[Recommendations for respiratory support in the newborn (iii). Surfactant and nitric oxide]. / Recomendaciones para la asistencia respiratoria en el recién nacido (iii). Surfactante y óxido nítrico.

The recommendations included in this document will be part a series of updated reviews of the literature on respiratory support in the newborn infant. These recommendations are structured into twelve modules, and in this work module 7 is presented. Each module is the result of a consensus process including all members of the Surfactant and Respiratory Group of the Spanish Society of Neonatology. They represent a summary of the published papers on each specific topic, and of the clinical experience of each one of the members of the group.

[Respiratory care in neonatal intensive care units. Situation in the year 2005]. / Asistencia respiratoria en las unidades de cuidados intensivos neonatales en España: situación en 2005.

AIM: To learn the characteristic of the neonatal intensive care units (NICUs) that offer neonatal respiratory assistance in Spain. MATERIAL AND METHOD: A structured survey was developed and sent to all Spanish neonatal units to learn about the respiratory care offered in 2005. RESULTS: A total of 96 Units answered the survey, with an estimated representatively of 63%, with a range from 3 to 92%, depending on the geographical area. Level IIIc Units were in the upper range. Answer the survey 26 units type IIb (27%), 16 IIIa (17%), 40 IIIb (42%) and 14 IIIc (14%). The total number of level III NICU beds was 541 (1.2 beds per 1000 livebirths; range, 0.7-1.7). The mean number of beds per NICU was 4.1 in level IIIa Units, 2.8 in those IIIb and 14.6 in type IIIc NICUs. In level III NICUs, the bed per physician ratio was 2.4 and that of beds per registered nurse was 2.8 (2.2 in level IIIc NICUs). There were a total 13,219 admissions, 54% of those needed mechanical ventilation (36% in IIIa and 65% in level IIIc NICUs). Oxygen blenders for resuscitation at birth were available in 42% of level IIIb and IIIc NICUs. NICUs had one neonatal ventilator per bed, and 63% of units had high frequency ventilation available. All units had nasal-CPAP systems, 25% of level IIIa Units, 58% IIIb and 64% of those type IIIc had systems for nasal ventilation. All level IIIc and 93% of level IIIb NICUs were able to provide inhaled nitric oxygen therapy. Four NICUS offered ECMO. CONCLUSIONS: The mean number of NICU beds per 1000 livebirths is within the lower limits of those been recommended, and there were wide variations among different geographical areas. A 54% of those babies admitted to NICUs required mechanical ventilation. The mean number of NICU beds per registered nurse was 2.8. There was an adequate number of neonatal ventilators (one per bed) and 63% were able to provide HFV. All NICUs hand n-CPAP systems.

[Ibuprofen versus indomethacin in the preterm persistent patent ductus arteriosus therapy: review and meta-analysis]. / Ibuprofeno frente a indometacina para el tratamiento de la persistencia del conducto arterioso del prematuro: revisión sistemática y metaanálisis.

INTRODUCTION: Persistent patent ductus arteriosus (PDA) is a common pathology in the preterm whose traditional treatment has been indomethacin. Recently, ibuprofen has shown its effectiveness in closing the PDA with less hemodynamic effects. The objective of this paper is to review the current literature in order to determine if there is any benefit of ibuprofen versus indomethacin in the PDA therapy. MATERIAL AND METHODS: Eleven trials comparing intravenous ibuprofen versus indomethacin in the treatment of PDA confirmed by echocardiography in < 35 weeks preterm or < 1,500 g birth weight were included. A meta-analysis of the trials data was performed. RESULTS: No trial show statistically significant differences in the failure of closing PDA, neither the meta-analysis (RR 0.96 [CI 95 %: 0.74-1.26], with a power of 0.995). No differences were found in the rate of reopening and surgical ligation. Complications were similar, except for a significant lower incidence of oliguria in the ibuprofen group (RR 0.23 [CI 95 %: 0.10-0.51]). There were no differences in the respiratory outcomes (RR of bronchopulmonary dysplasia (BPD) at 28 days 1.32 [CI 95 %: 0.99-1.76]). CONCLUSIONS: In our revision ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications except for less renal impairment with ibuprofen. A higher risk of BPD in the ibuprofen group is not confirmed, although more studies are needed.

