Sustained lung inflation in late preterm infants: a randomized controlled trial.

OBJECTIVE: To assess the need for respiratory support in late preterm infants treated with sustained lung inflation (SLI) at birth. STUDY DESIGN: In this controlled trial, we randomly assigned infants born at 34(+0) to 36(+6) weeks of gestation to receive SLI (25 cmH2O for 15 s) at birth, followed by continuous positive airway pressure (CPAP) or assistance according to the recommendations of the American Academy of Pediatrics. The primary outcome was the need for any type of respiratory support. The secondary outcomes included neonatal intensive care unit (NICU) admission for respiratory distress and length of stay. The risk ratios (RRs) and 95% confidence intervals (CIs) of the outcomes were calculated for the SLI group in reference to the control group. RESULTS: A total of 185 infants were enrolled: 93 in the SLI group and 92 in the control group. No difference was found in the need for any type of respiratory support between the infants treated with SLI and the control group (10.6 vs 8.7%, RR 1.24, 95% CI 0.51 to 2.99). The NICU admission for respiratory distress and the length of stay did not differ between the groups. CONCLUSION: Providing SLI at birth in late preterm infants does not affect their need for respiratory support.

Positional effects on lung mechanics of ventilated preterm infants with acute and chronic lung disease.

BACKGROUND: The role of prone position in preterm infants has not been completely clarified. We investigated prone versus supine posture-related changes in respiratory system resistance (Rrs) and reactance (Xrs) measured by the Forced Oscillation Technique (FOT) in mechanically ventilated preterm newborns. METHODS: Patients were studied in the supine versus prone positions in random order. Oxygen saturation, transcutaneous partial pressure of oxygen (ptcO2 ), carbon dioxide (ptcCO2 ), Rrs and Xrs were measured in each position. RESULTS: Nine patients with respiratory distress syndrome (RDS) and nine with evolving broncho-pulmonary dysplasia (BPD) were studied. Rrs was, on average, 9.8 (1.3, 18.3 as 95%CI) cmH2 O*s/l lower in the prone compared to the supine position (P = 0.02), while no differences in Xrs, ptcO2 , ptcCO2 , and breathing pattern were observed between postures. Only patients with evolving BPD showed a significant reduction of Rrs from 69.0 ± 27.4 to 53.0 ± 16.7 cmH2 O*s/l, P = 0.01. No significant correlations were found between changes in lung mechanics and ptcO2 , ptcCO2 , or breathing pattern. CONCLUSIONS: On short-term basis, prone positioning does not offer significant advantages in lung mechanics in mechanically ventilated infants with RDS, while it is associated with lower Rrs values in patients with evolving BPD.

Assessment of pulmonary function in a follow-up of premature infants: our experience.

Respiratory diseases are a major cause of morbidity in neonates, especially preterm infants; a long term complication of prematurity such as bronchopulmonary dysplasia (BPD) is particularly relevant today. The exact role of the Pulmonary Function Test (PFT) in this area is not yet well defined; the PFT in newborns and infants - in contrast to what happens in uncooperative children and adults - are routinely used only in a few centers. The assessment of pulmonary function in newborns and infants, however, is nowadays possible with the same reliability that in cooperative patients with the possibility to extend the assessment of polmonary function from bench to bed. The assessment of pulmonary function must be carried out with non invasive and safe methods, at the bedside, with the possibility of continuous monitoring and providing adequate calculation and management of data. The ability to assess lung function helps to define the mechanisms of respiratory failure, improving the treatment and its effects and is therefore a useful tool in the follow-up of newborn and infant with pulmonary disease.

Comparison between two different modes of non-invasive ventilatory support in preterm newborn infants with respiratory distress syndrome mild to moderate: preliminary data.

Despite of improved survival of premature infants, the incidence of long term pulmonary complications, mostly associated with ventilation-induced lung injury, remains high. Non invasive ventilation (NIV) is able to reduce the adverse effects of mechanical ventilation. Although nasal continuous positive airway pressure (NCPAP) is an effective mode of NIV, traumatic nasal complications and intolerance of the nasal interface are common. Recently high flow nasal cannula (HFNC) is emerging as a better tolerated form of NIV, allowing better access to the baby's face, which may improve nursing, feeding and bonding. HFNC may be effective in the treatment of some neonatal respiratory conditions while being more user-friendly for care-givers than conventional NCPAP. Limited evidence is available to support the specific role, efficacy and safety of HFNC in newborns and to demonstrate efficacy compared with NCPAP; some studies suggest a potential role for HFNC in respiratory care of the neonate as a distinct non invasive ventilatory support. We present the preliminary data of a randomized clinical trial; the aim of this study was to assess efficacy and safety of HFNC compared to NCPAP in preterm newborns with mild to moderate respiratory distress syndrome (RDS).

