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Objective Bilateral vocal-fold immobility (BFVI) is a rare but significant cause of severe respiratory distress in neonates. The primary aim of treatment is to provide an adequate airway while minimizing adverse effects such as aspiration and dysphonia. Our objective here is to describe the outcomes of a series of neonates undergoing percutaneous endoscopic suture lateralization for BVFI using a novel technique. Methods In this retrospective case series, we present 6 neonates (mean age: 18 days) with BVFI from three tertiary academic medical centers. The etiologies included 4 idiopathic, 1 unspecified neurodegenerative disorder, and 1 acquired from cardiac surgery. All had stridor and respiratory distress with hypoxemia requiring respiratory support at diagnosis. Endoscopic vocal-fold lateralization was performed under spontaneous-breathing suspension laryngoscopy using a novel technique of percutaneous needle-directed placement of 4–0 prolene suture without use of specialized equipment. Results All patients had clinical improvement in stridor and respiratory support requirements and avoided tracheostomy. One patient had persistent aspiration after lateralization that resolved after suture removal. One patient required bilateral lateralization procedures. One patient expired of epilepsy due to neurodegenerative disease unrelated to airway pathology. At last follow-up (mean 12.6 months), 5/5 remaining patients were on room air without tracheostomy and feeding orally without aspiration; 4/5 had partial or complete return of vocal-fold function. Conclusion Endoscopic percutaneous suture lateralization may be a safe and effective non-destructive primary treatment modality for neonatal BVFI. All neonates undergoing this procedure avoided tracheotomy. [ABSTRACT FROM AUTHOR]

A salivary gland anlage tumour (SGAT) is a very rare type of benign tumour that usually presents in early infancy with respiratory distress which is exacerbated upon feeding. We report a full-term male neonate who was referred to the Al Nahdha Hospital, Muscat, Oman, in 2015 with severe neonatal respiratory distress due to a nasopharyngeal obstruction immediately after birth. Computed tomography and magnetic resonance imaging revealed a well-circumscribed mass in the nasopharynx, without intracranial extension. Histopathological analysis of the lesion confirmed a diagnosis of SGAT. Following excision of the tumour, the postoperative period was uneventful. No recurrence was observed over the next two years. This case report highlights the importance of the early recognition of this extremely rare and potentially life-threatening, yet easily curable, condition. [ABSTRACT FROM AUTHOR]

Surfactant treatment of neonatal respiratory distress syndrome (RDS) was introduced in Europe during the 1990s. Meta-analyses have indicated that using less invasive surfactant administration techniques on preterm neonates receiving continuous positive airway pressure (CPAP) results in improved survival rates without bronchopulmonary dysplasia. Surfactant should be administered early and ventilator settings adapted to changing oxygen requirements and lung mechanics. Side effects including initial bradycardia, oxygen desaturation, tube obstruction and isolated cases of pulmonary haemorrhage have been reported.Conclusion: Less invasive surfactant therapy improves pulmonary outcomes in preterm neonates with RDS and should ideally be administered in combination with CPAP. [ABSTRACT FROM AUTHOR]

Respiratory distress syndrome (RDS) impacts a high proportion of preterm neonates, resulting in significant morbidity and mortality. Advances in pharmacotherapy, specifically antenatal corticosteroids and postnatal surfactant therapy, have significantly reduced the incidence and impact of neonatal RDS. Antenatal corticosteroids accelerate fetal lung maturation by increasing the activity of enzymes responsible for surfactant biosynthesis, resulting in improved lung compliance. Maternal antenatal corticosteroid treatment has improved survival of preterm neonates and lowered the incidence of brain injury. After birth, exogenous surfactant administration improves lung compliance and oxygenation, resulting in reductions in the incidence of pneumothorax and of death. Future research will identify the optimal surfactant product, timing of the initial dose, and mode of delivery. [ABSTRACT FROM AUTHOR]

Objective: To compare the effectiveness of sedation by intranasal administration of midazolam (nMDZ) or ketamine (nKTM) for neonatal intubation.Design: A multicentre, prospective, randomised, double-blind study.Setting: Delivery rooms at four tertiary perinatal centres in France.Patients: Preterm neonates with respiratory distress requiring non-emergent endotracheal intubation for surfactant instillation.Interventions: Treatment was randomly allocated, with each neonate receiving a bolus of 0.1 mL/kg in each nostril, corresponding to 0.2 mg/kg for nMDZ and 2 mg/kg for nKTM. The drug was repeated once 7 min later at the same dose if adequate sedation was not obtained.Main Outcome Measures: Success was defined by adequate sedation before intubation and adequate comfort during the procedure. Intubation features, respiratory and cardiovascular events were recorded.Results: Sixty newborns, with mean (SD) gestational age and birth weight of 28 (3) weeks and 1100 (350) g, were included within the first 20 min of life. nMDZ was associated with a higher success rate (89% vs 58%; RR: 1.54, 95% CI 1.12 to 2.12, p<0.01) and shorter delays between the first dose and intubation (10 (6) vs 16 (8) min, p<0.01).Number of attempts, time to intubation, mean arterial blood pressure measures over the first 12 hours after birth and length of invasive ventilation were not different.Conclusions: nMDZ was more efficient than nKTM to adequately sedate neonates requiring intubation in the delivery room. The haemodynamic and respiratory effects of both drugs were comparable.Clinical Trial: This clinical trial was recorded on the National Library of Medicine registry (NCT01517828). [ABSTRACT FROM AUTHOR]

• The Pediatric Assessment Triangle uses appearance, work of breathing, and circulation to quickly gauge the severity of illness and identify the underlying physiologic disturbance. • Inspiratory stridor generally is a sign of obstruction above the vocal cords, while expiratory stridor is an indication of obstruction in the trachea. Biphasic stridor is an indication of subglottic narrowing, whereas signs of lower airway obstruction include grunting, wheezing, and crackles. • Heated humidified high-flow nasal cannula is studied most commonly as an alternative form of respiratory support where continuous positive airway pressure (CPAP) is indicated. Outside of its role in infants with bronchiolitis, there is relatively limited evidence for heated humidified high-flow nasal cannula therapy in children. • The CPAP apparatus is available as a nasal plug, a nasal mask that covers the nares, a face mask that covers both the nares and the mouth, or a complete face mask that covers the entire face. When CPAP is used, the recommendation is to start low pressures (5 cmH2O) and increase in increments of 1 cmH2O as tolerated by the patient for goals of an exhaled tidal volume > 7 mL/kg, a respiratory rate normal for given age, and oxygen saturation > 90%. • Traditionally, bi-level positive airway pressure (BiPAP) has been used for pediatric patients with neuromuscular disorders, chronic lung disease, and obstructive airways. In the pediatric population, it has been limited to children weighing more than 20 kg because of the concern that small children are incapable of initiating supported breaths while on BiPAP; however, recent studies have shown BiPAP as a beneficial treatment modality for acute severe asthma exacerbations in children of all weights. • New American Academy of Pediatrics guidelines for bronchiolitis do not recommend routine chest radiographs or trials of albuterol or epinephrine aerosols. [ABSTRACT FROM AUTHOR]

