nursing charts the ventilator’s setting parameters rather than measured ones. HFOV and non-invasive ventilation were the most quoted aspects of neonatal ventilation felt as to be improved. Conclusion The routine respiratory support practices in Italy showed marked variations among units. Focused interventions are largely required to improve clinical practice.
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Affiliation(s)
| | - Camilla Gizzi
- Azienda Ospedaliera Regionale "San Carlo", Potenza, Italy
| | - Gianfranco Maffei
- Division of Neonatology, Azienda Ospedaliero-Universitaria "Ospedali Riuniti di Foggia", Foggia, Italy
| | - Piero G Matassa
- Department of Clinical Sciences and Community Health, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Università degli Studi di Milano, Milan, Italy
| | | | - Cinzia Ricci
- Department of Woman and Child Health and Public Health, Division of Neonatology, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Roberta Pastorino
- Section of Hygiene, Institute of Public Health - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Vento
- Department of Woman and Child Health and Public Health, Division of Neonatology, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy.
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25
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Oakley RB, Tingay DG, McCall KE, Perkins EJ, Sourial M, Dargaville PA, Pereira-Fantini PM. Gestational Age Influences the Early Microarchitectural Changes in Response to Mechanical Ventilation in the Preterm Lamb Lung. Front Pediatr 2019; 7:325. [PMID: 31497582 PMCID: PMC6712425 DOI: 10.3389/fped.2019.00325] [Citation(s) in RCA: 5] [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: 04/01/2019] [Accepted: 07/19/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Preterm birth is associated with abnormal lung architecture, and a reduction in pulmonary function related to the degree of prematurity. A thorough understanding of the impact of gestational age on lung microarchitecture requires reproducible quantitative analysis of lung structure abnormalities. The objectives of this study were (1) to use quantitative histological software (ImageJ) to map morphological patterns of injury resulting from delivery of an identical ventilation strategy to the lung at varying gestational ages and (2) to identify associations between gestational age-specific morphological alterations and key functional outcomes. Method: Lung morphology was compared after 60 min of a standardized ventilation protocol (40 cm H2O sustained inflation and then volume-targeted positive pressure ventilation with positive end-expiratory pressure 8 cm H2O) in lambs at different gestations (119, 124, 128, 133, 140d) representing the spectrum of premature developmental lung states and the term lung. Age-matched controls were compared at 124 and 128d gestation. Automated and manual functions of Image J were used to measure key histological features. Correlation analysis compared morphological and functional outcomes in lambs aged ≤128 and >128d. Results: In initial studies, unventilated lung was indistinguishable at 124 and 128d. Ventilated lung from lambs aged 124d gestation exhibited increased numbers of detached epithelial cells and lung tissue compared with 128d lambs. Comparing results from saccular to alveolar development (120-140d), lambs aged ≤124d exhibited increased lung tissue, average alveolar area, and increased numbers of detached epithelial cells. Alveolar septal width was increased in lambs aged ≤128d. These findings were mirrored in the measures of gas exchange, lung mechanics, and molecular markers of lung injury. Correlation analysis confirmed the gestation-specific relationships between the histological assessments and functional measures in ventilated lambs at gestation ≤128 vs. >128d. Conclusion: Image J allowed rapid, quantitative assessment of alveolar morphology, and lung injury in the preterm lamb model. Gestational age-specific patterns of injury in response to delivery of an identical ventilation strategy were identified, with 128d being a transition point for associations between morphological alterations and functional outcomes. These results further support the need to develop individualized respiratory support approaches tailored to both the gestational age of the infant and their underlying injury response.