[Therapy with high-flow nasal prongs in preterm infants]. / La terapia con nasocannule ad alto flusso nel neonato pretermine.

Despite of improved survival of premature infants, the incidence of long-term pulmonary complications, mostly associated with ventilation-induced lung injury, remains high. Non invasive ventilation (NIV) is able to reduce the adverse effects of mechanical ventilation. Although nasal continuous positive airway pressure (NCPAP) is an effective mode of NIV, traumatic nasal complications and intolerance of the nasal interface are common. Recently high flow nasal cannula (HFNC) is emerging as an efficient, better tolerated form of NIV, allowing better access to the baby's face, which may improve nursing, feeding and bonding. The aim of this review is to discuss the available evidence of effectiveness and safety of HFNC in preterm newborns with respiratory distress syndrome (RDS). It is known that distending pressure generated by HFNC increases with increasing flow rate and decreasing infant size and varies according to the amount of leaks by nose and mouth. The effects of HFNC on lung mechanics, its clinical efficacy and safety are still insufficiently investigated. In conclusion, there is a growing evidence of the feasibility of HFNC as an alternative mode of NIV. However, further larger randomized trials are required, before being able to recommend HFNC in the treatment of moderate respiratory distress of preterm infants.

Relationship between respiratory impedance and positive end-expiratory pressure in mechanically ventilated neonates.

PURPOSE: To evaluate the feasibility of forced oscillation technique (FOT) measurements at the bedside and to describe the relationship between positive end-expiration pressure (PEEP) and lung mechanics in different groups of ventilated infants. METHODS: Twenty-eight infants were studied: 5 controls, 16 newborns with respiratory distress syndrome (RDS) and 7 chronically ventilated newborns that developed bronchopulmonary dysplasia. An incremental/decremental PEEP trial was performed by changing PEEP in 1-min steps of 1 cmH(2)O between 2 and 10 cmH(2)O. Forced oscillations at 5 Hz were superimposed on the ventilator waveform. Pressure and flow, measured at the inlet of the ETT, were used to compute resistance (Rrs) and reactance (Xrs). RESULTS: In controls Rrs and Xrs were on average 41 ± 21 and -22 ± 6 cmH(2)O s/l respectively and were almost unaffected by PEEP. RDS infants presented similar Rrs (48 ± 25 cmH(2)O s/l) and reduced Xrs (-71 ± 19 cmH(2)O s/l) at the beginning of the trial. Two behaviours were observed as PEEP was increased: in extremely low birth weight infants Xrs decreased with PEEP with marked hysteresis; in very low and low birth weight infants Xrs and Rrs were less PEEP dependent. Chronically ventilated infants had very high Rrs and very negative Xrs values at very low PEEPs (121 ± 41 and -95 ± 13 cmH(2)O s/l at PEEP = 2 cmH(2)O) that markedly changed as PEEP exceeded 3-4 cmH(2)O. CONCLUSIONS: Rrs and Xrs measurement in preterm newborns is feasible, and data are representative of the lung mechanics and very sensitive to its changes with PEEP, making FOT a promising technique for the non-invasive bedside titration of mechanical ventilation in preterm newborns.

[Assessment of pulmonary function in a follow-up of premature infants: our experience]. / Valutazione della funzionalità respiratoria nell'ambito di un follow up respiratorio di neonati prematuri: la nostra esperienza.

Respiratory diseases are a major cause of morbidity in neonates, especially preterm infants; a long-term complication of prematurity such as bronchopulmonary dysplasia (BPD) is particularly relevant today. The exact role of the Pulmonary Function Test (PFT) in this area is not yet well defined; the PFT in newborns and infants--in contrast to what happens in uncooperative children and adults--are routinely used only in a few centers. The assessment of pulmonary function in newborns and infants, however, is nowadays possible with the same reliability that in cooperative patients with the possibility to extend the assessment of polmonary function from bench to bed. The assessment of pulmonary function must be carried out with non invasive and safe methods, at the bedside, with the possibility of continuous monitoring and providing adequate calculation and management of data. The ability to assess lung function helps to define the mechanisms of respiratory failure, improving the treatment and its effects and is therefore a useful tool in the follow-up of newborn and infant with pulmonary disease.

Pregnancy and neonatal respiratory outcome.

Preterm labor is the final common pathway of different complications of pregnancy and despite substantial progress in antenatal care, preterm birth remains a major health issue across the globe. Preterm deliveries in the larger group of spontaneous preterm labor or preterm prelabor rupture of membranes (PPROM) are often associated with intrauterine chorioamnionitis. Current evidence underlines the role of "inflammatory" and "placental dysfunction" disorders in pregnancy on prematurity-associated morbidity, particularly respiratory outcome. (www.actabiomedica.it).

