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Davies IM, Crossley KJ, McGillick EV, Nitsos I, Rodgers K, Thiel A, Zahra VA, Badurdeen S, te Pas AB, Hooper SB. Adverse respiratory patterns in near-term spontaneously breathing newborn lambs with elevated airway liquid volumes at birth. Front Pediatr 2024; 12:1336154. [PMID: 38690521 PMCID: PMC11058214 DOI: 10.3389/fped.2024.1336154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
Introduction Recent evidence indicates that respiratory distress (RD) in near-term infants is caused by elevated airway liquid (EL) volume at the beginning of air-breathing after birth. While the adverse effects EL volumes on newborn lung function are known, the effects on respiratory control and breathing patterns shortly after birth (<4 h) are unknown. We investigated the effects of EL volumes on cardiorespiratory function and breathing patterns in spontaneously breathing near-term newborn lambs in the first hours after birth. Methods At 137-8 days gestation (2-3 days prior to delivery; term ∼147 days), sterile surgery was performed on fetal sheep (n = 17) to implant catheters and blood flow probes. At 140 days, lambs were delivered via caesarean section under spinal anaesthesia. Airway liquid volumes were adjusted to mimic the level expected following vaginal delivery (∼10 ml/kg; Controls; n = 7), or elective caesarean section (∼30 ml/kg; elevated airway liquid group; EL; n = 10). Spontaneous breathing and cardiorespiratory parameters were recorded over four hours after birth. Non-invasive respiratory support with supplemental oxygen was provided if required. Results EL lambs required higher inspired oxygen levels (p = 0.0002), were less active (p = 0.026), fed less (p = 0.008) and had higher respiratory morbidity scores than Controls (p < 0.0001). EL lambs also displayed higher rates of breathing patterns associated with RD, such as expiratory braking and tachypnoea. These patterns were particularly evident in male EL lambs who displayed higher levels of severe respiratory morbidity (e.g., expiratory braking) than female EL lambs. Conclusion The study demonstrates that EL volumes at birth trigger respiratory behaviour and breathing patterns that resemble clinically recognised features of RD in term infants.
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Affiliation(s)
- I. M. Davies
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - K. J. Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - E. V. McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - I. Nitsos
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - K. Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - A. Thiel
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - V. A. Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - S. Badurdeen
- Department of Paediatrics, Mercy Hospital for Women, Heidelberg, VIC, Australia
- Neonatal Research, Murdoch Children’s Research Institute, Melbourne, VIC, Australia
| | - A. B. te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - S. B. Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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Gaertner VD, Büchler VL, Waldmann A, Bassler D, Rüegger CM. Deciphering Mechanisms of Respiratory Fetal-to-Neonatal Transition in Very Preterm Infants. Am J Respir Crit Care Med 2024; 209:738-747. [PMID: 38032260 DOI: 10.1164/rccm.202306-1021oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/30/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale: The respiratory mechanisms of a successful transition of preterm infants after birth are largely unknown. Objectives: To describe intrapulmonary gas flows during different breathing patterns directly after birth. Methods: Analysis of electrical impedance tomography data from a previous randomized trial in preterm infants at 26-32 weeks gestational age. Electrical impedance tomography data for individual breaths were extracted, and lung volumes as well as ventilation distribution were calculated for end of inspiration, end of expiratory braking and/or holding maneuver, and end of expiration. Measurements and Main Results: Overall, 10,348 breaths from 33 infants were analyzed. We identified three distinct breath types within the first 10 minutes after birth: tidal breathing (44% of all breaths; sinusoidal breathing without expiratory disruption), braking (50%; expiratory brake with a short duration), and holding (6%; expiratory brake with a long duration). Only after holding breaths did end-expiratory lung volume increase: Median (interquartile range [IQR]) = 2.0 AU/kg (0.6 to 4.3), 0.0 (-1.0 to 1.1), and 0.0 (-1.1 to 0.4), respectively; P < 0.001]. This was mediated by intrathoracic air redistribution to the left and non-gravity-dependent parts of the lung through pendelluft gas flows during braking and/or holding maneuvers. Conclusions: Respiratory transition in preterm infants is characterized by unique breathing patterns. Holding breaths contribute to early lung aeration after birth in preterm infants. This is facilitated by air redistribution during braking/holding maneuvers through pendelluft flow, which may prevent lung liquid reflux in this highly adaptive situation. This study deciphers mechanisms for a successful fetal-to-neonatal transition and increases our pathophysiological understanding of this unique moment in life. Clinical trial registered with www.clinicaltrials.gov (NCT04315636).
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
- Division of Neonatology, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Vanessa L Büchler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Andreas Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital Zurich and University of Zürich, Zürich, Switzerland
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Hadley L, Flemmer AW, Kitchen MJ, Croughan MK, Crossley KJ, Lee KL, McGillick E, Wallace MJ, Pearson JT, DeKoninck P, Hodges R, Te Pas AB, Hooper SB, Thio M. Sustained inflation improves initial lung aeration in newborn rabbits with a diaphragmatic hernia. Pediatr Res 2024; 95:660-667. [PMID: 37952056 DOI: 10.1038/s41390-023-02874-x] [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] [Received: 07/11/2022] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Infants with a congenital diaphragmatic hernia (DH) have underdeveloped lungs and require mechanical ventilation after birth, but the optimal approach is unknown. We hypothesised that sustained inflation (SI) increases lung aeration in newborn kittens with a DH. METHODS In pregnant New Zealand white rabbits, a left-sided DH was induced in two fetal kittens per doe at 24-days gestation (term = 32 days); litter mates acted as controls. DH and control kittens were delivered by caesarean section at 30 days, intubated and mechanically ventilated (7-10 min) with either an SI followed by intermittent positive pressure ventilation (IPPV) or IPPV throughout. The rate and uniformity of lung aeration was measured using phase-contrast X-ray imaging. RESULTS Lung weights in DH kittens were ~57% of controls. An SI increased the rate and uniformity of lung aeration in DH kittens, compared to IPPV, and increased dynamic lung compliance in both control and DH kittens. However, this effect of the SI was lost when ventilation changed to IPPV. CONCLUSION While an SI improved the rate and uniformity of lung aeration in both DH and control kittens, greater consideration of the post-SI ventilation strategy is required to sustain this benefit. IMPACT Compared to intermittent positive pressure ventilation (IPPV), an initial sustained inflation (SI) increased the rate and uniformity of lung aeration after birth. However, this initial benefit is rapidly lost following the switch to IPPV. The optimal approach for ventilating CDH infants at birth is unknown. While an SI improves lung aeration in immature lungs, its effect on the hypoplastic lung is unknown. This study has shown that an SI greatly improves lung aeration in the hypoplastic lung. This study will guide future studies examining whether an SI can improve lung aeration in infants with a CDH.
