Comparison of morbidity and mortality of very low birth weight infants in a Central Hospital in Johannesburg between 2006/2007 and 2013.

BACKGROUND: Health protocols need to be guided by current data on survival and benefits of interventions within the local context. Periodic clinical audits are required to inform and update health care protocols. This study aimed to review morbidity and mortality in very low birth weight (VLBW) infants in 2013 compared with similar data from 2006/2007. METHODS: We performed a retrospective review of patients' records from a neonatal computer database for 562 VLBW infants. These neonates weighed between 500 and 1500 g at birth, and were admitted within 48 hours after birth between 01 January 2013 and 31 December 2013. Patients' characteristics, complications of prematurity, and therapeutic interventions were compared with 2006/2007 data. Univariate analysis and multiple logistic regression were performed to establish significant associations of various factors with survival to discharge for 2013. RESULTS: Survival in 2013 was similar to that in 2006/2007 (73.4% vs 70.2%, p = 0.27). However, survival in neonates who weighed 750-900 g significantly improved from 20.4% in 2006/2007 to 52.4% in 2013 (p = 0.001). The use of nasal continuous positive airway pressure (NCPAP) increased from 20.3% to 62.9% and surfactant use increased from 19.2% to 65.5% between the two time periods (both p < 0.001). Antenatal care attendance improved from 54.4% to 70.6% (p = 0.001) and late onset sepsis (>72 hours after birth) increased from 12.5% to 19% (p = 0.006) between the two time periods. Other variables remained unchanged between 2006/2007 and 2013. The main determinants of survival to discharge in 2013 were birth weight (odds ratio 1.005, 95% confidence interval 1.003-1.0007, resuscitation at birth (2.673, 1.375-5.197), NCPAP (0.247, 0.109-0.560), necrotising enterocolitis (4.555, 1.659-12.51), and mode of delivery, including normal vaginal delivery (0.456, 0.231-0.903) and vaginal breech (0.069, 0.013-0.364). CONCLUSIONS: There was a marked improvement in the survival of neonates weighing between 750 and 900 g at birth, most likely due to provision of surfactant and NCPAP. Provision of NCPAP, prevention of necrotising enterocolitis, and control of infection need to be prioritised in VLBW infants to improve their outcome.

Neonatal revolution - the introduction of PEEP.

Fifty years ago, a baby born at 24-26 weeks was not considered viable. It was a tragedy for the mother having carried it for so long. I witnessed such an event as a student. The scourge of premature deliveries was the lack of surfactant in many tiny babies. In general, if a premature infant with hyaline membrane disease, as it was called respiratory distress syndrome (RDS), could not maintain a pO(2) above 60 mmHg in 100% oxygen, it was not expected to survive. In late 1969, two babies with suspected RDS came to ICU and were treated by the author with the buffer (tris hydroxyl amino methane, [THAM] which reduced both metabolic and respiratory acidosis and did not contain sodium) and an isoprenaline infusion (ß(1) stimulant and pulmonary vasodilator). The X-ray appearances of RDS disappeared. Unfortunately, one died of portal vein thrombosis because the drugs were administered by umbilical catheter, which were commonly used at the time. The other one recovered but the physicians then said the diagnosis must have been wrong!

Outcome of neonates requiring assisted ventilation.

Over a two-year period, we studied a total of 100 newborns delivered in our hospital, needing ventilation. The indications for ventilation, complications, outcome, and factors influencing outcome were analyzed. Of the 100 babies, 54 were preterm, 44 term and 2 post-term. Overall survival was 58%. The commonest indication for ventilation was meconium aspiration syndrome in term babies and hyaline membrane disease in preterms. Babies ventilated for pneumonia had the best outcome, while the poorest outcome was in sepsis. Survival increased significantly with increasing birth weight and gestational age. Downes score, Apgar score and pH at birth did not correlate significantly with outcome. The maximum peak inspiratory pressure requirement was significantly higher in the non-survivors. In pneumonia and sepsis, increased FiO2 requirement significantly impaired survival. The commonest complication was shock. Incidence of disseminated intravascular coagulation, pulmonary hemorrhage and pneumothorax was significantly higher in non-survivors; however, none of these factors was independently predictive of mortality.

[Lung morphological changes in premature neonates with hyaline membrane disease due to the use of exogenous surfactants during mechanical ventilation].

