Hemodynamic effects of high frequency oscillatory ventilation with volume guarantee in a piglet model of respiratory distress syndrome

Respiratory failure is a common condition faced by critically ill neonates with respiratory distress syndrome (RDS). High frequency oscillatory ventilation (HFOV) is often used for neonates with refractory respiratory failure related to RDS. Volume guarantee (VG) mode has been added to some HFOV ventilators for providing consistent tidal volume. We sought to examine the impact of adding the VG mode during HFOV on systemic and cerebral hemodynamics, which has not been studied to date. A neonatal piglet model of moderate to severe RDS was induced by saline lavage. Piglets (full term, age 1–3 days, weight 1.5–2.4 kg) were randomized to have RDS induced and receive either HFOV or HFOV+VG (n = 8/group) or sham-operation (n = 6) without RDS. Cardiac function measured by a Millar^® catheter placed in the left ventricle as well as systemic and carotid hemodynamic and oxygen tissue saturation parameters were collected over 240 min of ventilation. Mean airway pressure, alveolar-arterial oxygen difference and left ventricular cardiac index of piglets on HFOV vs. HFOV+VG were not significantly different during the experimental period. Right common carotid artery flow index by in-situ ultrasonic flow measurement and cerebral tissue oxygen saturation (near-infrared spectroscopy) significantly decreased in HFOV+VG at 240 min compared to HFOV (14 vs. 31 ml/kg/min, and 30% vs. 43%, respectively; p<0.05). There were no significant differences in lung, brain and heart tissue markers of oxidative stress, ischemia and inflammation. HFOV+VG compared to HFOV was associated with similar left ventricular function, however HFOV+VG had a negative effect on cerebral blood flow and oxygenation.

Antenatal corticosteriods decrease forced vital capacity in infants born fullterm

Antenatal corticosteroids (ACS) administration to pregnant women for threatened preterm labor is standard obstetric care to reduce neonatal respiratory distress syndrome and the associated respiratory morbidity. While ACS stimulates surfactant production in the fetal lung, the effects of ACS upon the subsequent growth and development of the lung are unclear. Follow-up studies outside of the neonatal period have been primarily limited to spirometry, and most subjects evaluated were born prematurely. To our knowledge, no study has assessed both airway and parenchymal function in infants or adults following ACS exposure. We hypothesized that ACS impairs lung growth and performed infant pulmonary function testing, which included spirometry, alveolar volume (VA ) and lung diffusion (DL ). As a pilot study, we limited our assessment to infants whose mothers received ACS for threatened preterm labor, but then proceeded to full term delivery. This approach evaluated a more homogenous population and eliminated the confounding effects of preterm birth. We evaluated 36 full-term infants between 4 to 12 months of age; 17 infants had ACS exposure and 19 infants had no ACS exposure. Infants exposed to ACS had a significantly lower forced vital capacity compared with non-ACS exposed infants (250 vs 313 mL; P = .0075). FEV0.5 tended to be lower for the ACS exposed group (205 vs 237 mL; P = .075). VA and DL did not differ between the two groups. These findings suggest that ACS may impair subsequent growth of the lung parenchyma.

Updates on Management for Acute and Chronic Phenotypes of Neonatal Pulmonary Hypertension

Neonatal pulmonary hypertension is a heterogeneous disease in term and preterm neonates. It is characterized by persistent increase of pulmonary artery pressures after birth (acute) or an increase in pulmonary artery pressures after approximately 4 weeks of age (chronic); both phenotypes result in exposure of the right ventricle to sustained high afterload. In-depth clinical assessment plus echocardiographic measures evaluating pulmonary blood flow, pulmonary vascular resistance, pulmonary capillary wedge pressure, and myocardial contractility are needed to determine the cause and provide individualized targeted therapies. This article summarizes the causes, risk factors, hemodynamic assessment, and management of neonatal pulmonary hypertension.

The effectiveness of the neonatal diagnosis-related group scheme

The goal of this study is to investigate the effectiveness of the neonatal diagnosis-related group scheme in patients affected by respiratory distress syndrome. The variable costs of individual patients in the same group are examined. This study uses the data of infants (N = 243) hospitalized in the Neonatal Intensive Care Unit of the Gaslini Children's Hospital in Italy in 2016. The care unit's operating and management costs are employed to estimate the average cost per patient. Operating costs include those related to personnel, drugs, medical supplies, treatment tools, examinations, radiology, and laboratory services. Management costs relate to administration, maintenance, and depreciation cost of medical equipment. Cluster analysis and Tobit regression are employed, allowing for the assessment of the total cost per patient per day taking into account the main cost determinants: birth weight, gestational age, and discharge status. The findings highlight great variability in the costs for patients in the same diagnosis-related group, ranging from a minimum of €267 to a maximum of €265,669. This suggests the inefficiency of the diagnosis-related group system. Patients with very low birth weight incurred costs approximately twice the reimbursement set by the policy; a loss of €36,420 is estimated for every surviving baby with a birth weight lower than 1,170 grams. On the contrary, at term, newborns cost about €20,000 less than the diagnosis-related group reimbursement. The actual system benefits hospitals that mainly treat term infants with respiratory distress syndrome and penalizes hospitals taking care of very low birth weight patients. As a result, strategic behavior and "up-coding" might occur. We conduct a cluster analysis that suggests a birth weight adjustment to determine new fees that would be fairer than the current costs.

Blood urea in preterm infants on routine parenteral nutrition: A multiple linear regression analysis

BACKGROUND

Blood urea is considered a marker of amino acid utilization in preterm infants on routine parenteral nutrition. However, the association between blood urea and intravenous amino acid intake remains debated.

AIMS

To evaluate the association between blood urea and both nutrition and clinical data, in a large cohort of preterm infants.

METHODS

Consecutively admitted preterm infants with a gestational age of less than 32 weeks and a birth weight lower than 1250 g on routine parenteral nutrition from the first hour of life were studied. Clinical and nutrition data collected hourly during the hospitalization were used in multiple linear regression analysis.

RESULTS

We studied 674 patients and 1863 blood urea determinations. Blood urea concentration was positively associated with blood creatinine concentration, intravenous amino acid intake, patent ductus arteriosus and respiratory distress syndrome, and negatively associated with intravenous non-protein energy intakes, daily weight change, gestational age, being small for gestational age, antenatal steroids therapy and reverse flow in the umbilical artery (p < 0.001; R = 0.7).

CONCLUSIONS

From a nutrition perspective, in our large cohort of small preterm infants blood urea was positively correlated with intravenous amino acid intake and negatively correlated with intravenous non-protein energy intake. This is in line with current knowledge in human physiology and suggest that a reduction of intravenous amino acid intake based on blood urea concentrations was justified.

Quality assessment and response to less invasive surfactant administration (LISA) without sedation

BACKGROUND

Although sedative premedication for endotracheal intubation is considered standard of care, less invasive surfactant administration (LISA) is often performed without sedative premedication. The aim of this study was to assess success rates, technical quality and vital parameters in LISA without sedative premedication.

METHODS

Prospective observational study in 86 neonates <32 weeks' gestation. LISA was performed according to a standardized protocol without use of sedative premedication. Outcome measures were success rates of LISA attempts, reasons for failure and quality of technical conditions. In 37 neonates, heart rate and oxygen saturation levels from 20 min before until 30 min after start of LISA were collected.

RESULTS

In 48% of LISAs the first attempt failed and in 34% quality of technical conditions was inadequate. The success rate was significantly correlated with quality of technical conditions and experience of the performer. Desaturations <80% occurred in 54% of patients while bradycardia <80/min did not occur.

CONCLUSION

This study shows a relatively low success rate of the first attempt of LISA, frequent inadequacy of technical quality and frequent oxygen desaturations. These effects may be improved by the use of sedative premedication.

