1
|
Keszler M, Abubakar MK. Volume-targeted ventilation. Semin Perinatol 2024; 48:151886. [PMID: 38553330 DOI: 10.1016/j.semperi.2024.151886] [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] [Indexed: 04/14/2024]
Abstract
Despite strong evidence of important benefits of volume-targeted ventilation, many high-risk extremely preterm infants continue to receive traditional pressure-controlled ventilation in the United States and elesewhere. Reluctance to abandon one's comfort zone, lack of suitable equipment and a lack of understanding of the subtleties of volume-targeted ventilation appear to contribute to the relatively slow uptake of volume-targeted ventilation. This review will underscore the benefits of using tidal volume as the primary control variable, to improve clinicians' understanding of the way volume-targeted ventilation interacts with the awake, breathing infant and to provide information about evidence-based tidal volume targets in various circmstances. Focus on underlying lung pathophysiology, individualized ventilator settings and tidal volume targets are essential to successful use of this approach thereby improving important clinical outcomes.
Collapse
Affiliation(s)
- Martin Keszler
- Emeritus Professor of Pediatrics, Alpert Medical School of Brown University, Department of Pediatrics, Women & Infants Hospital of Rhode Island, 101 Dudley Street, Providence RI 02905, USA.
| | - M Kabir Abubakar
- Professor of Clinical Pediatrics, Georgetown University School of Medicine, Chief of Neonatology, MedStar Medical Group, Chief, Division of Neonatal Perinal Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington DC, 20007, USA.
| |
Collapse
|
2
|
Sant'Anna G, Shalish W. Weaning from mechanical ventilation and assessment of extubation readiness. Semin Perinatol 2024; 48:151890. [PMID: 38553331 DOI: 10.1016/j.semperi.2024.151890] [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] [Indexed: 04/14/2024]
Abstract
Tremendous advancements in neonatal respiratory care have contributed to the improved survival of extremely preterm infants (gestational age ≤ 28 weeks). While mechanical ventilation is often considered one of the most important breakthroughs in neonatology, it is also associated with numerous short and long-term complications. For those reasons, clinical research has focused on strategies to avoid or reduce exposure to mechanical ventilation. Nonetheless, in the extreme preterm population, 70-100% of infants born 22-28 weeks of gestation are exposed to mechanical ventilation, with nearly 50% being ventilated for ≥ 3 weeks. As contemporary practices have shifted towards selectively reserving mechanical ventilation for those patients, mechanical ventilation weaning and extubation remain a priority yet offer a heightened challenge for clinicians. In this review, we will summarize the evidence for different strategies to expedite weaning and assess extubation readiness in preterm infants, with a particular focus on extremely preterm infants.
Collapse
Affiliation(s)
- Guilherme Sant'Anna
- Professor of Pediatrics, Division of Neonatology, Montreal Children's Hospital Departments of Pediatrics and Experimental Medicine, Senior Scientist of the Research Institute of the McGill University Health Center, McGill University Health Center, 1001 Boulevard Decarie, Room B05.2711, Montreal, Quebec H4A3J1, Canada.
| | - Wissam Shalish
- Assistant Professor of Pediatrics, Division of Neonatology, Montreal Children's Hospital Departments of Pediatrics and Experimental Medicine, Junior Scientist of FRQS, McGill University Health Center, Montreal, Quebec, Canada
| |
Collapse
|
3
|
Travers CP, Carlo WA, Nakhmani A, Laney D, Chahine RA, Aban I, Ambalavanan N. Late permissive hypercapnia and respiratory stability among very preterm infants: a pilot randomised trial. Arch Dis Child Fetal Neonatal Ed 2023; 108:530-534. [PMID: 36914233 PMCID: PMC10578058 DOI: 10.1136/archdischild-2022-325166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVE Determine if targeting higher transcutaneous carbon dioxide improves respiratory stability among very preterm infants on ventilatory support. DESIGN Single-centre pilot randomised clinical trial. SETTING The University of Alabama at Birmingham. PATIENTS Very preterm infants on ventilatory support after postnatal day 7. INTERVENTIONS Infants were randomised to two different transcutaneous carbon dioxide levels targeting 5 mm Hg (0.67 kPa) changes with four sessions each lasting 24 hours for 96 hours: baseline-increase-baseline-increase or baseline-decrease-baseline-decrease. MAIN OUTCOME MEASURES We collected cardiorespiratory data evaluating episodes of intermittent hypoxaemia (oxygen saturations (SpO2)<85% for ≥10 s), bradycardia (<100 bpm for ≥10 s), and cerebral and abdominal hypoxaemia on near-infrared spectroscopy. RESULTS We enrolled 25 infants with a gestational age of 24 w 6 d±11 d (mean±SD) and birth weight 645±142 g on postnatal day 14±3. Continuous transcutaneous carbon dioxide values (56.8±6.9 in the higher group vs 54.5±7.8 in the lower group; p=0.36) did not differ significantly between groups during the intervention days. There were no differences in intermittent hypoxaemia (126±64 vs 105±61 per 24 hours; p=0.30) or bradycardia (11±16 vs 15±23 per hour; p=0.89) episodes between groups. The proportion of time with SpO2<85%, SpO2<80%, cerebral hypoxaemia or abdominal hypoxaemia did not differ (all p>0.05). There was moderate negative correlation between mean transcutaneous carbon dioxide and bradycardia episodes (r=-0.56; p<0.001). CONCLUSION Targeting 5 mm Hg (0.67 kPa) changes in transcutaneous carbon dioxide did not improve respiratory stability among very preterm infants on ventilatory support but the intended carbon dioxide separation was difficult to achieve and maintain. TRIAL REGISTRATION NUMBER NCT03333161.