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Affiliation(s)
- Regina B Oakley
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - David G Tingay
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Neonatology, Royal Children's Hospital, Parkville, VIC, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Karen E McCall
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,School of Medicine and Medicinal Sciences, University College Dublin, Dublin, Ireland
| | - Elizabeth J Perkins
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Magdy Sourial
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Prue M Pereira-Fantini
- Neonatal Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia.,Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
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26
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Burstal RJ, Threlfo SJ. Delivery of sevoflurane using a neonatal ventilator. Paediatr Anaesth 2018; 28:774-779. [PMID: 30004609 DOI: 10.1111/pan.13447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Most anesthetic ventilators are designed to cope with a wide range of patient sizes and may lack precision at the lowest end of the minute volume scale. Neonatal intensive care ventilators on the other hand are designed specifically for this patient group, but are not able to deliver volatile anesthesia. AIMS We aimed to adapt the neonatal ventilator currently in use in our institution to deliver sevoflurane by incorporating a vaporizer and a scavenging system. METHODS We used a Diamedica draw-over vaporizer incorporated into the ventilator circuit and a custom designed open interface scavenging system. A number of safety measures are described to ensure that this equipment is correctly inserted into the circuit. RESULTS Bench testing revealed that the vaporizer output is linear and stable within the circuit flow range 4-8 L/min in all modes except high frequency oscillation where concentrations are not predictable. The scavenging system was found to be effective and did not affect volumes, pressures or waveforms when ventilating a test lung over a wide range of flows and pressures. This remained the case over the full range of scavenger flow adjustment. CONCLUSION The addition of a Diamedica vaporizer to a Fabian neonatal ventilator was shown in bench testing to provide stable, linear vapor concentrations without compromise of ventilator function. The system should not be used in high frequency oscillation mode because concentrations will exceed those expected and will not maintain a linear relationship with the vaporizer setting.
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Affiliation(s)
- Richard J Burstal
- Department of Anaesthesia, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Steven J Threlfo
- Department of Anaesthesia, John Hunter Hospital, Newcastle, New South Wales, Australia
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27
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Pereira-Fantini PM, Byars SG, McCall KE, Perkins EJ, Oakley RB, Dellacà RL, Dargaville PA, Davis PG, Ignjatovic V, Tingay DG. Plasma proteomics reveals gestational age-specific responses to mechanical ventilation and identifies the mechanistic pathways that initiate preterm lung injury. Sci Rep 2018; 8:12616. [PMID: 30135517 PMCID: PMC6105628 DOI: 10.1038/s41598-018-30868-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 08/02/2018] [Indexed: 12/15/2022] Open
Abstract
The preterm lung is particularly vulnerable to ventilator-induced lung injury (VILI) as a result of mechanical ventilation. However the developmental and pathological cellular mechanisms influencing the changing patterns of VILI have not been comprehensively delineated, preventing the advancement of targeted lung protective therapies. This study aimed to use SWATH-MS to comprehensively map the plasma proteome alterations associated with the initiation of VILI following 60 minutes of standardized mechanical ventilation from birth in three distinctly different developmental lung states; the extremely preterm, preterm and term lung using the ventilated lamb model. Across these gestations, 34 proteins were differentially altered in matched plasma samples taken at birth and 60 minutes. Multivariate analysis of the plasma proteomes confirmed a gestation-specific response to mechanical ventilation with 79% of differentially-expressed proteins altered in a single gestation group only. Six cellular and molecular functions and two physiological functions were uniquely enriched in either the extremely preterm or preterm group. Correlation analysis supported gestation-specific protein-function associations within each group. In identifying the gestation-specific proteome and functional responses to ventilation we provide the founding evidence required for the potential development of individualized respiratory support approaches tailored to both the developmental and pathological state of the lung.
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Affiliation(s)
- Prue M Pereira-Fantini
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia. .,Department of Paediatrics, University of Melbourne, Parkville, Australia.