Clinical Profile of Neonates with Respiratory Distress in a Tertiary Care Hospital

Introduction: Respiratory distress in newborns is a very common reason for admission in Neonatal Intensive Care Unit which may be transient or pathological; morbidity is high if not prompted for early diagnosis and treatment. The present study is undertaken to find out the clinical profile of neonates with respiratory distress in infants in a tertiary care hospital in western Nepal. Methods: A descriptive cross-sectional study was carried out in a tertiary care hospital in the western region of Nepal from April 2017 to March 2018 after approval from the institutional review committee. Sample size was calculated and consecutive sampling was done to reach the sample size. Data were collected from the study population after taking consent and entered in a predesigned proforma. It was then entered in a Statistical Package for Social Sciences, data analysis was done to find frequency and proportion for binary data. Results: Tachypnea was the most common presentation 77 (69.36%). Out of 1694 live deliveries during the study period, the prevalence of respiratory distress was 6.55 % in the total live deliveries while 30.83 % in admitted cases in Neonatal Intensive Care Unit. Survival rate was 95.50% while mortality rate accounted for 4.50%. Conclusions: Perinatal asphyxia accounted for the commonest cause of respiratory distress. To lessen the morbidity and mortality of the neonates with respiratory distress it is advocated that we practice proper and timely neonatal resuscitation, recognize the risk factors as early as possible so that perinatal asphyxia can be minimized.      

Visual function scale for identification of infants with low respiratory compliance

AIM

Precise estimation of respiratory function is essential to optimise neonatal respiratory care. However, current clinical scores have not been validated with quantitative measures of respiratory function. The aim of this study was to develop a physiological scoring system to predict low respiratory dynamic compliance of <0.6 ml/cmH₂O/kg.

METHODS

Forty-four newborn infants were studied before (dynamic compliance) and shortly after scheduled extubation (physiological signs). A novel scoring system was developed based on the association between physiological signs and dynamic compliance.

RESULTS

The respiratory rate was identified as the primary independent variable for dynamic compliance in the univariate analysis. The prediction score for low dynamic compliance comprised the presence of nasal flaring, see-saw respiration, suprasternal/intercostal retraction, and the respiratory rate ranks (0-3). The area under the receiver-operating characteristics curve of the composite score had discriminatory capability of 0.86 (95% confidence interval: 0.75-0.97) to predict low dynamic compliance with the optimal cut-off value of ≥3 (sensitivity, 0.882; specificity, 0.667).

CONCLUSION

Our novel scoring system might help predict newborn infants with low dynamic compliance, who may require escalation of respiratory support, or transfer to higher level units.

Role of oxidative stress in neonatal respiratory distress syndrome

Respiratory distress syndrome is the commonest respiratory disorder in preterm infants. Although it is well known that preterm birth has a key role, the mechanisms of lung injury have not been fully elucidated. The pathogenesis of this neonatal condition is based on the rapid formation of the oxygen reactive species, which surpasses the detoxification capacity of anti-oxidative defense system. The high reactivity of free radical leads to damage to a variety of molecules and may induce respiratory cell death. There is evidence that the oxidative stress involved in the physiopathology of this disease, is particularly related to oxygen supplementation, mechanical ventilation, inflammation/infection and diabetes. This narrative review summarizes what is known regarding the connection between oxidative stress and respiratory distress syndrome.

Dynamic changes of pulmonary arterial pressure in perinatal neonates with pulmonary and extrapulmonary acute lung injury/respiratory distress syndrome

This study aims to explore the dynamic changes of pulmonary arterial pressure (PAP) and its clinical significance in prenatal neonates with pulmonary and extra-pulmonary acute lung injury/respiratory distress syndrome (ALI/ARDS).A prospective study was conducted in the Neonate Intensive Care Unit (NICU) between May 2015 and April 2017. A total of 78 prenatal neonates with ALI/ARDS were selected and divided into 2 groups: pulmonary group (n = 37) and extra-pulmonary group (n = 41). These neonates were further divided into 3 groups according to the OSI index: mild, moderate, and severe groups. The dynamic changes of PAP were observed in these neonates. In the moderate and severe groups, PAP was significantly higher in neonates with pulmonary ALI/ADDS (ALI/ARDSp) than in neonates with extrapulmonary ALI/ARDS(ALI/ARDSexp) (62.5 ± 5.4 vs 68.0 ± 6.5, 54.7 ± 5.9 vs 64.2 ± 4.9; t = 3.264, 3.123; P = .004,.039). Furthermore, PAP was higher in neonates with ALI/ADDSp in the severe group, compared with those in the moderate group (t = 2.420, P < .05). There was significant difference among the 3 subgroups of neonates with ALI/ADDSexp (F = 60.100, P = .000). PAP was positively correlated with the OSI index (r = 0.823). The overall dynamic PAP monitoring results revealed that PAP was higher in the pulmonary group than that in the extrapulmonary group, and this exhibited a gradually decreasing trend as the condition of the subject improved.PAP in perinatal neonates with ALI/ARDS increases in varying degrees, and its extent was related to the severity of the illness. PAP was significantly higher in neonates with ALI/ADDSp than in neonates with ALI/ADDSexp. This can be used as a monitoring indicator for the severity of illness.

Can Placental Corticotropin-Releasing Hormone Inform Timing of Antenatal Corticosteroid Administration?

CONTEXT

Antenatal corticosteroids are commonly administered to pregnant women at risk for delivering between 23 and 34 gestational weeks; they provide crucial benefits to fetal lung maturation and reduce risk for neonatal morbidity and mortality. Corticosteroids are maximally efficacious for lung maturation when administered within 2 to 7 days of delivery. Accurately identifying the timing of preterm delivery is thus critical to ensure that antenatal corticosteroids are administered within a week of delivery and to avoid unnecessary administration to women who will deliver at term. A plausible biomarker for predicting time of delivery is placental corticotropin-releasing hormone (pCRH).

OBJECTIVE

To assess whether pCRH concentrations predict time to delivery and specifically which women will deliver within a week of treatment.

DESIGN

pCRH concentrations were evaluated before administration of the corticosteroid betamethasone, and timing of delivery was recorded.

PARTICIPANTS

A total of 121 women with singleton pregnancies who were prescribed betamethasone.

RESULTS

Elevated pCRH concentrations were associated with a shorter time from treatment to delivery. Receiver-operating characteristic curves revealed that pCRH may improve the precision of predicting preterm delivery.

CONCLUSIONS

In the current sample, pCRH concentrations predicted the likelihood of delivering within 1 week of corticosteroid treatment. Current findings suggest that pCRH may be a diagnostic indicator of impending preterm delivery. Increasing the precision in predicting time to delivery could inform when to administer antenatal corticosteroids, thus maximizing benefits and reducing the likelihood of exposing fetuses who will be delivered at term.

Visual assessment versus computer-assisted gray scale analysis in the ultrasound evaluation of neonatal respiratory status

Background and aim

Lung ultrasound has been used to describe common respiratory diseases both by visual and computer-assisted gray scale analysis. In the present paper, we compare both methods in assessing neonatal respiratory status keeping two oxygenation indexes as standards.

Patients and methods

Neonates admitted to the NICU for respiratory distress were enrolled. Two neonatologists not attending the patients performed a lung scan, built a single frame database and rated the images with a standardized score. The same dataset was processed using the gray scale analysis implemented with textural features and machine learning analysis. Both the oxygenation ratio (PaO2/FiO2) and the alveolar arterial oxygen gradient (A-a) were kept as reference standards.

Results

Seventy-five neonates with different respiratory status were enrolled in the study and a dataset of 600 ultrasound frames was built. Visual assessment of respiratory status correlated significantly with PaO2/FiO2 (r = -0.55; p<0.0001) and the A-a (r = 0.59; p<0.0001) with a strong interobserver agreement (K = 0.91). A significant correlation was also found between both oxygenation indexes and the gray scale analysis of lung ultrasound scans using regions of interest corresponding to 50K (r = -0.42; p<0.002 for PaO2/FiO2; r = 0.46 p<0.001 for A-a) and 100K (r = -0.35 p<0.01 for PaO2/FiO2; r = 0.58 p<0.0001 for A-a) pixels regions of interest.

Conclusions

A semi quantitative estimate of the degree of neonatal respiratory distress was demonstrated both by a validated scoring system and by computer assisted analysis of the ultrasound scan. This data may help to implement point of care ultrasound diagnostics in the NICU.