A complex of studies was used in 4 groups of premature babies to study lung tissue morphological changes in hyaline membrane disease, by applying exogenous surfactants during mechanical ventilation. Background diseases, pre- and intranatal risk factors, the babies' longevity, and the specific features of lung tissue and forming hyaline membranes were ascertained. Exogenous surfactants were found to have a blocking effect on the formation of hyaline membranes under mechanical ventilation.

A survey on criteria for intubation in moderate to late preterm infants with respiratory distress.

BACKGROUND: Majority of preterm infants do well with continuous positive airway pressure (CPAP) as the sole respiratory management; but some require endotracheal intubation and surfactant administration. While intubation is needed predominantly in extremely preterm infants (<28 weeks); some of the more mature preterm infants also require it. Currently, there are no clear guidelines regarding indications for endotracheal intubation in such infants. AIMS: To understand the current practice regarding "criteria for intubation" in moderate to late preterm infants with respiratory distress. METHODS: A survey of neonatologists in Australia New Zealand Neonatal Network (ANZNN) was conducted between April and June 2019. RESULTS: At least one neonatologist each from 29 of the 30 tertiary ANZNN Neonatal Intensive Care Units (NICUs) responded to the survey. In total, 118/200 (59%) neonatologists responded. The most common criteria for intubation were CPAP = 8 cmH2 O (61%), pH < 7.2 (55%), pCO2 > 70 mmHg (48%), FiO2 > 40% (40%), chest retractions (48%), more than two episodes of apnea requiring intervention (54%), and chest X-ray (CXR) showing moderate-severe hyaline membrane disease (HMD, 49%). CONCLUSION: While there were variations in practice, nearly 50% of the neonatologists shared a common threshold with regards to the CPAP level, FiO2 , blood gas parameters, and clinical and radiological findings. The results of this survey will help in designing future randomized controlled trials (RCTs) on this subject.

[Juvenile hyaline fibromatosis]. / Juvenile hyaline Fibromatose.

Juvenile hyaline fibromatosis is a rare autosomal recessive disease of the connective tissue. We present the case of a 6-year-old normal mental developed boy with confluent pearly papules behind the ears and in the paranasal folds, firm nodules of the scalp, the back and metaphalangs, and severe gingival hypertrophy.

Co-initiation of continuous renal replacement therapy, peritoneal dialysis, and extracorporeal membrane oxygenation in neonatal life-threatening hyaline membrane disease: A case report.

RATIONALE: Extracorporeal membrane oxygenation (ECMO) is a well-known technique to provide cardio-pulmonary support. Although continuous renal replacement therapy (CRRT) is frequently indicated, the need for faster fluid removal as the primary indication for ECMO is uncommon. Experiences on concomitant applications of ECMO, peritoneal dialysis (PD) and CRRT in neonates are relatively limited. PATIENT CONCERNS: We report a 2-day-old male neonate with life-threatening hyaline membrane disease (HMD), accompained by severe systemic fluid retention, sepsis and abdominal compartment syndrome. DIAGNOSIS: Hyaline membrane disease (HMD), neonatal respiratory distress syndrome, sepsis, capillary leakage syndrome, and abdominal compartment syndrome. INTERVENTION: Veno-arterial ECMO, CRRT, and PD were synchronously initiated for the sake of faster fluid removal possible. OUTCOMES: The infant was successfully weaned from ECMO circuit and fluid overload was greatly improved four days after extracorporeal life support (ECLS), without major complications. LESSONS: Initiation of CRRT and PD during ECMO therapy is effective and safe to release fluid overload in neonates, and severe complications are absent. When a neonate requires dialysis of urgency, ECMO offers assured vascular access to hemodialysis, allowing faster fluid removal.

Hyaline membrane disease (HMD): an historical and Oslerian perspective.

Hyaline membrane disease (HMD) offers an illustration of a disease discovered during the lifetime of William Osler and effectively treated in the twentieth century-the perspective that suggests that there was a straightforward progressive identification of the disease process, a discovery of the underlying biochemical agent responsible for the pathophysiology, and the pharmacological refinement of that agent to be used to treat the disease is illusory. By reviewing the timeline from the earliest pathological description of what was to be later termed HMD to the discovery of surfactant and its impact on infant mortality, this narrative will demonstrate how various random historical events served to affect the progress of developing a treatment for HMD; how the marked reduction in deaths due to HMD may have set the stage for unrealistic expectations; and how the humanities have warned us of the potential for excessive optimism in our understanding of nature.