Background: Nasal continuous positive airway pressure (nCPAP) is the standard noninvasive respiratory support for newborns with respiratory distress. Evidence for high-flow nasal cannula (HFNC) as an alternative mode of respiratory support is inconclusive. Objective: The aim of this work was to evaluate whether HFNC is not inferior to nCPAP in reducing the need for higher respiratory support in the first 72 h of life when applied as a noninvasive respiratory support mode for preterm neonates with respiratory distress. Methods: Preterm infants (gestation ≥28 weeks and birth weight ≥1,000 g) with respiratory distress were randomized to either HFNC or nCPAP in a non-inferiority trial. Failure of the support mode in the first 72 h after birth was the primary outcome. Infants failing HFNC were rescued either with nCPAP or mechanical ventilation, and those failing nCPAP received mechanical ventilation. Results: During the study period, 139 and 133 infants were randomized to the nCPAP and HFNC groups, respectively. The study was stopped after an interim analysis showed a significant difference (p < 0.001) in the primary outcome between the 2 groups. The treatment failure was significantly higher in the HFNC group (HFNC, n = 35, 26.3%, vs. CPAP, n = 11, 7.9%, risk difference 18.4 percentage points, 95% CI 9.7–27). Among the infants in the HFNC group who had treatment failure (n = 35), 32 were initially rescued with CPAP. The rate of mechanical ventilation in the first 3 and 7 days of life was similar between the 2 groups. Treatment failure was significantly higher in the HFNC group per protocol and also in the subgroups of infants with moderate (Silverman Anderson score, SAS ≤5) or severe respiratory distress (SAS score >5). Conclusions: When comparing HFNC to nCPAP as a primary noninvasive respiratory support in preterm infants with respiratory distress, HFNC is inferior to nCPAP in avoiding the need for a higher mode of respiratory support in the first 72 h of life. [ABSTRACT FROM AUTHOR]

Background: Heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity as an alternative to nasal continuous positive airway pressure (nCPAP) therapy in the management of preterm neonates with respiratory distress due to ease of administration and patient comfort. However, limited evidence is available addressing its risks and benefits. To study the efficacy and safety of HHHFNC in comparison to nCPAP for the facilitation of extubation in preterm neonates (born at 27-34 weeks of gestation) with respiratory distress. Methods: A prospective observational study was conducted, where 64 neonates were assigned either to nCPAP (n=34) or HHHFNC (n=30) groups post-extubation. The primary outcome was treatment failure (defined by pre-specified criteria) requiring a higher modality of respiratory support within 72 hours after extubation. Results: Treatment failure was seen in 36.7% of neonates assigned to the HHHFNC group compared to 14.7% in the nCPAP group (P=0.043). The incidence and severity of nasal trauma were higher in the nCPAP group compared to the HHHFNC group (nCPAP: 58.6% vs. HHHFNC: 15.7%; P=0.001). No significant difference was observed between the two groups in terms of other outcomes such as days on primary non-invasive ventilation (NIV), days of total NIV, duration of hospitalization, days to reach full enteral feeding, weight gain at discharge, incidence and severity of nasal trauma, incidence of pneumothorax, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity, sepsis, and death. Conclusion: Though a gentler modality with less incidence of nasal trauma, HHHFNC does not appear to be as effective as nCPAP in the management of preterms with respiratory distress. [ABSTRACT FROM AUTHOR]

For prehospital providers, guidelines for managing children with respiratory distress are often based on expert opinion, extrapolated from studies in the inpatient or emergency department setting or studies with adult patients. Implementing research protocols to develop best practices for pediatric prehospital management is challenging due to the infrequent opportunities emergency medical services (EMS) providers have to provide care to pediatric patients. Critically ill or injured children with respiratory distress due to airway compromise or underlying illness such as severe asthma exacerbations are relatively low frequency but high risk events in the prehospital setting. Improving the pipeline from prehospital scientific research to clinical practice for higher quality evidence has been an Institute of Medicine (IOM) recommendation for over a decade. The objective of this article is to describe current evidence guiding prehospital management of children with respiratory distress and to discuss potential research opportunities. [ABSTRACT FROM AUTHOR]

Respiratory emergencies have a variety of underlying causes and presentations. Studies have shown the point-of-care lung ultrasound is useful in determining the diagnosis in adult populations. There is also growing pediatric literature detailing the usefulness of point-of-care lung ultrasound in pediatric emergency care. This article will review the current evidence behind the use of point-of-care lung ultrasound in diagnosing pneumothorax, pleural effusions, pneumonia, pulmonary contusions, bronchiolitis, and pulmonary edema. [ABSTRACT FROM AUTHOR]

Damage to the endothelial glycocalyx is a critical factor in increased pulmonary vascular permeability, which is the basic pathological feature of acute respiratory distress syndrome (ARDS). Neferine (Nef), a bisbenzylisoquinoline alkaloid isolated from green seed embryos of Nelumbo nucifera Gaertn, has extensive pharmacological activity. In this study, we showed that Nef reduced lung-capillary permeability, down-regulated the production of cytokines (IL-1β, IL-6, TNF-α, and IL-10) and inhibited the activation of the NF-κB signaling pathway in mice with lipopolysaccharide (LPS)-induced ARDS. Further analysis indicated that Nef provided protection against endothelial glycocalyx degradation in LPS-induced ARDS mice (in vivo) and in LPS-stimulated human umbilical vein endothelial cells (in vitro). The glycocalyx-protective effect of Nef may be initiated by suppressing the production of mitochondrial ROS (mtROS) and decreasing oxidative damage. Nef was also found to promote glycocalyx restoration by accelerating the removal ofmtROS in endothelial cells in LPS-induced ARDS. These results suggested the potential of Nef as a therapeutic agent for ARDS associated with Gram-negative bacterial infections and elucidated the mechanisms underlying the protection and restoration of the endothelial glycocalyx. [ABSTRACT FROM AUTHOR]

Acute respiratory distress syndrome (ARDS) mainly involves acute respiratory failure. In addition to this affected patients feel progressive arterial hypoxemia, dyspnea, and a marked increase in the work of breathing. The only clinical solution for the above pathological state is ventilation. Mechanical ventilation is necessary to support life in ARDs but it itself worsen lung injury and the term is known clinically as 'ventilation induced lung injury' (VILI). At the cellular level, respiratory epithelial cells are subjected to cyclic stretch, i.e. repeated cycles of positive and negative strain, during normal tidal ventilation. In aerated areas of diseased lungs, or even normal lungs subjected to injurious positive pressure mechanical ventilation, the cells are at risk of being over distended, and worsening injury by disrupting the alveolar epithelial barrier. Further, hypercapnic acidosis (HCA) in itself confers protection from stretch injury, potentially via a mechanisms involving inhibition of nuclear factor κB (NF-κB), a transcription factor central to inflammation, injury and repair. Mesenchymal stem cells are the latest in the field and are being investigated as a possible therapy for ARDS. [ABSTRACT FROM AUTHOR]

Background: Filling the lung with dense liquid perfluorocarbons during total liquid ventilation (TLV) might compress the myocardium, a plausible explanation for the instability occasionally reported with this technique. Our objective is to assess the impacts of TLV on the cardiovascular system, particularly left ventricular diastolic function, in an ovine model of neonatal respiratory distress syndrome. Method: Eight newborns lambs, 3.0 ± 0.4 days (3.2 ± 0.3kg) were used in this crossover experimental study. Animals were intubated, anesthetized and paralyzed. Catheters were inserted in the femoral and pulmonary arteries. A high-fidelity pressure catheter was inserted into the left ventricle. Surfactant deficiency was induced by repeated lung lavages with normal saline. TLV was then conducted for 2 hours using a liquid ventilator prototype. Thoracic echocardiography and cardiac output assessment by thermodilution were performed before and during TLV. Results: Left ventricular end diastolic pressure (LVEDP) (9.3 ± 2.1 vs. 9.2 ± 2.4mmHg, p = 0.89) and dimension (1.90 ± 0.09 vs. 1.86 ± 0.12cm, p = 0.72), negative dP/dt (-2589 ± 691 vs. -3115 ± 866mmHg/s, p = 0.50) and cardiac output (436 ± 28 vs. 481 ± 59ml/kg/min, p = 0.26) were not affected by TLV initiation. Left ventricular relaxation time constant (tau) slightly increased from 21.5 ± 3.3 to 24.9 ± 3.7ms (p = 0.03). Mean arterial systemic (48 ± 6 vs. 53 ± 7mmHg, p = 0.38) and pulmonary pressures (31.3 ± 2.5 vs. 30.4 ± 2.3mmHg, p = 0.61) were stable. As expected, the inspiratory phase of liquid cycling exhibited a small but significant effect on most variables (i.e. central venous pressure +2.6 ± 0.5mmHg, p = 0.001; LVEDP +1.18 ± 0.12mmHg, p<0.001). Conclusions: TLV was well tolerated in our neonatal lamb model of severe respiratory distress syndrome and had limited impact on left ventricle diastolic function when compared to conventional mechanical ventilation. [ABSTRACT FROM AUTHOR]