Gestational intermittent hypoxia increases susceptibility to neuroinflammation and alters respiratory motor control in neonatal rats

Sleep disordered breathing (SDB) and obstructive sleep apnea (OSA) during pregnancy are growing health concerns because these conditions are associated with adverse outcomes for newborn infants. SDB/OSA during pregnancy exposes the mother and the fetus to intermittent hypoxia. Direct exposure of adults and neonates to IH causes neuroinflammation and neuronal apoptosis, and exposure to IH during gestation (GIH) causes long-term deficits in offspring respiratory function. However, the role of neuroinflammation in CNS respiratory control centers of GIH offspring has not been investigated. Thus, the goal of this hybrid review/research article is to comprehensively review the available literature both in humans and experimental rodent models of SDB in order to highlight key gaps in knowledge. To begin to address some of these gaps, we also include data demonstrating the consequences of GIH on respiratory rhythm generation and neuroinflammation in CNS respiratory control regions. Pregnant rats were exposed to daily intermittent hypoxia during gestation (G10-G21). Neuroinflammation in brainstem and cervical spinal cord was evaluated in P0-P3 pups that were injected with saline or lipopolysaccharide (LPS; 0.1mg/kg, 3h). In CNS respiratory control centers, we found that GIH attenuated the normal CNS immune response to LPS challenge in a gene-, sex-, and CNS region-specific manner. GIH also altered normal respiratory motor responses to LPS in newborn offspring brainstem-spinal cord preparations. These data underscore the need for further study of the long-term consequences of maternal SDB on the relationship between inflammation and the respiratory control system, in both neonatal and adult offspring.

[Effect of prone positioning on respiratory function in very preterm infants undergoing mechanical ventilation]

OBJECTIVE

To explore the effect of prone positioning on respiratory function in very preterm infants undergoing mechanical ventilation.

METHODS

A total of 83 very preterm infants treated with mechanical ventilation were enrolled in the study and were randomly assigned to supine group and prone group. Four infants withdrew from the study and 79 infants completed treatment and observation (37 in the supine group and 42 in the prone group). Infants in both groups were mechanically ventilated in a volume assist-control mode. Infants in the prone group were ventilated in the supine position for 4 hours and in the prone position for 2 hours. Ventilator parameters, arterial blood gas analysis, and vital signs were recorded before grouping, every 6 hours in the supine group, and every hour after conversion into the prone position in the prone group, respectively.

RESULTS

Fraction of inspired oxygen (FiO²), peak inspiratory pressure, mean inspiratory pressure, and duration of ventilation were significantly lower in the prone group than in the supine group (P<0.05); there were no significant differences in tidal volume or positive end-expiratory pressure between the two groups (P>0.05). The prone group had a significantly higher PO²/FiO² ratio but significantly lower oxygenation index and respiratory rate than the supine group (P<0.05). There were no significant differences in arterial oxygen tension, pH, base excess, heart rate, or mean blood pressure between the two groups (P>0.05).

CONCLUSIONS

Alternating ventilation between the prone position and supine position can improve oxygenation function, decrease the fraction of inspired oxygen, and shorten the duration of mechanical ventilation in very preterm infants undergoing mechanical ventilation.

Non-invasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with respiratory distress syndrome: Study protocol for a multi-center prospective randomized controlled trial

BACKGROUND

Invasive mechanical ventilation (IMV) is associated with the development of adverse pulmonary and non-pulmonary outcomes in very premature infants. Various modes of non-invasive respiratory support are increasingly being used to decrease the incidence of bronchopulmonary dysplasia. The aim of this trial is to compare the effect of non-invasive high-frequency oscillatory ventilation (NHFOV) and nasal continuous positive airway pressure (NCPAP) in preterm infants with respiratory distress syndrome (RDS) as a primary non-invasive ventilation support mode.

METHODS/DESIGN

In this multi-center randomized controlled trial, 300 preterm infants born at a gestational age of 266/7 to 336/7 weeks with a diagnosis of RDS will be randomized to NHFOV or NCPAP as a primary mode of non-invasive respiratory support. The study will be conducted in 18 tertiary neonatal intensive care units in China. The primary outcome is the need for IMV during the first 7 days after enrollment in preterm infants randomized to the two groups. The prespecified secondary outcomes include days of hospitalization, days on non-invasive respiratory support, days on IMV, days on supplemental oxygen, mortality, need for a surfactant, severe retinopathy of prematurity requiring laser treatment or surgery, patent ductus arteriosus needing ligation, bronchopulmonary dysplasia, abdominal distention, air leak syndromes, intraventricular hemorrhage (≥ grade 3), spontaneous intestinal perforation, necrotizing enterocolitis (≥II stage), and nasal trauma. Other secondary outcomes include Bayley Scales of Infant Development at 18-24 months of corrected age.

DISCUSSION

In recent decades, several observational studies have compared the effects of NHFOV and NCPAP in neonates as a rescue mode or during weaning from IMV. To our knowledge, this will be the first multi-center prospective, randomized controlled trial to evaluate NHFOV as a primary mode in preterm infants with RDS in China or any other part of the world. Our trial may help to establish guidelines for NHFOV in preterm infants with RDS to minimize the need for IMV, and to decrease the significant pulmonary and non-pulmonary morbidities associated with IMV.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03099694 . Registered on 4 April 2017.

EVALUATION OF DEVELOPMENTAL OUTCOMES WITH BAYLEY III TEST IN PRETERM INFANTS WITH RESPIRATORY DISTRESS SYNDROME

Aim of our study was assessment of developmental outcome of neonates with respiratory distress syndrome, evaluation of the impact of RDS on child's health, growth and neurodevelopment at 2 years of age. Case control study included 138 children, from those, 74 preterm (gestational age 32-36 weeks), who were divided into 2 study groups: I groups - involved 38 preterm with RDS and II group - 36 preterm patients without RDS and other neonatal problems. Control group included 42 patients born term with uncomplicated history. To assess the impact of RDS without other co-factors, we excluded from the study children with congenital malformations, genetic and metabolic disorders; intracranial hemorrhage, neuromuscular diseases, severe hyperbilirubinemia, sepsis, congenital infections as well as family with drug or alcohol addiction, severe mental disorder, parents younger than 17 years of age at the time of the baby's birth. The study and control group were homogenous based on family social-economic status, parents education, mean parental age, mother health status, to minimize the bias. We assessed the health status, physical growth and development of children at mean age (corrected age) of 24+4 months. Physical growth was assessed based on the WHO Standard Deviation growth charts, health status based on detailed history and clinical examination, child development was assessed using Bayley Scales of Infant and toddler development III. We calculate composite scores for each sphere and compare mean composite scores of each group to each other. Statistical analyses were based on SPSS 17. The assessment of the health shows that children with RDS as well as prematurely born children without RDS have more respiratory infections during first years of life and more hospitalization than control group. The p-value is >0,5 comparing children with RDS and children with prematurity without RDS, but p < 0,05 if we compare the both group of premature with control group of term infants. Our study does not show that RDS affects significantly the prevalence of acute respiratory infections. The main causes of hospitalization in studied as well as in control group are respiratory tract infections and diarrhea. Growth assessment does not show significant difference in child's height and head circumference, while the percentage of children with underweight according corrected age was more evident in I and II group than in control (p=0,0401). The motor composite scores are lower in premature infants with RDS, but it does not show the significant difference (p=0.7755) compared to second group of premature infants without RDS, at the same time comparing both groups to controls show significant difference (P =0.0021). Mostly were affected fine motor abilities. Assessment of the cognitive scores does not show difference between study and control groups, while the language developmental scores in first and second group were significantly lower than in control (P < 0.0001), but there was no difference between I and groups. We found that premature children at 2 years of age despite RDS have lower scores comparing to term newborns in fine motor and language development. Prematurity increases risk for neurodevelopmental impairments that is important to identify and start early intervention to improve the outcomes. It is shown that neonatal complications (Jaundice, infections, asphyxia and etc.) affect development more than prematurity itself, it is very important to conduct big cohort studies on neonates with RDS to identify the risks associated with RDS and its severity.

Thyroid function in healthy and unhealthy preterm newborns

BACKGROUND

The thyroid gland and hormonal regulation are among the most important systems to be investigated in pre-term infants. This study sought to investigate thyroid hormone levels of healthy and unhealthy pre-term infants.

METHODS

The prospective study included 53 consecutive premature infants admitted to the neonatal intensive care unit within a duration of one year. Of these preterm babies, 20 were healthy, while 33 had problems such as asphyxia or RDS. Venous blood samples were collected at baseline 0-24 hours, 7 and 14 days and FT3, FT4, and TSH levels were determined. Other data recorded included demographic characteristics of the patients and clinical variables.

