Search

Rationale: Immature control of breathing is associated with apnea, periodic breathing, intermittent hypoxemia, and bradycardia in extremely preterm infants. However, it is not clear if such events independently predict worse respiratory outcome. Objectives: To determine if analysis of cardiorespiratory monitoring data can predict unfavorable respiratory outcomes at 40 weeks postmenstrual age (PMA) and other outcomes, such as bronchopulmonary dysplasia at 36 weeks PMA. Methods: The Prematurity-related Ventilatory Control (PreVent) study was an observational multicenter prospective cohort study including infants born at,29 weeks of gestation with continuous cardiorespiratory monitoring. The primary outcome was either “favorable” (alive and previously discharged or inpatient and off respiratory medications/O2/support at 40 wk PMA) or “unfavorable” (either deceased or inpatient/previously discharged on respiratory medications/O2/support at 40 wk PMA). Measurements and Main Results: A total of 717 infants were evaluated (median birth weight, 850 g; gestation, 26.4 wk), 53.7% of whom had a favorable outcome and 46.3% of whom had an unfavorable outcome. Physiologic data predicted unfavorable outcome, with accuracy improving with advancing age (area under the curve, 0.79 at Day 7, 0.85 at Day 28 and 32 wk PMA). The physiologic variable that contributed most to prediction was intermittent hypoxemia with oxygen saturation as measured by pulse oximetry,90%. Models with clinical data alone or combining physiologic and clinical data also had good accuracy, with areas under the curve of 0.84–0.85 at Days 7 and 14 and 0.86–0.88 at Day 28 and 32 weeks PMA. Intermittent hypoxemia with oxygen saturation as measured by pulse oximetry,80% was the major physiologic predictor of severe bronchopulmonary dysplasia and death or mechanical ventilation at 40 weeks PMA. Conclusions: Physiologic data are independently associated with unfavorable respiratory outcome in extremely preterm infants. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to compare the effect of targeting arterial oxygen saturation (SpO2) in the high (93–95%) versus the low portion (90–92%) of the recommended range of 90–95% on oxygenation stability in extremely premature infants. Methods: Premature infants of ≤28 weeks of gestational age who received a fraction of inspired oxygen (FiO2) > 0.21 after day 14 were eligible. FiO2 was adjusted by a dedicated investigator to keep SpO2 between 90–92% and 93–95% for 2 h each in random sequence. Episodes of intermittent hypoxemia (IH) were defined as SpO2 <90% for ≥10 s; severe IH episodes were defined as SpO2 <80% for ≥10 s. Hyperoxemia was defined as SpO2 >95% or >98%. Results: Eighteen premature infants were enrolled. Their (mean ± SD) GA was 26 ± 1.5 w. Seven infants were on mechanical ventilation, 4 infants on nasal ventilation, and 7 infants on nasal cannula. They were on a mean FiO2 0.38 ± 0.12 at study entry. Episodes of IH and severe IH were more frequent during the low compared to the high target (36.6 [27.0–41.3] vs. 16.0 [7.8–19.0], p < 0.001; 8.4 ± 9.3 vs. 3.2 ± 4.3, p = 0.002). The proportions of time with SpO2 >95% and >98% were greater with the high target (13.9 ± 11 vs. 34.1 ± 15.4%, p < 0.001; 0.9 [0–5.7] vs. 3.4 [0.5–16.1]%, p = 0.002). Conclusion: In this group of extremely premature infants, targeting SpO2 at the lower portion of the recommended range resulted in more frequent episodes of IH. However, targeting the higher SpO2 range led to more hyperoxemia. This trade-off warrants further investigation. [ABSTRACT FROM AUTHOR]

Apnea of prematurity is a developmental disorder affecting most extremely preterm infants. The consequences of apnea of prematurity on neurodevelopment are not well established, but several reports suggest that apnea and hypoxemia episodes may be associated with worse neurological outcome. Caffeine is the only FDA-approved drug for the prevention and treatment of apnea of prematurity. Besides its clear effectiveness to reduce apnea, the use of caffeine appears to have a wide margin of safety and has been associated with possible beneficial effects on later neurodevelopmental outcome. At the same time, there are also many studies in experimental animals and some in preterm infants suggesting potential serious adverse effects from caffeine administration, especially when using higher doses. Because of these uncertainties, there is a wide variation in caffeine use across institutions. This review summarizes some of the available evidence on caffeine use in this population, its indications and best timing of initiation and discontinuation, appropriate dosing, and some of the possible adverse effects of caffeine administration. Because of the many gaps in knowledge, especially as it relates to efficacy and safety, we encourage further basic and clinical studies to provide stronger evidence, not only on its potential beneficial effects but also its side effects. [ABSTRACT FROM AUTHOR]