Introduction: significant progress in treating respiratory distress syndrome (RDS) can be attributed to prenatal identification of high-risk pregnancies, prenatal use of glucocorticoid, administration of surfactant, progression in respiratory support, application of noninvasive ventilation by nasal continuous pressure trough nasal prongs. These measures resulted in the reduction of mortality and morbidity rates in preterm newborns. Aim: to study the effect of nasal continuous positive airway pressure (NCPAP) in preterm newborns with RDS. Materials and methods: the research included 236 preterm newborns with respiratory distress syndrome hospitalized in Neonatal Intensive Care Unit (NICU), Pediatric Clinic, Clinical Center University of Sarajevo. The study group consisted of 118 preterm newborns, treated with NCPAP The control group consisted of 118 preterm newborns of approximately the same gestational age and weight. They were intubated and received conventional mechanical ventilation. Results: treatment with nasal continuous positive airway pressure (NCPAP) significantly reduced mortality rate (p=0.05). There was a significant difference in the incidence of pneumonia, pulmonary hemorrhage and intracranial hemorrhage in the group of preterm newborns treated with NCPAP in comparison to the group of newborns treated with conventional mechanical ventilation (p=0.05). Conclusion: the use of NCPAP significantly reduces mortality and morbidity rate of preterm newborns with RDS compared to newborns of approximately same gestational age with RDS treated with conventional mechanical ventilation. Application of NCPAP leads to a reduction in lung complications: pneumonia, pulmonary hemorrhage and extrapulmonary complications such as intracranial hemorrhage. [ABSTRACT FROM AUTHOR]

Objective: Binasal prongs are the most commonly used interface for the delivery of nasal positive airway pressure (CPAP) to preterm infants. However, they are associated with pressure-related nasal injury, which causes pain and discomfort. Nasal injury may necessitate a change in interface and occasionally damage is severe enough to require surgical repair. We aim to determine the incidence and risk factors for nasal injury in preterm infants, and to provide clinicians with strategies to effectively prevent and treat it.Design: We conducted a systematic search of databases including MEDLINE (PubMed including the Cochrane Library), EMBASE, CINAHL and Scopus. Included studies enrolled human preterm infants and were published prior to 20 February 2017.Results: Forty-five studies were identified, including 14 ra ndomised controlled trials, 10 observational studies, two cohort studies, eight case reports and 11 reviews. The incidence of nasal injury in preterm infants ranged from 20-100%. Infants born <30 weeks' gestation are at highest risk. Strategies shown to reduce nasal injury included: nasal barrier dressings (2 studies, n=244, risk ratio (RD) -0.12, 95%, CI - 0.20 to -0.04), nasal high flow therapy as an alternative to binasal prong CPAP (7 studies, n=1570, risk difference (RD) -0.14, 95% CI -0.17 to -0.10), and nasal masks rather than binasal prongs (5 studies, n=544, RR 0.80, 95% CI 0.64 to 1.00).Conclusions and Relevance: Nasal injury is common in preterm infants born <30 weeks' gestational age receiving CPAP via binasal prongs. Larger randomised trials are required to fully evaluate strategies to reduce nasal injury. [ABSTRACT FROM AUTHOR]

Background: Respiratory distress syndrome (RDS) is mainly a disease of prematurity; noninvasive respiratory support has become the preferred method of management. Objectives: study the demographic characteristics of preterm infants admitted to the neonatal unit (NNU)diagnosed with RDS and compares the effectiveness of three modes of noninvasive respiratory support. Patient and methods: An observational comparison study of 545 newborns delivered at the Al Yarmouk teaching hospital, admitted to NNU with clinical and radiological diagnosis of RDS managed with three modes of noninvasive respiratory support from January2013 -December 2014. Results: Primary outcome: treatment failure ended with mechanical ventilation in the A group 49/200(24.5%), B group 30/200(17.5%), relative risk{CI=0.9937-2.2905(p=0.053)}. Secondary outcome: hours spent on the nCPAP support, = 72 hours the B group 169/200(84.5%) infants compared to A group 112/200(56%) infants who had not received surfactant, p=0.0001 ; infants from (B group) who spent >72 hr were 31/200(15.5%) compared to A group 88/200(44%), p= 0.0076. Days of hospitalization : a significant less days of hospitalization were spent by the B group versus A group (P=<0.0001) ;B group versus group C, (P= 0.0001). Outcome in A group was 60.5%(121\200) infants were discharged well and 39.5%(79/200) passed away during their hospital stay, 73% infants of B group survived (146/200) and 27% died(54/200) while 60% of infants treated with Oxyhood only survived (87/145) and 40% died (58/145). Conclusion: The INSURE method nCPAP most effective intervention within the settings of our limited resources. [ABSTRACT FROM AUTHOR]

The article discusses the associations between neighborhood, the Centers for Disease Control and Prevention Social Vulnerability Index, and medically attended acute respiratory illness among infants with bronchopulmonary dysplasia, examining its potential in explaining racial disparities.

Background: Pulmonary disorders and respiratory failure represent one of the most common morbidities of preterm newborns admitted to neonatal intensive care units (NICUs). The use of nasal high-flow therapy (nHFT) has been more recently introduced into the NICUs as a non-invasive respiratory (NIV) support. Methods: We performed a retrospective study to evaluate safety and effectiveness of nHFT as primary support for infants born < 29 weeks of gestation and/or VLBW presenting with mild Respiratory Distress Syndrome (RDS). The main outcome was the percentage of patients that did not need mechanical ventilation. Secondary outcomes were rate of bronchopulmonary dysplasia (BDP), air leaks, nasal injury, late onset sepsis (LOS), intraventricular hemorrhage (IVH), retinopathy (ROP), necrotizing enterocolitis (NEC), hemodynamically-significant patent ductus arteriosus (PDA) and death. Results: Sixty-four preterm newborns were enrolled. Overall, 93% of enrolled patients did not need mechanical ventilation. In a subgroup analysis, 88.5% of infants < 29 weeks and 86.7% of infants ELBW (< 1000 g BW) did not need mechanical ventilation. BPD was diagnosed in 26.6% of preterms enrolled (Mild 20%, Moderate 4.5%, Severe 1.5%). In subgroup analysis, BPD was diagnosed in 53.9% of newborns with GA < 29 weeks, in 53.3% of ELBW newborns and in 11.1% of small for gestational age (SGA) newborns. Neither air leaks nor nasal injury were recorded as well as no exitus occurred. LOS, IVH, ROP, NEC and PDA occurred respectively in 16.1%, 0%, 7.8%, and 1.6% of newborns. Conclusions: According to our results, n-HFT seems to be effective as first respiratory support in preterm newborns with mild RDS. Further studies in a larger number of preterm newborns are required to confirm nHFT effectiveness in the acute phase of RDS. [ABSTRACT FROM AUTHOR]

Nasal injuries with use of nasal continuous positive airway pressure (CPAP) range from blanching of nasal tip to septal necrosis and septal drop. This analysis was done in preterm neonates of < 34-week gestation, who received nasal CPAP as primary support as part of a randomized trial comparing Jet device with Bubble device for delivery of CPAP, both through nasal prongs of different structure, make and fixation methods. Nasal injury was assessed using a validated nasal injury score. Out of 170 neonates enrolled, 103 (61%) had nasal injuries; moderate and severe injuries were observed in 18 (11%) and 8 (5%) infants, respectively. Septum was the most common site injured. The incidence and severity of nasal injury were significantly lesser in Jet group compared to Bubble group [RR 0.6 (95% C.I. 0.5-0.8); p < 0.001]. Similarly, neonates in Jet group had lesser average [median (IQR): 3 (3,4) vs. 4 [8, 14]; p = 0.04] as well as peak N-PASS pain scores [median (IQR): 4 [8, 14] vs. 5 [13, 16]; p = 0.01] in comparison to Bubble group. However, Jet group neonates had significantly more common prong displacements.Conclusion: Bubble CPAP device with its nasal interface had higher and more serious incidence of nasal injuries in comparison to Jet CPAP device. What is known: • Nasal injuries are becoming increasingly common with use of nasal CPAP low gestational age, low birth weight, longer use of CPAP and longer NICU stay are risk factors for such injuries • Validated nasal injury scores have been created for assessment of nasal trauma in neonates What is new: • Bubble device with its interface had higher and more serious incidence of nasal injuries in comparison to Jet device • Even though pain assessed by N-PASS was less with Jet device, prong displacements were more frequent with its system. [ABSTRACT FROM AUTHOR]