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Affiliation(s)
- Lauren Hadley
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Andreas W Flemmer
- Division of Neonatology, University Children's Hospital and Perinatal Center, LMU Hospital, Munich, Germany
| | - Marcus J Kitchen
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Michelle K Croughan
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Kelly J Crossley
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Katie L Lee
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Erin McGillick
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Megan J Wallace
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - James T Pearson
- National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Physiology, Victoria Heart Institute and Monash Biomedicine Institute, Monash University, Melbourne, VIC, Australia
| | - Philip DeKoninck
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Fetal Medicine, Erasmus MC University Medical Center - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ryan Hodges
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.
| | - Marta Thio
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia
- The Murdoch Children's Research Institute, Melbourne, VIC, Australia
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Robinson JL, Gatford KL, Clifton VL, Morrison JL, Stark MJ. The impact of maternal asthma on the fetal lung: Outcomes, mechanisms and interventions. Paediatr Respir Rev 2023:S1526-0542(23)00086-6. [PMID: 38195368 DOI: 10.1016/j.prrv.2023.12.004] [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: 11/27/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 01/11/2024]
Abstract
Maternal asthma affects up to 17% of pregnancies and is associated with adverse infant, childhood, and adult respiratory outcomes, including increased risks of neonatal respiratory distress syndrome, childhood wheeze and asthma. In addition to genetics, these poor outcomes are likely due to the mediating influence of maternal asthma on the in-utero environment, altering fetal lung and immune development and predisposing the offspring to later lung disease. Maternal asthma may impair glucocorticoid signalling in the fetus, a process critical for lung maturation, and increase fetal exposure to proinflammatory cytokines. Therefore, interventions to control maternal asthma, increase glucocorticoid signalling in the fetal lung, or Vitamin A, C, and D supplementation to improve alveologenesis and surfactant production may be beneficial for later lung function. This review highlights potential mechanisms underlying maternal asthma and offspring respiratory morbidities and describes how pregnancy interventions can promote optimal fetal lung development in babies of asthmatic mothers.
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Affiliation(s)
- Joshua L Robinson
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia; Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia.
| | - Kathryn L Gatford
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; School of Biomedicine, University of Adelaide, Adelaide, Australia
| | - Vicki L Clifton
- Mater Research Institute, University of Queensland, Brisbane, Australia
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Michael J Stark
- Robinson Research Institute, University of Adelaide, Adelaide, Australia; Adelaide Medical School, University of Adelaide, Adelaide, Australia; Department of Neonatal Medicine, Women's & Children's Hospital, Adelaide, Australia.
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Zong HF, Guo G, Liu J, Yang CZ, Bao LL. Influence of Alveolar Fluid on Aquaporins and Na+/K+-ATPase and Its Possible Theoretical or Clinical Significance. Am J Perinatol 2022; 29:1586-1595. [PMID: 33611784 DOI: 10.1055/s-0041-1724001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Pulmonary edema is the most common pathophysiological change in pulmonary disease. Aquaporins (AQPs) and Na+/K+-ATPase play pivotal roles in alveolar fluid clearance. This study aimed to explore the influence of increased alveolar fluid on the absorption of lung fluid. STUDY DESIGN Eighty New Zealand rabbits were randomly divided into eight groups (n = 10 in each group), and models of different alveolar fluid contents were established by the infusion of different volumes of normal saline (NS) via the endotracheal tube. Five animals in each group were sacrificed immediately after infusion to determine the wet/dry ratio, while the remaining animals in each group were killed 4 hours later to determine the wet/dry ratio at 4 hours. Additionally, lung specimens were collected from each group, and quantitative real-time PCR (qRT-PCR), western blot, and immunohistochemical (IHC) analyses of AQPs and Na+/K+-ATPase were performed. RESULTS The qRT-PCR analysis and western blot studies showed markedly decreased mRNA and protein levels of AQP1 and Na+/K+-ATPase when the alveolar fluid volume was ≥6 mL/kg, and the mRNA level of AQP5 was significantly reduced when the alveolar fluid volume was ≥4 mL/kg. In addition, IHC analysis showed the same results. At 4 hours, the lung wet/dry ratio was significantly increased when the alveolar fluid volume was ≥6 mL/kg; however, compared with 0 hours after NS infusion, there was still a significant absorption of alveolar fluid for a period of 4 hours. CONCLUSION The results of this study suggest that increased alveolar fluid may induce the downregulation of the mRNA and protein expression of AQPs and Na+/K+-ATPase, which appear to affect alveolar fluid clearance in rabbit lungs. Early intervention is required to avoid excessive alveolar fluid accumulation. KEY POINTS · The expression levels of AQPs and Na+/K+--ATPase were significantly decreased as alveolar fluid increased.. · At 4 hours, wet/dry ratio was significantly increased when infusion volume was ≥ 6 mL/kg.. · Early intervention is required to avoid excessive alveolar fluid accumulation..