RESULTS

The most frequent health problems were RDS (87.9%), sepsis (30.3%), and retinopathy of prematurity (24.2%). The mean TSH levels showed a consistent decline at three consequent measurements in both groups, which were always significantly lower in unhealthy pre-terms. In both groups, TSH levels showed significant decreases on Day 7 and Day 14 compared to the baseline levels (p<005). The levels of FT3 and FT4 consistently showed significant correlations with gestational week and birth weight at each of the three measurements.

CONCLUSION

Pre-term infants, especially those having problems, have significant hypothyroxinemia that may require thyroid hormone replacement therapy.

Recessive distal motor neuropathy with pyramidal signs in an Omani kindred: underlying novel mutation in the SIGMAR1 gene

BACKGROUND AND PURPOSE

Distal hereditary motor neuropathy (dHMN) due to sigma non-opioid intracellular receptor 1 (SIGMAR1) gene mutation (OMIM 601978.0003) is a rare neuromuscular disorder characterized by prominent amyotrophic distal limb weakness and co-existing pyramidal signs initially described in a Chinese family recently. We report an extended consanguineous Omani family segregating dHMN with pyramidal signs in an autosomal recessive pattern and describe a novel mutation in the SIGMAR1 gene underlying this motor phenotype. We also provide an update on the reported phenotypic profile of SIGMAR1 mutations.

METHODS

We utilized homozygosity mapping and whole-exome sequencing of leucocyte DNA obtained from three affected members of an Omani family who manifested with a length-dependent motor neuropathy and pyramidal signs.

RESULTS

We identified a novel C>T transition at nucleotide position 238 (c.238C>T) in exon 2 of the SIGMAR1 gene. Sanger sequencing and segregation analysis confirmed the presence of two copies of the variant in the affected subjects, unlike the unaffected healthy parents/sibling who carried, at most, a single copy. The T allele is predicted to cause a truncating mutation (p.Gln80*), probably flagging the mRNA for nonsense-mediated decay leading to a complete loss of function, thereby potentially contributing to the disease process.

CONCLUSIONS

Our finding expands the spectrum of SIGMAR1 mutations causing recessive dHMN and indicates that this disorder is pan-ethnic. SIGMAR1 mutation should be included in the diagnostic panel of a dHMN, especially if there are co-existing pyramidal signs and autosomal recessive inheritance.

Lung ultrasound in early diagnosis of neonatal transient tachypnea and its differentiation from other causes of neonatal respiratory distress

BACKGROUND

Transient tachypnea of the newborn (TTN) is one of the most common causes of neonatal respiratory distress (RD). However, distinguishing TTN from other causes of RD may be difficult during the first 12:24 h after birth. Lung ultrasonography (LUS) has been successfully utilized in the diagnosis and differential diagnosis of neonatal RD. This study aimed to investigate the diagnostic value of LUS for early diagnosis of TTN as well as differentiate it from other causes of neonatal RD in near and full term Egyptian neonates.

METHODS

LUS was performed in 65 near and full term neonates presented with RD within the first 12:24 hours of admission in NICU of Suez Canal University, Ismailia, Egypt.

RESULTS

Among the 65 neonates included in the study, 73.8% were diagnosed to have TTN, 18.5% were diagnosed to have pneumonia, 4.6% had meconium aspiration syndrome (MAS) and 3.1% had respiratory distress syndrome (RDS). The Double lung point has 69.6% sensitivity, 100% specificity, 100% PPV and 39.1% NPV for detecting TTN. We have novel data showing a positive correlation between the degree of alveolar-interstitial syndrome (AIS) and the type of oxygen support offered to neonates diagnosed with TTN.

CONCLUSION

We found LUS to be a reliable and non-invasive tool for the early diagnosis of TTN and its differentiation from other causes of neonatal RD in near and full term Egyptian neonates.

End-tidal carbon dioxide measurement in preterm infants with low birth weight

Objective

There are conflicting data regarding the use of end-tidal carbon dioxide (PetCO₂) measurement in preterm infants. The aim of this study was to evaluate the effects of different dead space to tidal volume ratios (V_D/V_T) on the correlation between PetCO₂ and arterial carbon dioxide pressure (PaCO₂) in ventilated preterm infants with respiratory distress syndrome (RDS).

Methods

We enrolled ventilated preterm infants (with assist control mode or synchronous intermittent mandatory mode) with RDS who were treated with surfactant in this prospective study. Simultaneous PetCO₂ and PaCO₂ data pairs were obtained from ventilated neonates monitored using mainstream capnography. Data obtained before and after surfactant treatment were also analyzed.

Results

One-hundred and one PetCO₂ and PaCO₂ pairs from 34 neonates were analyzed. There was a moderate correlation between PetCO₂ and PaCO₂ values (r = 0.603, P < 0.01). The correlation was higher in the post-surfactant treatment group (r = 0.786, P < 0.01) than the pre-surfactant treatment group (r = 0.235). The values of PaCO₂ and PetCO₂ obtained based on the treatment stage of surfactant therapy were 42.4 ± 8.6 mmHg and 32.6 ± 7.2 mmHg, respectively, in pre-surfactant treatment group, and 37.8 ± 10.3 mmHg and 33.7 ± 9.3 mmHg, respectively, in the post-surfactant treatment group. Furthermore, we found a significant decrease in V_D/V_T in the post-surfactant treatment group when compared to the pre-surfactant treatment group (P = 0.003).

Conclusions

V_D/V_T decreased significantly after surfactant therapy and the correlation between PetCO₂ and PaCO₂ was higher after surfactant therapy in preterm infants with RDS.

Physiological, Biochemical, and Biophysical Characterization of the Lung-Lavaged Spontaneously-Breathing Rabbit as a Model for Respiratory Distress Syndrome

Nasal continuous positive airway pressure (nCPAP) is a widely accepted technique of non-invasive respiratory support in spontaneously-breathing premature infants with respiratory distress syndrome (RDS). Surfactant administration techniques compatible with nCPAP ventilation strategy are actively investigated. Our aim is to set up and validate a respiratory distress animal model that can be managed on nCPAP suitable for surfactant administration techniques studies. Surfactant depletion was induced by bronchoalveolar lavages (BALs) on 18 adult rabbits. Full depletion was assessed by surfactant component analysis on the BALs samples. Animals were randomized into two groups: Control group (nCPAP only) and InSurE group, consisting of a bolus of surfactant (Poractant alfa, 200 mg/kg) followed by nCPAP. Arterial blood gases were monitored until animal sacrifice, 3 hours post treatment. Lung mechanics were evaluated just before and after BALs, at the time of treatment, and at the end of the procedure. Surfactant phospholipids and protein analysis as well as surface tension measurements on sequential BALs confirmed the efficacy of the surfactant depletion procedure. The InSurE group showed a significant improvement of blood oxygenation and lung mechanics. On the contrary, no signs of recovery were appreciated in animals treated with just nCPAP. The surfactant-depleted adult rabbit RDS model proved to be a valuable and efficient preclinical tool for mimicking the clinical scenario of preterm infants affected by mild/moderate RDS who spontaneously breathe and do not require mechanical ventilation. This population is of particular interest as potential target for the non-invasive administration of surfactant.

Early extubation failure in very low birth weight infants: Clinical outcomes and predictive factors

OBJECTIVE

To identify the clinical outcomes and the potential predictive factors of early extubation failure (EEF) in very low birth weight (VLBW) infants.

METHODS

A retrospective study of VLBW infants admitted to the neonatal intensive care unit (NICU) over fifteen years. Neonates were intubated and mechanically ventilated on the first day of life, and early extubated within the first 3 days. EEF was defined as the need for re-intubation within 3 days of the first extubation. A composite outcome of mortality or any major morbidity (grade 3-4 intraventricular hemorrhage or periventricular leukomalacia; stage 3-4 retinopathy of prematurity, moderate-severe bronchopulmonary dysplasia or stage 2-3 necrotizing enterocolitis) was assessed.

RESULTS

In total, 394 infants were extubated early. Of those, 347 (88%) had early extubation success (EES), whereas 47 (12%) had EEF. Incidence of the composite outcome was significantly higher in the EEF group than the EES group, even after adjusting for confounding factors. Logistic regression indicated that birth weight < 1000 g (p < 0.01), administration of≥2 doses of surfactant (p < 0.01) and administration of≥2 inotropic agents (p < 0.01) were all significantly associated with EEF. The area under the curve (AUC) for the combination of these three factors (AUC = 0.77) indicated significantly higher predictive value (p < 0.01) for EEF in VLBW infants, compared with individual factors (AUC = 0.59 for≥2 inotropic agents, AUC = 0.64 for birth weight≤1000 g and AUC = 0.66 for≥2 doses of surfactant).