Purpose: To describe the incidence, indications and clinical outcomes following high pressures on noninvasive respiratory support (NRS) in preterm neonates.Study Design: Retrospective cohort study of all neonates with BW <1.500 g admitted from July 2012 to June 2014 and placed on high noninvasive respiratory support (NRS), defined as mean airway pressure ≥10 cm H2O for at least 12 continuous hours using nasal continuous positive airway pressure (NCPAP) and/or nasal high-frequency ventilation (NIHFV). Clinical and physiological outcomes following high NRS were ascertained. Median (IQR) and percentages were used to describe continuous and categorical data, respectively.Results: There were 131 instances of high NRS use in 70 of 315 eligible infants. Most common indication was post-extubation, observed in 37% (49/131) of high NRS instances. Intubation was avoided in 71% (93/131) of instances in the first 7 days following high NRS initiation. There were no physiological perturbations in heart rate, blood pressure or oxygen requirement. Furthermore, there were no instances of lung hyperinflation, pneumothoraces or spontaneous intestinal perforation following high NRS.Conclusion: The use of high NRS pressure was followed by avoidance of intubation in the majority of cases without adverse effects. Further research on high NRS use including its indications, clinical outcomes and safety profile is warranted. [ABSTRACT FROM AUTHOR]

Background: Maintenance of a patent airway while the neonate is on nasal continuous positive airway pressure (nasal CPAP) requires vigilant monitoring and oral/nasopharyngeal suctioning. Currently, no evidence-based guidelines for safe suctioning in neonates while on bubble nasal CPAP have been published.Purpose: (1) To characterize the clinical and behavioral responses of neonates on bubble nasal CPAP in a level III neonatal intensive care unit following routine oral and nasopharyngeal suctioning.Methods: This pilot study has a 1-sample within-subject repeated-measures design in which neonates (N = 16) served as their own control. Data on a neonate's physiological and behavior measures (heart rate, respiratory rate, oxygen saturation [SaO2], and Premature Infant Pain Profile [PIPP] score) were collected before, during, and after the completion of suctioning sequence.Finding/results: A total of 16 neonates with a mean gestational age of 29.76 weeks and an average day of life of 3.4 were enrolled. The infant's heart rates did not differ significantly (P = .51) across the suctioning sequence. There were no statistical significant changes in the average respiratory rate across the suctioning sequences (P = .79). SaO2 demonstrated a drop between baseline and after each suctioning (P < .001). The PIPP score demonstrated a precipitous increase throughout the procedure (P < .001). On average, it took 9.5 seconds (SD = 4.9) to complete the suctioning sequences.Implications For Practice: Our results suggest that the guideline tested is safe and tolerated by infants.Implications For Research: This guideline should be tested in a larger sample and with neonates on other nasal CPAP systems. [ABSTRACT FROM AUTHOR]

Objective To investigate the effect of alveolar recruitment combined with surfactant administration on children with acute respiratory distress syndrome (ARDS). Material and Methods A prospective, randomized, controlled and sequential study was carried out. Group A (16 children) was treated with both the alveolar recruitment manoeuvres (ARM) and the administration of the surfactant every 8 h for 3 days; group B (15) received the usual treatment only. The alveolar recruitment was carried out by increasing positive end-expiratory pressure 2 by 2 cm H2O to improve the transcutaneous oxygen saturation values up to 88% and 90%. Demographic data, gasometric and ventilator parameters, chest radiography and 28-day mortality were evaluated. Results There were no significant differences in baseline characteristics between groups. An hour after treatment, significant differences ( P < 0.001) were observed in transcutaneous oxygen saturation (SaO2; Group A: 94.1%, Group B: 89.9%), PaO2/FiO2 (212.7 and 126.4) and oxygenation index (OI; 11.4 and 18.5). After 8 h, the differences in SaO2 (Group A: 94.6%, Group B: 90.3%), PaO2/FiO2 (225.8 and 126.9) and OI (10.8 and 18.4) were also significant ( P < 0.001). From the fifth dose of the surfactant, the static compliance ( P = 0.0034) and radiological images ( P = 0.002) were more greatly improved in group A than in group B. Survival was significantly higher in group A (81.3%) than in group B (26.7%) ( P = 0.006). Conclusions The combined treatment of surfactant administration and ARM resulted in a better oxygenation and survival in children with ARDS than when only recruitment was used. [ABSTRACT FROM AUTHOR]

This paper reports finding from a nested qualitative study designed to elicit the views and perceptions of those who participated in a randomised controlled feasibility trial testing a non-pharmacological intervention, Respiratory Distress Symptom Intervention (RDSI), for the management of the breathlessness-cough-fatigue symptom cluster in lung cancer. Semi-structured interviews were conducted with 11 lung cancer patients, three caregivers and seven researchers involved in recruitment, consent, RDSI training and delivery and participant follow-up. Thematic analysis identified key considerations including: the importance of informed consent emphasising commitment to completion of paperwork and raising awareness of potential sensitivities relating to content of questionnaires; ensuring screening for the presence of symptoms reflects the language used by patients; appreciation of the commitment required from participants to learn intervention techniques and embed them as part of everyday life; conduct of interviews with patients who decline to participate; and conduct of serial interviews with those receiving RDSI to further inform its routine implementation into clinical practice. This study will inform the development of a fully powered follow-on trial testing the hypothesis that RDSI plus usual care is superior to usual care alone in the effective management of this symptom cluster in lung cancer. [ABSTRACT FROM AUTHOR]

Background Surfactant replacement therapy is widely used for treating neonatal respiratory distress syndrome, but insufficient evidence is available on the use of Surfacten® (S- TA). This study investigated the inadvertent loss of S- TA during instillation via feeding catheters with different bore sizes. Methods In this bench-based study, we measured the weight of syringes and tubes before and after surfactant treatment using a high-accuracy balance, and determined the amount of S- TA lost in tubes. We injected 120 mg of S- TA suspended in 4 or 3 mL into tubes followed with or without air boluses. Experiments were performed in triplicate. Percent weight loss of S- TA in each tube was calculated with or without air boluses. Results Percent weight loss of S- TA was significantly higher in larger-bore tubes ( P < 0.01, overall ANOVA), and was significantly lower after air bolus flushing in 3 Fr, 4 Fr, and 5 Fr tubes ( P < 0.005, respectively). The 3 mL S- TA suspensions had a significantly higher percent loss than the 4 mL S- TA suspensions when using 4 Fr and 5 Fr tubes, and the 5 Fr closed system ( P < 0.05, respectively). Conclusions Routine air bolus flushing effectively reduces S- TA loss in tubes. The 3 mL S- TA suspensions appear to be more susceptible to inadvertent S- TA loss during instillation. Therefore, caution is warranted for this procedure. [ABSTRACT FROM AUTHOR]

Infantile hepatic hemangioma (IHH) is the most common benign hepatic tumor of infancy. It is characterized by rapid proliferation in the first year of life, followed by slow involution during childhood. presentation can range from asymptomatic to severe, high-output congestive heart failure (CHF). The purpose of this article is to review the case of an infant with an atypical presentation of Ihh. It also addresses pathophysiology, diagnosis, management, and multidisciplinary team care. [ABSTRACT FROM AUTHOR]

