Detection of positional airway obstruction in neonates by acoustic reflection

In neonates intubated with an uncuffed endotracheal tube (ETT), positional changes of the head may induce obstruction (side position-related ETT obstruction [SPRO]) due to abutment of the beveled distal ETT orifice against the tracheal wall. We studied whether the acoustic reflection (ACR) method, a 4-s measurement that maps cross-sectional area as a function of the distance along the ETT and the airways, could detect SPRO. Eleven preterm newborns intubated with 2.5-mm ETTs and clinically suspected of having SPRO were studied with the head oriented to the left and to the right. In all patients there was a marked decrease in the ACR-measured area beyond the distal tip of the ETT in the presence of obstruction (decrease = 38 +/- 22% [mean +/- SD] of the ETT inside area), while the ACR-measured area increased markedly in the absence of obstruction (increase = 49 +/- 17%). For six of the 11 infants, we also recorded the maximal flow produced by a set mechanical inflation pressure. This maximal flow decreased in the presence of obstruction (decrease = 47 +/- 18%), and was constantly associated with a decrease in ACR-measured area beyond the ETT. In conclusion, ACR measurement is an efficient method for diagnosing positional ETT obstruction in intubated newborns.

Estimation of inspiratory pressure drop in neonatal and pediatric endotracheal tubes

Endotracheal tubes (ETTs) constitute a resistive extra load for intubated patients. The ETT pressure drop (DeltaP(ETT)) is usually described by empirical equations that are specific to one ETT only. Our laboratory previously showed that, in adult ETTs, DeltaP(ETT) is given by the Blasius formula (F. Lofaso, B. Louis, L. Brochard, A. Harf, and D. Isabey. Am. Rev. Respir. Dis. 146: 974-979, 1992). Here, we also propose a general formulation for neonatal and pediatric ETTs on the basis of adimensional analysis of the pressure-flow relationship. Pressure and flow were directly measured in seven ETTs (internal diameter: 2.5-7.0 mm). The measured pressure drop was compared with the predicted drop given by general laws for a curved tube. In neonatal ETTs (2.5-3.5 mm) the flow regime is laminar. The DeltaP(ETT) can be estimated by the Ito formula, which replaces Poiseuille's law for curved tubes. For pediatric ETTs (4.0-7.0 mm), DeltaP(ETT) depends on the following flow regime: for laminar flow, it must be calculated by the Ito formula, and for turbulent flow, by the Blasius formula. Both formulas allow for ETT geometry and gas properties.

Apnea threshold and breathing rhythmicity in newborn lambs

This study was designed to determine the effect of the removal of chemical stimuli on breathing rhythmicity in awake newborn lambs; it was also designed to define the chemical threshold below which breathing would stop [arterial PCO2 (PaCO2) apnea threshold]. We used a technique of graded extracorporeal CO2 removal with apneic oxygenation in three groups of animals according to age and carotid body (CB) integrity: < 2 days, CB intact (n = 5); 12 days, CB intact (n = 7); and 12 days, CB denervated (CBD; n = 5). In all animals, whatever their age and CB status, suppression of the chemical drive resulted in sustained apnea. The study, performed at four constant levels of oxygenation (hyperoxia, normoxia, moderate hypoxia, and severe hypoxia), allowed precise determination of the PaCO2 apnea threshold. We found that this PaCO2 apnea threshold depended on the degree of postnatal maturation (it was higher in the younger lambs), the level of arterial oxygenation (it was lowered by hypoxia), and CB status (it was higher in CBD animals). Moreover, we found that the 12-day-old CBD lambs breathe at a level of PaCO2 set close to the point of apnea.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic and cardiorespiratory effects of doxapram and theophylline in sleeping newborn piglets

To evaluate the contribution of a change in metabolic rate to ventilatory changes after the administration of respiratory stimulants, we studied the effect of two respiratory stimulants, doxapram and theophylline, on ventilation and metabolic rate during sleep in piglets. Metabolic rate (O2 consumption and CO2 production) was measured in a metabolic chamber, and alveolar ventilation (VA) was derived from arterial PCO2 and CO2 production. We studied the animals during a baseline period and for 2 h after the administration of theophylline or doxapram. With doxapram, there was no change in VA, metabolic rate, or arterial PCO2. In contrast, with theophylline, VA increased [20 +/- 14% (SD), P less than 0.003] as a result of both an increased metabolic rate and hyperventilation. Doxapram, however, increased mean blood pressure (from 67 +/- 11 to 75 +/- 13 mmHg, P less than 0.005), whereas theophylline did not result in blood pressure changes. In summary, during quiet sleep, doxapram, unlike theophylline, does not stimulate either respiration or metabolic rate. We speculate that the previous reports of increased ventilation after the administration of doxapram are due to the general stimulation of activity in the awake state, an effect not seen during sleep.