[Ibuprofen versus indomethacin in the treatment of patent ductus arteriosus in preterm infants]. / Ibuprofeno frente a indometacina en el tratamiento del conducto arterioso persistente del prematuro.

INTRODUCTION: Persistent patent ductus arteriosus (PDA) is a common entity in preterm infants. The most commonly used pharmacological treatment to close the ductus is indomethacin but it can affect cerebral, renal and mesenteric blood flow. Ibuprofen has recently been shown to be effective in closing PDA with fewer hemodynamic effects. In this study we compared the safety and efficacy of ibuprofen and indomethacin in the treatment of PDA in preterm infants. MATERIAL AND METHODS: A randomized trial was performed. Premature infants with symptomatic PDA confirmed by echocardiography in the first week of life and who required respiratory support were included. The patients were randomly assigned to receive either intravenous indomethacin or ibuprofen. The rate of ductal closure, need for additional treatment, complications, and clinical course were evaluated. RESULTS: Twenty-four patients were treated with indomethacin and 23 with ibuprofen. The clinical characteristics before treatment were similar in both groups. Both treatments were effective in closing PDA (87.5% in the indomethacin group and 82.6% in the ibuprofen group). The two cohorts did not differ in the rate of reopening, need for a second pharmacologic treatment, or surgical ductal ligation. No patient in the ibuprofen group developed gastrointestinal adverse effects, but two infants in the indomethacin group had isolated bowel perforation and one had necrotizing enterocolitis. Transient renal dysfunction developed in seven patients (29%) in the indomethacin group versus two (9%) in the ibuprofen group. Transient renal insufficiency was found in one patient in the indomethacin group and in none in the ibuprofen group. The rate of other complications was similar in both groups. CONCLUSIONS: In our trial ibuprofen was as effective as indomethacin in closing PDA. No significant differences were found in the incidence of complications but fewer renal complications and no gastrointestinal complications were found in the ibuprofen group.

[Nasal continuous positive airway pressure in preterm infants: comparison of two low-resistance models]. / Presión positiva continua en la vía aérea por vía nasal en el recién nacido prematuro: estudio comparativo de dos modelos de baja resistencia.

OBJECTIVE: To compare the safety and efficacy of two low expiratory resistance models of nasal continuous positive airway pressure (n-CPAP) in preterm infants. MATERIAL AND METHODS: A 1-year prospective trial was performed in the Neonatal Intensive Care Unit of La Fe Hospital to compare the Infant Flow (IF) and Medijet (MJ) devices. All preterm infants requiring n-CPAP for respiratory distress at birth (group I), infants weighting less than 1500 g requiring postextubation (group II) and those with apnea-bradycardia syndrome (ABS) (group III) were included. The patients were randomly assigned to IF or MJ. RESULTS: A total of 125 patients received 226 treatments (IF: n 5 126: MJ: n 5 110). The mean gestational age was 29.4 weeks and the mean birth weight was 1340 g.Efficacy. In group I (n 5 73) no difference were found between systems and 6 hours' after initiation of n-CPAP decreases in FiO2, CO2 and respiratory effort were similar. The need for intubation was also similar (IF: 34.6 %; MJ: 24.1 %). In group II (n 5 73) the need for reintubation at 48 hours was similar with both treatments (IF:19 %; MJ: 8 %). In group III (n 5 80) resolution of ABS was similar after 24 hours of n-CPAP (IF: 46 %; MJ: 58 %). The need for intubation was also similar (IF: 26 %; MJ: 10 %).Complications. Air leaks occurred in six preterm infants (IF: 4; MJ: 2). Severe abdominal distension occurred in 5 % with both systems. Five infants had significant nasal lesions (IF: 1; MJ: 4). CONCLUSIONS: The efficacy and safety of both systems was similar in the variables studied and no significant differences were found.