High-flow nasal cannula: transient fashion or new method of non-invasive ventilatory assistance?

Respiratory failure in the premature infants remains a difficult challenge. An alternative to the use of nasal continuous positive airway pressure (NCPAP) as a non-invasive modality to support respiratory distress in premature infants has been the recent introduction of high flow nasal cannula (HFNC) devices in many neonatal units. There has been increased use of HFNC presumably because of anecdotal reports and experience that it is easy to use, and well tolerated by the infants, while experiencing decreased nasal septumerosion. The paucity of evidence regarding its efficacy and safety, would support a caution approach to the use of HFNC. Particular concern has focused on the imprecise regulation and generation of pressure that may occur at higher flows especially in the smallest of infants.

Delayed meconium passage in very low birth weight infants.

BACKGROUND: Delayed meconium passage, typical of premature newborns, is a predisposing condition for bowel perforation with a significant risk of morbidity and mortality. AIM OF THE STUDY: A retrospective study was undertaken to verify the entity of the disease, assess the average time to meconium passage in a neonatal population of very low birth weight (VLBW) infants, and identify associated risk factors. METHODS: The time of first stool passage was studied in 110 VLBW infants (weighing less than 1500 g at birth). Their perinatal features, clinical course, and treatment were reviewed and studied retrospectively. RESULTS: Delayed meconium passage was recorded in 81% of this group. Patent ductus arteriosus, mechanical ventilation and uteroplacental insufficiency were significantly associated with delayed passage. An inverse relationship between gestational age, birth weight and meconium passage was found. Bowel perforation occurred in 4.5% of this neonatal population with a mortality of 50%. CONCLUSIONS: In very low birth weight infants delay in the passage of the first stool is common. Perforation in these patients may represent a fatal event, and procedures such as daily rectal enemas, which can prevent this complication, must be applied.

[Delivery room intensive care unit]. / [In Process Citation]

Over the most recent 10 years there have been no significant further improvements in survival or morbidity rates of preterm infants, mostly the extremely-low-gestational-age-neonates (ELGANs, defined as less than or equal to 28 weeks' gestation).The incidence of some of the major morbidities associated with extreme prematurity, such as BPD, could potentially be affected by management in the first minutes of life; it may be necessary to apply the principles of care that occur in the neonatal intensive care unit in the delivery room to achieve a further improvements in short and long-term outcome of these neonates. Up to now, the care of the smallest preterm infants in the delivery room has received little attention: few resuscitation protocols addressed to these newborns, not advanced equipment used and subjective monitoring based on clinical examination. Therefore, it may be useful to incorporate an intensive care environment into the delivery room to enhance survival rates and reduce morbidity of the extremely preterm infants. New approaches in the first minutes of life using more gentle parameters of intervention are being studied but further evidence is needed to improve resuscitation procedures in these newborns.

Pharyngeal pressure value using two continuous positive airway pressure devices.

The aim of the study was to measure the difference between the set continuous positive airway pressure (CPAP) value and the pharyngeal pressure reading during CPAP in premature infants with mild respiratory distress syndrome, using two different devices: hood CPAP and the conventional nasal system. The preliminary results suggest that hood CPAP may produce more stable pharyngeal pressure than the conventional nasal device.

Prenatal diagnosis and postnatal management of congenital laryngeal atresia in a preterm infant.

Laryngeal atresia is a rare congenital cause of high airway obstruction that can lead to death if not correctly recognized and treated at birth. Postnatal management is difficult and the prognosis is often poor. We report a case of prenatal diagnosis of laryngeal atresia in a fetus that was delivered preterm at 29 weeks of gestation. Tracheotomy was performed as an ex utero intrapartum treatment (EXIT) to guarantee patent airway, and laryngotracheoplasty was performed at 22 months of corrected age. A favorable ventilatory and neurodevelopmental outcome was observed at 33 months of age.

Respiratory management of the premature infant in the delivery room.

The preterm surfactant-deficient lung is highly susceptible to tissue injury with the initiation of ventilation. The respiratory management of preterm infants in the delivery room may be the key to minimizing acute lung injury and its sequelae, including chronic lung disease. Volume-targeted ventilation, optimization of the alveolar recruitment with positive end-expiratory pressure and prophylaxis with surfactant in infants with small volumes of lung gas and delicate lung tissue might help in limiting acute damage during resuscitation in the delivery room. It is desirable to monitor oxygen saturation and tailor oxygen supplementation when resuscitating premature infants.