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Affiliation(s)
- Hai-Feng Zong
- Neonatal Intensive Care Unit, Southern Medical University, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Guo Guo
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
- Department of Pediatrics, Medical School of Chinese PLA, Beijing, China
- Department of Neonatology, The Fifth Medical Center of the PLA General Hospital, Beijing, China
| | - Jing Liu
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Chuan-Zhong Yang
- Neonatal Intensive Care Unit, Southern Medical University, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Shenzhen, China
| | - Lin-Lin Bao
- Department of Dermatology, Shenzhen People's Hospital, Shenzhen, China
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6
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Yamaoka S, Crossley KJ, McDougall AR, Rodgers K, Zahra VA, Moxham A, Te Pas AB, McGillick EV, Hooper SB. Increased airway liquid volumes at birth impairs cardiorespiratory function in preterm and near-term lambs. J Appl Physiol (1985) 2022; 132:1080-1090. [PMID: 35271407 DOI: 10.1152/japplphysiol.00640.2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Respiratory distress is relatively common in infants born at or near-term, particularly in infants delivered following elective cesarean section. The pathophysiology underlying respiratory distress at term has largely been explained by a failure to clear airway liquid, but recent physiological evidence has indicated that it results from elevated airway liquid at the onset of air-breathing. We have investigated the effect of elevated airway liquid volumes at birth on cardiorespiratory function in preterm and near-term lambs. Preterm (130 ± 0 days gestation, term ~147 days gestation; n=13) and near-term (139 ± 1 days gestation; n=13) lambs were instrumented (to measure blood pressure, blood flow and blood gas status) and at delivery airway liquid volumes were adjusted to mimic levels expected following vaginal delivery (Controls; ~7mL/kg) or elective caesarean section with no labour (elevated liquid; EL; 37mL/kg). Lambs were delivered, mechanically ventilated and monitored for blood gas status, oxygenation, ventilator requirements, blood flows (carotid artery and pulmonary artery) and blood pressure during the first few hours of life. Preterm and near-term EL lambs had poorer gas exchange and required greater ventilatory support to maintain adequate oxygenation. Pulmonary blood flow was reduced and carotid artery blood flow, mean arterial blood pressure and heart rate were reduced in EL near-term but not preterm lambs. These data provide further evidence that greater airway liquid volumes at birth adversely effects newborn cardiorespiratory function, with the effects being greater in near-term newborns.
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Affiliation(s)
- Shigeo Yamaoka
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Division of Neonatology, Department of Pediatrics, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Annie Ra McDougall
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Karyn Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Valerie A Zahra
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Alison Moxham
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Erin Victoria McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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Bruschettini M, Hassan KO, Romantsik O, Banzi R, Calevo MG, Moresco L. Interventions for the management of transient tachypnoea of the newborn - an overview of systematic reviews. Cochrane Database Syst Rev 2022; 2:CD013563. [PMID: 35199848 PMCID: PMC8867535 DOI: 10.1002/14651858.cd013563.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Transient tachypnoea of the newborn (TTN) is characterised by tachypnoea and signs of respiratory distress. It is caused by delayed clearance of lung fluid at birth. TTN typically appears within the first two hours of life in term and late preterm newborns. Although it is usually a self-limited condition, admission to a neonatal unit is frequently required for monitoring, the provision of respiratory support, and drugs administration. These interventions might reduce respiratory distress during TTN and enhance the clearance of lung liquid. The goals are reducing the effort required to breathe, improving respiratory distress, and potentially shortening the duration of tachypnoea. However, these interventions might be associated with harm in the infant. OBJECTIVES The aim of this overview was to evaluate the benefits and harms of different interventions used in the management of TTN. METHODS We searched the Cochrane Database of Systematic Reviews on 14 July 2021 for ongoing and published Cochrane Reviews on the management of TTN in term (> 37 weeks' gestation) or late preterm (34 to 36 weeks' gestation) infants. We included all published Cochrane Reviews assessing the following categories of interventions administered within the first 48 hours of life: beta-agonists (e.g. salbutamol and epinephrine), corticosteroids, diuretics, fluid restriction, and non-invasive respiratory support. The reviews compared the above-mentioned interventions to placebo, no treatment, or other interventions for the management of TTN. The primary outcomes of this overview were duration of tachypnoea and the need for mechanical ventilation. Two overview authors independently checked the eligibility of the reviews retrieved by the search and extracted data from the included reviews using a predefined data extraction form. Any disagreements were resolved by discussion with a third overview author. Two overview authors independently assessed the methodological quality of the included reviews using the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews) tool. We used the GRADE approach to assess the certainty of evidence for effects of interventions for TTN management. As all of the included reviews reported summary of findings tables, we extracted the information already available and re-graded the certainty of evidence of the two primary outcomes to ensure a homogeneous assessment. We provided a narrative summary of the methods and results of each of the included reviews and summarised this information using tables and figures. MAIN RESULTS We included six Cochrane Reviews, corresponding to 1134 infants enrolled in 18 trials, on the management of TTN in term and late preterm infants, assessing salbutamol (seven trials), epinephrine (one trial), budesonide (one trial), diuretics (two trials), fluid restriction (four trials), and non-invasive respiratory support (three trials). The quality of the included reviews was high, with all of them fulfilling the critical domains of the AMSTAR 2. The certainty of the evidence was very low for the primary outcomes, due to the imprecision of the estimates (few, small included studies) and unclear or high risk of bias. Salbutamol may reduce the duration of tachypnoea compared to placebo (mean difference (MD) -16.83 hours, 95% confidence interval (CI) -22.42 to -11.23, 2 studies, 120 infants, low certainty evidence). We did not identify any review that compared epinephrine or corticosteroids to placebo and reported on the duration of tachypnoea. However, one review reported on "trend of normalisation of respiratory rate", a similar outcome, and found no differences between epinephrine and placebo (effect size not reported). The evidence is very uncertain regarding the effect of diuretics compared to placebo (MD -1.28 hours, 95% CI -13.0 to 10.45, 2 studies, 100 infants, very low certainty evidence). We did not identify any review that compared fluid restriction to standard fluid rates and reported on the duration of tachypnoea. The evidence is very uncertain regarding the effect of continuous positive airway pressure (CPAP) compared to free-flow oxygen therapy (MD -21.1 hours, 95% CI -22.9 to -19.3, 1 study, 64 infants, very low certainty evidence); the effect of nasal high-frequency (oscillation) ventilation (NHFV) compared to CPAP (MD -4.53 hours, 95% CI -5.64 to -3.42, 1 study, 40 infants, very low certainty evidence); and the effect of nasal intermittent positive pressure ventilation (NIPPV) compared to CPAP on duration of tachypnoea (MD 4.30 hours, 95% CI -19.14 to 27.74, 1 study, 40 infants, very low certainty evidence). Regarding the need for mechanical ventilation, the evidence is very uncertain for the effect of salbutamol compared to placebo (risk ratio (RR) 0.60, 95% CI 0.13 to 2.86, risk difference (RD) 10 fewer, 95% CI 50 fewer to 30 more per 1000, 3 studies, 254 