[The value of capnography and exhaled CO2 in neonatal intensive care units]. / Valor de la capnografía y del CO2 exhalado en las unidades de cuidados intensivos neonatales.

OBJECTIVE: The objective of this study was to investigate the reliability of end-tidal CO2 (PetCO2) as a non-invasive guide of PaCO2 in the newborn and to analyze the influence of the relationship between ventilation-perfusion in the correlation between both determinations. PATIENTS AND METHODS: End-tidal CO2 (PetCO2) was monitored by capnography in 9 ventilated newborns: 146 arterial blood gas samples were drawn and the results were compared with the PetCO2 values obtained. The gradient or difference between PaCO2 and PetCO2 was calculated to determine the correlation. The ratio a/AO2 was used as an indirect indicator of the ventilation/perfusion relationship (V/Q ratio). RESULTS: The mean gestational age was 30.9 +/- 2.8 weeks and birth weight 1,648 +/- 596 g. The age at the beginning of the study was 2 +/- 1.5 days. The diagnoses corresponded to 5 cases of RDS (56%), 2 cases of wet lung syndrome (22%), 1 case of pneumonia (11%) and 1 pneumothorax (11%). The results of this monitoring were classified in function of the a/AO2 ratio obtained: Group A, a/AO2 < 0.2 and PaCO2-PetCO2 gradient = 13.3 +/- 5; Group B, a/AO2 = 0.2-0.29 and PaCO2-PetCO2 gradient = 8 +/- 2.7; and Group C, a/AO2 > 0.29 and PaCO2-PetCO2 gradient = 2 +/- 1.7. The results show a very good correlation from a a/AO2 ratio > or = 0.3 onwards. The a/AO2 ratio is the major determinant of PaCO2-PetCO2 differences and respiratory frequency has less influence. CONCLUSIONS: 1) Monitoring of end-tidal CO2 does not maintain a good correlation with PaCO2 in serious lung illness. 2) End-tidal CO2 measurement is an effective and accurate technique for the monitoring of newborns when the a/AO2 ratio > or = 0.3 and it can be useful for weaning of mechanical ventilation. 3) PaCO2-PetCO2 differences accurately show the changes in the ventilation-perfusion relationship.

[High frequency oscillatory ventilation in the newborn infant]. / Ventilación oscilatoria de alta frecuencia en el recién nacido.

OBJECTIVE: The objective of this study was to determine the effectivity, results and complications after application of HFOV in a group of newborns with serious respiratory distress. PATIENTS AND METHODS: Between February and October 1995, HFOV was required by 18 newborns in the NICU of the Hospital "La Fe" of Valencia, as ventilatory rescue therapy because of the failure of conventional ventilation in 10 cases (group A) and serious air leaks in 8 cases (group B). We used pure HFOV without superimposed cycles of conventional IMV following a high volume-high pressure strategy. Among the lung pathology, RDS was most frequent (11/18). RESULTS: Twenty-four hours after beginning HFOV, a decrease of the FiO2 was obtained in group A from 0.89 to 0.4 and in group B from 0.7 to 0.4. Oxygenation, ventilation, OI and a/AO2 ration also improved. In the group with conventional ventilation failure, this improvement was significant for all parameters in the first two hours after the start of HFOV (p < 0.01). In the group with air leaks, all parameters improved at two hours, but this change was significant only for oxygenation (p < 0.01). Four newborns died (22%) in the first month. CONCLUSIONS: HFOV is an effective and secure ventilatory method when conventional ventilation fails or serious air leaks occur. Important improvement in oxygenation and ventilation is obtained during the first two hours and it is possible to decrease the oxygen requirements at 24 hours after the start of HFOV.

[Pneumopericardium in the newborn (author's transl)]. / Neumopericardio en el período neonatal.

A case of pneumopericardium in a newborn affected of hyaline membrane disease, and undergoing assisted ventilación is presented. Literature is reviewed. Physiopatology, morbidity, mortality, and predispossing factors are described. Knowledge of the clinical simptomatology is essential in order to perform the prompt pericardiocentesis, should cardiac tamponade be present.