Pneumopericardium occurs when air accumulates in the pericardial sac surrounding the heart and is one of the rarest forms of air leaks in neonates. Because of various advances in neonatal care, including gentler modes of ventilation, surfactant replacement, and antenatal steroids, the incidence of pneumopericardium has decreased. despite the decrease in incidence of pneumopericardium, most cases arise in premature infants with a history of respiratory distress and mechanical ventilation. evidence has shown that the incidence is inversely related to birth weight and that pneumopericardium has high mortality and morbidity rates. [ABSTRACT FROM AUTHOR]

Paraquat (PQ, methyl viologen) was widely used in agricultural production throughout the world in 1962 for its efficient herbicidal activity. PQ was also highly toxic drug. About 5 mL medicine including 20% paraquat was life-threatening that can cause poisoning. In 1966, some people died because of PQ poisoning. Most patients had acute respiratory distress syndrome after 2 wk, and 70% of them died due to the lack of effective detoxification drugs. Thus, it was particularly important to understand the pathogenesis of PQ poisoning and give some effective treatments. This article will review the toxicological mechanism and treatment on PQ poisoning of acute lung injury. [ABSTRACT FROM AUTHOR]

Mechanical ventilation ( MV) used in patients with acute respiratory distress syndrome ( ARDS) can increase lung inflammation and pulmonary fibrogenesis. Src is crucial in mediating the transforming growth factor ( TGF)-β1-induced epithelial-mesenchymal transition ( EMT) during the fibroproliferative phase of ARDS. Nintedanib, a multitargeted tyrosine kinase inhibitor that directly blocks Src, has been approved for the treatment of idiopathic pulmonary fibrosis. The mechanisms regulating interactions among MV, EMT and Src remain unclear. In this study, we suggested hypothesized that nintedanib can suppress MV-augmented bleomycin-induced EMT and pulmonary fibrosis by inhibiting the Src pathway. Five days after administrating bleomycin to mimic acute lung injury ( ALI), C57 BL/6 mice, either wild-type or Src-deficient were exposed to low tidal volume ( VT) (6 ml/kg) or high VT (30 ml/kg) MV with room air for 5 hrs. Oral nintedanib was administered once daily in doses of 30, 60 and 100 mg/kg for 5 days before MV. Non-ventilated mice were used as control groups. Following bleomycin exposure in wild-type mice, high VT MV induced substantial increases in microvascular permeability, TGF-β1, malondialdehyde, Masson's trichrome staining, collagen 1a1 gene expression, EMT (identified by colocalization of increased staining of α-smooth muscle actin and decreased staining of E-cadherin) and alveolar epithelial apoptosis ( P < 0.05). Oral nintedanib, which simulated genetic downregulation of Src signalling using Src-deficient mice, dampened the MV-augmented profibrotic mediators, EMT profile, epithelial apoptotic cell death and pathologic fibrotic scores ( P < 0.05). Our data indicate that nintedanib reduces high VT MV-augmented EMT and pulmonary fibrosis after bleomycin-induced ALI, partly by inhibiting the Src pathway. [ABSTRACT FROM AUTHOR]

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Objective: There are conflicting data regarding the use of end-tidal carbon dioxide (PetCO2) measurement in preterm infants. The aim of this study was to evaluate the effects of different dead space to tidal volume ratios (VD/VT) on the correlation between PetCO2 and arterial carbon dioxide pressure (PaCO2) in ventilated preterm infants with respiratory distress syndrome (RDS). Methods: We enrolled ventilated preterm infants (with assist control mode or synchronous intermittent mandatory mode) with RDS who were treated with surfactant in this prospective study. Simultaneous PetCO2 and PaCO2 data pairs were obtained from ventilated neonates monitored using mainstream capnography. Data obtained before and after surfactant treatment were also analyzed. Results: One-hundred and one PetCO2 and PaCO2 pairs from 34 neonates were analyzed. There was a moderate correlation between PetCO2 and PaCO2 values (r = 0.603, P < 0.01). The correlation was higher in the post-surfactant treatment group (r = 0.786, P < 0.01) than the pre-surfactant treatment group (r = 0.235). The values of PaCO2 and PetCO2 obtained based on the treatment stage of surfactant therapy were 42.4 ± 8.6 mmHg and 32.6 ± 7.2 mmHg, respectively, in pre-surfactant treatment group, and 37.8 ± 10.3 mmHg and 33.7 ± 9.3 mmHg, respectively, in the post-surfactant treatment group. Furthermore, we found a significant decrease in VD/VT in the post-surfactant treatment group when compared to the pre-surfactant treatment group (P = 0.003). Conclusions: VD/VT decreased significantly after surfactant therapy and the correlation between PetCO2 and PaCO2 was higher after surfactant therapy in preterm infants with RDS. [ABSTRACT FROM AUTHOR]

Objective Our aim was to compare the success of extubation in neonatesmanaged with nonsynchronized intermittent nasal positive-pressure ventilation (nsNIPPV) and twomodes of nasal continuous positive airway pressure (NCPAP) after the first extubation. Study Design Randomized controlled clinical trial conducted in the neonatal intensive care unit (NICU) included infants with gestational age ≤ 34 weeks and birth weights (BW) 500 to 1,500 g with a diagnosis of respiratory distress syndrome (RDS), divided into three groups: ventilation with nsNIPPV, bubble-NCPAP, and ventilator-NCPAP. Extubation failure (EF) was defined as occurring within 48 hours after extubation. Results We included 101 newborns: nsNIPPV (n = 36); bubble-NCPAP (n = 32) ventilator-NCPAP (n = 33). Overall, the extubation success rate was 81.2%. There were no skin, gastric, or pulmonary complications related to noninvasive ventilation (NIV) (p = 1). There was no difference between the groups regarding the success/EF (p = 0.4). There was extubation success in 81 (81.2%) cases, and EF occurred in 20 (19.8%), associated with longer invasive mechanical ventilation time (p < 0.001) and development of bronchopulmonary dysplasia (p = 0.04). Conclusion In this trial, three modalities of NIV applied in the success/failure outcomes of extubation avoided reintubation in 80% of infants. document was downloaded for personal use only. Unauthorized distribution [ABSTRACT FROM AUTHOR]

We describe a pragmatic training-of-trainers program for the use of continuous positive airway pressure (CPAP) for neonatal and pediatric patients. The program is designed for medical professionals working in low- and middle-income countries and involves 2 days of in-class training followed by 1 day of in-service training. The program was created after training in Cambodia, Ghana, Honduras, Kenya and Rwanda and addresses the issues of resource availability, cultural context and local buy-in and partnership in low- and middle-income countries. We hope others will use the training program to increase knowledge and use of CPAP with the ultimate goal of improving neonatal and pediatric survival globally. [ABSTRACT FROM AUTHOR]

Objective: To analyze the change in quality indicators due to the use of high-flow nasal cannula therapy as a non-invasive ventilation method in children with respiratory distress/failure in a non-invasive ventilation device-free pediatric intensive care unit. Methods: Retrospective chart review of children with respiratory distress/failure admitted 1 year before (period before high-flow nasal cannula therapy) and 1 year after (period after high-flow nasal cannula therapy) the introduction of high-flow nasal cannula therapy. We compared quality indicators as rate of mechanical ventilation, total duration of mechanical ventilation, rate of reintubation, pediatric intensive care unit length of stay, and mortality rate between these periods. Results: Between November 2012 and November 2014, 272 patients: 141 before and 131 after high-flow nasal cannula therapy were reviewed (median age was 20.5 mo). Of the patients in the severe respiratory distress/failure subgroup, the rate of intubation was significantly lower in period after than in period before high-flow nasal cannula therapy group (58.1% vs. 76.1%; P<0.05). The median pediatric intensive care unit length of stay was significantly shorter in patients who did not require mechanical ventilation in the period after than in the period before high-flow nasal cannula therapy group (3d vs. 4d; P<0,05). Conclusions: Implementation of high-flow nasal cannula therapy in pediatric intensive care unit significantly improves the quality of therapy and its outcomes. [ABSTRACT FROM AUTHOR]