infants, very low certainty evidence); the effect of epinephrine compared to placebo (RR 0.67, 95% CI 0.08 to 5.88, RD 70 fewer, 95% CI 460 fewer to 320 more per 1000, 1 study, 20 infants, very low certainty evidence); and the effect of corticosteroids compared to placebo (RR 0.52, 95% CI 0.05 to 5.38, RD 40 fewer, 95% CI 170 fewer to 90 more per 1000, 1 study, 49 infants, very low certainty evidence). We did not identify a review that compared diuretics to placebo and reported on the need for mechanical ventilation. The evidence is very uncertain regarding the effect of fluid restriction compared to standard fluid administration (RR 0.73, 95% CI 0.24 to 2.23, RD 20 fewer, 95% CI 70 fewer to 40 more per 1000, 3 studies, 242 infants, very low certainty evidence); the effect of CPAP compared to free-flow oxygen (RR 0.30, 95% CI 0.01 to 6.99, RD 30 fewer, 95% CI 120 fewer to 50 more per 1000, 1 study, 64 infants, very low certainty evidence); the effect of NIPPV compared to CPAP (RR 4.00, 95% CI 0.49 to 32.72, RD 150 more, 95% CI 50 fewer to 350 more per 1000, 1 study, 40 infants, very low certainty evidence); and the effect of NHFV versus CPAP (effect not estimable, 1 study, 40 infants, very low certainty evidence). Regarding our secondary outcomes, duration of hospital stay was the only outcome reported in all of the included reviews. One trial on fluid restriction reported a lower duration of hospitalisation in the restricted-fluids group, but with very low certainty of evidence. The evidence was very uncertain for the effects on secondary outcomes for the other five reviews. Data on potential harms were scarce, as all of the trials were underpowered to detect possible increases in adverse events such as pneumothorax, arrhythmias, and electrolyte imbalances. No adverse effects were reported for salbutamol; however, this medication is known to carry a risk of tachycardia, tremor, and hypokalaemia in other settings. AUTHORS' CONCLUSIONS This overview summarises the evidence from six Cochrane Reviews of randomised trials regarding the effects of postnatal interventions in the management of TTN. Salbutamol may reduce the duration of tachypnoea slightly. We are uncertain as to whether salbutamol reduces the need for mechanical ventilation. We are uncertain whether epinephrine, corticosteroids, diuretics, fluid restriction, or non-invasive respiratory support reduces the duration of tachypnoea and the need for mechanical ventilation, due to the extremely limited evidence available. Data on harms were lacking.
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Affiliation(s)
- Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | | | - Olga Romantsik
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
| | - Rita Banzi
- Center for Health Regulatory Policies, Mario Negri Institute for Pharmacological Research IRCCS, Milan, Italy
| | - Maria Grazia Calevo
- Epidemiology, Biostatistics Unit, IRCCS, Istituto Giannina Gaslini, Genoa, Italy
| | - Luca Moresco
- Pediatric and Neonatology Unit, Ospedale San Paolo, Savona, Italy
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8
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McGillick EV, Te Pas AB, van den Akker T, Keus JMH, Thio M, Hooper SB. Evaluating Clinical Outcomes and Physiological Perspectives in Studies Investigating Respiratory Support for Babies Born at Term With or at Risk of Transient Tachypnea: A Narrative Review. Front Pediatr 2022; 10:878536. [PMID: 35813383 PMCID: PMC9260080 DOI: 10.3389/fped.2022.878536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/09/2022] [Indexed: 12/02/2022] Open
Abstract
Respiratory distress in the first few hours of life is a growing disease burden in otherwise healthy babies born at term (>37 weeks gestation). Babies born by cesarean section without labor (i.e., elective cesarean section) are at greater risk of developing respiratory distress due to elevated airway liquid volumes at birth. These babies are commonly diagnosed with transient tachypnea of the newborn (TTN) and historically treatments have mostly focused on enhancing airway liquid clearance pharmacologically or restricting fluid intake with limited success. Alternatively, a number of clinical studies have investigated the potential benefits of respiratory support in newborns with or at risk of TTN, but there is considerable heterogeneity in study designs and outcome measures. A literature search identified eight clinical studies investigating use of respiratory support on outcomes related to TTN in babies born at term. Study demographics including gestational age, mode of birth, antenatal corticosteroid exposure, TTN diagnosis, timing of intervention (prophylactic/interventional), respiratory support (type/interface/device/pressure), and study outcomes were compared. This narrative review provides an overview of factors within and between studies assessing respiratory support for preventing and/or treating TTN. In addition, we discuss the physiological understanding of how respiratory support aids lung function in newborns with elevated airway liquid volumes at birth. However, many questions remain regarding the timing of onset, pressure delivered, device/interface used and duration, and weaning of support. Future studies are required to address these gaps in knowledge to provide evidenced based recommendations for management of newborns with or at risk of TTN.
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Affiliation(s)
- Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Center, Leiden, Netherlands.,Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J M H Keus
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Marta Thio
- Newborn Research, The Royal Women's Hospital, Melbourne, VIC, Australia.,The Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
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9
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McGillick EV, Te Pas AB, Croughan MK, Crossley KJ, Wallace MJ, Lee K, Thio M, DeKoninck PLJ, Dekker J, Flemmer AW, Cramer SJE, Hooper SB, Kitchen MJ. Increased end-expiratory pressures improve lung function in near-term newborn rabbits with elevated airway liquid volume at birth. J Appl Physiol (1985) 2021; 131:997-1008. [PMID: 34351817 DOI: 10.1152/japplphysiol.00918.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Approximately 53% of near-term newborns admitted to intensive care experience respiratory distress. These newborns are commonly delivered by cesarean section and have elevated airway liquid volumes at birth, which can cause respiratory morbidity. We investigated the effect of providing respiratory support with a positive end-expiratory pressure (PEEP) of 8 cmH2O on lung function in newborn rabbit kittens with elevated airway liquid volumes at birth. Near-term rabbits (30 days; term = 32 days) with airway liquid volumes that corresponded to vaginal delivery (∼7 mL/kg, control, n = 11) or cesarean section [∼37 mL/kg; elevated liquid (EL), n = 11] were mechanically ventilated (tidal volume = 8 mL/kg). The PEEP was changed after lung aeration from 0 to 8 to 0 cmH2O (control, n = 6; EL, n = 6), and in a separate group of kittens, PEEP was changed after lung aeration from 8 to 0 to 8 cmH2O (control, n = 5; EL, n = 5). Lung function (ventilator parameters, compliance, lung gas volumes, and distribution of gas within the lung) was evaluated using plethysmography and synchrotron-based phase-contrast X-ray imaging. EL kittens initially receiving 0 cmH2O PEEP had reduced functional residual capacities and lung compliance, requiring higher inflation pressures to aerate the lung compared with control kittens. Commencing ventilation with 8 cmH2O PEEP mitigated the adverse effects of EL, increasing lung compliance, functional residual capacity, and the uniformity and distribution of lung aeration, but did not normalize aeration of the distal airways. Respiratory support with PEEP supports lung function in near-term newborn rabbits with elevated airway liquid volumes at birth who are at a greater risk of suffering respiratory distress.NEW & NOTEWORTHY Term babies born by cesarean section have elevated airway liquid volumes, which predisposes them to respiratory distress. Treatments targeting molecular mechanisms to clear lung liquid are ineffective for term newborn respiratory distress. We showed that respiratory support with an end-expiratory pressure supports lung function in near-term rabbits with elevated airway liquid volumes at birth. This study provides further physiological understanding of lung function in newborns with elevated airway liquid volumes at risk of respiratory distress.