Collapse
Affiliation(s)
- Colm P Travers
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Waldemar A Carlo
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arie Nakhmani
- Department of Electrical and Computer Engineering, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Deborah Laney
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rouba A Chahine
- Department of Biostatistics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Immaculada Aban
- Department of Biostatistics, The University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | | |
Collapse
|
4
|
Taiorazova GB, Alimbayeva AR, Tanatarov SZ, Smailova ZK. A Modern Look at the Development of Intrauterine Pneumonia in Premature Newborns: Literature Review. Respir Physiol Neurobiol 2023; 314:104073. [PMID: 37178744 DOI: 10.1016/j.resp.2023.104073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/01/2023] [Accepted: 05/09/2023] [Indexed: 05/15/2023]
Abstract
Infectious diseases such as malaria, pneumonia, diarrhea and preventable neonatal diseases are common causes of death in children. Globally, neonatal mortality is 44% (2.9 million) annually, with up to 50% of babies dying within the first day of life. Pneumonia kills between 750000 and 1.2 million infants in the neonatal period each year in developing countries. Premature birth, pneumonia, and labor complications are common causes of neonatal mortality. The objective of the study is to present the general characteristics of congenital pneumonia, vitamin D deficiency and micronutrient deficiencies in premature infants. To date, numerous studies confirm the relationship between the inadequate supply of the body with macro- and microelements and the development of diseases of varying severity, including metabolic disorders. Based on this, primary screening, aimed at identifying metabolic disorders of macro- and microelements and further drug correction, should become the main concept for the management of patients in modern times.
Collapse
Affiliation(s)
- Gulnara B Taiorazova
- Department of Pediatrics and Medical Rehabilitation named after D.M. Tusupova, Semey Medical University, Semey, Republic of Kazakhstan.
| | - Aliya R Alimbayeva
- Department of Pediatrics and Medical Rehabilitation named after D.M. Tusupova, Semey Medical University, Semey, Republic of Kazakhstan
| | - Sayat Z Tanatarov
- Department of Аnesthesiology, Resuscitation and Narcology, Semey Medical University, Semey, Republic of Kazakhstan
| | - Zhanargul K Smailova
- Department of Biochemistry and Chemical Disciplines named after Doctor of Medical Sciences, Professor S.O. Tapbergenov, Semey Medical University, Semey, Republic of Kazakhstan
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Branagan A, Yu I, Gurusamy K, Miletin J. Thresholds for surfactant use in preterm neonates: a network meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022:archdischild-2022-324184. [PMID: 36600484 DOI: 10.1136/archdischild-2022-324184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To perform a network meta-analysis of randomised controlled trials of different surfactant treatment strategies for respiratory distress syndrome (RDS) to assess if a certain fraction of inspired oxygen (FiO2) is optimal for selective surfactant therapy. DESIGN Systematic review and network meta-analysis using Bayesian analysis of randomised trials of prophylactic versus selective surfactant for RDS. SETTING Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Science Citation Index Expanded. PATIENTS Randomised trials including infants under 32 weeks of gestational age. INTERVENTIONS Intratracheal surfactant, irrespective of type or dose. MAIN OUTCOME MEASURES Our primary outcome was neonatal mortality, compared between groups treated with selective surfactant therapy at different thresholds of FiO2. Secondary outcomes included respiratory morbidity and major complications of prematurity. RESULTS Of 4643 identified references, 14 studies involving 5298 participants were included. We found no statistically significant differences between 30%, 40% and 50% FiO2 thresholds. A sensitivity analysis of infants treated in the era of high antenatal steroid use and nasal continuous positive airway pressure as initial mode of respiratory support showed no difference in mortality, RDS or intraventricular haemorrhage alone but suggested an increase in the combined outcome of major morbidities in the 60% threshold. CONCLUSION Our results do not show a clear benefit of surfactant treatment at any threshold of FiO2. The 60% threshold was suggestive of increased morbidity. There was no advantage seen with prophylactic treatment. Randomised trials of different thresholds for surfactant delivery are urgently needed to guide clinicians and provide robust evidence. PROSPERO REGISTRATION NUMBER CRD42020166620.
Collapse
Affiliation(s)
- Aoife Branagan
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland .,Division of Surgery and Interventional Science, UCL, London, UK
| | - Ivan Yu
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,Division of Surgery and Interventional Science, UCL, London, UK
| | - Kurinchi Gurusamy
- Division of Surgery and Interventional Science, UCL, London, UK.,Department of Therapy, I.M. Sechenov First Moscow State Medical University, Moskva, Russian Federation
| | - Jan Miletin
- Paediatric and Newborn Medicine, Coombe Women and Infants University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland.,Institute for the Care of Mother and Child, Prague, Czech Republic.,2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| |
Collapse
|
7
|
Ozawa Y, Miyake F, Isayama T. Efficacy and safety of permissive hypercapnia in preterm infants: A systematic review. Pediatr Pulmonol 2022; 57:2603-2613. [PMID: 35945674 DOI: 10.1002/ppul.26108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 07/07/2022] [Accepted: 08/05/2022] [Indexed: 11/11/2022]
Abstract
CONTEXT In adults, permissive hypercapnia reduces mortality and ventilation duration. However, in preterm infants, the findings from past research regarding the efficacy and safety of permissive hypercapnia are controversial. OBJECTIVE To evaluate the efficacy and safety of permissive hypercapnia versus normocapnia in preterm infants on mechanical ventilation. DATA SOURCES MEDLINE, EMBASE, CENTRAL, and CINAHL STUDY SELECTION: Published randomized controlled trials (RCTs), non-RCTs, interrupted time series, cohort studies, case-control studies, and controlled before-and-after studies were included. DATA EXTRACTION Two reviewers independently screened the title, abstract, and full text, extracted data, assessed the risk of bias, and evaluated certainty of evidence (CoE) according to the Grading of Recommendations Assessment and Development and Evaluation approach. A meta-analysis of RCTs was performed using the random-effects model. RESULTS Four RCTs (693 infants) and one cohort study (371 infants) were included. No significant differences existed between the permissive hypercapnia and normocapnia groups for bronchopulmonary dysplasia (BPD) (risk ratio [RR], 0.94; 95% confidence interval [CI], 0.74-1.18; very low CoE) and a composite outcome of death or BPD (RR, 1.05; 95% CI, 0.90-1.23; very low CoE). Permissive hypercapnia may increase necrotizing enterocolitis (RR, 1.69; 95% CI, 0.98-2.91; very low CoE), but the null or trivial effect cannot be excluded. No significant differences existed between the two groups for any other outcome assessed (very low-to-low CoE). LIMITATIONS The sample sizes were less than the optimal sizes for all outcomes assessed, indicating the need for further trials. CONCLUSIONS Permissive hypercapnia did not have any significant benefit or harm in preterm infants.