CONCLUSION

EEF is associated with poor clinical outcomes in VLBW infants. The combination of birth weight and the requirement for surfactants and inotropic agents can predict EEF.

Plasma level of soluble receptor for advanced glycation end-products and aquaporin 5 in preterm infants with acute respiratory distress syndrome

BACKGROUND

The aim of this study was to determine the plasma level of soluble receptors for advanced glycation end-products (sRAGE) and aquaporin 5 (AQP5) in preterm infants with acute respiratory distress syndrome (RDS).

METHODS

Forty-three preterm infants diagnosed with RDS were the experimental group. Ten apparently healthy preterm neonate infants were as normal controls. The experimental group was further divided into three subgroups based on PaO2/FiO2 (P/F): the mild group (200<P/F<300), the moderate group (100<P/F≤200) and the severe group (P/F≤100). Collected the plasma of all 53 newborns at 24, 48 and 72 hours after birth, detected the plasma level of sRAGE and AQP5 by enzyme linked immunosorbent assay.

RESULTS

The plasma levels of sRAGE and AQP5 of the control group were significantly lower than that of experimental group at three time points (all P<0.05). The severity of RDS in preterm infants seemed to be associated with the plasma level of sRAGE and AQP5: the more severe the disease, the higher the plasma level of sRAGE and AQP5.

CONCLUSIONS

The plasma level of sRAGE and AQP5 might be associated with the severity of RDS in preterm infants.

[Tidal breathing pulmonary function after treatment in neonates with respiratory distress syndrome]

OBJECTIVE

To investigate the pulmonary function after treatment in neonates with respiratory distress syndrome (RDS) at varying disease severity levels and different gestational ages.

METHODS

A total of 107 neonates with RDS were divided into <34 weeks group (65 neonates), late preterm group (21 neonates), full-term group (21 neonates). Another 121 non-RDS children were enrolled as the control group. According to the severity of RDS, the RDS neonates were divided into mild RDS group (grades 1 and 2; 76 neonates), and severe RDS (grades 3 and 4; 21 neonates). The tidal breathing pulmonary function was measured at a corrected gestational age of 44weeks.

RESULTS

The pulmonary function parameters showed no significant differences across the groups of RDS neonates of different gestational ages; the tidal volume per kilogram of body weight (VT/kg) showed no significant difference between the RDS and non-RDS groups, while the RDS group had significantly higher ratio of time to peak tidal expiratory flow to total expiratory time (tPTEF/tE) and ratio of volume to peak tidal expiratory flow to total expiratory volume (vPTEF/vE) than the non-RDS group of the same gestational age (P<0.05). At a corrected gestational age of 44 weeks, the two groups of neonates with varying severity levels of RDS had significantly lower tPTEF/tE and vPTEF/vE than the control group (P<0.05), and tPTEF/tE and vPTEF/vE tended to decrease with the increasing severity level of RDS.

CONCLUSIONS

Neonates with RDS have significantly decreased pulmonary function than those without RDS. At a corrected gestational age of 44 weeks, the tidal breathing pulmonary function in neonates with RDS is not associated with gestational age, but is associated with the severity of RDS.

Pediatric Acute Hypoxemic Respiratory Failure: Management of Oxygenation

Acute hypoxemic respiratory failure (AHRF) is one of the hallmarks of acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), which are caused by an inflammatory process initiated by any of a number of potential systemic and/or pulmonary insults that result in heterogeneous disruption of the capillary-pithelial interface. In these critically sick patients, optimizing the management of oxygenation is crucial. Physicians managing pediatric patients with ALI or ARDS are faced with a complex array of options influencing oxygenation. Certain treatment strategies can influence clinical outcomes, such as a lung protective ventilation strategy that specifies a low tidal volume (6 mL/kg) and a plateau pressure limit (30 cm H2O). Other strategies such as different levels of positive end expiratory pressure, altered inspiration to expiration time ratios, recruitment maneuvers, prone positioning, and extraneous gases or drugs may also affect clinical outcomes. This article reviews state-of-the-art strategies on the management of oxygenation in acute hypoxemic respiratory failure in children.

In vitro assessment of the effect of proportional assist ventilation on the work of breathing

During proportional assist ventilation, elastic and resistive unloading can be delivered to reduce the work of breathing (WOB). Our aim was to determine the effects of different levels of elastic and resistive unloading on the WOB in lung models designed to mimic certain neonatal respiratory disorders. Two dynamic lung models were used, one with a compliance of 0.4 ml/cm H2O to mimic an infant with respiratory distress syndrome and one with a resistance of 300 cm H2O/l/s to mimic an infant with bronchopulmonary dypslasia. Pressure volume curves were constructed at each unloading level. Elastic unloading in the low compliance model was highly effective in reducing the WOB measured in the lung model; the effective compliance increased from 0.4 ml/cm H2O at baseline to 4.1 ml/cm H2O at maximum possible elastic unloading (2.0 cm H2O/ml). Maximum possible resistive unloading (200 cm H2O/l/s) in the high-resistance model only reduced the effective resistance from 300 to 204 cm H2O/l/s. At maximum resistive unloading, oscillations appeared in the airway pressure waveform.

CONCLUSION

Our results suggest that elastic unloading will be helpful in respiratory conditions characterised by a low compliance, but resistive unloading as currently delivered is unlikely to be of major clinical benefit.

WHAT IS KNOWN

• During PAV, the ventilator can provide elastic and resistive unloading. What is New: • Elastic unloading was highly effective in reducing the work of breathing. • Maximum resistive unloading only partially reduced the effective resistance.

[The characteristics of function of endothelium in premature neonates with respiratory distress-syndrome]

The examined sampling consisted of 637 premature neonates in early neonatal period at 1-3 and 5-8 days of life. The analysis was applied to indices characterizing epithelium condition and regulating its function. It is noted that in premature neonates with respiratory distress-syndrome of derangement of regulation of function of endothelium are accompanied by increasing of hemostatic disorders and is characterized by increasing of thrombogenic and adhesive characteristics, decreasing of levels of VEGF, higher content of nitric oxide in the form of nitrites, cytokinemia and activation of complement systems.

Recognition of Undiagnosed Neonatal Heart Disease

Heart defects are the most common congenital malformation. Approximately 8000 infants per year in the United States require diagnosis in the newborn period to avoid severe injury or death. It is incumbent on the neonatologist and pediatrician to expeditiously detect the presence of symptomatic heart disease so that infants can be stabilized before cardiovascular decompensation. Evaluating infants and further categorizing them into the particular pathophysiology are necessary to stabilize them in anticipation of more definitive care by the pediatric cardiac team.

Effect of Minimally Invasive Surfactant Therapy on Lung Volume and Ventilation in Preterm Infants

OBJECTIVE

To assess the changes in (regional) lung volume and gas exchange during minimally invasive surfactant therapy (MIST) in preterm infants with respiratory distress syndrome.

STUDY DESIGN

In this prospective observational study, infants requiring a fraction of inspired oxygen (FiO2) ≥ 0.30 during nasal continuous positive airway pressure of 6 cmH2O were eligible for MIST. Surfactant (160-240 mg/kg) was administered in supine position in 1-3 minutes via an umbilical catheter placed 2 cm below the vocal cords. Changes in end-expiratory lung volume (EELV), tidal volume, and its distribution were recorded continuously with electrical impedance tomography before and up to 60 minutes after MIST. Changes in transcutaneous oxygen saturation (SpO2) and partial carbon dioxide pressure, FiO2, respiratory rate, and minute ventilation were recorded.

RESULTS

A total of 16 preterm infants were included. One patient did not finish study protocol because of severe apnea 10 minutes after MIST. In the remaining infants (gestational age 29.8 ± 2.8 weeks, body weight 1545 ± 481 g) EELV showed a rapid and sustained increase, starting in the dependent lung regions, followed by the nondependent regions approximately 5 minutes later. Oxygenation, expressed as the SpO2/FiO2 ratio, increased from 233 (IQR 206-257) to 418 (IQR 356-446) after 60 minutes (P < .001). This change was significantly correlated with the change in EELV (ρ = 0.70, P < .01). Tidal volume and minute volume decreased significantly after MIST, but transcutaneous partial carbon dioxide pressure was comparable with pre-MIST values. Ventilation distribution remained unchanged.