Background and aims: To investigate whether performing alveolar recruitment or adding inspiratory pauses could promote physiologic benefits (VT) during moderately-high-frequency positive pressure ventilation (MHFPPV) delivered by a conventional ventilator in a porcine model of severe acute respiratory distress syndrome (ARDS). Methods: Prospective experimental laboratory study with eight pigs. Induction of acute lung injury with sequential pulmonary lavages and injurious ventilation was initially performed. Then, animals were ventilated on a conventional mechanical ventilator with a respiratory rate (RR) = 60 breaths/minute and PEEP titrated according to ARDS Network table. The first two steps consisted of a randomized order of inspiratory pauses of 10 and 30% of inspiratory time. In final step, we removed the inspiratory pause and titrated PEEP, after lung recruitment, with the aid of electrical impedance tomography. At each step, PaCO2 was allowed to stabilize between 57–63 mmHg for 30 minutes. Results: The step with RR of 60 after lung recruitment had the highest PEEP when compared with all other steps (17 [16,19] vs 14 [10, 17]cmH2O), but had lower driving pressures (13 [13,11] vs 16 [14, 17]cmH2O), higher P/F ratios (212 [191,243] vs 141 [105, 184] mmHg), lower shunt (23 [20, 23] vs 32 [27, 49]%), lower dead space ventilation (10 [0, 15] vs 30 [20, 37]%), and a more homogeneous alveolar ventilation distribution. There were no detrimental effects in terms of lung mechanics, hemodynamics, or gas exchange. Neither the addition of inspiratory pauses or the alveolar recruitment maneuver followed by decremental PEEP titration resulted in further reductions in VT. Conclusions: During MHFPPV set with RR of 60 bpm delivered by a conventional ventilator in severe ARDS swine model, neither the inspiratory pauses or PEEP titration after recruitment maneuver allowed reduction of VT significantly, however the last strategy decreased driving pressures and improved both shunt and dead space. [ABSTRACT FROM AUTHOR]

To date, preterm infants with respiratory distress syndrome (RDS) after birth have been managed with a combination of endotracheal intubation, surfactant instillation, and mechanical ventilation. It is now recognized that noninvasive ventilation (NIV) such as nasal continuous positive airway pressure (CPAP) in preterm infants is a reasonable alternative to elective intubation after birth. Recently, a metaanalysis of large controlled trials comparing conventional methods and nasal CPAP suggested that CPAP decreased the risk of the combined outcome of bronchopulmonary dysplasia or death. Since then, the use of NIV as primary therapy for preterm infants has increased, but when and how to give exogenous surfactant remains unclear. Overcoming this problem, minimally invasive surfactant therapy (MIST) allows spontaneously breathing neonates to remain on CPAP in the first week after birth. MIST has included administration of exogenous surfactant by intrapharyngeal instillation, nebulization, a laryngeal mask, and a thin catheter. In recent clinical trials, surfactant delivery via a thin catheter was found to reduce the need for subsequent endotracheal intubation and mechanical ventilation, and improves short-term respiratory outcomes. There is also growing evidence for MIST as an alternative to the INSURE (intubation-surfactantextubation) procedure in spontaneously breathing preterm infants with RDS. In conclusion, MIST is gentle, safe, feasible, and effective in preterm infants, and is widely used for surfactant administration with noninvasive respiratory support by neonatologists. However, further studies are needed to resolve uncertainties in the MIST method, including infant selection, optimal surfactant dosage and administration method, and need for sedation. [ABSTRACT FROM AUTHOR]

Objectives: We aimed to evaluate the efficacy of respiratory support and surfactant in incidence, management and outcome of neonatal hypoxemic respiratory failure (NRF) in Chinese emerging regional neonatal-perinatal care system in the era of universal health insurance policy.Study Design: Clinical data of NRF were prospectively collected in 12 consecutive months from 2011 to 2012 in 12 neonatal intensive care units (NICU) in major cities of Northwest China. NRF was defined as hypoxemia requiring nasal continuous positive airway pressure (nCPAP) or intratracheal ventilation combined with surfactant for at least 24 h, with associated risk factors, mortality rate and major co-morbidities analyzed.Results: Among 9816 admissions, there were 1324 NRF cases with 60.2% being preterm. The incidence of NRF was 13.4% with a mortality of 15.5%. The major underlying diseases were respiratory distress syndrome (RDS, 38.9%) and pneumonia/sepsis (38.0%). Only 15.9% of NRF and 33.8% of RDS received surfactant, which contributed to >70% and >85% survival in RDS patients of birth weight (BW) < 1500 g and >1500 g, respectively. Multivariate logistic regression analysis showed that premature rupture of membrane ≥ 24 h, very low BW and gestational age < 32 weeks, resuscitation at delivery, illness severity at admission, intratracheal ventilation and sepsis were the independent risk factors for the mortality of NRF. The length and cost of NICU stay for survivors reflected care burden in the era of universal health insurance.Conclusions: Surfactant significantly improved the survival of neonates with NRF and RDS, reflecting the respiratory care standard in emerging regional neonatal-perinatal care network with limited resources. [ABSTRACT FROM AUTHOR]

Background: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are severe inflammatory lung diseases. Methylprednisolone (MP) is a common drug against inflammation in clinic. In this study, we aim to investigate the protective effect of MP on ALI and potential mechanisms.Methods: Male BABL/c mice were injected through tail vein using lipopolysaccharide (LPS, 5 mg/kg) with or without 5 mg/kg MP. Lung mechanics, tissue injury and inflammation were examined. Macrophage subsets in the lung were identified by flow cytometry. Macrophages were cultured from bone marrow of mice with or without MP. Then, we analyzed and isolated the subsets of macrophages. These isolated macrophages were then co-cultured with CD4+ T cells, and the percentage of regulatory T cells (Tregs) was examined. The expression of IL-10 and TGF-β in the supernatant was measured. The Tregs immunosuppression function was examined by T cell proliferation assay. To disclose the mechanism of the induction of Tregs by M2c, we blocked IL-10 or/and TGF-β using neutralizing antibody.Results: Respiratory physiologic function was significantly improved by MP treatment. Tissue injury and inflammation were ameliorated in the MP-treated group. After MP treatment, the number of M1 decreased and M2 increased in the lung. In in vitro experiment, MP promoted M2 polarization rather than M1. We then induced M1, M2a and M2c from bone marrow cells. M1 induced more Th17 while M2 induced more CD4+CD25+Fxop3+ Tregs. Compared with M2a, M2c induced more Tregs, and this effect could be blocked by anti-IL-10 and anti-TGF-β antibodies. However, M2a and M2c have no impact on Tregs immunosuppression function.Conclusion: In conclusion, MP ameliorated ALI by promoting M2 polarization. M2, especially M2c, induced Tregs without any influence on Tregs immunosuppression function. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study are (i) to evaluate the feasibility of using an inexpensive air pump to maintain reliable oxygen concentration in a continuous positive airway pressure (CPAP) system and (ii) to evaluate whether an inexpensive air pump can maintain infant 02 sats >90%.Methods: This prospective study, which included 19 babies in pilot phase and 90 during extension phase, was conducted at a neonatal intensive care unit in a resource-poor academic medical center in India. The intervention involved introduction of an air pump in the CPAP delivery system. Outcome measures were oxygen concentration in the air-oxygen blend and oxygen saturation of the study babies.Results: Oxygen concentration at the outlets ranged between 56 and 70% and in the blend between 42 and 51%. Oxygen saturation ranged between 90 and 97%.Conclusion: A simple and inexpensive air pump can work as a safe and effective oxygen blender. [ABSTRACT FROM AUTHOR]

