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Solís-García G, Bravo MC, Pellicer A. Cardiorespiratory interactions during the transitional period in extremely preterm infants: a narrative review. Pediatr Res 2024:10.1038/s41390-024-03451-6. [PMID: 39179873 DOI: 10.1038/s41390-024-03451-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 07/03/2024] [Accepted: 07/18/2024] [Indexed: 08/26/2024]
Abstract
We aimed to review the physiology and evidence behind cardiorespiratory interactions during the transitional circulation of extremely preterm infants with fragile physiology and to propose a framework for future research. Cord clamping strategies have a great impact on initial haemodynamic changes, and appropriate transition can be facilitated by establishing spontaneous ventilation before cord clamping. Mechanical ventilation modifies preterm transitional haemodynamics, with positive pressure ventilation affecting the right and left heart loading conditions. Pulmonary vascular resistances can be minimized by ventilating with optimal lung volumes at functional residual capacity, and other pulmonary vasodilator treatments such as inhaled nitric oxide can be used to improve ventilation/perfusion mismatch. Different cardiovascular drugs can be used to provide support during transition in this population, and it is important to understand both their cardiovascular and respiratory effects, in order to provide adequate support to vulnerable preterm infants and improve outcomes. Current available non-invasive bedside tools, such as near-infrared spectroscopy, targeted neonatal echocardiography, or lung ultrasound offer the opportunity to precisely monitor cardiorespiratory interactions in preterm infants. More research is needed in this field using precision medicine to strengthen the benefits and avoid the harms associated to early neonatal interventions. IMPACT: In extremely preterm infants, haemodynamic and respiratory transitions are deeply interconnected, and their changes have a key impact in the establishment of lung aireation and postnatal circulation. We describe how mechanical ventilation modifies heart loading conditions and pulmonary vascular resistances in preterm patients, and how hemodynamic interventions such as cord clamping strategies or cardiovascular drugs affect the infant respiratory status. Current available non-invasive bedside tools can help monitor cardiorespiratory interactions in preterm infants. We highlight the areas of research in which precision medicine can help strengthen the benefits and avoid the harms associated to early neonatal interventions.
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Affiliation(s)
- Gonzalo Solís-García
- Department of Neonatology, La Paz University Hospital and IdiPaz (La Paz Hospital Institute for Health Research), Madrid, Spain.
| | - María Carmen Bravo
- Department of Neonatology, La Paz University Hospital and IdiPaz (La Paz Hospital Institute for Health Research), Madrid, Spain
- Consultant Neonatologist, Rotunda Hospital, Dublin, Ireland
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital and IdiPaz (La Paz Hospital Institute for Health Research), Madrid, Spain
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Kuypers KLAM, van Zanten HA, Heesters V, Kamlin O, Springer L, Lista G, Cavigioli F, Vento M, Núñez-Ramiro A, Kuester H, Horn S, Weinberg DD, Foglia EE, Morley CJ, Davis PG, Te Pas AB. Resuscitators' opinions on using a respiratory function monitor during neonatal resuscitation. Acta Paediatr 2023; 112:63-68. [PMID: 36177808 PMCID: PMC10092741 DOI: 10.1111/apa.16559] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/06/2022] [Accepted: 09/29/2022] [Indexed: 12/13/2022]
Abstract
AIM The aim of this study was to assess the resuscitators' opinions of the usefulness and clinical value of using a respiratory function monitor (RFM) when resuscitating extremely preterm infants with positive pressure ventilation. METHODS The link to an online survey was sent to 106 resuscitators from six countries who were involved in a multicentre trial that compared the percentage of inflations within a predefined target range with and without the RFM. The resuscitators were asked to assess the usefulness and clinical value of the RFM. The survey was online for 4 months after the trial ended in May 2019. RESULTS The survey was completed by 74 (70%) resuscitators of which 99% considered the RFM to be helpful during neonatal resuscitation and 92% indicated that it influenced their decision-making. The majority (76%) indicated that using the RFM improved their practice and made resuscitation more effective, even when the RFM was not available. Inadequate training was the key issue that limited the effectiveness of the RFM: 45% felt insufficiently trained, and 78% felt more training in using and interpreting the RFM would have been beneficial. CONCLUSION Resuscitators considered the RFM to be helpful to guide neonatal resuscitation, but sufficient training was required to achieve the maximum benefit.
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Affiliation(s)
- Kristel L A M Kuypers
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Henriëtte A van Zanten
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Veerle Heesters
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
| | - Omar Kamlin
- Royal Women's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Laila Springer
- Department of Neonatology, University Children's Hospital, Tübingen, Germany
| | - Gianluca Lista
- Department of Neonatology, V. Buzzi Children's Hospital, ASST-FBF-Sacco, Milan, Italy
| | - Francesco Cavigioli
- Department of Neonatology, V. Buzzi Children's Hospital, ASST-FBF-Sacco, Milan, Italy
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Antonio Núñez-Ramiro
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Helmut Kuester
- Neonatology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Sebastian Horn
- Neonatology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Danielle D Weinberg
- Division of Neonatology, Department of Paediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Paediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Colin J Morley
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, UK
| | - Peter G Davis
- Royal Women's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Centre, Leiden, the Netherlands
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A multi-centre randomised controlled trial of respiratory function monitoring during stabilisation of very preterm infants at birth. Resuscitation 2021; 167:317-325. [PMID: 34302924 DOI: 10.1016/j.resuscitation.2021.07.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 11/21/2022]
Abstract
AIM To determine whether the use of a respiratory function monitor (RFM) during PPV of extremely preterm infants at birth, compared with no RFM, leads to an increase in percentage of inflations with an expiratory tidal volume (Vte) within a predefined target range. METHODS Unmasked, randomised clinical trial conducted October 2013 - May 2019 in 7 neonatal intensive care units in 6 countries. Very preterm infants (24-27 weeks of gestation) receiving PPV at birth were randomised to have a RFM screen visible or not. The primary outcome was the median proportion of inflations during manual PPV (face mask or intubated) within the target range (Vte 4-8 mL/kg). There were 42 other prespecified monitor measurements and clinical outcomes. RESULTS Among 288 infants randomised (median (IQR) gestational age 26+2 (25+3-27+1) weeks), a total number of 51,352 inflations were analysed. The median (IQR) percentage of inflations within the target range in the RFM visible group was 30.0 (18.0-42.2)% vs 30.2 (14.8-43.1)% in the RFM non-visible group (p = 0.721). There were no differences in other respiratory function measurements, oxygen saturation, heart rate or FiO2. There were no differences in clinical outcomes, except for the incidence of intraventricular haemorrhage (all grades) and/or cystic periventricular leukomalacia (visible RFM: 26.7% vs non-visible RFM: 39.0%; RR 0.71 (0.68-0.97); p = 0.028). CONCLUSION In very preterm infants receiving PPV at birth, the use of a RFM, compared to no RFM as guidance for tidal volume delivery, did not increase the percentage of inflations in a predefined target range. TRIAL REGISTRATION Dutch Trial Register NTR4104, clinicaltrials.gov NCT03256578.
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