Oxygen saturation during sleep in patients with bronchopulmonary dysplasia

We hypothesized that significant sleep desaturation might occur in infants with bronchopulmonary dysplasia whose awake saturations were between 90 and 92%. Supplemental oxygen was continued until the awake saturation on room air was 90% or greater. Sleep saturations were monitored by oximetry sampling for a 3-min period every hour overnight. Significant desaturation was considered to be present if the saturation fell repeatedly below 88%. There were 39 studies performed in room air, and 14 studies in supplemental oxygen. We demonstrated that patients with acceptable awake saturation may desaturate while sleeping. However, only 1 of 25 patients whose saturation in room air was 92% or more repeatedly desaturated during sleep.

Interactive ventilatory effects of two respiratory stimulants, caffeine and doxapram, in newborn lambs

Caffeine and doxapram are two respiratory stimulants used in the treatment of apnea in newborns. When used concurrently, these drugs may produce interactive effects on the control of breathing in the newborn. The ventilatory effects of these drugs, given alone or together, were measured during 150 min of drug infusion in two groups of awake lambs 2-5 days old. The first group (n = 5) received a caffeine loading dose of 10 mg/kg followed by a maintenance dose of 0.1 mg/kg/h and incremental doses of doxapram: 0.25, 0.5, 1.25 and 2.5 mg/kg/30 min. The second group (n = 5) received a doxapram loading dose of 5.5 mg/kg followed by a maintenance dose of 1 mg/kg/h and incremental doses of caffeine: 2.5, 5.0, 7.5 and 10.0 mg/kg/30 min. In the first group, ventilation increased after the caffeine loading dose from 566 +/- 55 to 680 +/- 74 ml/kg/min (plasma caffeine = 14.7 +/- 1.6 mg/l) and progressively increased with the addition of incremental doses of doxapram up to 1,000 +/- 108 ml/kg/min at 2.5 mg/kg of doxapram (p less than 0.001 compared to baseline and caffeine loading dose). In contrast, in the second group, the doxapram loading dose markedly increased ventilation from 582 +/- 50 to 936 +/- 75 (p less than 0.002 and p less than 0.04 compared to caffeine loading dose) at plasma doxapram of 5.3 +/- 0.8 mg/l, but incremental doses of caffeine had no effects. We conclude that doxapram exerts a brisk and powerful respiratory stimulant effect and produces an additional dose-dependent ventilatory response when added to caffeine.

Pharmacodynamic effects and pharmacokinetic profiles of keto-doxapram and doxapram in newborn lambs

Keto-doxapram (keto-dox), an oxidative metabolite of doxapram, is a possible ventilatory stimulating agent. Our study characterizes its ventilatory properties, pharmacodynamic effects, and pharmacokinetic profile, and those of its parent compound, doxapram. Two groups of five awake, unsedated, newborn lambs (2- to 6-d old) received, respectively, i.v. infusions of keto-dox or doxapram (2.5 mg/kg) over a period of 1 min. Ventilatory parameters were continuously recorded before and for 1 h after the drug infusion. The pharmacokinetic profiles of both drugs were determined from blood samples collected serially before and after drug injection. Both drugs stimulated ventilation. Keto-dox increased baseline minute ventilation by 46 +/- 6.1% and 27.8 +/- 8.1% (p less than 0.002) at 1 and 5 min, respectively, an effect that decreased after 5 min of infusion. Doxapram increased minute ventilation by 57 +/- 9% (p less than 0.002) at 1 min, and by 48 +/- 7% at 5 min, but its effect lasted for 20 min after injection. Compared with the effects of keto-dox, this doxapram increase was significantly higher (p less than 0.02). Also, doxapram, but not keto-dox, caused an increase in systolic blood pressure (from 110 +/- 3.5 to 118 +/- 3.4 mm Hg at 10 min, p less than 0.01), as well as a change in neuro-behavior. Both drugs exhibited a biexponential decay curve, characterized by a short alpha and a longer beta t1/2, but keto-dox has a faster elimination rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Dynamics of breathing in the hypoxic awake lamb