Collapse
Affiliation(s)
- Yuri Ozawa
- Division of Pediatrics, Kyorin University, Tokyo, Japan.,Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Fuyu Miyake
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan.,Department of Environmental Epidemiology, Institute of Industrial Ecological Sciences, University of Occupational and Environmental Health, Fukuoka, Japan
| | - Tetsuya Isayama
- Division of Neonatology, Center for Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
8
|
Carbon dioxide levels in neonates: what are safe parameters? Pediatr Res 2022; 91:1049-1056. [PMID: 34230621 PMCID: PMC9122818 DOI: 10.1038/s41390-021-01473-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 02/01/2023]
Abstract
There is no consensus on the optimal pCO2 levels in the newborn. We reviewed the effects of hypercapnia and hypocapnia and existing carbon dioxide thresholds in neonates. A systematic review was conducted in accordance with the PRISMA statement and MOOSE guidelines. Two hundred and ninety-nine studies were screened and 37 studies included. Covidence online software was employed to streamline relevant articles. Hypocapnia was associated with predominantly neurological side effects while hypercapnia was linked with neurological, respiratory and gastrointestinal outcomes and Retinpathy of prematurity (ROP). Permissive hypercapnia did not decrease periventricular leukomalacia (PVL), ROP, hydrocephalus or air leaks. As safe pCO2 ranges were not explicitly concluded in the studies chosen, it was indirectly extrapolated with reference to pCO2 levels that were found to increase the risk of neonatal disease. Although PaCO2 ranges were reported from 2.6 to 8.7 kPa (19.5-64.3 mmHg) in both term and preterm infants, there are little data on the safety of these ranges. For permissive hypercapnia, parameters described for bronchopulmonary dysplasia (BPD; PaCO2 6.0-7.3 kPa: 45.0-54.8 mmHg) and congenital diaphragmatic hernia (CDH; PaCO2 ≤ 8.7 kPa: ≤65.3 mmHg) were identified. Contradictory findings on the effectiveness of permissive hypercapnia highlight the need for further data on appropriate CO2 parameters and correlation with outcomes. IMPACT: There is no consensus on the optimal pCO2 levels in the newborn. There is no consensus on the effectiveness of permissive hypercapnia in neonates. A safe range of pCO2 of 5-7 kPa was inferred following systematic review.
Collapse
|
9
|
Li BH, Zhao CL, Cao SL, Geng HL, Li JJ, Zhu M, Niu SP. Effect of electrode temperature on measurements of transcutaneous carbon dioxide partial pressure and oxygen partial pressure in very low birth weight infants. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:809-813. [PMID: 34511170 DOI: 10.7499/j.issn.1008-8830.2103143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the accuracy and safety of measurements of transcutaneous carbon dioxide partial pressure (TcPCO2) and transcutaneous oxygen partial pressure (TcPO2) at electrode temperatures lower than the value used in clinical practice in very low birth weight infants. METHODS A total of 45 very low birth weight infants were enrolled. TcPCO2 and TcPO2 measurements were performed in these infants. Two transcutaneous monitors were placed simultaneously for each subject. One electrode was set and maintained at 42℃ used in clinical practice for neonates (control group), and the other was successively set at 38℃, 39℃, 40°C, and 41℃ (experimental group). The paired t-test was used to compare the measurement results between the groups. A Pearson correlation analysis was used to analyze the correlation between the measurement results of the experimental group and control group, and between the measurement results of experimental group and arterial blood gas parameters. RESULTS There was no significant difference in TcPCO2 between each experimental subgroup (38-41℃) and the control group. TcPCO2 in each experimental subgroup (38-41℃) was strongly positively correlated with TcPCO2 in the control group (r>0.9, P<0.05) and arterial carbon dioxide partial pressure (r>0.8, P<0.05). There were significant differences in TcPO2 between each experimental subgroup (38-41℃) and the control group (P<0.05), but TcPO2 in each experimental subgroup (38-41℃) was positively correlated with TcPO2 in the control group (r=0.493-0.574, P<0.05) and arterial oxygen partial pressure (r=0.324-0.399, P<0.05). No skin injury occurred during transcutaneous measurements at all electrode temperatures. CONCLUSIONS Lower electrode temperatures (38-41℃) can accurately measure blood carbon dioxide partial pressure in very low birth weight infants, and thus can be used to replace the electrode temperature of 42°C. Transcutaneous measurements at the lower electrode temperatures may be helpful for understanding the changing trend of blood oxygen partial pressure.