One of the most complex areas in perinatal/neonatal medicine is the use of oxygen in neonatal therapies. To address the knowledge gaps that preclude optimal, evidence-based care in this critical field of perinatal medicine, the National Institute of Child Health and Human Development organized a workshop, Oxygen in Neonatal Therapies: Controversies and Opportunities for Research, in August 2005. The information presented at the workshop included basic and translational oxygen research; a review of completed, ongoing, and planned clinical trials; oxygen administration for neonatal resuscitation; and a review of the collaborative home infant monitoring evaluation study. This article provides a summary of the discussions, focusing on major knowledge gaps, with prioritized suggestions for studies in this area. Key Words bronchopulmonary dysplasia, intensive care, neonatal resuscitation, oxygen, retinopathy of prematurity, ventilation, IN THE 1890s, Thomas Morgan Rotch, a pioneer US pediatrician, administered oxygen to premature infants in small doses as a stimulant, often combining it with brandy as a second stimulant. [...]

BACKGROUND. Prolonged mechanical ventilation is associated with lung injury in preterm infants. In these infants, weaning from synchronized intermittent mandatory ventilation may be delayed by their inability to cope with increased respiratory loads. The addition of pressure support to synchronized intermittent mandatory ventilation can offset these loads and may facilitate weaning. OBJECTIVE. The purpose of this work was to compare synchronized intermittent mandatory ventilation and synchronized intermittent mandatory ventilation plus pressure support in weaning from mechanical ventilation and the duration of supplemental oxygen dependency in preterm infants with respiratory failure. METHODS. Preterm infants weighing 500 to 1000 g at birth who required mechanical ventilation during the first postnatal week were randomly assigned to synchronized intermittent mandatory ventilation or synchronized intermittent mandatory ventilation plus pressure support. In both groups, weaning followed a set protocol during the first 28 days. Outcomes were assessed during the first 28 days and until discharge or death. RESULTS. There were 107 infants enrolled (53 synchronized intermittent mandatory ventilation plus pressure support and 54 synchronized intermittent mandatory ventilation). Demographic and perinatal data, mortality, and morbidity did not differ between groups. During the first 28 days, infants in the synchronized intermittent mandatory ventilation plus pressure support group reached minimal ventilator settings and were extubated earlier than infants in the synchronized intermittent mandatory ventilation group. Total duration of mechanical ventilation, duration of oxygen dependency, and oxygen need at 36 weeks&apos; postmenstrual age alone or combined with death did not differ between groups. However, infants in synchronized intermittent mandatory ventilation plus pressure support within the 700- to lO00-g birth weight strata had a shorter oxygen dependency. CONCLUSIONS. The results of this study suggest that the addition of pressure support as a supplement to synchronized intermittent mandatory ventilation during the first 28 days may play a role in reducing the duration of mechanical ventilation in extremely low birth-weight infants, and it may lead to a reduced oxygen dependency in the 700- to 1000-g birth weight strata. Key Words mechanical ventilation, synchronized intermittent mandatory ventilation, pressure support, preterm infant, weaning, supplemental oxygen Abbreviations SIMV--synchronized intermittent mandatory ventilation PIP--peak inspiratory pressure PS--pressure support BW--birth weight PIE--pulmonary interstitial emphysema HFOV--high frequency oscillatory ventilation PEEP--positive end expiratory pressure FI[O.sub.2]--fraction of inspired oxygen SP[O.sub.2]--arterial oxygen saturation by pulse oximetry VT--tidal volume PaC[O.sub.2]--arterial carbon dioxide tension PMA--postmenstrual age IVH--intraventricular hemorrhage PDA--patent ductus arteriosus NEC--necrotizing enterocolitis ROP--retinopathy of prematurity A/C--assist/control, DESPITE THE EMERGENCE of new modes of mechanical ventilation, the optimal ventilatory strategy that can provide adequate ventilation and minimize the risk of lung injury in premature infants with respiratory [...]