BACKGROUND: The current study aimed to compare the efficacy and safety of 2 noninvasive respiratory support methods, which included helmet CPAP and high-flow nasal cannula (HFNC) in children with respiratory distress admitted to a pediatric intermediate care unit. METHODS: This study was a prospective observational study conducted on children with respiratory distress (age 1-24 months) who were admitted to our acute and emergency operative unit. All included subjects were randomly treated with helmet CPAP or HFNC in a 1:1 fashion until their clinical picture, oxygen saturation, and arterial blood gas (ABG) parameters resolved. The efficiencies of helmet CPAP and HFNC were evaluated by breathing frequency, ..., ABG pH, ABG ..., ABG ..., and ..., recorded once at baseline and then after 1 and 6 h of treatment. Both noninvasive respiratory support modalities were compared with a control group of subjects with respiratory distress under standard therapeutic pharmaceutical protocols. RESULTS: We found that both helmet CPAP and HFNC were efficient in improving the clinical conditions of subjects with mildto-moderate respiratory distress, although clinical response to helmet CPAP was more efficient and rapid compared with HFNC. Children who received respiratory support had a better clinical course in terms of hospitalization, days of intravenous rehydration therapy, and days of drug administration compared with the control group (P < .001). CONCLUSIONS: Based on our knowledge, the present study is the first research comparing the effects of CPAP and HFNC in respiratory distress resolution in a pediatric intermediate care setting. It aims to identify the most efficient treatment to avoid pediatric ICU admissions and endotracheal intubation and reduce the administration of drugs and days of hospitalization. [ABSTRACT FROM AUTHOR]

Zinc chloride smoke bomb exposure is frequently seen in military drills, combat exercises, metal industry works, and disaster simulations. Smoke exposure presents with variety of pulmonary damage based on the intensity of the exposure. Smoke induced severe acute respiratory distress syndrome (ARDS) is often fatal and there are no standard treatment guidelines. We report the first survival of smoke induced severe ARDS in the United States (US) with prolonged use of high dose steroids (five weeks) and lung protective ventilation alone. Previously reported surviving patients in China and Taiwan required extracorporeal membrane oxygenation (ECMO) and other invasive modalities. We suggest that an extended course of high dose corticosteroids should be considered for the treatment of smoke inhalation related ARDS and should be introduced as early as possible to minimize the morbidity and mortality. We further suggest that patients with smoke inhalation should be observed in the hospital for at least 48 to 72 hours before discharge, as ARDS can have a delayed onset. Being vigilant for infectious complications is important due to prolonged steroid treatment regimen. Patients must also be monitored for critical illness polyneuromyopathy. Additionally, upper airway injury should be suspected and early evaluation by otorhinolaryngology may be beneficial. [ABSTRACT FROM AUTHOR]

Aim: Different catheters can be used for less invasive surfactant therapy (LIST): feeding tubes inserted with or without Magill forceps, different angiocatheters and centre specific devices, such as umbilical catheters affixed to a stylet. This study compared the effectiveness of LIST devices and endotracheal tubes (ETT).Methods: Video recordings of 20 neonatologists simulating different LIST techniques on two manikin heads were analysed. Procedural effectiveness was evaluated by the duration of procedures and failure rates. Ease of use was scored.Results: The median procedure time for the Neonatal Intubation Trainer was significantly longer with feeding tubes without Magill forceps. For the more difficult ALS Baby Trainer, successful procedures lasted a median of 24 (17-32) seconds with ETT, 24 (15-36) seconds with stylet-guided catheters and 34 (27-46) seconds and 37 (29-42) seconds with 13-cm and 30-cm angiocatheters, respectively. Both methods using feeding tubes were statistically slower than ETT intubation, lasting 32 (25-44) seconds and 39 (27-95) seconds with or without Magill forceps. Failure rates (7-20%) were no different between the LIST methods. Techniques using feeding tubes were rated as more difficult.Conclusion: Only rigid or stylet-guided catheters required tracheal catheterisation times similar to those of endotracheal intubation and neonatologists found them easier. [ABSTRACT FROM AUTHOR]

BACKGROUND: High-frequency jet ventilation (HFJV) has been used in conjunction with conventional ventilation for infants with respiratory failure. We sought to identify parameters that were associated with successful application of HFJV in patients with hypercapnic respiratory failure. METHODS: A single-center, retrospective review of infants who received HFJV was conducted. Subjects were enrolled if birthweight was ≤2,000 g and capillary ... was ≥55 mm Hg. Ventilator parameters and physiologic data were recorded at 1 h before HFJV initiation and at hours 1, 4, and 6 following conversion. Subjects were classified as responders if capillary ... was reduced by ≥10% after 1 h of HFJV. Data included peak inspiratory pressure, PEEP, capillary ..., and oxygen saturation index (equal to mean airway pressure x ... x 100/...). Because the data were not normally distributed, they are reported as median (interquartile range), and the Mann-Whitney test was used to assess differences in continuous data between groups. Categorical data were analyzed using a chi-square and Fisher exact test. RESULTS: Thirty-four premature infants (n = 24 male) were studied. Twenty-five subjects were classified as responders and demonstrated a significant reduction of capillary ... and ... and increased pH within the first hour. The non-responders demonstrated a higher conventional ventilation peak inspiratory pressure (25 cm H2O vs 19 cm H2O, P = .005) and had a greater postmenstrual age (30 weeks vs 26.5 weeks, P = .01). This group had a higher oxygen saturation index (7.25 vs 3.36, P = .03) and ... requirements (0.6 vs 0.35, P = .038) at 4 h. CONCLUSIONS: We identified that lower postmenstrual age, improvements in capillary ... and pH at 1 h, and a reduction of ... were associated with good response to HFJV. These data may help to identify patients who are likely to benefit from HFJV in the neonatal intensive care unit. [ABSTRACT FROM AUTHOR]

Aim: The aim of the study is to evaluate extracorporeal life support system (ECLS) employed in neonates in pediatric cardiac intensive care unit.Material and Methods: Twenty-five neonates that required ECLS in between November 2010 and November 2015 were evaluated.Results: The median age was 12 days (range 3-28 days) and the median body weight was 3 kg (range 2.5-5 kg). Venoarterial ECLS was performed in all of the cases. Ascendan aorta-right atrial cannulation in 22 patients and neck cannulation in three patients were performed. The reason for ECLS was E-CPR in two patients, inability to wean from cardiopulmonary bypass (CPB) in seven patients, respiratory insufficiency and hypoxia in nine patients, low cardiac output (LCOS) in seven patients. Median duration of ECLS was four days (range 1-15). Hemorrhagic complications developed in 15, renal complications in 13, pulmonary complications in 12, infectious complications in 11, neurologic complications in three and mechanical complications in two of the patients. Weaning was successful in 15 of the patients. Eleven patients were successfully discharged.Conclusion: ECLS is an important treatment option that is performed successfully in many centers around the world to maintain life support in patients unresponsive to medical treatment. The utilization of this modality especially in newborns with congenital heart disease should be taken into consideration. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive surfactant therapy (MIST) is a new strategy to avoid mechanical ventilation (MV) in respiratory distress syndrome. The primary aim of this study was to test MIST as a means of avoiding MV exposure and pneumothorax occurrence in moderate and late preterm infants (32 to 36 weeks' gestational age). Methods: This was a randomized controlled trial including three Canadian centres. Patients were randomized to standard management or to the intervention if they required nasal continuous positive airway pressure of 6 cm H[sub 2]O and 35% FiO[sub 2] in the first 24 hours of life. Patients from the intervention group received MIST immediately after inclusion. The primary outcome was either need for MV or development of a pneumothorax requiring a chest tube. To ensure that clinicians were not biased toward delaying intubation in the intervention group, clinical failure criteria were also used as a primary outcome. The primary outcome was analyzed using bivariate and multivariate logistic regressions. Results: Among 45 randomized patients, 24 were assigned to MIST and 21 to standard management. Eight infants (33%) from the intervention group met the primary outcome criteria versus 19 (90%) in the control group (absolute risk reduction 0.57, 95% confidence interval 0.54 to 0.60). One patient in each group reached the primary outcome because of pneumothorax occurrence. The other patients were exposed to MV. None of the patients reached the clinical failure criteria. Conclusion: MIST for respiratory distress syndrome management in moderate and late preterm infants was associated with a significant reduction of MV exposure and pneumothorax occurrence. [ABSTRACT FROM AUTHOR]