Collapse
Affiliation(s)
- Bing-Hui Li
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Chang-Liang Zhao
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Shun-Li Cao
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Hong-Li Geng
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Jing-Jing Li
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Min Zhu
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| | - Shi-Ping Niu
- Department of Neonatology, Zibo Maternal and Child Health Hospital, Zibo, Shandong 255000, China
| |
Collapse
|
10
|
Implementing Volume-targeted Ventilation to Decrease Hypocarbia in Extremely Low Birth Weight Infants during the First Week of Life: A Quality Improvement Project. Pediatr Qual Saf 2021; 6:e398. [PMID: 33977188 PMCID: PMC8104191 DOI: 10.1097/pq9.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 10/22/2020] [Indexed: 11/27/2022] Open
Abstract
Hypocarbia in neonates increases the risk of poor neurodevelopmental outcomes. Volume-targeted ventilation (VTV) is associated with decreased hypocarbia and other respiratory morbidities. We noticed a high incidence of hypocarbia in extremely low birth weight (ELBW; <1,000 g) neonates in our Neonatal Intensive Care Unit. Thus, we undertook a quality improvement project to decrease the incidence of hypocarbia (the occurrence of PCO2 < 35 mm Hg) in ELBW neonates during the first week of life by 50% over 1 year. Methods Our major interventions were employing VTV as the primary mode of mechanical ventilation in neonates less than 28 weeks of gestation or ELBW at birth and increasing staff knowledge regarding hypocarbia. The baseline period spanned May-August 2016. We implemented the interventions in October 2016 and tracked the use of VTV and the incidence of hypocarbia during the first week of life for 12 months. Results We analyzed data on 28 and 77 patients in the baseline and postintervention periods, respectively. The use of VTV increased from 39% to 65%. However, the incidence of hypocarbia was not reduced (57% preintervention vs. 64% postintervention). In the postintervention cohort, the incidence of hypocarbia was comparable between VTV and other modes (60% vs. 70%; 95% confidence interval: -32%, 12%; P = 0.367), but we noted decreased blood gas sampling and earlier extubation in the VTV group (P = 0.002 and P = 0.046, respectively). Conclusions Successfully increasing VTV in our Neonatal Intensive Care Unit did not decrease hypocarbia during the first week of life. However, we observed the safety of VTV and obtained other desirable results.
Collapse
|
11
|
Gibbs K, Jensen EA, Alexiou S, Munson D, Zhang H. Ventilation Strategies in Severe Bronchopulmonary Dysplasia. Neoreviews 2021; 21:e226-e237. [PMID: 32238485 DOI: 10.1542/neo.21-4-e226] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is an acquired, developmental chronic lung disease that is a consequence of premature birth. In the most severe form of the disease, infants may require prolonged periods of positive pressure ventilation. BPD is a heterogeneous disease with lung mechanics that differ from those in respiratory distress syndrome; strategies to manage the respiratory support in infants with severe BPD should take this into consideration. When caring for these infants, practitioners need to shift from the acute care ventilation strategies that use frequent blood gases and support adjustments designed to minimize exposure to positive pressure. Infants with severe BPD benefit from a chronic care model that uses less frequent ventilator adjustments and provides the level of positive support that will achieve the longer-term goal of ongoing lung growth and repair.
Collapse
Affiliation(s)
| | | | - Stamatia Alexiou
- Pulmonology, Department of Pediatrics, Children's Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | |
Collapse
|
12
|
Sullivan KP, White HO, Grover LE, Negron JJ, Lee AF, Rhein LM. Transcutaneous carbon dioxide pattern and trend over time in preterm infants. Pediatr Res 2021; 90:840-846. [PMID: 33469188 PMCID: PMC7814526 DOI: 10.1038/s41390-020-01308-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 10/08/2020] [Accepted: 10/29/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Chronic lung disease remains a burden for extremely preterm infants. The changes in ventilation over time and optimal ventilatory management remains unknown. Newer, non-invasive technologies provide insight into these patterns. METHODS This single-center prospective cohort study enrolled infants ≤32 0/7 weeks. We obtained epochs of transcutaneous carbon dioxide (TcCO2) measurements twice each week to describe the pattern of hypercarbia throughout their hospitalization. RESULTS Patterns of hypercarbia varied based on birth gestational age and post-menstrual age (PMA) (p = 0.03), regardless of respiratory support. Infants receiving the most respiratory support had values 16-21 mmHg higher than those on room air (p < 0.001). Infants born at the youngest gestational ages had the greatest total change but the rate of change was slower (p = 0.049) compared to infants born at later gestational ages. All infants had TcCO2 values stabilize by 31-33 weeks PMA, when values were not significantly different compared to discharge. No rebound was observed when infants weaned off invasive support. CONCLUSIONS Hypercarbia improves as infants approached 31-33 weeks PMA. Hypercarbia was the highest in the most immature infants and improved with age and growth despite weaning respiratory support. IMPACT This study describes the evolution of hypercarbia as very preterm infants grow and develop. The pattern of ventilation is significantly different depending on the gestational age at birth and post-menstrual age. Average transcutaneous carbon dioxide (TCO2) decreased over time as infants became more mature despite weaning respiratory support. This improvement was most significant in infants born at the lowest gestational ages.
Collapse
Affiliation(s)
- Katherine P. Sullivan
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Heather O. White
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Lindsay E. Grover
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Jordi J. Negron
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA
| | - Austin F. Lee
- grid.168645.80000 0001 0742 0364Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA USA ,grid.32224.350000 0004 0386 9924Department of Surgery, Massachusetts General Hospital, Worcester, MA USA
| | - Lawrence M. Rhein
- grid.168645.80000 0001 0742 0364Department of Neonatology, University of Massachusetts Medical School, Worcester, MA USA ,grid.168645.80000 0001 0742 0364Department of Pediatric Pulmonary Medicine, University of Massachusetts Medical School, Worcester, MA USA
| |
Collapse
|
13
|
Rantakari K, Rinta-Koski OP, Metsäranta M, Hollmén J, Särkkä S, Rahkonen P, Lano A, Lauronen L, Nevalainen P, Leskinen MJ, Andersson S. Early oxygen levels contribute to brain injury in extremely preterm infants. Pediatr Res 2021; 90:131-139. [PMID: 33753894 PMCID: PMC7984503 DOI: 10.1038/s41390-021-01460-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extremely low gestational age newborns (ELGANs) are at risk of neurodevelopmental impairments that may originate in early NICU care. We hypothesized that early oxygen saturations (SpO2), arterial pO2 levels, and supplemental oxygen (FiO2) would associate with later neuroanatomic changes. METHODS SpO2, arterial blood gases, and FiO2 from 73 ELGANs (GA 26.4 ± 1.2; BW 867 ± 179 g) during the first 3 postnatal days were correlated with later white matter injury (WM, MRI, n = 69), secondary cortical somatosensory processing in magnetoencephalography (MEG-SII, n = 39), Hempel neurological examination (n = 66), and developmental quotients of Griffiths Mental Developmental Scales (GMDS, n = 58). RESULTS The ELGANs with later WM abnormalities exhibited lower SpO2 and pO2 levels, and higher FiO2 need during the first 3 days than those with normal WM. They also had higher pCO2 values. The infants with abnormal MEG-SII showed opposite findings, i.e., displayed higher SpO2 and pO2 levels and lower FiO2 need, than those with better outcomes. Severe WM changes and abnormal MEG-SII were correlated with adverse neurodevelopment. CONCLUSIONS Low oxygen levels and high FiO2 need during the NICU care associate with WM abnormalities, whereas higher oxygen levels correlate with abnormal MEG-SII. The results may indicate certain brain structures being more vulnerable to hypoxia and others to hyperoxia, thus emphasizing the role of strict saturation targets. IMPACT This study indicates that both abnormally low and high oxygen levels during early NICU care are harmful for later neurodevelopmental outcomes in preterm neonates. Specific brain structures seem to be vulnerable to low and others to high oxygen levels. The findings may have clinical implications as oxygen is one of the most common therapies given in NICUs. The results emphasize the role of strict saturation targets during the early postnatal period in preterm infants.