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Affiliation(s)
- Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Michelle K Croughan
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Megan J Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Katie Lee
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Marta Thio
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia.,The Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus Medical Center University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Andreas W Flemmer
- Division of Neonatology, University Children's Hospital and Perinatal Centre, Ludwig-Maximilians University, Munich, Germany
| | - Sophie J E Cramer
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
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10
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van Leuteren RW, Kho E, de Waal CG, Te Pas AB, Salverda HH, de Jongh FH, van Kaam AH, Hutten GJ. Cardiorespiratory monitoring in the delivery room using transcutaneous electromyography. Arch Dis Child Fetal Neonatal Ed 2021; 106:352-356. [PMID: 33214154 DOI: 10.1136/archdischild-2020-319535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To assess feasibility of transcutaneous electromyography of the diaphragm (dEMG) as a monitoring tool for vital signs and diaphragm activity in the delivery room (DR). DESIGN Prospective observational study. SETTING Delivery room. PATIENTS Newborn infants requiring respiratory stabilisation after birth. INTERVENTIONS In addition to pulse oximetry (PO) and ECG, dEMG was measured with skin electrodes for 30 min after birth. OUTCOME MEASURES We assessed signal quality of dEMG and ECG recording, agreement between heart rate (HR) measured by dEMG and ECG or PO, time between sensor application and first HR read-out and agreement between respiratory rate (RR) measured with dEMG and ECG, compared with airway flow. Furthermore, we analysed peak, tonic and amplitude diaphragmatic activity from the dEMG-based respiratory waveform. RESULTS Thirty-three infants (gestational age: 31.7±2.8 weeks, birth weight: 1525±661 g) were included.18%±14% and 22%±21% of dEMG and ECG data showed poor quality, respectively. Monitoring HR with dEMG was fast (median 10 (IQR 10-11) s) and accurate (intraclass correlation coefficient (ICC) 0.92 and 0.82 compared with ECG and PO, respectively). RR monitoring with dEMG showed moderate (ICC 0.49) and ECG low (ICC 0.25) agreement with airway flow. Diaphragm activity started high with a decreasing trend in the first 15 min and subsequent stabilisation. CONCLUSION Monitoring vital signs with dEMG in the DR is feasible and fast. Diaphragm activity can be detected and described with dEMG, making dEMG promising for future DR studies.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands .,Amsterdam Reproduction & Development Research Institute, Amsterdam, North-Holland, Netherlands
| | - Eline Kho
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Technical Medicine, University of Twente, Enschede, Overijssel, Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Hylke H Salverda
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, Overijssel, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
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11
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Morrison JL, Ayonrinde OT, Care AS, Clarke GD, Darby JRT, David AL, Dean JM, Hooper SB, Kitchen MJ, Macgowan CK, Melbourne A, McGillick EV, McKenzie CA, Michael N, Mohammed N, Sadananthan SA, Schrauben E, Regnault TRH, Velan SS. Seeing the fetus from a DOHaD perspective: discussion paper from the advanced imaging techniques of DOHaD applications workshop held at the 2019 DOHaD World Congress. J Dev Orig Health Dis 2021; 12:153-167. [PMID: 32955011 DOI: 10.1017/s2040174420000884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Advanced imaging techniques are enhancing research capacity focussed on the developmental origins of adult health and disease (DOHaD) hypothesis, and consequently increasing awareness of future health risks across various subareas of DOHaD research themes. Understanding how these advanced imaging techniques in animal models and human population studies can be both additively and synergistically used alongside traditional techniques in DOHaD-focussed laboratories is therefore of great interest. Global experts in advanced imaging techniques congregated at the advanced imaging workshop at the 2019 DOHaD World Congress in Melbourne, Australia. This review summarizes the presentations of new imaging modalities and novel applications to DOHaD research and discussions had by DOHaD researchers that are currently utilizing advanced imaging techniques including MRI, hyperpolarized MRI, ultrasound, and synchrotron-based techniques to aid their DOHaD research focus.