Prophylactic nasal continuous positive airways pressure in newborns of 28-31 weeks gestation: multicentre randomised controlled clinical trial.

BACKGROUND: The role of nasal continuous positive airways pressure (nCPAP) in the management of respiratory distress syndrome in preterm infants is not completely defined. OBJECTIVE: To evaluate the benefits and risks of prophylactic nCPAP in infants of 28-31 weeks gestation. DESIGN: Multicentre randomised controlled clinical trial. SETTING: Seventeen Italian neonatal intensive care units. PATIENTS: A total of 230 newborns of 28-31 weeks gestation, not intubated in the delivery room and without major malformations, were randomly assigned to prophylactic or rescue nCPAP. INTERVENTIONS: Prophylactic nCPAP was started within 30 minutes of birth, irrespective of oxygen requirement and clinical status. Rescue nCPAP was started when Fio2 requirement was > 0.4, for more than 30 minutes, to maintain transcutaneous oxygen saturation between 93% and 96%. Exogenous surfactant was given when Fio2 requirement was > 0.4 in nCPAP in the presence of radiological signs of respiratory distress syndrome. MAIN OUTCOME MEASURES: Primary end point: need for exogenous surfactant. Secondary end points: need for mechanical ventilation and incidence of air leaks. RESULTS: Surfactant was needed by 22.6% in the prophylaxis group and 21.7% in the rescue group. Mechanical ventilation was required by 12.2% in both the prophylaxis and rescue group. The incidence of air leaks was 2.6% in both groups. More than 80% of both groups had received prenatal steroids. CONCLUSIONS: In newborns of 28-31 weeks gestation, there is no greater benefit in giving prophylactic nCPAP than in starting nCPAP when the oxygen requirement increases to a Fio2 > 0.4.

Impact of targeted-volume ventilation on lung inflammatory response in preterm infants with respiratory distress syndrome (RDS).

Volutrauma and pulmonary inflammation are thought to be the most important predisposing factors of chronic lung disease (CLD), a major complication of prematurity. A new option in patient-triggered ventilation (PTV), the volume guarantee (VG), a volume-targeted ventilation, seems to be a promising approach in reducing the risk of CLD, by limiting lung inflammatory injury and volutrauma. Our aim was to evaluate lung inflammatory response in preterm infants with respiratory distress syndrome (RDS), mechanically ventilated with and without VG, as measured by proinflammatory cytokines (IL-6, IL-8, and TNF-alpha) in tracheobronchial aspirate (TA) fluid. Fifty-three preterm infants (GA = 25-32 weeks) with RDS were randomized at birth to be ventilated using pressure support ventilation (PSV) with VG (Vt = 5 ml/kg) (n = 30) and without VG (n = 23) (Draeger Babylog 8000 Plus, 5.n). IL-6, IL-8, and TNF-alpha were determined by ELISA in TA samples on days 1, 3, and 7 of life. We observed a significant difference (ANOVA) in IL-8 and IL-6 levels on day 3 between the two groups (P < 0.05), and an increasing significative trend in IL-8 values in PSV group (P < 0.05). Mechanical ventilation lasted longer in the PSV group (12.3 +/- 3 vs. 8.8 +/- 3 days) (P = no significance). In conclusion, these preliminary data suggest a role for volume-targeted ventilatory strategy in reducing acute inflammatory response in preterm infants with RDS. Further studies are required in order to define whether this ventilatory strategy prevents lung injury.

[Lung injury and ventilatory strategies]. / Danno polmonare e strategie ventilatorie.

Premature lungs are highly susceptible to lung injury induced by chorioamionitis, mechanical ventilation or persistent exposure to high O2 concentrations. The Authors linger on the central role of atelectrauma and volutrauma (by inadequate tidal volume-Vt) in course of mechanical ventilation of preterm infants with RDS. In particular, they evaluate the efficacy and safety of the targeted volume ventilation with the option of the Volume Guarantee (VG). For this reason they present the results of randomized clinical trials in preterm infants (25-32 wks of gestational age) with severe RDS, in mechanical ventilation, without VG or with two different VG (Vt = 3 or 5 ml/Kg). Data collected demonstrate a significative difference (p < 0.05) in terms od reduction of mean airway pressure (PAW), peak inspiratory pressure (PIP) and cytokines production (IL6-IL8 and TNF alfa) in tracheal aspirate fluid in preterm infants in synchronized ventilation with VG set at 5 ml/Kg. These preliminary results seem to demonstrate the protective role of targeted volume ventilation with Vt = 5 ml/Kg (minimal volutrauma with less lung inflammatory response), but without significative reduction of chronic lung disease (CLD) in this group (probably due to multifactorial pathogenesis of CLD).