| | - Sean G Byars
- Department of Pathology, University of Melbourne, Parkville, Australia.,Centre for Systems Genomics, University of Melbourne, Parkville, Australia
| | - Karen E McCall
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia.,University College Dublin, Dublin, Ireland
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia
| | - Regina B Oakley
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia
| | - R L Dellacà
- Laboratorio di Tecnologie Biomediche, Dipartimento di Elettronica, Informazione e Ingegneria Biomedica-DEIB, Politecnico di Milano University, Milano, Italy
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Peter G Davis
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia.,The Royal Women's Hospital, Parkville, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Australia
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Parkville, Australia.,Haematology Research, Murdoch Childrens Research Institute, Parkville, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Australia.,Department of Neonatology, Royal Children's Hospital, Parkville, Australia
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Farrell O, Perkins EJ, Black D, Miedema M, Paul JD, Pereira-Fantini PM, Tingay DG. Volume guaranteed? Accuracy of a volume-targeted ventilation mode in infants. Arch Dis Child Fetal Neonatal Ed 2018; 103:F120-F125. [PMID: 28659362 DOI: 10.1136/archdischild-2017-312640] [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: 01/05/2017] [Revised: 04/28/2017] [Accepted: 05/01/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Volume-targeted ventilation (VTV) is widely used and may reduce lung injury, but this assumes the clinically set tidal volume (VTset) is accurately delivered. This prospective observational study aimed to determine the relationship between VTset, expiratory VT (VTe) and endotracheal tube leak in a modern neonatal -volume-targeted ventilator (VTV) and the resultant partial arterial pressure of carbon dioxide (PaCO2) relationship with and without VTV. DESIGN Continuous inflations were recorded for 24 hours in 100 infants, mean (SD) 34 (4) weeks gestation and 2483 (985) g birth weight, receiving synchronised mechanical ventilation (SLE5000, SLE, UK) with or without VTV and either the manufacturer's V4 (n=50) or newer V5 (n=50) VTV algorithm. The VTset, VTe and leak were determined for each inflation (maximum 90 000/infant). If PaCO2 was sampled (maximum of 2 per infant), this was compared with the average VTe data from the preceding 15 min. RESULTS A total of 7 497 137 inflations were analysed. With VTV enabled (77 infants), the VTset-VTe bias (95% CI) was 0.03 (-0.12 to 0.19) mL/kg, with a median of 80% of VTe being ±1.0 mL/kg of VTset. Endotracheal tube leak up to 30% influenced VTset-VTe bias with the V4 (r2=-0.64, p<0.0001; linear regression) but not V5 algorithm (r2=0.04, p=0.21). There was an inverse linear relationship between VTe and PaCO2 without VTV (r2=0.26, p=0.004), but not with VTV (r2=0.04, p=0.10), and less PaCO2 within 40-60 mm Hg, 53% versus 72%, relative risk (95% CI) 1.7 (1.0 to 2.9). CONCLUSION VTV was accurate and reliable even with moderate leak and PaCO2 more stable. VTV algorithm differences may exist in other devices.
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Affiliation(s)
- Olivia Farrell
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Don Black
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia
| | - Martijn Miedema
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia.,Neonatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Joel Don Paul
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Prue M Pereira-Fantini
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - David Gerald Tingay
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Neonatology, Royal Children's Hospital, Melbourne, Australia
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29
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Lee SM, Namgung R, Eun HS, Lee SM, Park MS, Park KI. Effective Tidal Volume for Normocapnia in Very-Low-Birth-Weight Infants Using High-Frequency Oscillatory Ventilation. Yonsei Med J 2018; 59:101-106. [PMID: 29214783 PMCID: PMC5725345 DOI: 10.3349/ymj.2018.59.1.101] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/29/2017] [Accepted: 09/30/2017] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Removal of CO₂ is much efficient during high-frequency oscillatory ventilation (HFOV) for preterm infants. However, an optimal carbon dioxide diffusion coefficient (DCO₂) and tidal volume (VT) have not yet been established due to much individual variance. This study aimed to analyze DCO₂ values, VT, and minute volume in very-low-birth-weight (VLBW) infants using HFOV and correlates with plasma CO₂ (pCO₂). MATERIALS AND METHODS Daily respiratory mechanics and ventilator settings from twenty VLBW infants and their two hundred seventeen results of blood gas analysis were collected. Patients were treated with the Dräger Babylog VN500 ventilator (Drägerwerk Ag & Co.) in HFOV mode. The normocapnia was indicated as pCO₂ ranging from 45 mm Hg to 55 mm Hg. RESULTS The measured VT was 1.7 mL/kg, minute volume was 0.7 mL/kg, and DCO₂ was 43.5 mL²/s. Mean results of the blood gas test were as follows: pH, 7.31; pCO₂, 52.6 mm Hg; and SpO₂, 90.5%. In normocapnic state, the mean VT was significantly higher than in hypercapnic state (2.1±0.5 mL/kg vs. 1.6±0.3 mL/kg), and the mean DCO₂ showed significant difference (68.4±32.7 mL²/s vs. 32.4±15.7 mL²/s). The DCO₂ was significantly correlated with the pCO₂ (p=0.024). In the receiver operating curve analysis, the estimated optimal cut-off point to predict the remaining normocapnic status was a VT of 1.75 mL/kg (sensitivity 73%, specificity 80%). CONCLUSION In VLBW infants treated with HFOV, VT of 1.75 mL/kg is recommended for maintaining proper ventilation.