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Affiliation(s)
- Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Oyekoya T Ayonrinde
- Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Alison S Care
- The Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Geoffrey D Clarke
- Department of Radiology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Justin M Dean
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- The Department of Obstetrics and Gynecology, Monash University, Melbourne, Victoria, Australia
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | | | - Andrew Melbourne
- School of Biomedical Engineering and Imaging Sciences, Kings College London, London, UK
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- The Department of Obstetrics and Gynecology, Monash University, Melbourne, Victoria, Australia
| | - Charles A McKenzie
- Department of Medical Biophysics, Western University, London, ON, Canada
- Lawson Health Research Institute and Children's Health Research Institute, London, ON, Canada
| | - Navin Michael
- Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
| | - Nuruddin Mohammed
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, Pakistan
| | - Suresh Anand Sadananthan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
| | - Eric Schrauben
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Timothy R H Regnault
- Lawson Health Research Institute and Children's Health Research Institute, London, ON, Canada
- Department of Obstetrics and Gynecology, Western University, London, ON, Canada
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - S Sendhil Velan
- Singapore Bioimaging Consortium, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
- Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
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12
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Wellmann S, Manegold-Brauer G, Fischer T, Schäffer L, Gaertner VD, Malfertheiner SF, Burkhardt T. Improving Neonatal and Maternal Outcome by Inducing Mild Labor before Elective Cesarean Section: The Lacarus Randomized Controlled Trial. Neonatology 2021; 118:116-121. [PMID: 33472211 DOI: 10.1159/000512752] [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: 07/23/2020] [Accepted: 10/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Newborns delivered by elective cesarean section (CS) are at higher respiratory risk than those delivered vaginally or by CS proceeded by labor (secondary CS). The oxytocin challenge test (OCT) induces uterine contractions that trigger the release of fetal hormones regulating lung fluid clearance during transition from the uterine to an air-breathing environment. OBJECTIVES The aim is to summarize current evidence and outline the Lacarus trial protocol. METHODS Literature review informed the design of a randomized placebo-controlled multicenter trial of OCT preceding elective CS in 1,450 women with a singleton pregnancy due for CS at >35 weeks gestation, without preceding contractions, rupture of the membranes, or antenatal steroids. OCT comprises the infusion of oxytocin 5 IU/500 mL Ringer lactate at a rate of 12 mL/h, doubling every 10 min until inducing 5 uterine contractions per 15-min interval. The primary endpoint is the occurrence of neonatal respiratory morbidity within 24 h after birth. Secondary endpoints include biochemical and physiological parameters of fetal and maternal well-being, such as breastfeeding rate and fetal plasma copeptin concentrations. CONCLUSION This is the first trial to test the hypothesis that oxytocin-induced contractions before elective CS is a promising application of physiologic principles gleaned from natural birth to improve neonatal and maternal outcomes.
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Affiliation(s)
- Sven Wellmann
- University Children's Hospital Regensburg (KUNO), University of Regensburg, Regensburg, Germany.,Division of Neonatology, University of Basel Children's Hospital (UKBB), Basel, Switzerland
| | | | - Tina Fischer
- Department of Obstetrics, Community Hospital St. Gallen, St. Gallen, Switzerland
| | - Leonhard Schäffer
- Department of Obstetrics, Community Hospital Baden, Baden, Switzerland
| | - Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Sara Fill Malfertheiner
- University Department of Obstetrics and Gynecology at the Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Germany
| | - Tilo Burkhardt
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland,
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13
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Gaertner VD, Bassler D, Zimmermann R, Fontijn JR. Reference Values for Umbilical Artery Lactate by Mode of Delivery and Gestational Age: A Retrospective Observational Study. Neonatology 2021; 118:609-616. [PMID: 34515182 DOI: 10.1159/000518748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/20/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Umbilical artery cord blood provides information about the intrauterine metabolism during labor. Umbilical artery lactate is a useful parameter in predicting neonatal morbidity, but data on normal values are limited. We aimed to provide reference ranges of umbilical artery lactate values across the combination of gestational age and mode of delivery. METHODS A single-center retrospective observational study of liveborn infants born between 23 and 42 completed weeks gestation was conducted. Lactate, base deficit (BD), and pH from arterial cord blood were assessed between June 2018 and November 2020 and compared across gestational ages and modes of delivery. RESULTS Overall, there were 3,353 infants with evaluable data. Lactate values at the 50th, 90th, and 97th percentile were 3.4, 7.0, and 9.0 mmol/L. Lactate was inversely correlated with pH (r = -0.77, p < 0.001) and positively correlated with BD (r = 0.63, p < 0.001). Lactate values changed significantly across gestational age (Kruskal-Wallis test, p < 0.001) which was attributable to an increase in lactate at 39-41 weeks gestational age. Also, lactate values were different across modes of delivery (Kruskal-Wallis test, p < 0.001) with lowest values in elective CS and highest values in vaginal instrumental deliveries. Comprehensive reference ranges across modes of delivery and gestational ages could be established. DISCUSSION Mode of delivery and gestational age contribute to lactate levels with highest values occurring in vaginal instrumental deliveries and between 39 and 41 weeks gestational age. Based on these observations, we provide detailed reference ranges for clinical use.
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Affiliation(s)
- Vincent D Gaertner
- Department of Neonatology, Newborn Research Zurich, University Hospital and University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Department of Neonatology, Newborn Research Zurich, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roland Zimmermann
- Department of Obstetrics and Gynecology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jehudith R Fontijn
- Department of Neonatology, Newborn Research Zurich, University Hospital and University of Zurich, Zurich, Switzerland
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14
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Recent Advances in Pathophysiology and Management of Transient Tachypnea of Newborn. J Perinatol 2021; 41:6-16. [PMID: 32753712 DOI: 10.1038/s41372-020-0757-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 05/22/2020] [Accepted: 07/22/2020] [Indexed: 11/08/2022]
Abstract
Transient tachypnea of newborn (TTN) results from failure of the newborn to effectively clear the fetal lung fluid soon after birth. TTN represents the most common etiology of respiratory distress in term gestation newborns and sometimes requires admission to the neonatal intensive care unit. TTN can lead to maternal-infant separation, the need for respiratory support, extended unnecessary exposure to antibiotics and prolonged hospital stays. Recent evidence also suggests that TTN may be associated with wheezing syndromes later in childhood. New imaging modalities such as lung ultrasound can help in the diagnosis of TTN and early management with distending pressure using continuous positive airway pressure may prevent exacerbation of respiratory distress.