Newborn mammals respond to hypoxia with an immediate hyperventilation that is rapidly dampened. Changes in mechanical properties of the respiratory system during hypoxia have been considered an important reason for this fall in minute ventilation (VE). We have studied the dynamic mechanical behavior of the respiratory system in eight unanesthetized intact newborn lambs (mean age 2 days) during normoxia and hypoxia (FIO2 = 0.08). Mouth pressure (P), airflow (V), and volume (V) were recorded while lambs were breathing through a leak-proof face mask and a pneumotachograph. Active compliance (C') and resistance (R') of the respiratory system were computed from P developed during an inspiratory effort against airway closure at end expiration and V and V of the preceding breaths. Tidal expiratory V-V curves were analyzed to estimate the elevation in functional residual capacity (FRC) over resting volume (Vr). After hypoxia, there was an immediate increase in VE in the first 2 min, from 0.49 to 1.13 l.kg-1.min-1, followed by a rapid decrease to 0.80. After 8 min of hypoxia, C' was unchanged. The inspiratory R' decreased during hypoxia, probably reflecting a drop in inspiratory laryngeal resistance. The expiratory V-V curves during hypoxia showed considerable braking, often with a double peak in expiratory V. This pattern was only occasionally seen during normoxia. In animals with a linear segment of the expiratory V-V curves the FRC-Vr difference could be calculated and averaged 1.93 ml/kg during normoxia and 3.47 during hypoxia. The recoil P of the respiratory system at end expiration was 0.75 cmH2O during normoxia vs. 1.63 cmH2O during hypoxia (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacotherapy in bronchopulmonary dysplasia

This article reviews the current data available on the most frequently used drugs in bronchopulmonary dysplasia. Oxygen, diuretics, bronchodilators, steroids, ribavirin, and antioxidants, as well as medication available for pulmonary hypertension, systemic hypertension, and gastroesophageal reflux are discussed, with emphasis on known advantages, side effects, and current dosage.

Exponential and diphasic ventilatory response to hypoxia in conscious lambs

This study was undertaken to test the hypothesis that in the neonate the hypoxic chemoreflex drive adapts to steady-state hypoxia but not to progressive hypoxia. First we have compared the ventilatory (VE) response of 2-day-old conscious lambs to steady-state hypoxia with their response to progressive hypoxia. Second, we have quantified the chemoreceptor excitatory function operating at the end of each period of hypoxia by studying the immediate VE response to the withdrawal of the hypoxic stimulus. Lambs responded to steady-state hypoxia [fractional concentration of inspired O2 (FIO2) = 0.08] by a diphasic VE response but responded to progressive hypoxia (FIO2 0.21-0.08) by an exponential VE increase. Hyperventilation in steady-state hypoxia was transient; VE increased immediately from 532 to a mean peak response of 712 ml X kg-1 X min-1 and decreased to 595 ml X kg-1. min-1 within 10 min. With progressive hypoxia, VE increased within 13 min from 514 to 705 ml X kg-1 X min-1. At the end of steady-state and progressive hypoxia the abrupt withdrawal of the hypoxic drive caused an instantaneous VE decrease to 390 and 399 ml X kg-1 X min-1, respectively; the VE decrease was respectively 306 and 205 ml X kg-1 X min-1 (P less than 0.05). This demonstrates that during steady-state hypoxia the lambs had suffered a loss of one third of the chemoreceptor excitatory function.(ABSTRACT TRUNCATED AT 250 WORDS)

Abolition of ventilatory response to caffeine in chemodenervated lambs

In this study we have evaluated the role of the peripheral chemoreceptors in the ventilatory response to caffeine at a dose currently used in human infants for treatment of central apneas (10 mg/kg). Twelve lambs were studied; six had carotid body denervation (CBD) and six had a sham denervation (intact). The denervation was done the 2nd wk of life, and the study of the response to caffeine infusion was carried out at a mean age of 82 days. The awake and nonsedated animals received 10 mg/kg of caffeine, and caffeine blood levels were, respectively, 8.8 and 9.0 mg/l in the intact and in the CBD lambs. The intact lambs responded to caffeine by a significant immediate increase in minute ventilation (VE) of 46% from 274 to 400 ml X min-1 X kg-1 (P less than 0.001), 1 min after caffeine infusion. This response rapidly faded, but VE was still increased at 2 h, 314 ml X min-1 X kg-1. The increase in ventilation was brought about by a change in mean inspiratory flow (VT/TI), which increased from 9.9 to 14.0 ml X s-1 X kg-1 within 1 min (P less than 0.01); VT/TI was still increased at 11.2 ml X s-1 X kg-1 2 h later. In contrast, for the CBD lambs there was no response to caffeine infusion as measured by VE or VT/TI. We conclude that bolus caffeine infusion produces a rapid response in VE followed by a fall in VE that remained above base line until at least 2 h postinfusion, and the intact chemoreceptor function appears as an essential mediator for these increases in ventilation, since the peripheral chemodenervation has completely abolished the VE response to this particular dose of caffeine.

Simplified oxygen administration in tracheostomized patients with bronchopulmonary dysplasia

The report describes a simple effective system of meeting the oxygen requirements of tracheostomized infants in the home setting. It consists of oxygen tubing which may be run under the infant's clothing and connected to the tracheostomy tube through a specially created hole. This allows a continuous administration of oxygen while minimizing the risk of accidental decannulation of disconnection by the infant grabbing the oxygen tubing. This has been used successfully in the management of infants with tracheostomies and chronic oxygen needs due to bronchopulmonary dysplasia.