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Affiliation(s)
- Seul Mi Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ran Namgung
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Ho Sun Eun
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea.
| | - Min Soo Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - Kook In Park
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
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30
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Lista G, Bresesti I, Cavigioli F, Castoldi F, Lupo E, LoMauro A, Aliverti A. Efficacy of lung volume optimization maneuver monitored by optoelectronic pletismography in the management of congenital diaphragmatic hernia. Respir Med Case Rep 2017; 22:133-136. [PMID: 28794965 PMCID: PMC5547244 DOI: 10.1016/j.rmcr.2017.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/30/2022] Open
Abstract
Newborns affected by congenital diaphragmatic hernia (CDH) need cardio-respiratory stabilization before undergoing surgical repair. Open lung strategy is a well-established approach to optimize lung volume in preterm infants with Respiratory Distress Syndrome (RDS), using both High Frequency Oscillatory Ventilation (HFOV) and Conventional Mechanical Ventilation (CMV). We report a case of left CDH with severe lung hypoplasia, managed applying open lung strategy in HFOV (pre-surgery period) and in Assist-Control with Volume Guarantee (post-surgery period), guided by SpO2 changes, TcPO2 and TcPCO2 monitoring. Opto-electronic plethysmography was used to measure end-expiratory chest wall volume changes (ΔEEcw) related to lung volume variations occurring during pressure changes. OEP confirmed the efficacy of using SpO2 and transcutaneous gas monitoring during this recruitment maneuver.
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Affiliation(s)
- G Lista
- Division of Neonatology, "V.Buzzi Children's Hospital" - ASST FBF-Sacco, Milan, Italy
| | - I Bresesti
- Division of Neonatology, "V.Buzzi Children's Hospital" - ASST FBF-Sacco, Milan, Italy
| | - F Cavigioli
- Division of Neonatology, "V.Buzzi Children's Hospital" - ASST FBF-Sacco, Milan, Italy
| | - F Castoldi
- Division of Neonatology, "V.Buzzi Children's Hospital" - ASST FBF-Sacco, Milan, Italy
| | - E Lupo
- Division of Neonatology, "V.Buzzi Children's Hospital" - ASST FBF-Sacco, Milan, Italy
| | - A LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - A Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
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Bhatia R, Davis PG, Tingay DG. Regional Volume Characteristics of the Preterm Infant Receiving First Intention Continuous Positive Airway Pressure. J Pediatr 2017; 187:80-88.e2. [PMID: 28545875 DOI: 10.1016/j.jpeds.2017.04.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/27/2017] [Accepted: 04/21/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine whether applying nasal continuous positive airway pressure (CPAP) using systematic changes in continuous distending pressure (CDP) results in a quasi-static pressure-volume relationship in very preterm infants receiving first intention CPAP in the first 12-18 hours of life. STUDY DESIGN Twenty infants at <32 weeks' gestation with mild respiratory distress syndrome (RDS) managed exclusively with nasal CPAP had CDP increased from 5 to 8 to 10 cmH2O, and then decreased to 8 cmH2O and returned to baseline CDP. Each CDP was maintained for 20 min. At each CDP, relative impedance change in end-expiratory thoracic volume (ΔZEEV) and tidal volume (ΔZVT) were measured using electrical impedance tomography. Esophageal pressure (Poes) was measured as a proxy for intrapleural pressure to determine transpulmonary pressure (Ptp). RESULTS Overall, there was a relationship between Ptp and global ΔZEEV representing the pressure-volume relationship in the lungs. There were regional variations in ΔZEEV, with 13 infants exhibiting hysteresis with the greatest gains in EEV and tidal volume in the dependent lung with no hemodynamic compromise. Seven infants did not demonstrate hysteresis during decremental CDP changes. CONCLUSION It was possible to define a pressure-volume relationship of the lung and demonstrate reversal of atelectasis by systematically manipulating CDP in most very preterm infants with mild RDS. This suggests that CDP manipulation can be used to optimize the volume state of the preterm lung.