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15
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Pryor EJ, Kitchen MJ, Croughan MK, Crossley KJ, Wallace MJ, Lee K, Te Pas AB, McGillick EV, Hooper SB. Improving lung aeration in ventilated newborn preterm rabbits with a partially aerated lung. J Appl Physiol (1985) 2020; 129:891-900. [PMID: 32816641 DOI: 10.1152/japplphysiol.00426.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Preterm newborns commonly receive intermittent positive pressure ventilation (iPPV) at birth, but the optimal approach that facilitates uniform lung aeration is unknown, particularly in a partially aerated lung. As both inflation time and exogenous surfactant facilitate uniform lung aeration, we investigated whether they can improve lung aeration and lung mechanics in a partially aerated lung immediately after birth. Preterm rabbit kittens (29 days of gestation, term ~32 days) were delivered by caesarean section and partial lung aeration was created by intubating and mechanically ventilating the right lung. The tube was then withdrawn to ventilate both lungs using inflation times of 0.2 s or 1.0 s, with or without exogenous surfactant (200 mg/kg; Curosurf) and a tidal volume (Vt) of 8 mL/kg. Simultaneous phase contrast X-ray imaging and plethysmography were used to measure lung aeration and mechanics. Kittens ventilated with longer inflation times (1.0 s) reached their target Vt with fewer inflations, required lower inflation pressures (28.5 ± 1.1 vs. 33.5 ± 1.3 cmH2O, P = 0.01) and had higher dynamic lung compliances (0.54 ± 0.3 vs. 0.40 ± 0.3 cmH2O·mL-1·kg-1, P = 0.003). Surfactant increased functional residual capacity (FRC; 31.9 ± 3.2 vs. 18.0 ± 3.9 mL/kg, P = 0.02) and the proportion of the Vt entering the previously unaerated lung but had no effect on dynamic lung compliance. Combining early surfactant treatment with longer inflation times increases FRC levels, improves dynamic lung compliance, reduces inflation pressures and markedly increases the proportion of the lungs being ventilated during iPPV in preterm kittens with a partially aerated lung.NEW & NOTEWORTHY Preterm newborns commonly receive intermittent positive pressure ventilation (iPPV) at birth, but the optimal approach that facilitates uniform lung aeration is unknown, particularly in a partially aerated lung. Using phase contrast X-ray imaging, we showed that combining a long inflation time (1.0 s) with surfactant improved lung mechanics and aeration in the immediate newborn period. The current clinical practice of using short inflation times during iPPV might be suboptimal and a different approach is needed.
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Affiliation(s)
- Emily J Pryor
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Michelle K Croughan
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Megan J Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Katie Lee
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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16
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Assessment of breath sounds at birth using digital stethoscope technology. Eur J Pediatr 2020; 179:781-789. [PMID: 31907638 DOI: 10.1007/s00431-019-03565-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/20/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Abstract
Newborn transition is a phase of complex change involving lung fluid clearance and lung aeration. We aimed to use a digital stethoscope (DS) to assess the change in breath sound characteristics over the first 2 h of life and its relationship to mode of delivery. A commercially available DS was used to record breath sounds of term newborns at 1-min and 2-h post-delivery via normal vaginal delivery (NVD) or elective caesarean section (CS). Sound analysis was conducted, and two comparisons were carried out: change in frequency profiles over 2 h, and effect of delivery mode. There was a significant drop in the frequency profile of breath sounds from 1 min to 2 h with mean (SD) frequency decreasing from 333.74 (35.42) to 302.71 (47.19) Hz, p < 0.001, and proportion of power (SD) in the lowest frequency band increasing from 0.27 (0.11) to 0.37 (0.15), p < 0.001. At 1 min, NVD infants had slightly higher frequency than CS but no difference at 2 h.Conclusion: We were able to use DS technology in the transitioning infant to depict significant changes to breath sound characteristics over the first 2 h of life, reflecting the process of lung aeration.What is Known:• Lung fluid clearance and lung aeration are critical processes that facilitate respiration and mode of delivery can impact this• Digital stethoscopes offer enhanced auscultation and have been used in the paediatric population for the assessment of pulmonary and cardiac soundsWhat is New:• This is the first study to use digital stethoscope technology to assess breath sounds at birth• We describe a change in breath sound characteristics over the first 2 h of life and suggest a predictive utility of this analysis to predict the development of respiratory distress in newborns prior to the onset of symptoms.
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17
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Bruschettini M, Hassan KO, Romantsik O, Banzi R, Calevo MG, Moresco L. Interventions for the management of transient tachypnoea of the newborn - an overview of systematic reviews. Hippokratia 2020. [DOI: 10.1002/14651858.cd013563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Matteo Bruschettini
- Lund University, Skåne University Hospital; Department of Clinical Sciences Lund, Paediatrics; Lund Sweden
- Skåne University Hospital; Cochrane Sweden; Wigerthuset, Remissgatan 4, first floor room 11-221 Lund Sweden 22185
| | | | - Olga Romantsik
- Lund University, Skåne University Hospital; Department of Clinical Sciences Lund, Paediatrics; Lund Sweden
| | - Rita Banzi
- IRCCS - Mario Negri Institute for Pharmacological Research; Laboratory of Regulatory Policies; via G La Masa 19 Milan Italy 20156
| | - Maria Grazia Calevo
- Istituto Giannina Gaslini; Epidemiology, Biostatistics Unit, IRCCS; Genoa Italy 16147
| | - Luca Moresco
- Ospedale San Paolo; Pediatric and Neonatology Unit; Savona Italy
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18
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Abstract
The transition from fetal to newborn life involves a complex series of physiological events that commences with lung aeration, which is thought to involve 3 mechanisms. Two mechanisms occur during labour, Na+ reabsorption and fetal postural changes, and one occurs after birth due to pressure gradients generated by inspiration. However, only one of these mechanisms, fetal postural changes, involves the loss of liquid from the respiratory system. Both other mechanisms involve liquid being reabsorbed from the airways into lung tissue. While this stimulates an increase in pulmonary blood flow (PBF), in large quantities this liquid can adversely affect postnatal respiratory function. The increase in PBF (i) facilitates the onset of pulmonary gas exchange and (ii) allows pulmonary venous return to take over the role of providing preload for the left ventricle, a role played by umbilical venous return during fetal life. Thus, aerating the lung and increasing PBF before umbilical cord clamping (known as physiological based cord clamping), can avoid the loss of preload and reduction in cardiac output that normally accompanies immediate cord clamping.