Collapse
Affiliation(s)
- Krista Rantakari
- Children's Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Olli-Pekka Rinta-Koski
- grid.5373.20000000108389418Department of Computer Science, Aalto University School of Science, Espoo, Finland
| | - Marjo Metsäranta
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jaakko Hollmén
- grid.5373.20000000108389418Department of Computer Science, Aalto University School of Science, Espoo, Finland ,grid.10548.380000 0004 1936 9377Department of Computer and Systems Sciences, Stockholm University, Stockholm, Sweden
| | - Simo Särkkä
- grid.5373.20000000108389418Department of Computer Science, Aalto University School of Science, Espoo, Finland
| | - Petri Rahkonen
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Aulikki Lano
- grid.7737.40000 0004 0410 2071Pediatric Neurology, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Leena Lauronen
- grid.7737.40000 0004 0410 2071Clinical Neurophysiology, HUS Medical Imaging Center, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Päivi Nevalainen
- grid.7737.40000 0004 0410 2071Clinical Neurophysiology, HUS Medical Imaging Center, Children’s Hospital, Helsinki University Hospital, University of Helsinki, Helsinki, Finland ,grid.7737.40000 0004 0410 2071BioMag Laboratory, HUS Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Markus J. Leskinen
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Sture Andersson
- grid.7737.40000 0004 0410 2071Children’s Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| |
Collapse
|
14
|
Foligno S, De Luca D. Porcine versus bovine surfactant therapy for RDS in preterm neonates: pragmatic meta-analysis and review of physiopathological plausibility of the effects on extra-pulmonary outcomes. Respir Res 2020; 21:8. [PMID: 31910825 PMCID: PMC6947871 DOI: 10.1186/s12931-019-1267-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 12/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND While porcine seems to be superior to bovine surfactants in terms of respiratory outcomes, it is unclear if a surfactant can improve extra-pulmonary outcomes in preterm neonates with respiratory distress syndrome and if there is any physiopathological/biological mechanism linking surfactant therapy to these outcomes. We aim to fill these knowledge gaps. METHODS Systematic and pragmatic review coupled with meta-analysis of randomized controlled trials of bovine or porcine surfactants administered to treat RDS in preterm neonates; common extra-pulmonary neonatal intensive care outcomes were considered. As additional analysis, animal or human translational studies about mechanisms linking surfactant replacement to extra-pulmonary neonatal outcomes were also systematically reviewed. RESULTS Porcine surfactant is associated with lower incidence of patent ductus arteriosus (OR:0.655; 95%CI:0.460-0.931); p = 0.018; 12 trials; 1472 patients); prenatal steroids (coeff.:-0.009, 95%CI:-0.03-0.009, p = 0.323) and gestational age (coeff.:0.079, 95%CI:-0.18-0.34, p = 0.554) did not influence this effect size. No significant differences were found between porcine and bovine surfactants on neonatal intensive care unit length of stay (mean difference (days):-2.977; 95%CI:-6.659-0.705; p = 0.113; 8 trials; 855 patients), intra-ventricular hemorrhage of any grade (OR:0.860; 95%CI:0.648-1.139); p = 0.293; 15 trials; 1703 patients), severe intra-ventricular hemorrhage (OR:0.852; 95%CI:0.624-1.163); p = 0.313; 15 trials; 1672 patients), necrotizing entero-colitis (OR:1.190; 95%CI:0.785-1.803); p = 0.412; 9 trials; 1097 patients) and retinopathy of prematurity (OR:0.801; 95%CI:0.480-1.337); p = 0.396; 10 trials; 962 patients). CONCLUSIONS Physiopathological mechanisms explaining the effect of surfactant have been found for patent ductus arteriosus only, while they are lacking for all other endpoints. Porcine surfactant is associated with lower incidence of PDA than bovine surfactants. As there are no differences in terms of other extra-pulmonary outcomes and no physiopathological plausibility, these endpoints should not be used in future trials. REGISTRATION PROSPERO n.CRD42018100906.
Collapse
Affiliation(s)
- Silvia Foligno
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A. Béclère", Paris Saclay University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Medical Center "A. Béclère", Paris Saclay University Hospitals, Assistance Publique-Hôpitaux de Paris (APHP) and Paris-Saclay University, Paris, France.