CONCLUSIONS

MIST results in a rapid and homogeneous increase in EELV, which is associated with an improvement in oxygenation.

Congenital lobar emphysema

Congenital lobar emphysema is a rare variety of congenital malformation of lung characterized by over distension of a lobe of the lung due to partial obstruction of the bronchus. It is one of the rare causes of infantile respiratory distress requiring surgical resection of affected lobe. We are reporting the case of an 8-week-old baby who presented with respiratory distress related to CLE affecting the left upper lobe. Lobectomy was performed under general anaesthesia followed by an uneventful recovery.

Hemodynamic Effects of Nasal Intermittent Positive Pressure Ventilation in Preterm Infants

Nasal intermittent positive pressure ventilation (NIPPV) and nasal continuous positive airway pressure (NCPAP) have proven to be effective modes of noninvasive respiratory support in preterm infants. Although they are increasingly used in neonatal intensive care, their hemodynamic consequences have not been fully evaluated. The aim of this study was to investigate the hemodynamic changes between NIPPV and NCPAP in preterm infants.This prospective observational study enrolled clinically stable preterm infants requiring respiratory support received NCPAP and nonsynchronized NIPPV at 40/minute for 30 minutes each, in random order. Cardiac function and cerebral hemodynamics were assessed by ultrasonography after each study period. The patients continued the study ventilation during measurements.Twenty infants with a mean gestational age of 27 weeks (range, 25-32 weeks) and birth weight of 974 g were examined at a median postnatal age of 20 days (range, 9-28 days). There were no significant differences between the NCPAP and NIPPV groups in right (302 vs 292 mL/kg/min, respectively) and left ventricular output (310 vs 319 mL/kg/min, respectively), superior vena cava flow (103 vs 111 mL/kg/min, respectively), or anterior cerebral artery flow velocity.NIPPV did not have a significant effect on the hemodynamics of stable preterm infants. Future studies assessing the effect of NIPPV on circulation should focus on less stable and very preterm infants.

Randomized controlled trial to compare sleep and wake in preterm infants less than 32weeks of gestation receiving two different modes of non-invasive respiratory support

AIM

To determine whether respiratory support via heated humidified high flow nasal cannulae (HHHFNC) results in infants <32weeks gestation spending a greater proportion of time in sleep compared to those receiving nasal continuous positive airway pressure (NCPAP).

METHODS

A subgroup of infants enrolled in a randomized controlled trial to compare HHHFNC or NCPAP post-extubation had sleep and wake activity measured by actigraphy for 72hours post-extubation. Activity diaries were completed contemporaneously to record episodes of infant handling. Actigraphy data were downloaded with known periods of handling excluded from the analysis.

RESULTS

28 infants with mean gestation of 28.3weeks (SD 2) and birth weight 1074g (SD 371) were studied. Infants receiving HHHFNC spent a lesser proportion of time in sleep 59.8% (SD 18.5) than those on NCPAP 82.2% (SD 23.8) p=0.004. Infants receiving HHHFNC had a lower sleep efficiency and higher mean activity score than those on NCPAP (p=0.003, p=0.002, respectively).

CONCLUSION

Infants receiving HHHFNC had a higher mean activity score and spent less time in sleep than those allocated NCPAP. Further study of sleep wake activity in preterm infants receiving respiratory support is required as this may impact on neurodevelopmental outcomes.

Do Sustained Lung Inflations during Neonatal Resuscitation Affect Cerebral Blood Volume in Preterm Infants? A Randomized Controlled Pilot Study

BACKGROUND

Sustained lung inflations (SLI) during neonatal resuscitation may promote alveolar recruitment in preterm infants. While most of the studies focus on respiratory outcome, the impact of SLI on the brain hasn't been investigated yet.

OBJECTIVE

Do SLI affect cerebral blood volume (CBV) in preterm infants?

METHODS

Preterm infants of gestation 28 weeks 0 days to 33 weeks 6 days with requirement for respiratory support (RS) were included in this randomized controlled pilot trial. Within the first 15 minutes after birth near-infrared spectroscopy (NIRS) measurements using 'NIRO-200-NX' (Hamamatsu, Japan) were performed to evaluate changes in CBV and cerebral tissue oxygenation. Two groups were compared based on RS: In SLI group RS was given by applying 1-3 SLI (30 cmH2O for 15 s) continued by respiratory standard care. Control group received respiratory standard care only.

RESULTS

40 infants (20 in each group) with mean gestational age of 32 weeks one day (±2 days) and birth weight of 1707 (±470) g were included. In the control group ΔCBV was significantly decreasing, whereas in SLI group ΔCBV showed similar values during the whole period of 15 minutes. Comparing both groups within the first 15 minutes ΔCBV showed a tendency toward different overall courses (p = 0.051).

CONCLUSION

This is the first study demonstrating an impact of SLI on CBV. Further studies are warranted including reconfirmation of the present findings in infants with lower gestational age. Future investigations on SLI should not only focus on respiratory outcome but also on the consequences on the developing brain.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00005161 https://drks-neu.uniklinik-freiburg.de/drks_web/setLocale_EN.do.

Hemodynamic management of the preterm infant with acute respiratory failure: role of the functional echocardiography

The functional echocardiography is a useful tool to evaluate the hemodynamic status of preterm infants, often needing a respiratory support during the first critical days of life. In NICU it can be helpful either for the clinical monitoring or the therapeutic management and the use of this technique can potentially improve short-term outcome of preterm infants.

Respiratory Development and Respiratory Distress Syndrome

Respiratory development is crucial for all newborn infants. Premature infants may be born at an early stage of development and lack sufficient surfactant production. This results in respiratory distress syndrome. This article reviews the normal fetal development of the lung as well as the disorder that develops because of an early birth.

Congenital chylothorax in newborn with trisomy 21

Neonatal chylothorax results from the accumulation of chyle in the pleural space and may be either congenital or an acquired condition. Congenital chylothorax is most likely due to abnormal development or obstruction of the lymphatic system. It is often associated with hydrops fetalis. It can be idiopathic or may be associated with various chromosomal anomalies including Trisomy 21, Turner syndrome, Noonan syndrome, and other genetic abnormalities. Congenital pulmonary lymphangiectasia and generalized lymphangiomatosis have also been reported to be associated with congenital chylothorax. Several case reports indicate that congenital chylothorax can recur in subsequent offspring, suggesting a possible underlying genetic etiology. It is important to identify infants with chylothorax, as there are specific issues that need to be addressed in the management of these patients. We present a case of newborn with trysomy 21 (trisomy 21 was diagnosed antenatally by amniocentesis with support of Association "Perinatology"), who developed moderate Respiratory Distress Syndrome, chest X-ray and US reveal pleural effusion on right side rapid intervention was made before deterioration, requiring intensive life-saving measures. In the neonate, chylous effusion is not a common cause of pleural effusions. It is characterized as an exudate because of the high protein and lipid content once the infant is fed. The fluid will be clear/yellow to slightly cloudy in the unfed state and will quickly become milky following feeding, as chylomicrons appear in the fluid. Lymphocytes predominate in the differential cell count of chyle. The volume of fluid output can be high, and management can be challenging. We review the common manifestations of congenital chylotoraxes and emphasize the importance of early diagnosis and intervention in preventing devastating outcomes from this condition.

[Application of lung recruitment maneuver in preterm infants with respiratory distress syndrome ventilated by proportional assist ventilation]

OBJECTIVE

To understand the effect of lung recruitment maneuver (LRM) with positive end-expiratory pressure (PEEP) on oxygenation and outcomes in preterm infants with respiratory distress syndrome (RDS) ventilated by proportional assist ventilation (PAV).

METHOD

From January 2012 to June 2013, thirty neonates with a diagnosis of RDS who required mechanical ventilation were divided randomly into LRM group (n=15, received an LRM and surport by PAV) and control group (n=15, only surport by PAV). There were no statistically significant differences in female (7 vs. 6); gestational age [(29.3±1.2) vs. (29.5±1.1) weeks]; body weight[(1,319±97) vs. (1,295±85) g]; Silverman Anderson(SA) score for babies at start of ventilation (7.3±1.2 vs. 6.9±1.4); initial FiO2 (0.54±0.12 vs. 0.50±0.10) between the two groups (all P>0.05). LRM entailed increments of 0.2 cmH2O (1 cmH2O=0.098 kPa) PEEP every 5 minutes, until fraction of inspired oxygen (FiO2)=0.25. Then PEEP was reduced and the lung volume was set on the deflation limb of the pressure/volume curve.When saturation of peripheral oxygen fell and FiO2 rose, we reincremented PEEP until SpO2 became stable. The related clinical indicators of the two group were observed.