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19
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DeKoninck PLJ, Crossley KJ, Kashyap AJ, Skinner SM, Thio M, Rodgers KA, Deprest JA, Hooper SB, Hodges RJ. Effects of tracheal occlusion on the neonatal cardiopulmonary transition in an ovine model of diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2019; 104:F609-F616. [PMID: 30728180 DOI: 10.1136/archdischild-2018-316047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/27/2018] [Accepted: 01/02/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Fetoscopic endoluminal tracheal occlusion (FETO) aims to reverse pulmonary hypoplasia associated with congenital diaphragmatic hernia (CDH) and mitigate the associated respiratory insufficiency and pulmonary hypertension after birth. We aimed to determine whether FETO improves the cardiopulmonary transition at birth in an ovine model of CDH. METHODS In 12 ovine fetuses with surgically induced diaphragmatic hernia (DH; 80 dGA), an endotracheal balloon was placed tracheoscopically at ≈110 dGA and removed at ≈131 dGA (DH+FETO), while 10 were left untreated (DH). At ≈138 dGA, all lambs (survival at delivery: 67% [DH+FETO], 70% [DH]) were delivered via caesarean section and ventilated for 2 hours. Physiological and ventilation parameters were continuously recorded, and arterial blood-gas values were measured. RESULTS Compared with DH, DH+FETO lambs had increased wet lung-to-body-weight ratio (0.031±0.004 vs 0.016±0.002) and dynamic lung compliance (0.7±0.1 vs 0.4±0.1 mL/cmH2O). Pulmonary vascular resistance was lower in DH+FETO lambs (0.44±0.11 vs 1.06±0.17 mm Hg/[mL/min]). However, after correction for lung weight, pulmonary blood flow was not significantly different between the groups (4.19±0.57 vs 4.05±0.60 mL/min/g). Alveolar-arterial difference in oxygen tension was not significantly different between DH+FETO and DH (402±41mm Hg vs 401±45 mm Hg). CONCLUSIONS FETO accelerated lung growth in fetuses with CDH and improved neonatal respiratory function during the cardiopulmonary transition at birth. However, despite improved lung compliance and reduced pulmonary vascular resistance, there were less pronounced benefits for gas exchange during the first 2 hours of life.
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Affiliation(s)
- Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Aidan J Kashyap
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Sasha M Skinner
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Marta Thio
- Newborn Research, The Royal Women's Hospital, Melbourne, Victoria, Australia.,The Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Karyn A Rodgers
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Jan A Deprest
- Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Cluster Woman and Child, Faculty of Medicine, KU Leuven, Leuven, Belgium.,Institute for Women's Health, University College London Hospital, London, UK
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Ryan J Hodges
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Monash Women's Service, Monash Health, Melbourne, Victoria, Australia
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20
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Thio M, Dawson JA, Crossley KJ, Moss TJ, Roehr CC, Polglase GR, Davis PG, Hooper SB. Delivery of positive end-expiratory pressure to preterm lambs using common resuscitation devices. Arch Dis Child Fetal Neonatal Ed 2019; 104:F83-F88. [PMID: 29500315 DOI: 10.1136/archdischild-2017-314064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 01/29/2018] [Accepted: 02/06/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND In neonatal resuscitation, a ventilation device providing positive end-expiratory pressure (PEEP) is recommended. There is limited information about PEEP delivery in vivo, using different models of self-inflating bag (SIB) at different inflation rates and PEEP settings. METHODS We compared PEEP delivery to intubated preterm lambs using four commonly available models of paired SIBs and PEEP valves, with a T-piece, with gas flow of 8 L/min. Peak inspiratory pressure inflations of 30 cmH2O, combined with set PEEP of 5, 7 and 10 cmH2O, were delivered at rates of 20, 40 and 60/min. These combinations were repeated without gas flow. We measured mean PEEP, maximum and minimum PEEP, and its difference (PEEP reduction). RESULTS A total of 3288 inflations were analysed. The mean PEEP delivered by all SIBs was lower than set PEEP (P<0.001), although some differences were <0.5 cmH2O. In 55% of combinations, the presence of gas flow resulted in increased PEEP delivery (range difference 0.3-2 cmH2O). The mean PEEP was closer to set PEEP with faster inflation rates and higher set PEEPs. The mean (SD) PEEP reduction was 3.9 (1.6), 8.2 (1.8), 2 (0.6) and 1.1 (0.6) cmH2O with the four SIBs, whereas it was 0.5 (0.2) cmH2O with the T-piece. CONCLUSIONS PEEP delivery with SIBs depends on the set PEEP, inflation rate, device model and gas flow. At recommended inflation rates of 60/min, some devices can deliver PEEP close to the set level, although the reduction in PEEP makes some SIBs potentially less effective for lung recruitment than a T-piece.
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Affiliation(s)
- Marta Thio
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia.,PIPER - Neonatal Retrieval Services Victoria, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Jennifer A Dawson
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Timothy J Moss
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Charles C Roehr
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,Department of Paediatrics, Newborn Services, University of Oxford, John Radcliffe Hospital, NHS Foundation Trust, Oxford, UK
| | - Graeme R Polglase
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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21
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Foglia EE, te Pas AB. Effective ventilation: The most critical intervention for successful delivery room resuscitation. Semin Fetal Neonatal Med 2018; 23:340-346. [PMID: 29705089 PMCID: PMC6288818 DOI: 10.1016/j.siny.2018.04.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Lung aeration is the critical first step that triggers the transition from fetal to postnatal cardiopulmonary physiology after birth. When an infant is apneic or does not breathe sufficiently, intervention is needed to support this transition. Effective ventilation is therefore the cornerstone of neonatal resuscitation. In this article, we review the physiology of cardiopulmonary transition at birth, with particular attention to factors the caregiver should consider when providing ventilation. We then summarize the available clinical evidence for strategies to monitor and perform positive pressure ventilation in the delivery room setting.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA,
| | - Arjan B. te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands,
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22
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Abstract
PURPOSE OF REVIEW As the infant's physiology changes dramatically after birth, modern neonatal resuscitation approaches should detect and be modified in response to these changes. This review describes the changes in respiratory physiology at birth and highlights approaches that can assist these changes. RECENT FINDINGS To better target assistance given to infants at birth, the changes in lung physiology have been classified into three phases. The first phase involves lung aeration. As little or no gas exchange can occur, assistance should focus on airway liquid clearance. During the second phase, as airway liquid resides in lung tissue, assistance should focus on minimizing the complications associated with lung edema. The third phase occurs whenever the liquid is cleared from the tissue and respiratory mechanics stabilize. Although more traditional approaches are most effective during this phase, this is not the case for the first two phases. Furthermore, the glottis actively adducts during apnea in newborns and so noninvasive respiratory support requires the infant to be breathing so that the glottis will open. SUMMARY The respiratory support provided to infants at birth should match the infant's changing physiology during transition, which requires a more sophisticated approach and equipment than current recommendations.
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