[Consequences of premature rupture of the membranes in the perinatal lung]. / Physiopathologie des conséquences respiratoires néonatales de la rupture prématurée des membranes: application à la prise en charge néonatale.

Early premature rapture of the membranes (PROM) during pregnancy is associated with a high risk of perinatal morbidity and mortality. Early PROM impairs lung structures and function through 3 mechanisms : 1) oligo-hydramnios ; 2) fetal inflammatory syndrome ; and 3) prematurity. Thus, the related causes of respiratory failure at birth after PROM are: hyaline membrane disease, persistent pulmonary hypertension induced by impaired endothelial function and/or lung hypoplasia, materno-fetal infection, and bronchopulmonary dysplasia resulting at least in part from the fetal inflammatory syndrome. Severity of the respiratory morbidity is largely unpredictable. Even if gestational age at PROM is considered as a prognostic factor, survival without morbidity exist after PROM as early as 18 weeks GA. Better knowledge of the pathophysiology improved the outcome of the preterm infants born after early PROM. Optimal management of the respiratory failure including minimizing barotrauma is required to prevent from bronchopulmonary dysplasia.

[Dynamic change in respiratory mechanic dynamics and its clinical significance during mechanical ventilation in hyaline membrane disease of children].

OBJECTIVE: To explore the characteristics of changes in respiratory mechanic dynamics and clinical significance in hyaline membrane disease (HMD) under mechanical ventilation. METHODS: One hundred and twenty-six newborns with HMD undergoing mechanical ventilation were divided into two groups: complication group with 43 cases and no-complication group with 83 cases. The blood gases and indices of respiratory mechanic dynamics were monitored 2, 24, 48 and 72 hours after the first ventilation and before the first weaning from ventilation. RESULTS: Pulmonary compliance [(0.55+/-0.10) ml.cm H(2)O(-1).kg(-1), (0.43+/-0.10) ml.cm H(2)O(-1).kg(-1)] and minute volume [MV, (0.65+/-0.10) L/min, (0.62+/-0.30) L/min] were elevated compared with that after ventilation for 2-72 hours, however the oxygenation index [OI, (10.2+/-1.9)mm Hg vs. (13.6+/-4.3) mm Hg] significantly lower. The compliance and MV in no-complication group were higher than that in complication group 24 and 48 hours after ventilation. There were no differences in the airway resistance and lung inflation index between two groups. The pulmonary compliance was negatively correlated with OI (r=-0.208, P<0.01) and corrected with MV (r=0.218, P<0.01). In no-complication group, all cases ventilation was weaned successfully at once in all the patients,and their mean compliance and MV were (0.55+/-0.10) ml.cm H(2)O(-1).kg(-1) and (0.65+/-0.20) L/min respectively. However, in complication group, weaning failed 38 patients, their mean compliance and MV were (1.03+/-0.30) ml.cm H(2)O(-1).kg(-1) and (0. 33+/-0.30) L/min respectively. CONCLUSION: Respiratory mechanic dynamics monitoring is beneficial in evaluating the severity of hyaline membrane disease and complications, guiding mechanical ventilation management and weaning.

[Treatment of hyaline membrane disease in the preterm newborn with exogenous lung surfactant: a controlled study]. / Estudio controlado del tratamiento de la enfermedad de membrana hialina del recién nacido pretérmino con surfactante pulmonar exógeno (porcino vs. bovino).

BACKGROUND: Hyaline membrane disease (HMD) due to lung surfactant deficiency in the preterm newborn is an important cause of neonatal morbidity and mortality. Exogenous lung surfactant has transformed HMD therapy in developed countries, but an equivalent benefit has not been accomplished in developing countries due to a variety of factors. Porcine surfactant developed in Cuba is an inexpensive alternative to other surfactants, and its use has not been studied in our settings. METHODS: A randomized, open, prospective and controlled trial was undertaken in 44 preterm newborns with HMD diagnosis. One group received bovine surfactant (BS) (Survanta) and the other Cuban porcine surfactant (PS) (Surfacen). The following clinical response variables were evaluated: oxygenation and ventilation indexes, days with supplementary oxygen, days with mechanical ventilation, incidence of complications, time of hospitalization, and mortality. RESULTS: 23 Patients received bovine surfactant and 21 the porcine type. The two groups were clinically similar, with patterns of oxygenation and ventilation response that were the same between groups, with a tendency to higher initial oxygenation increase in the PS group. The incidence of complications was similar between groups. 10 Patients (47.6%) died in the PS group, versus 12 (52.2%) in the BS group (p > 0.05). CONCLUSIONS: Porcine surfactant had similar clinical effects than bovine surfactant in the oxygenation and ventilation variables, with no significant differences in complications ormortality. Porcine surfactant is an effective and lower cost altenative to bovine surfactant in the treatment of HMD.

