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Advances in neonatal intensive care have markedly improved survival rates for infants born at a very early lung development stage (<26 weeks gestation). In these premature infants, even low inspired oxygen concentrations and gentle ventilatory methods may disrupt distal lung growth, a condition described as 'new' bronchopulmonary dysplasia (BPD). BPD usually develops into a mild form, with only few infants requiring ventilator support and oxygen supplementation at 36 weeks post-conception. No magic bullets exist for treating infants with established severe BPD. Current management of the disease aims at maintaining an adequate gas exchange while promoting optimal lung growth. Prolonged oxygen therapy and ventilator support through nasal cannulae or a tracheotomy are often required to maintain blood gases. Short-course, low-dose corticosteroids may improve lung function and accelerate weaning from oxygen and mechanical ventilation. Pulmonary hypertension is a major complication in infants with severe BPD. Pulmonary vasodilators, such as sildenafil followed by bosentan, may improve the oxygenation and pulmonary outcome. [ABSTRACT FROM AUTHOR]

Exogenous surfactant has been the primary life-saving therapy for respiratory distress syndrome (RDS) of preterm infants for many years. More recently, early surfactant treatment administered less invasively by transient endotracheal intubation and combined to nasal ventilation has been shown to further improve neonatal outcome by reducing the need of mechanical ventilation. In addition to RDS, other neonatal and pediatric respiratory disorders characterized by surfactant inactivation or dysfunction, such as pulmonary hemorrhage, aspiration pneumonia, and viral lower respiratory tract infection, might also be amenable to surfactant replacement therapy. However, the nature of lung injury and the influence of co-morbidities may reduce the efficacy of surfactant in these conditions. Currently under investigation are new syntethic surfactant formulations which may be more effective and resistant to inactivation than natural ones and could be produced at a lower cost. The use of surfactants to deliver drugs directly to the lung also seems to be a promising technique worthy of study. [ABSTRACT FROM AUTHOR]

Background: Nasal flow-synchronized intermittent positive pressure ventilation (NFSIPPV) is a new non-invasive ventilatory mode that delivers synchronized mechanical breaths through the nasal prongs. An unmasked, prospective randomized controlled trial was conducted to compare the efficacy of NFSIPPV and conventional nasal continuous positive airway pressure (NCPAP) in increasing the likelihood for successful extubation in very low-birthweight infants. Methods: Consecutive infants who weighed <1251 g at birth, required endotracheal intubation within 48 h of birth and met specific predetermined criteria for extubation by day 14 of life were recruited. Each infant was randomized to receive either NFSIPPV or NCPAP soon after extubation. Extubation was deemed successful if re-intubation was not needed for at least 72 h. Criteria for re-intubation were persistent severe respiratory acidosis (arterial pH <7.20 with pCO2 >70 mmHg), severe recurrent apneic episodes not responding to increased ventilatory settings and then requiring bag ventilation, and hypoxemia (SaO2 <90% or pO2 <60 mmHg with FiO2 ≥0.70). Results: There were no significant differences in clinical characteristics between the two groups at randomization. Ninety-four percent (30/32) infants were successfully extubated to NFSIPPV but only 61% (19/31) to conventional NCPAP ( P > 0.005). Infants assigned to NCPAP failed extubation mainly because of apnea and hypercapnia, and those assigned to NFSIPPV because of hypoxia. Neither procedure induced major adverse effects. Conclusions: NFSIPPV in the post-extubation period is safe and more effective than NCPAP in preventing re-ventilation. [ABSTRACT FROM AUTHOR]

Mechanical ventilation is often required by very preterm infants with respiratory failure, even if invasive respiratory support is related to lung injury and adverse neurologic outcomes. The exposure to mechanical ventilation should be therefore limited. Optimal extubation however remains challenging, as approximately 30% of intubated preterm infants fails attempted extubation due to poor respiratory drive, atelectasis, residual pulmonary function abnormalities or intercurrent illness. This review outlines the advantages of different weaning strategies that should be considered by neonatologists for current use to reduce unsuccessful extubation. [ABSTRACT FROM AUTHOR]