Lung ultrasound for the assessment of lung recruitment in neonates with massive pneumothorax during extracorporeal membrane oxygenation: a case report.

Bedside lung ultrasound may be an effective method for the assessment of lung recruitment in newborns with extracorporeal membrane oxygenation (ECMO). We report a case of a neonate who had severe hypoxemia with persistent pulmonary hypertension and massive pneumothorax due to meconium aspiration syndrome and was treated with ECMO. Positive pressure mechanical ventilation resulted in persistent massive air leakage from the disrupted pulmonary tissue. When ECMO was initiated, a "total lung rest" ventilation strategy was used to facilitate healing of the lung rupture and absorption of the pneumothorax. After complete absorption of the pneumothorax, lung recruitment was performed by progressively increasing the positive end-expiratory pressure under the guidance of lung ultrasound. Bedside lung ultrasound was successfully used to assess pneumothorax absorption and improvement of pulmonary inflammation and successfully guided the recruitment of collapsed alveoli and the withdrawal of ECMO.

Survival of newborn infants with severe respiratory failure before and after establishing an extracorporeal membrane oxygenation program.

BACKGROUND: Severe hypoxic respiratory failure is a leading cause of neonatal mortality in Chile. Extracorporeal membrane oxygenation improves survival in neonates with hypoxic respiratory failure. OBJECTIVE: To determine the impact of the establishment of a Neonatal Extracorporeal Membrane Oxygenation Program on the outcome of newborns with severe hypoxic respiratory failure in a developing country. DESIGN/PATIENTS: Data of newborns (birthweight > 2,000 g and gestational age ≥ 35 wk) with hypoxic respiratory failure and oxygenation index greater than 25 were compared before and after extracorporeal membrane oxygenation was available. Extracorporeal membrane oxygenation was initiated in infants with refractory hypoxic respiratory failure who failed to respond to inhaled nitric oxide/high-frequency oscillatory ventilation. MAIN RESULTS: Data from 259 infants were analyzed; 100 born in the pre-extracorporeal membrane oxygenation period and 159 born after the extracorporeal membrane oxygenation program was established. Patients were similar in terms of risk factors for death for both periods except for a higher oxygenation index and a greater proportion of outborn infants during the extracorporeal membrane oxygenation period. Survival significantly increased from 72% before extracorporeal membrane oxygenation to 89% during the extracorporeal membrane oxygenation period (p < 0.01). During the extracorporeal membrane oxygenation period, 98 of 159 patients (62%) with hypoxic respiratory failure were rescued using inhaled nitric oxide/high-frequency oscillatory ventilation, whereas 61 (38%) did not improve; 52 of these 61 neonates were placed on extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation survival rate to discharge was 85%. After adjusting for potential confounders, the severity of the pretreatment oxygenation index, a late arrival to the referral center, the presence of a pneumothorax, and the diagnosis of a diaphragmatic hernia were significantly associated with the need for extracorporeal membrane oxygenation or death. CONCLUSIONS: The establishment of an extracorporeal membrane oxygenation program was associated with a significant increase in the survival of newborns more than or equal to 35 weeks old with severe hypoxic respiratory failure.

Treatment of persistent pulmonary hypertension of the newborn without hyperventilation: an assessment of diffusion of innovation.

OBJECTIVE: The treatment of neonates with persistent pulmonary hypertension of the newborn (PPHN) is controversial with no consensus on diagnostic criteria or treatments. Hyperventilation has been the therapeutic mainstay. However, two widely variant alternative approaches have been proposed: ventilation without induced alkalosis, or more aggressive therapies such as high frequency ventilation or extracorporeal membrane oxygenation. We wished to determine the extent to which these alternative treatments have diffused into practice. METHODS: A forced choice questionnaire was mailed to a sample representing 10% of 3740 practicing neonatologists. Sixty percent of those surveyed responded. Data on treatment practices was tabulated. Subanalyses with respect to training era, practice site, and geographic region were performed. RESULTS: In patients with meconium aspiration syndrome, without evidence of PPHN, 36% described their initial management as hyperventilation. If PPHN was confirmed, hyperventilation was used in 90% of patients by 44% of the respondents. Muscular paralysis and inotropic support were also used frequently. Alkali and vasodilator infusion were used less frequently. The gentle ventilation strategy proposed by Wung and James at Columbia Babies Hospital was used infrequently by 47% of respondents. Gentle ventilation was used more frequently by board-certified neonatologists than those not certified. No significant differences in practice were identified by geographic region or era of training. When standard treatment failed, only 40% of the respondents utilized rescue treatments such as high frequency ventilation or extracorporeal membrane oxygenation. CONCLUSIONS: This study documents that gentle ventilation, an easily and inexpensively adopted innovation, has not diffused into practice significantly while more expensive high technology treatments, such as high frequency ventilation and extracorporeal membrane oxygenation, have penetrated more significantly.

Do insults to the developing lung increase the incidence of wheezing in infants.

This study reports on the possible role of perinatal and early infantile factors in the aetiology of the 'wheezy baby syndrome'. Over a 2 year period we recruited 150 infants from the outpatients department who had a typical wheezing attack, with chest X-ray showing only hyperinflation and non-specific increased markings, and who had been born in hospital with available perinatal and postnatal records. One hundred and fifty control infants were also recruited. A retrospective study was then undertaken comparing the two groups of infants for the incidence of neonatal problems and the incidence of previous lower respiratory tract infections. The results showed that 40 per cent of cases had previously had meconium aspiration syndrome compared with only 2.6 per cent of controls, and that 26.6 per cent of cases had previously had at least one lower respiratory tract infection compared with 5.3 per cent of controls. Other factors, including the incidence of transient tachypnea, and personal and family history of atopy, showed no significant trends. Meconium aspiration syndrome and lower respiratory tract infections are important aetiological factors in the pathogenesis of 'wheezy baby syndrome', rather than inheritance of atopic diathesis.