[High-frequency oscillatory lung ventilation in complex therapy for congenital pneumonia and hyaline membrane disease in newborns].

Fifty-eight neonatal infants with hyaline membrane disease (HMD) and congenital pneumonia were examined in the critical status. In 32 of them, high-frequency oscillatory lung ventilation (HFOLV) was employed. The use of HFOLV was found to reduce the length of stay in neonates on toxic oxygen concentrations by more than 2 times and to accelerate the normalization of ventilation-perfusion relationships by more than 3 times. A study of the basic parameters of central and regional hemodynamics showed that HFOLV failed to affect the patients' hemodynamic status. The efficiency of correction of severe respiratory disorders in neonatal infants with HMD was ascertained to increase with the combined use of the Russian surfactant and HFOLV. A formula was developed to calculate the starting amplitude of oscillations when HFOLV was employed. The maximum allowable values of mean airway pressure at which HFOLV could be discontinued were determined, which prevented the regimens from toughening when HFOLV was changed to the routine artificial ventilation. The use of HFOLV was established to reduce the risk of severe cerebral structural and vascular lesions and mortality rates.

Randomized controlled trial of exogenous surfactant for the treatment of hyaline membrane disease.

We conducted a prospective, randomized, unblinded, controlled trial of exogenous bovine surfactant (surfactant TA) in premature infants requiring ventilator support for the treatment of severe hyaline membrane disease. Forty-one low birth weight infants with severe hyaline membrane disease were randomly assigned to saline or surfactant therapy and treated within eight hours of birth. Significant improvements in oxygenation (increased arterial/alveolar PO2) and respiratory support (decreased mean airway pressure) were seen in the group receiving surfactant within four hours after treatment. These improvements were maintained in the surfactant-treated infants, who also had fewer pneumothoraces and fewer number of days in environments of fractional inspiratory oxygen greater than 0.4 mm Hg. No problems were associated with administration of surfactant, and no acute side effects were detected. We conclude that exogenous surfactant, administered early in the course of severe hyaline membrane disease, is an effective therapy that can diminish the amount of respiratory support required during the first 48 hours of life.

Airway resistance in infants after various treatments for hyaline membrane disease: special emphasis on prolonged high levels of inspired oxygen.

Thoracic gas volume, airway resistance (Raw), and dynamic lung compliance (CL) were measured in 48 infants surviving after hyaline membrane disease. Some infants were found to have a small reduction in CL after recovery from the acute phase of the illness but no other abnormalities were detected, irrespective of the type of treatment received. When studied again between the ages of 4 and 10 months, CL had returned to normal, but all infants who had been treated with intermittent positive pressure ventilation (IPPV) during the neonatal period were found to have developed a raised Raw. In contrast, all nonventilated infants, including those who had received up to five days of oxygen therapy in concentrations above 80%, had normal lung function. We conclude that IPPV, and not the increased inspired oxygen concentration, damaged the airways and interfered with their growth.

Is continuous transpulmonary pressure better than conventional respiratory management of hyaline membrane disease? A controlled study.

The influence of continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP) on mortality and complication rates in severe hyaline membrane disease (HMD) was evaluated in a randomized, prospective study. Patients were admitted to the study if the Po2 was less than 50 mm Hg with FiO2 greater than 0.6. Twenty-four patients in each of three weight groups were equally divided between treatment and control groups. The treatment regimen included CPAP (6 to 14 cm H2O) for spontaneously breathing patients and PEEP for patients requiring mechanical ventilation for apnea or hypercapnia (Pco2 greater than 65 mm Hg). Control patients received oxygen and were mechanically ventilated if they had apnea, hypercapnia, or Po2 less than 50 mm Hg with FiO2 greater than 0.8. Oxygenation improved after the start of CPAP or PEEP; however, Pco2 rose after CPAP was initiated. There was no significant difference between treatment and control groups in mortality, requirement for mechanical ventilation, or incidence of pulmonary sequelae. The incidence of pulmonary air-leak was increased with Peep. the findings suggest that CPAP and PEEP have not significantly altered the outcome of HMD.