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Affiliation(s)
- Risha Bhatia
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Neonatal Research, Murdoch Childrens Research Institute, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, Australia.
| | - Peter G Davis
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Neonatal Research, Murdoch Childrens Research Institute, Melbourne, Australia; The University of Melbourne, Melbourne, Australia
| | - David G Tingay
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Neonatal Research, Murdoch Childrens Research Institute, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; Department of Neonatology, The Royal Children's Hospital, Melbourne, Australia
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Reiterer F, Schwaberger B, Freidl T, Schmölzer G, Pichler G, Urlesberger B. Lung-protective ventilatory strategies in intubated preterm neonates with RDS. Paediatr Respir Rev 2017; 23:89-96. [PMID: 27876355 DOI: 10.1016/j.prrv.2016.10.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 10/20/2016] [Indexed: 11/16/2022]
Abstract
This article provides a narrative review of lung-protective ventilatory strategies (LPVS) in intubated preterm infants with RDS. A description of strategies is followed by results on short-and long-term respiratory and neurodevelopmental outcomes. Strategies will include patient-triggered or synchronized ventilation, volume targeted ventilation, the technique of intubation, surfactant administration and rapid extubation to NCPAP (INSURE), the open lung concept, strategies of high-frequency ventilation, and permissive hypercapnia. Based on this review single recommendations on optimal LPVS cannot be made. Combinations of several strategies, individually applied, most probably minimize or avoid potential serious respiratory and cerebral complications like bronchopulmonary dysplasia and cerebral palsy.
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Affiliation(s)
- F Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria.
| | - B Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - T Freidl
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - G Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, Canada; Department of Pediatrics, University of Alberta, Edmonton, Canada
| | - G Pichler
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
| | - B Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescence Medicine, Medical University Graz, Austria
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Abouzeid T, Perkins EJ, Pereira-Fantini PM, Rajapaksa A, Suka A, Tingay DG. Tidal Volume Delivery during the Anesthetic Management of Neonates Is Variable. J Pediatr 2017; 184:51-56.e3. [PMID: 28410092 DOI: 10.1016/j.jpeds.2017.01.074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 01/03/2017] [Accepted: 01/31/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To describe expiratory tidal volume (VT) during routine anesthetic management of neonates at a single tertiary neonatal surgical center, as well as the proportion of VT values within the range of 4.0-8.0 mL/kg. STUDY DESIGN A total of 26 neonates needing surgery under general anesthesia were studied, of whom 18 were intubated postoperatively. VT was measured continuously during normal clinical care using a dedicated neonatal respiratory function monitor (RFM), with clinicians blinded to values. VT, pressure, and cardiorespiratory variables were recorded regularly while intubated intraoperatively, during postoperative transport, and for 15 minutes after returning to the neonatal intensive care unit (NICU). In addition, paired VT values from the anesthetic machine were documented intraoperatively. RESULTS A total of 2597 VT measures were recorded from 26 neonates. Intraoperative and postoperative transport expiratory VT values were highly variable compared with the NICU VT (P < .0001, Kruskal-Wallis test), with 51% of inflations outside the 4.0-8.0 mL/kg range (35% and 38% of VT >8.0 mL/kg, respectively), compared with 29% in the NICU (P < .001, χ2 test). The use of a flow-inflating bag resulted in a median (range) VT of 8.5 mL/kg (range, 5.3-11.4 mL/kg) vs 5.6 ml/kg (range, 4.3-7.9 mL/kg) using a Neopuff T-piece system (P < .0001, Mann-Whitney U test). The mean anesthetic machine expiratory VT was 3.2 mL/kg (95% CI, -4.5 to 10.8 mL/kg) above RFM. CONCLUSIONS VT is highly variable during the anesthetic care of neonates, and potentially injurious VT is frequently delivered; thus, we suggest close VT monitoring using a dedicated neonatal RFM.
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Affiliation(s)
- Thanaa Abouzeid
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia
| | | | - Anushi Rajapaksa
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Australia
| | - Asha Suka
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Australia
| | - David G Tingay
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Australia; Neonatology, The Royal Children's Hospital, Parkville, Australia.