RESULT

The doses of surfactant administered (1.1±0.3 vs. 1.5±0.5, P=0.027), Lowest FiO2 (0.29±0.05 vs. 0.39±0.06, P=0.000), time to lowest FiO2[ (103±18) vs. (368±138) min, P=0.000] and O2 dependency [(7.6±1.0) vs.( 8.8±1.3) days, P=0.021] in LRM group were lower than that in control group (all P<0.05). The maximum PEEP during the first 12 hours of life [(8.4±0.8) vs. (6.8±0.8) cmH2O, P=0.000] in LRM group were higher than that in control group (P<0.05). FiO2 levels progressively decreased (F=35.681, P=0.000) and a/AO2 Gradually increased (F=37.654, P=0.000). No adverse events and no significant differences in the outcomes were observed.

CONCLUSION

LRM can reduce the doses of pulmonary surfactant administered, time of the respiratory support and the oxygen therapy in preterm children with RDS.

Respiratory mechanics during NCPAP and HHHFNC at equal distending pressures

OBJECTIVE

To compare the effect of heated, humidified, high-flow nasal cannula (HHHFNC) and nasal continuous positive airways pressure (NCPAP) on lung function and mechanics in preterm infants with respiratory distress syndrome (RDS) at the same level of retropharyngeal pressure (Prp).

DESIGN

Randomised crossover trial.

SETTING

Neonatal intensive care unit, Ospedale Maggiore Policlinico, Milan, Italy.

PATIENTS

20 preterm infants (gestational age: 31±1 wks) with mild-moderate RDS requiring non-invasive respiratory support within 96 h after birth.

INTERVENTIONS

Infants were exposed to a randomised sequence of NCPAP and HHHFNC at different settings (2, 4 and 6 cmH₂O for NCPAP and 2, 4, 6 L/min for HHHFNC) to enable comparison at the same level of Prp.

MAIN OUTCOME MEASURES

Tidal volume by respiratory inductance plethysmography, pleural pressure estimated by oesophageal pressure, and gas exchange were evaluated at each setting and used to compute breathing pattern parameters, lung mechanics and work of breathing (WOB).

RESULTS

A poor linear regression between flow and Prp was found during HHHFNC (Prp=0.3+0.7*flow; r²=0.37). Only in 15 out of 20 infants it was possible to compare HHHFNC and NCPAP at a Prp of 2 and 4 cmH₂O. No statistically significant differences were found in breathing pattern, gas exchange, lung mechanics and total WOB. Resistive WOB in the upper airways was slightly but significantly higher during HHHFNC (0.65 (0.49;1.09) vs 1.57 (0.85;2.09) cmH₂O median (IQR)).

CONCLUSIONS

Despite differing mechanisms for generating positive airway pressure, when compared at the same Prp, NCPAP and HHHFNC provide similar effects on all the outcomes explored.

Response of smooth bronchial musculature in bronchoconstrictor substances in newborn with lung atelectasis at the respiratory distress syndrome (RDS)

Objective:

Role of the atelectasis (hypoxia) in the respiratory system of the live and exited newborn (250 up to 3000 g. of body weight), which has died due to different causes was studied in this work.

Methods:

Response of tracheal rings to dopamine, serotonine and ethanol in the different molar concentrations (dopamine: 0,05 mg/ml, 0,5 mg/ml, 5 mg/ml; serotonine (5-HT): 10^-4, 10^-3, 10^-2, 10^-1 mol/dm³; ethanol: 0,2 ml, 0,5 ml, 1,0 ml; 96%) was followed up. Study of the smooth tracheal musculature tone (STM) was elaborated in 16 tracheal preparations taken following the newborn death due to different causes.

Results:

Based on functional researches of tracheal isolated preparations, it was ascertained as follows: atelectasis (cases born with lung hypoxia) has changed the response of STM to dopamine, serotonine and ethanol in a significant manner (p<0,01) in comparison to cases of controlling group, which has died due to lung inflammatory processes (e.g. pneumonia, bronchopneumonia, cerebral hemorrhage), which have also caused significant response (p<0,05).

Conclusion:

Results suggest that exited cases from lung atelectasis and cases of controlling group reacts to above mentioned substances by causing significant constrictor action of tracheobronchial system.

Respiratory distress syndrome in newborns of gestational age of over 32 weeks

Albeit the aetiology of the respiratory distress syndrome (RDS) is well known, the paper shall demonstrate that the causes of RDS changed over the years 2006 and 2010. This retrospective study comprises analysis of the data collected from 60 newborns of over 32 weeks gestation with RDS in the Neonatal Intensive Care Unit at the Clinical Hospital Centre in Osijek. The focus of the paper lies in the difference in the incidence of RDS over two research periods (2006 and 2010), the most common and possible causes of RDS in newborns of over 32 weeks gestation as well as in the potential changes in the aetiology over the two research periods. An increase in the incidence of RDS was established in 2010, but it was statistically significant only for newborns of gestational age of 35 1/7 to 36 6/7 weeks. The most common cause of RDS in both research periods was sepsis, which decreased in its share in 2010, whereas the incidence of asphyxia and complications during pregnancy increased. The new potential cause in 2010 was maternal thrombophilia. The share of unknown causes of RDS decreased, although not significantly so. The results of the research indicate that the causes of RDS changed over the observed periods and that further research should focus on thrombophilia and other complications during pregnancy with the aim of reducing morbidity and improving neonatal outcomes as well as further reducing the incidence of RDS with unknown causes in newborns.

[Application of exogenous surfactant and recruitment maneuver in newborns with respiratory distress-syndrome]

Respiratory distress-syndrome (RDS) in newborns is a one of the most frequent critical conditions of neonatal period requires the use of invasive methods of respiratory support.

PURPOSE OF THE STUDY

To define an efficiency of complex application of exogenous surfactant and recruitment maneuver in newborns with RDS.

MATERIALS AND METHODS

30 newborns with RDS and progressive hypoxemia were included in the study. Average mass of body was 1575 grams. In 11 newborns RDS was accompanied severe hypoxemia and required the application of recruitment maneuver and exogenous surfactant administration.

RESULTS

Application of recruitment maneuver with exogenous surfactant administration allow to improve gas exchange and blood oxygenation in newborns with RDS (PaO2 54 vs 39 mmHg; SpO2 95 vs 90% and blood pH 7.34 vs 7.28). Application of recruitment maneuver with exogenous surfactant administration decrease number of complications and improve outcomes.

Increased incidence of neonatal respiratory distress in infants with mucopolysaccharidosis type II (MPS II, Hunter syndrome)

Records were reviewed on all patients with mucopolysaccharidosis type II (Hunter syndrome) seen at a single institution from 1999 to 2013 to identify those with a history of neonatal intensive care. Eleven of 34 patients were in a neonatal intensive care unit and all had respiratory distress with 8 diagnoses of respiratory distress syndrome and 3 of transient tachypnea of the newborn. None of the infants were premature; four were delivered by cesarean section. These findings suggest that respiratory distress is more commonly observed in neonates with MPS II than in the general population. This may reflect airway disease already present in this disorder at the time of birth.

Frequency-modulated orocutaneous stimulation promotes non-nutritive suck development in preterm infants with respiratory distress syndrome or chronic lung disease

OBJECTIVE

For the premature infant, extrauterine life is a pathological condition, which greatly amplifies the challenges to the brain in establishing functional oromotor behaviors. The extent to which suck can be entrained using a synthetically patterned orocutaneous input to promote its development in preterm infants who manifest chronic lung disease (CLD) is unknown. The objective of this study was to evaluate the effects of a frequency-modulated (FM) orocutaneous pulse train delivered through a pneumatically charged pacifier capable of enhancing non-nutritive suck (NNS) activity in tube-fed premature infants.

STUDY DESIGN

A randomized trial to evaluate the efficacy of pneumatic orocutaneous stimulation 3 × per day on NNS development and length of stay (LOS) in the neonatal intensive care unit among 160 newborn infants distributed among three sub-populations, including healthy preterm infants, respiratory distress syndrome (RDS) and CLD. Study infants received a regimen of orocutaneous pulse trains through a PULSED pressurized silicone pacifier or a SHAM control (blind pacifier) during gavage feeds for up to 10 days.