Background and Objective. Evidence suggests that synthetic surfactants consisting solely of phospholipids can be improved through the addition of peptides, such as sinapultide, that mimic the action of human surfactant protein-B (SP-B). A synthetic surfactant containing a mimic of SP-B may also reduce the potential risks associated with the use of animal-derived products. Our objective was to compare the efficacy and safety of a novel synthetic surfactant containing a functional SP-B mimic (lucinactant; Discovery Laboratories, Doylestown, PA) with those of a non-protein-containing synthetic surfactant (colfosceril palmitate; GlaxoSmithKline, Brentford, United Kingdom) and a bovine-derived surfactant (beractant; Abbott Laboratories, Abbott Park, IL) in the prevention of neonatal respiratory distress syndrome (RDS) and RDS-related death. Methods. We assigned randomly (double-masked) 1294 very preterm infants, weighing 600 to 1250 g and of [less than or equal to] 32 weeks gestational age, to receive colfosceril palmitate (n = 509), lucinactant (n = 527), or beractant (n = 258) within 20 to 30 minutes after birth. Primary outcome measures were the rates of RDS at 24 hours and the rates of death related to RDS during the first 14 days after birth. All-cause mortality rates, bronchopulmonary dysplasia (BPD) rates, and rates of other complications of prematurity were prespecified secondary outcomes. Primary outcomes, air leaks, and causes of death were assigned by an independent, masked, adjudication committee with prespecified definitions. The study was monitored by an independent data safety monitoring board. Results. Lucinactant reduced significantly the incidence of RDS at 24 hours, compared with colfosceril (39.1% vs 47.2%; odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.52-0.89). There was no significant difference in comparison with beractant (33.3%). However, lucinactant reduced significantly RDS-related mortality rates by 14 days of life, compared with both colfosceril (4.7% vs 9.4%; OR: 0.43; 95% CI: 0.25-0.73) and beractant (10.5%; OR: 0.35; 95% Ch 0.18-0.66). In addition, BPD at 36 weeks postmenstrual age was significantly less common with lucinactant than with colfosceril (40.2% vs 45.0%; OR: 0.75; 95% CI: 0.56-0.99), and the all-cause mortality rate at 36 weeks postmenstrual age was lower with lucinactant than with beractant (21% vs 26%; OR: 0.67; 95% Ch 0.45-1.00). Conclusions. Lucinactant is a more effective surfactant preparation than colfosceril palmitate for the prevention of RDS. In addition, lucinactant reduces the incidence of BPD, compared with colfosceril palmitate, and decreases RDS-related mortality rates, compared with beractant. Therefore, we conclude that lucinactant, the first of a new class of surfactants containing a functional protein analog of SP-B, is an effective therapeutic option for preterm infants at risk for RDS. Pediatrics 2005;115: 1018-1029; lucinactant, colfosceril palmitate, beractant, surfactant, respiratory distress syndrome., ABBREVIATIONS. RDS, respiratory distress syndrome; BPD, bronchopulmonary dysplasia; OR, odds ratio; CI, confidence interval; IVH, intraventricular hemorrhage; PVL, periventricular leukomalacia; PMA, postmenstrual age; SP, surfactant protein; DPPC, dipalmitoylphosphatidylcholine; FI[O.sub.2], fraction [...]

Objective. Volume guarantee (synchronized intermittent mandatory ventilation [SIMV]+VG) is a novel mode of SIMV for automatic adjustment of the peak inspiratory pressure to ensure a minimum set mechanical tidal volume ([V.sub.T mech]), The objective of this study was to compare the effects of SIMV+VG with conventional SIMV on ventilation and gas exchange in a group of very low birth weight infants recovering from acute respiratory failure. Methods. Nine infants were initially studied during 2 consecutive 60-minute ventilatory modalities of conventional SIMV (ventilator settings by clinical team) and SIMV+VG 4.5 ([V.sub.T mech] set at 4.5 mL/kg) in random order. Eight additional infants were studied during the same ventilatory modalities plus 1 additional epoch consisting of SIMV+VG 3.0 ([V.sub.T mech] set at 3.0 mL/kg). Results. Peak inspiratory pressure was significantly lower during SIMV+VG 3.0. Mean airway pressure, [V.sub.T mech], number of large [V.sub.T mech] (>7 mL/kg), and mechanical minute ventilation ([V&apos;.sub.E]) were reduced during SIMV+VG 4.5 compared with SIMV and were further reduced during SIMV+VG 3.0. Spontaneous [V&apos;.sub.E] increased during SIMV+VG 4.5 and was even higher during SIMV+VG 3.0. The resulting total [ V&apos;.sub.E] was higher during both SIMV+VG modes compared with SIMV. Arterial oxygen saturation by pulse oximetry, transcutaneous carbon dioxide tension, and fraction of inspired oxygen did not differ significantly, although transcutaneous carbon dioxide tension increased slightly during SIMV+VG 3.0. Conclusions. The short-term use of SIMV+VG resulted in automatic weaning of the mechanical support and enhancement of the spontaneous respiratory effort while maintaining gas exchange relatively unchanged in comparison to conventional SIMV. Pediatrics 2002;110: 529-533; mechanical ventilation, patient triggered ventilation, weaning., ABBREVIATIONS. VLBW, very low birth weight; SIMV, synchronized intermittent mandatory ventilation; PIP, peak inspiratory pressure; VG, volume guarantee ventilation; [V.sub.T mech], mechanical tidal volume; PEEP, positive end-expiratory pressure; FI[O.sub.2], fraction [...]