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Mohammad S, Gravenstein N, Gonsalves D, Vasilopoulos T, Lampotang S. Higher Fresh Gas Flow Rates Decrease Tidal Volume During Pressure Control Ventilation. Anesth Analg 2017; 124:1506-1511. [PMID: 28333703 PMCID: PMC6774243 DOI: 10.1213/ane.0000000000001944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We observed that increasing fresh gas flow (FGF) decreased exhaled tidal volume (VT) during pressure control ventilation (PCV). A literature search produced no such description whereby unintended VT changes occur with FGF changes during PCV. METHODS To model an infant's lungs, 1 lung of a mechanical lung model (Dual Adult TTL 1600; Michigan Instruments, Inc, Grand Rapids, MI) was set at a compliance of 0.0068 L/cm H2O. An Rp50 resistor (27.2 cm H2O/L/s at 15 L/min) simulated normal bronchial resistance. The simulated lung was connected to a pediatric breathing circuit via a 3.5-mm cuffed endotracheal tube. A ventilator with PCV capability (Model 7900; Aestiva, GE Healthcare, Madison, WI) measured exhaled VT, and a flow monitor (NICO; Respironics, Murraysville, PA) measured peak inspiratory flow, positive end-expiratory pressure (PEEP), and peak inspiratory pressure. In PCV mode, exhaled VT displayed by the ventilator at FGF rates of 1, 6, 10, and 15 L/min was manually recorded across multiple ventilator settings. This protocol was repeated for the Avance CS2 anesthesia machine (GE Healthcare). RESULTS For the Aestiva, higher FGF rates in PCV mode decreased exhaled VT. Exhaled VT for FGFs of 1, 6, 10, and 15 L/min were on average 48, 34.9, 16.5, and 10 mL, respectively, at ventilator settings of inspiratory pressure of 10 cm H2O, PEEP of 0 cm H2O, and respiratory rate of 20 breaths/min. This is a decrease by up to 27%, 65.6%, and 79.2% when FGFs of 6, 10, and 15 L/min are compared with a FGF of 1 L/min, respectively. In the GE Avance CS2 at the same ventilator settings, VT for FGF rates of 1, 6, 10, and 15 L/min were on average 46, 43, 40.4, and 39.7 mL, respectively. The FGF effect on VT was not as pronounced with the GE Avance CS2 as with the GE Aestiva. CONCLUSIONS FGF has a significant effect on VT during PCV in the Aestiva bellows ventilator, suggesting caution when changing FGF during PCV in infants. Our hypothesis is that at higher FGF rates, an inadvertent PEEP is developed by the flow resistance of the ventilator relief valve that is not recognized by the ventilator. In turn, less change in pressure is needed to reach the set inspiratory pressure, resulting in lower VT delivery at higher FGF rates. This underappreciated FGF-VT interaction during PCV with a bellows ventilator may be clinically significant in pediatric patients; prospective data collection in patients is needed for further evaluation.
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Affiliation(s)
- Shazia Mohammad
- From the *Department of Anesthesiology, University of Florida, Gainesville, Florida; †Center for Safety, Simulation & Advanced Learning Technologies, University of Florida, Gainesville, Florida; ‡Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, Florida; and §Clinical & Translational Science Institute Simulation Core, UF Health Shands Experiential Learning Center, University of Florida, Gainesville, Florida
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Abstract
OBJECTIVE Mechanically ventilated neonates have been observed to receive substantially different ventilation after switching ventilator models, despite identical ventilator settings. This study aims at establishing the range of output variability among 10 neonatal ventilators under various breathing conditions. DESIGN Relative benchmarking test of 10 neonatal ventilators on an active neonatal lung model. SETTING Neonatal ICU. SUBJECTS Ten current neonatal ventilators. INTERVENTIONS Ventilators were set identically to flow-triggered, synchronized, volume-targeted, pressure-controlled, continuous mandatory ventilation and connected to a neonatal lung model. The latter was configured to simulate three patients (500, 1,500, and 3,500 g) in three breathing modes each (passive breathing, constant active breathing, and variable active breathing). MEASUREMENTS AND MAIN RESULTS Averaged across all weight conditions, the included ventilators delivered between 86% and 110% of the target tidal volume in the passive mode, between 88% and 126% during constant active breathing, and between 86% and 120% under variable active breathing. The largest relative deviation occurred during the 500 g constant active condition, where the highest output machine produced 147% of the tidal volume of the lowest output machine. CONCLUSIONS All machines deviate significantly in volume output and ventilation regulation. These differences depend on ventilation type, respiratory force, and patient behavior, preventing the creation of a simple conversion table between ventilator models. Universal neonatal tidal volume targets for mechanical ventilation cannot be transferred from one ventilator to another without considering necessary adjustments.