| |
Collapse
|
15
|
Goswami IR, Abou Mehrem A, Scott J, Esser MJ, Mohammad K. Metabolic acidosis rather than hypo/hypercapnia in the first 72 hours of life associated with intraventricular hemorrhage in preterm neonates. J Matern Fetal Neonatal Med 2019; 34:3874-3882. [PMID: 31852289 DOI: 10.1080/14767058.2019.1701649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: Safe limits of arterial partial pressure of carbon dioxide (PaCO2) and acidosis in premature infants are not well defined. Both respiratory and systemic illness along with center-specific ventilation strategies contribute to PaCO2 fluctuations and acid-base imbalances during the critical time period of first 72 h of life. This study evaluated the association between early blood gas parameters and intraventricular hemorrhage (IVH) in preterm infants.Methods: This retrospective observational study included neonates with a gestational age (GA) of ≤29 wks, who had at least 7 blood gas analysis done within the first 72 h of life. By adjusting for known variables that predispose to IVH, multivariable logistic regression analysis was used to study the association of PaCO2 and acid-base measures with the risk of IVH.Results: Between 2013-2016, among 272 neonates who met inclusion criteria and were assessed for IVH on cranial ultrasound within first week of life, 101 neonates [mean GA of 25 ± 1.5 wks] had IVH and 171 neonates [mean GA of 25 ± 1.6 wks] had normal scans. After adjustment for confounding variables, higher values of maximum lactate (OR = 1.18, 95% CI = 1.1-1.3, p < .0001) and maximum base deficit (OR = 1.19, 95% CI = 1.1-1.2, p < .0001) within 72 h of life increased the likelihood of any grade of IVH. However, time-weighted average PaCO2, maximum and minimum PaCO2 had no statistically significant effect on the risk of IVH. The relationship remained unchanged even when moderate-severe IVH was considered as the primary outcome.Conclusion: Severe metabolic acidosis rather than hypo/hypercapnia during the first 72 h of life was associated with higher odds of IVH in infants born at ≤29 wks of gestation. Future studies determining levels of PaCO2 that is safe for premature brain would need to control for the metabolic component of acidosis.
Collapse
Affiliation(s)
- Ipsita R Goswami
- Section of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Ayman Abou Mehrem
- Section of Neonatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - James Scott
- Departments of Diagnostic Imaging and Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Michael J Esser
- Section of Pediatric Neurology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| |
Collapse
|
16
|
Travers CP, Abman SH, Carlo WA. Control of Breathing in Preterm Infants. Neonatal ICU and Beyond. Am J Respir Crit Care Med 2019; 197:1518-1520. [PMID: 29394088 DOI: 10.1164/rccm.201801-0137ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Colm P Travers
- 1 Division of Neonatology University of Alabama at Birmingham Birmingham, Alabama
| | - Steven H Abman
- 2 Section of Pulmonary Medicine Department of Pediatrics University of Colorado School of Medicine and.,3 Children's Hospital Colorado Aurora, Colorado
| | - Waldemar A Carlo
- 1 Division of Neonatology University of Alabama at Birmingham Birmingham, Alabama
| |
Collapse
|
17
|
Lohmann P, Wright C. Does permissive hypercapnia carry increased risk for neurodevelopmental sequelae? Acta Paediatr 2019; 108:1547. [PMID: 31222809 DOI: 10.1111/apa.14872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Clyde Wright
- University of Colorado Denver School of Medicine; Aurora CO USA
| |
Collapse
|
18
|
Cerebral Circulation and Hypotension in the Premature Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
19
|
Yap V, Perlman JM. Intraventricular Hemorrhage and White Matter Injury in the Preterm Infant. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
20
|
Keszler M. Volume-targeted ventilation: one size does not fit all. Evidence-based recommendations for successful use. Arch Dis Child Fetal Neonatal Ed 2019; 104:F108-F112. [PMID: 30068668 DOI: 10.1136/archdischild-2017-314734] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/03/2018] [Accepted: 07/04/2018] [Indexed: 12/14/2022]
Abstract
Despite level 1 evidence for important benefits of volume-targeted ventilation (VTV), many vulnerable extremely preterm infants continue to be exposed to traditional pressure-controlled ventilation. Lack of suitable equipment and a lack of appreciation of the fact that 'one size does NOT fit all' appear to contribute to the slow uptake of VTV. This review attempts to improve clinicians' understanding of the way VTV works and to provide essential information about evidence-based tidal volume (VT) targets. Focus on underlying lung pathophysiology, individualised ventilator settings and VTtargets are keys to successful use of VTV thereby improving important clinical outcomes.
Collapse
Affiliation(s)
- Martin Keszler
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Providence, RI 02905, USA
| |
Collapse
|
21
|
Özkan H, Erdeve Ö, Kutman HGK. Turkish Neonatal Society guideline on the management of respiratory distress syndrome and surfactant treatment. Turk Arch Pediatr 2018; 53:S45-S54. [PMID: 31236018 PMCID: PMC6568291 DOI: 10.5152/turkpediatriars.2018.01806] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Respiratory distress syndrome is the leading cause of respiratory failure in preterm infants. The incidence and severity of respiratory distress syndrome are inversely related to the gestational age of the newborn. The major underlying pathophysiologic mechanisms are surfactant deficiency and anatomic, structural immaturity of the lung. Recent improvements such as antenatal steroid treatment to enhance pulmonary maturity, appropriate resuscitation facilitated by placental transfusion and immediate use of continuous positive airway pressure for alveolar recruitment, early rescue administration of surfactant, ventilation with gentler modes to minimize damage to the immature lungs, and the other supportive therapies have significantly decreased respiratory distress syndrome-related morbidity and mortality. This guideline was addressed to overview the mentioned improvements in order to standardize respiratory distress syndrome management in neonatal intensive care units in Turkey.