RESULT

Mixed modeling, adjusted for the infant's gender, gestational age, postmenstrual age and birth weight, was used to handle interdependency among repeated measures within subjects. A significant main effect for stimulation mode (SHAM pacifier vs PULSED orosensory) was found among preterm infants for NNS bursts per min (P=0.003), NNS events per min (P=0.033) and for total oral compressions per min (NNS+nonNNS) (P=0.016). Pairwise comparison of adjusted means using Bonferroni adjustment indicated RDS and CLD infants showed the most significant gains on these NNS performance indices. CLD infants in the treatment group showed significantly shorter LOS by an average of 2.5 days.

CONCLUSION

FM PULSED orocutaneous pulse train stimuli delivered through a silicone pacifier are effective in facilitating NNS burst development in tube-fed RDS and CLD preterm infants, with an added benefit of reduced LOS for CLD infants.

[Severity of the lung disease index in infants with respiratory distress syndrome]

Optimization of respiratory support and prevention of ventilator-associate lung injure are the most important problems of neonatal resuscitation and intensive care.

THE AIM OF THE STUDY

To improve the results of intensive care for respiratory failure in preterm infants by optimizing respiratory support on the basis of the analysis of the biomechanical characteristics of the lungs and blood gas.

MATERIALS AND METHODS

The study included 138 infants with birth weight 1500g (1300-1740g) and a gestational age of 30.5 (29-32) weeks in need of mechanical ventilation. Apgar score at one minute was equal to 5.0 (4.0-6.0) points, and the fifth--7.0 (6.0-7.0) points. Biomechanical properties of light investigated the dynamic lung compliance, aerodynamic upper airway resistance, the coefficient of hyperextension, the time constant and the coefficient of RVR, reflecting the patient's spontaneous breathing pattern were evaluated.

RESULTS

It was found that the most significant biomechanical characteristics of lungs, reflecting the severity of the respiratory failure are the dynamic compliance, aerodynamic airway resistance, coefficient C20/C, and the time constant. Correlation between the index of oxygenation, clinical assessment of the severity of respiratory failure and the duration of control mechanical ventilation was demonstrated.

CONCLUSION

Rate of hyperextension and time constant are expressed by the correlation with the level of the oxygenation index, which allows them to be used for screening evaluation of severity critically ill patients during admission to the neonatal intensive care unit.

A comparison of supine and prone positioning on improves arterial oxygenation in premature neonates

BACKGROUND

Respiratory distress syndrome (RDS) is one of the most important causes of mortality and morbidity in premature newborns. The aim of this study was to determine the effect of body position on oxygen saturation in hospitalized premature infants with RDS.

METHODS

From June 2010 to December 2012, 69 premature infants with RDS were evaluated in an interventional analytic study. Patients had a mean gestational age (±SD) of 31.4 (±2.41) weeks (range: 28-35 weeks) with a mean birth weight (±SD) of 1446.6 (±218.90) grams (range: 850-2400 grams). Infants were studied both in supine and in prone positions. Oxygen saturation was monitored by trans-cutaneous pulse oximeter and oxygen saturation was continually monitored for 3 hours in each position and mean oxygen saturation was calculated at the end of each 3 hour period. All patients were premature, NPO, oxygen dependent and had RDS. The range of the postnatal age of the studied infants was 24-48 hr.

RESULTS

Means (±SD) of oxygen saturation during 3 hours in prone and supine positions were 92.54% (±2.24%) and 91.78% (±2.35%), respectively (p = 0.001). Also means (±SD) of oxygen saturation at the end of each 3-hours period prone and supine positions were 91.30% (±2.42%) and 90.30% (±3.15%), respectively (p = 0.006).

CONCLUSION

These findings suggest that, in premature infants with RDS, oxygen saturation was significantly higher in the prone compared with the supine posture.

Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis

OBJECTIVE

To assess the role of nasal continuous positive airway pressure (CPAP) initiated at birth for prevention of death and bronchopulmonary dysplasia in very preterm infants.

DESIGN

Systematic review.

DATA SOURCES

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and online Pediatric Academic Society abstracts from the year of inception to June 2013.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials evaluating the effect of nasal CPAP compared with intubation in preterm infants born at less than 32 weeks' gestation and presenting the outcomes of either death or bronchopulmonary dysplasia, or both (defined as the need for oxygen support or mechanical ventilation at 36 weeks corrected gestation), during hospital stay.

RESULTS

Four randomised controlled trials (2782 participants) met the inclusion criteria, with 1296 infants in the nasal CPAP group and 1486 in the intubation group. All the trials reported bronchopulmonary dysplasia independently at 36 weeks corrected gestation, with borderline significance in favour of the nasal CPAP group (relative risk 0.84, 95% confidence interval 0.68 to 1.04, risk difference -0.02, 95% confidence interval -0.04 to 0.01). [corrected] No difference in death was observed (relative risk 0.88, 0.68 to 1.14, risk difference -0.02, -0.04 to 0.01, respectively). Pooled analysis showed a significant benefit for the combined outcome of death or bronchopulmonary dysplasia, or both, at 36 weeks corrected gestation for babies treated with nasal CPAP (relative risk 0.90 (95% confidence interval 0.83 to 0.98, risk difference -0.04 (95% confidence interval -0.08 to -0.00), NNT [corrected] of 25).

CONCLUSION

One additional infant could survive to 36 weeks without bronchopulmonary dysplasia for every 25 babies treated with nasal CPAP in the delivery room rather than being intubated.

A comparison of two nasal continuous positive airway pressure interfaces--a randomized crossover study

BACKGROUND

In spite of widespread use of nasal CPAP there are comparatively few studies to guide the choice of nasal prongs.

OBJECTIVES

To determine whether the Fisher & Paykel Healthcare (FPH) neonatal continuous positive airway pressure (CPAP) interface was effective in providing bubble CPAP when compared to the Hudson prong interface.

METHODS

The study was a randomized cross-over study of twenty newborn infants 500 g or more requiring CPAP for respiratory support at birth. Infants were randomized to either the Fisher & Paykel Healthcare or Hudson CPAP interface for twenty four hours. Crossover between interfaces occurred after subsequent twenty four hour periods. The primary outcome was the provision of desired CPAP pressures, defined as provision of CPAP within ± one cm H2O of set pressure.

RESULTS

The percentage time CPAP was within ± one cm H2O of set pressure was 66.5% for the Hudson and 71.8% for the FPH interface (p = 0.66). Oxygen saturations for the Hudson interface were in target range for a median of 97.8% of the time, and, with the FPH interface, for a median of 98.2% of the time (p = 0.76). Clinically significant differences in primary or secondary outcomes between the two groups were not detected.

CONCLUSIONS

The nasal CPAP interfaces studied were equally effective in achieving desired bubble CPAP pressures and target saturations.

Effects of perinatal risk factors on common neonatal respiratory morbidities beyond 36 weeks of gestation

OBJECTIVE

To assess the incidence of respiratory morbidity (RM) in all single live neonates born more than 36 weeks of gestation, and the effects of perinatal characteristics on these morbidities.

METHODS

This is a prospective hospital based study covering a 12-month period. The study took place at the Department of Pediatrics, Jordan University Hospital, Amman, Jordan, between January and December 2009. The effects of different perinatal characteristics on RM including transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS) were analyzed.

RESULTS

A total of 2282 newborns were included. One thousand two hundred and seventy-six (55.9%) of the newborns were delivered by vaginal delivery and 1,006 (44%) by cesarean section (CS) (24.5% by emergency CS and 19.5% by elective CS). Respiratory morbidity was reported in 3.7%. The incidence of TTN was 2.9% and RDS was 0.7%. Elective CS was found to be a risk factor for RM development when the gestational age was less than 39 weeks. Maternal hypertension and diabetes mellitus, and the absence of labor were independent risk factors for RM. The emergency CS and large for gestational age babies were risk factors for TTN, while male gender and GA less than 37 0+6 weeks were risk factor for RDS.

CONCLUSION

The collaborative obstetric and neonatology responsibility helps to identify the risk factors for adverse respiratory outcome when considering the time and mode of delivery. The pregnant mother should be informed regarding this possibility if delivery by elective CS is performed before the 39 0+6 weeks of gestation.