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Wright CJ, Kirpalani H. When should we start continuous positive airway pressure in the delivery room and how high should we go? Acta Paediatr 2016; 105:868-70. [PMID: 27383516 DOI: 10.1111/apa.13459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO, USA.
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics The Children's Hospital of Philadelphia and the University of Pennsylvania, Philadelphia, PA, USA
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Wright CJ, Polin RA, Kirpalani H. Continuous Positive Airway Pressure to Prevent Neonatal Lung Injury: How Did We Get Here, and How Do We Improve? J Pediatr 2016; 173:17-24.e2. [PMID: 27025910 DOI: 10.1016/j.jpeds.2016.02.059] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/25/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Richard A Polin
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia at the University of Pennsylvania, Philadelphia, PA
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Tingay DG, Rajapaksa A, McCall K, Zonneveld CEE, Black D, Perkins E, Sourial M, Lavizzari A, Davis PG. The interrelationship of recruitment maneuver at birth, antenatal steroids, and exogenous surfactant on compliance and oxygenation in preterm lambs. Pediatr Res 2016; 79:916-21. [PMID: 26866905 DOI: 10.1038/pr.2016.25] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/07/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND To describe the interrelationship between antenatal steroids, exogenous surfactant, and two approaches to lung recruitment at birth on oxygenation and respiratory system compliance (Cdyn) in preterm lambs. METHODS Lambs (n = 63; gestational age 127 ± 1 d) received either surfactant at 10-min life (Surfactant), antenatal corticosteroids (Steroid), or neither (Control). Within each epoch lambs were randomly assigned to a 30-s 40 cmH2O sustained inflation (SI) or an initial stepwise positive end-expiratory pressure (PEEP) open lung ventilation (OLV) maneuver at birth. All lambs then received the same management for 60-min with alveolar-arterial oxygen difference (AaDO2) and Cdyn measured at regular time points. RESULTS Overall, the OLV strategy improved Cdyn and AaDO2 (all epochs except Surfactant) compared to SI (all P < 0.05; two-way ANOVA). Irrespective of strategy, Cdyn was better in the Steroid group in the first 10 min (all P < 0.05). Thereafter, Cdyn was similar to Steroid epoch in the OLV + Surfactant, but not SI + Surfactant group. OLV influenced the effect of steroid and surfactant (P = 0.005) on AaDO2 more than SI (P = 0.235). CONCLUSIONS The antenatal state of the lung influences the type and impact of a recruitment maneuver at birth. The effectiveness of surfactant maybe enhanced using PEEP-based time-dependent recruitment strategies rather than approaches solely aimed at initial lung liquid clearance.
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Affiliation(s)
- David G Tingay
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Neonatology, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Neonatal Research Group, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Anushi Rajapaksa
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Karen McCall
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Cornelis E E Zonneveld
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Don Black
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Elizabeth Perkins
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Magdy Sourial
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Neonatology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Anna Lavizzari
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università degli Studi di Milano, Milano, Italy
| | - Peter G Davis
- Neonatal Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Neonatal Research Group, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
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Ferrando C, Belda FJ. The Effects of Flow Waveform on Oxygenation in Pediatric Patients. Anesth Analg 2015; 121:1111. [PMID: 26378708 DOI: 10.1213/ane.0000000000000821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Carlos Ferrando
- Anesthesiology and Critical Care Department, Hospital Clinico Universitario of Valencia, Valencia, Spain Anesthesiology and Critical Care Department, Hospital Clinico Universitario of Valencia, Valencia, Spain; and, Department of Surgery, University of Valencia, Valencia, Spain,
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Bang SR. Neonatal anesthesia: how we manage our most vulnerable patients. Korean J Anesthesiol 2015; 68:434-41. [PMID: 26495052 PMCID: PMC4610921 DOI: 10.4097/kjae.2015.68.5.434] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 07/31/2015] [Accepted: 08/18/2015] [Indexed: 12/12/2022] Open
Abstract
Neonates undergoing surgery are at higher risk than older children for anesthesia-related adverse events. During the perioperative period, the maintenance of optimal hemodynamics in these patients is challenging and requires a thorough understanding of neonatal physiology and pharmacology. Data from animals and human cohort studies have shown relation of the currently used anesthetics may associate with neurotoxic brain injury that lead to later neurodevelopmental impairment in the developing brain. In this review, the unique neonatal physiologic and pharmacologic features and anesthesia-related neurotoxicity will be discussed.