Collapse
Affiliation(s)
- Hasan Özkan
- Division of Neonatology, Department of Pediatrics, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Ömer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - H Gözde Kanmaz Kutman
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Zekai Tahir Burak Womens' Health Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
22
|
Pahuja A, Hunt K, Murthy V, Bhat P, Bhat R, Milner AD, Greenough A. Relationship of resuscitation, respiratory function monitoring data and outcomes in preterm infants. Eur J Pediatr 2018; 177:1617-1624. [PMID: 30066181 DOI: 10.1007/s00431-018-3222-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/26/2022]
Abstract
Intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD) are major complications of premature birth. We tested the hypotheses that prematurely born infants who developed an IVH or BPD would have high expiratory tidal volumes (VTE) (VTE > 6 ml/kg) and/or low-end tidal carbon dioxide (ETCO2) levels (ETCO2 levels < 4.5 kPa) as recorded by respiratory function monitoring or hyperoxia (oxygen saturation (SaO2) > 95%) during resuscitation in the delivery suite. Seventy infants, median gestational age 27 weeks (range 23-33), were assessed; 31 developed an IVH and 43 developed BPD. Analysis was undertaken of 31,548 inflations. The duration of resuscitation did not differ significantly between the groups. Those who developed an IVH compared to those who did not had a greater number of inflations with a high VTE and a low ETCO2, which remained significant after correcting for differences in gestational age and birth weight between groups (p = 0.019). Differences between infants who did and did not develop BPD were not significant after correcting for differences in gestational age and birth weight. There were no significant differences in the duration of hyperoxia between the groups.Conclusions: Avoidance of high tidal volumes and hypocarbia in the delivery suite might reduce IVH development. What is known • Hypocarbia on the neonatal unit is associated with the development of intraventricular haemorrhage (IVH) and bronchopulmonary dysplasia (BPD). What is new • Infants who developed an IVH compared to those who did not had significantly more inflations with high expiratory tidal volumes and low ETCO2s.
Collapse
Affiliation(s)
- Anoop Pahuja
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Katie Hunt
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Prashanth Bhat
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anthony D Milner
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.
- MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- NIHR Biomedical Centre at Guy's and St Thomas NHS Foundation Trust, King's College London, London, UK.
| |
Collapse
|
23
|
Does prolonged severe hypercapnia interfere with normal cerebrovascular function in piglets? Pediatr Res 2018; 84:290-295. [PMID: 29907849 PMCID: PMC6185793 DOI: 10.1038/s41390-018-0061-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/16/2018] [Accepted: 04/17/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hypercapnia causes cerebral vasodilation and increased cerebral blood flow (CBF). During prolonged hypercapnia it is unknown whether cerebral vasodilation persists and whether cerebrovascular function is preserved. We investigated the effects of prolonged severe hypercapnia on pial arteriolar diameters (PAD) and cerebrovascular reactivity to vasodilators and vasoconstrictors. METHODS Piglets were anesthetized, intubated and ventilated. Closed cranial windows were implanted to measure PAD. Changes in PAD were documented during hypercapnia (PaCO2 75-80 mm Hg). Cerebrovascular reactivity was documented during normocapnia and at 30, 60, and 120 min of hypercapnia. RESULTS Cerebral vasodilation to hypercapnia was sustained over 120 min. Cerebrovascular responses to vasodilators and vasoconstrictors were preserved during hypercapnia. During hypercapnia, vasodilatory responses to second vasodilators were similar to normocapnia, while exposure to vasoconstrictors caused significant vasoconstriction. CONCLUSIONS Prolonged severe hypercapnia causes sustained vasodilation of pial arteriolar diameters indicative of hyperperfusion. During hypercapnia, cerebral vascular responses to vasodilators and vasoconstrictors were preserved, suggesting that cerebral vascular function remained intact. Of note, cerebral vessels during hypercapnia were capable of further dilation when exposed to additional cerebral vasodilators and, significant vasoconstriction when exposed to vasoconstrictors. Extrapolating these findings to infants, we suggest that severe hypercapnia should be avoided, because it could cause/increase cerebrovascular injury.
Collapse
|
24
|
Thome UH, Dreyhaupt J, Genzel-Boroviczeny O, Bohnhorst B, Schmid M, Fuchs H, Rohde O, Avenarius S, Topf HG, Zimmermann A, Faas D, Timme K, Kleinlein B, Buxmann H, Schenk W, Segerer H, Teig N, Ackermann B, Hentschel R, Heckmann M, Schlösser R, Peters J, Rossi R, Rascher W, Böttger R, Seidenberg J, Hansen G, Bode H, Zernickel M, Muche R, Hummler HD. Influence of PCO2 Control on Clinical and Neurodevelopmental Outcomes of Extremely Low Birth Weight Infants. Neonatology 2018; 113:221-230. [PMID: 29298438 DOI: 10.1159/000485828] [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: 09/03/2017] [Accepted: 11/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Levels or fluctuations in the partial pressure of CO2 (PCO2) may affect outcomes for extremely low birth weight infants. OBJECTIVES In an exploratory analysis of a randomized trial, we hypothesized that the PCO2 values achieved could be related to significant outcomes. METHODS On each treatment day, infants were divided into 4 groups: relative hypocapnia, normocapnia, hypercapnia, or fluctuating PCO2. Ultimate assignment to a group for the purpose of this analysis was made according to the group in which an infant spent the most days. Statistical analyses were performed with analysis of variance (ANOVA), the Kruskal-Wallis test, the χ2 test, and the Fisher exact test as well as by multiple logistic regression. RESULTS Of the 359 infants, 57 were classified as hypocapnic, 230 as normocapnic, 70 as hypercapnic, and 2 as fluctuating PCO2. Hypercapnic infants had a higher average product of mean airway pressure and fraction of inspired oxygen (MAP × FiO2). For this group, mortality was higher, as was the likelihood of having moderate/severe bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and poorer neurodevelopment. Multiple logistic regression analyses showed an increased risk for BPD or death associated with birth weight (p < 0.001) and MAP × FiO2 (p < 0.01). The incidence of adverse neurodevelopment was associated with birth weight (p < 0.001) and intraventricular hemorrhage (IVH; p < 0.01). CONCLUSIONS Birth weight and respiratory morbidity, as measured by MAP × FiO2, were the most predictive of death or BPD and NEC, whereas poor neurodevelopmental outcome was associated with low birth weight and IVH. Univariate models also identified PCO2. Thus, hypercapnia seems to reflect greater disease severity, a likely contributor to differences in outcomes.