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Affiliation(s)
- Si Ra Bang
- Department of Anesthesiology and Pain Medicine, Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea
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de Waal K, Kluckow M. Prolonged rupture of membranes and pulmonary hypoplasia in very preterm infants: pathophysiology and guided treatment. J Pediatr 2015; 166:1113-20. [PMID: 25681201 DOI: 10.1016/j.jpeds.2015.01.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 11/19/2014] [Accepted: 01/06/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Koert de Waal
- Department of Newborn Care, John Hunter Children's Hospital & University of Newcastle, NSW, Australia.
| | - Martin Kluckow
- Department of Neonatology, Royal North Shore Hospital & University of Sydney, NSW, Australia
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Gibson AM, Doyle LW. Respiratory outcomes for the tiniest or most immature infants. Semin Fetal Neonatal Med 2014; 19:105-11. [PMID: 24239022 DOI: 10.1016/j.siny.2013.10.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Extremely low birth weight (<1000 g birth weight) or extremely preterm (<28 weeks of gestation) infants are surviving in greater numbers as neonatal care advances. Many of these survivors, especially those who develop bronchopulmonary dysplasia, have more respiratory ill health in the first years after discharge home, reduced respiratory function and impaired exercise capacity throughout childhood and into adulthood compared with term-born controls. It is important to establish the long-term respiratory outcomes for the tiniest or most immature survivors as they grow older, since they may contribute disproportionately to rates of chronic obstructive pulmonary disease and respiratory ill-health in adulthood.
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Affiliation(s)
- Anne-Marie Gibson
- Respiratory Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Lex W Doyle
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.
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Hillman NH, Kemp MW, Noble PB, Kallapur SG, Jobe AH. Sustained inflation at birth did not protect preterm fetal sheep from lung injury. Am J Physiol Lung Cell Mol Physiol 2013; 305:L446-53. [PMID: 23873843 DOI: 10.1152/ajplung.00162.2013] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Sustained lung inflations (SI) at birth may recruit functional residual capacity (FRC). Clinically, SI increase oxygenation and decrease need for intubation in preterm infants. We tested whether a SI to recruit FRC would decrease lung injury from subsequent ventilation of fetal, preterm lambs. The preterm fetus (128±1 day gestation) was exteriorized from the uterus, a tracheostomy was performed, and fetal lung fluid was removed. While maintaining placental circulation, fetuses were randomized to one of four 15-min interventions: 1) positive end-expiratory pressure (PEEP) 8 cmH2O (n=4), 2) 20 s SI to 50 cmH2O then PEEP 8 cmH2O (n=10), 3) mechanical ventilation at tidal volume (VT) 7 ml/kg (n=13), or 4) 20 s SI then ventilation at VT 7 ml/kg (n=13). Lambs were ventilated with 95% N2/5% CO2 and PEEP 8 cmH2O. Volume recruitment was measured during SI, and fetal tissues were collected after an additional 30 min on placental support. SI achieved a mean FRC recruitment of 15 ml/kg (range 8-27). Fifty percent of final FRC was achieved by 2 s, 65% by 5 s, and 90% by 15 s, demonstrating prolonged SI times are needed to recruit FRC. SI alone released acute-phase proteins into the fetal lung fluid and increased mRNA expression of proinflammatory cytokines and acute-phase response genes in the lung. Mechanical ventilation further increased all markers of lung injury. SI before ventilation, regardless of the volume of FRC recruited, did not alter the acute-phase and proinflammatory responses to mechanical ventilation at birth.
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Affiliation(s)
- Noah H Hillman
- Saint Louis Univ., Cardinal Glennon-Neonatology, 1100 South Grand, Saint Louis, MO 63104.
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