Collapse
Affiliation(s)
- Ulrich H Thome
- Division of Neonatology, University Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Dix LML, Weeke LC, de Vries LS, Groenendaal F, Baerts W, van Bel F, Lemmers PMA. Carbon Dioxide Fluctuations Are Associated with Changes in Cerebral Oxygenation and Electrical Activity in Infants Born Preterm. J Pediatr 2017; 187:66-72.e1. [PMID: 28578157 DOI: 10.1016/j.jpeds.2017.04.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 04/05/2017] [Accepted: 04/20/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the effects of acute arterial carbon dioxide partial pressure changes on cerebral oxygenation and electrical activity in infants born preterm. STUDY DESIGN This retrospective observational study included ventilated infants born preterm with acute fluctuations of continuous end-tidal CO2 (etCO2) as a surrogate marker for arterial carbon dioxide partial pressure, during the first 72 hours of life. Regional cerebral oxygen saturation and fractional tissue oxygen extraction were monitored with near-infrared spectroscopy. Brain activity was monitored with 2-channel electroencephalography. Spontaneous activity transients (SATs) rate (SATs/minute) and interval between SATs (in seconds) were calculated. Ten-minute periods were selected for analysis: before, during, and after etCO2 fluctuations of ≥5 mm Hg. RESULTS Thirty-eight patients (mean ± SD gestational age of 29 ± 1.8 weeks) were included, with 60 episodes of etCO2 increase and 70 episodes of etCO2 decrease. During etCO2 increases, brain oxygenation increased (regional cerebral oxygen saturation increased, fractional tissue oxygen extraction decreased; P < .01) and electrical activity decreased (SATs/minute decreased, interval between SATs increased; P < .01). All measures recovered when etCO2 returned to baseline. During etCO2 decreases, brain oxygenation decreased (regional cerebral oxygen saturation decreased, fractional tissue oxygen extraction decreased; P < .01) and brain activity increased (SATs/minute increased, P < .05), also with recovery after return of etCO2 to baseline. CONCLUSION An acute increase in etCO2 is associated with increased cerebral oxygenation and decreased brain activity, whereas an acute decrease is associated with decreased cerebral oxygenation and slightly increased brain activity. Combining continuous CO2 monitoring with near-infrared spectroscopy may enable the detection of otherwise undetected fluctuations in arterial carbon dioxide partial pressure that may be harmful to the neonatal brain.
Collapse
Affiliation(s)
- Laura Marie Louise Dix
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Lauren Carleen Weeke
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Linda Simone de Vries
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Willem Baerts
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands
| | - Petra Maria Anna Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital/University Medical Center Utrecht, The Netherlands.
| |
Collapse
|
26
|
Abdel-Hady H, Shouman B. Permissive hypercapnia in extremely low-birthweight infants: how far should we go? Acta Paediatr 2017; 106:1011. [PMID: 28121055 DOI: 10.1111/apa.13727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 12/16/2016] [Accepted: 12/21/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Hesham Abdel-Hady
- Pediatrics/Neonatology, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Basma Shouman
- Pediatrics/Neonatology, Mansoura University Children's Hospital, Mansoura, Egypt
| |
Collapse
|
27
|
Leviton A, Allred EN, Joseph RM, O'Shea TM, Kuban KCK. Newborn blood gas derangements of children born extremely preterm and neurocognitive dysfunctions at age 10 years. Respir Physiol Neurobiol 2017; 242:66-72. [PMID: 28396202 DOI: 10.1016/j.resp.2017.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 03/30/2017] [Accepted: 04/01/2017] [Indexed: 01/03/2023]
Abstract
Among 740 children born extremely preterm, we evaluated the relationship between the highest and lowest quartiles of the distributions of PaO2 and PaCO2, as well as the lowest quartile of pH on one day, and separately on two days, and the risk of neurocognitive, language, and behavioral dysfunctions at age 10 years. Children who had hypoxemia, hyperoxemia, hypocapnia, hypercapnia, and acidemia, sometimes on only one day, and sometimes on two or more days, were more likely than others to have a high illness severity score (within the first 12 postnatal hours), and 10 years later to have multiple dysfunctions. The tendency of blood gas derangements to be associated with high illness severity scores and with multiple dysfunctions 10 years later is compatible with the possibility that blood gas derangements are indicators of physiologic instability/vulnerability/immaturity rather than contributors to brain damage.
Collapse
Affiliation(s)
- Alan Leviton
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | | | | | - T Michael O'Shea
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Karl C K Kuban
- Boston University School of Medicine, Boston, MA, USA; Boston Medical Center, Boston, MA, USA
| | | |
Collapse
|
28
|
Omer M, Molloy EJ. QUESTION 2: Is permissive hypercapnia beneficial to preterm infants? Arch Dis Child 2017; 102:113-115. [PMID: 27881376 DOI: 10.1136/archdischild-2016-312050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 11/07/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Murwan Omer
- Department of Paediatrics, Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Eleanor J Molloy
- Department of Neonatology, Our lady's Children's Hospital, Trinity College, the University of Dublin, Dublin, Ireland
| |
Collapse
|
29
|
Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2016 Update. Neonatology 2017; 111:107-125. [PMID: 27649091 DOI: 10.1159/000448985] [Citation(s) in RCA: 312] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 08/08/2016] [Indexed: 02/04/2023]
Abstract
Advances in the management of respiratory distress syndrome (RDS) ensure that clinicians must continue to revise current practice. We report the third update of the European Guidelines for the Management of RDS by a European panel of expert neonatologists including input from an expert perinatal obstetrician based on available literature up to the beginning of 2016. Optimizing the outcome for babies with RDS includes consideration of when to use antenatal steroids, and good obstetric practice includes methods of predicting the risk of preterm delivery and also consideration of whether transfer to a perinatal centre is necessary and safe. Methods for optimal delivery room management have become more evidence based, and protocols for lung protection, including initiation of continuous positive airway pressure and titration of oxygen, should be implemented from soon after birth. Surfactant replacement therapy is a crucial part of the management of RDS, and newer protocols for surfactant administration are aimed at avoiding exposure to mechanical ventilation, and there is more evidence of differences among various surfactants in clinical use. Newer methods of maintaining babies on non-invasive respiratory support have been developed and offer potential for greater comfort and less chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease although minimizing the time spent on mechanical ventilation using caffeine and if necessary postnatal steroids are also important considerations. Protocols for optimizing the general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
Collapse
Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|