Background Post-operative respiratory failure is common in liver transplant patients, with a direct effect on graft and recipient outcomes. We present a case of successful treatment for a patient who had acute respiratory distress syndrome combined with septic shock after living-donor liver transplantation with veno-arterial–venous hybrid mode of extracorporeal membrane oxygenation (ECMO) support. Methods A 49-year-old male patient underwent successful emergency living-donor liver transplantation for acute-on-chronic liver failure associated with alcoholic liver cirrhosis. The patient was diagnosed with concurrent active pulmonary tuberculosis and tuberculosis peritonitis just before emergency liver transplantation. Intermittent post-operative small-bowel obstruction caused by adhesions from tuberculosis peritonitis was nonresponsive to conservative management. Results On post-operative day 114, we performed emergency adhesio-lysis because of bowel ischemia signs. However, the patient had progressive deterioration of arterial oxygenation despite conventional ventilatory support and nitric oxide gas inhalation, and septic shock resulted from aspiration pneumonia. Therefore, we decided to administer ECMO. After initiation of ECMO support, hemodynamic status, pneumonic consolidation, and oxygenation status gradually improved, and the patient was weaned from ECMO on the 11th day. Finally, the patient was discharged on post-transplant day 204. Conclusions ECMO can be a beneficial rescue option for the management of refractory cardiopulmonary failure in liver transplant recipients. In addition, the hybrid mode of ECMO is a helpful salvage option when conventional modes of ECMO are inadequate. [ABSTRACT FROM AUTHOR]

Summary In the 50 years since acute respiratory distress syndrome (ARDS) was first described, substantial progress has been made in identifying the risk factors for and the pathogenic contributors to the syndrome and in characterising the protein expression patterns in plasma and bronchoalveolar lavage fluid from patients with ARDS. Despite this effort, however, pharmacological options for ARDS remain scarce. Frequently cited reasons for this absence of specific drug therapies include the heterogeneity of patients with ARDS, the potential for a differential response to drugs, and the possibility that the wrong targets have been studied. Advances in applied biomolecular technology and bioinformatics have enabled breakthroughs for other complex traits, such as cardiovascular disease or asthma, particularly when a precision medicine paradigm, wherein a biomarker or gene expression pattern indicates a patient's likelihood of responding to a treatment, has been pursued. In this Review, we consider the biological and analytical techniques that could facilitate a precision medicine approach for ARDS. [ABSTRACT FROM AUTHOR]

Summary Background Data from in-vitro, animal, and human lung injury models suggest that keratinocyte growth factor (KGF) might be beneficial in acute respiratory distress syndrome (ARDS). The objective of this trial was to investigate the effect of KGF in patients with ARDS. Methods We did a double-blind, allocation concealed, randomised, placebo-controlled phase 2 trial in two intensive care units in the UK, involving patients fulfilling the American-European Consensus Conference Definition of ARDS. Patients were randomly assigned (1:1) by computer-generated randomisation schedule with variable block size stratified by site and presence of severe sepsis requiring vasopressors to receive either recombinant human KGF (palifermin 60 μg/kg) or placebo (0·9% sodium chloride solution) daily for a maximum of 6 days. Both patients and investigators were masked to treatment. The primary endpoint was oxygenation index (OI) at day 7. Analyses were by intention to treat. The trial is registered with International Standard Randomised Controlled Trial Registry, number ISRCTN95690673. Findings Between Feb 23, 2011, and Feb 26, 2014, 368 patients were assessed for eligibility for inclusion in the trial. Of the 60 patients recruited, 29 patients were randomly assigned to receive KGF and 31 to placebo; all were included in the analysis of the primary outcome. There was no significant difference between the two groups in OI at day 7 (mean 62·3 [SD 57·8] in the KGF group, 43·1 [33·5] in the placebo group; mean difference 19·2, 95% CI −5·6 to 44·0, p=0·13). Of interest, although not defined as outcome measures a priori, the KGF group, compared with placebo, had fewer median ventilator-free days (1 day [IQR 0 to 17] in the KGF group vs 20 days [13–22] in the placebo group; difference −8 days, 95% CI −17 to −2; p=0·0002), a longer median duration of ventilation in survivors to day 90 (16 days [IQR 13–30] in the KGF group vs 11 days [8–16] in the placebo group; difference 6 days, 95% CI 2 to 14; p=0·002), and a higher mortality at 28 days (nine [31%] vs three [10%] deaths; risk ratio 3·2, 95% CI 1·0 to 10·7, p=0·054). Adverse events were more frequent in the KGF group than the placebo group (14 vs 5 events; odds ratio 4·9, 95% CI 1·3 to 20·3, p=0·008). The two adverse events assessed as related to KGF were due to pyrexia. Interpretation KGF did not improve physiological or clinical outcomes in ARDS and might be harmful to patient health. Funding The Northern Ireland Public Health Agency Research and Development Division. [ABSTRACT FROM AUTHOR]

Background: The lung-protective ventilation bundle has been shown to reduce mortality in adult acute respiratory distress syndrome (ARDS). This concept has expanded to other areas of acute adult ventilation and is recommended for pediatric ventilation. A component of lung-protective ventilation relies on a prediction of lean body weight from height. The predicted body weight (PBW) relationship employed in the ARDS Network trial is considered valid only for adults, with a dedicated formula required for each sex. No agreed PBW formula applies to smaller body sizes. This analysis investigated whether it might be practical to derive a unisex PBW formula spanning all body sizes, while retaining relevance to established adult protective ventilation practice.Methods: Historic population-based growth charts were adopted as a reference for lean body weight, from pre-term infant through to adult median weight. The traditional ARDSNet PBW formulae acted as the reference for prevailing protective ventilation practice. Error limits for derived PBW models were relative to these references.Results: The ARDSNet PBW formulae typically predict weights heavier than the population median, therefore no single relationship could satisfy both references. Four alternate piecewise-linear lean body-weight predictive formulae were presented for consideration, each with different balance between the objectives.Conclusions: The 'PBWuf + MBW' model is proposed as an appropriate compromise between prevailing practice and simplification, while also better representing lean adult body-weight. This model applies the ARDSNet 'female' formula to both adult sexes, while providing a tight fit to median body weight at smaller statures down to pre-term. The 'PBWmf + MBW' model retains consistency with current practice over the adult range, while adding prediction for small statures. [ABSTRACT FROM AUTHOR]

Objective: To analyze the therapeutic effect of pulmonary surfactant (PS) in combination with nasal continuous positive airway pressure (NCPAP) therapy on neonatal respiratory distress syndrome (NRDS). Methodology: Forty-nine neonates who were diagnosed as NRDS and admitted in our hospital from May 2014 to June 2015 were selected and divided into an observation group and a control group. The observation group was treated with PS and NCPAP. The control group was treated only with NCPAP. The clinical symptoms, pulmonary X-ray, arterial partial pressure of oxygen (PaO2) and prognosis of the two groups were observed. Results: Twelve hours after treatment, the partial pressure of carbon dioxide and oxygenation index decreased significantly (P<0.05) and PaO2 and ratio of arterial/pulmonary oxygen partial pressures increased significantly (P<0.05). Pulmonary X-ray examination showed that 78.3% of the observation group and 53.8% of the control group were relieved 12-24 hour after treatment, between which the difference was statistically significant (P<0.05). The improvement rate of the observation group was significantly higher than that of the control group (82.6% vs. 57.7%, P<0.05), the incidence of complications was significantly lower in the observation group (P<0.05) and the average length of stay in the observation group was significantly shorter (P<0.05). Conclusion: Both methods effectively treated NRDS, but PS in combination with NCPAP better improved oxygenation, reduced mortality and incidence of complications. [ABSTRACT FROM AUTHOR]

Antenatal steroid treatment to enhance fetal lung maturity and surfactant treatment to prevent or treat respiratory distress syndrome have been major advances in perinatal medicine in the past 40 years contributing to improved outcomes for preterm infants. Use of postnatal steroids to prevent or treat chronic lung disease in preterm infants has been less successful and associated with adverse neurodevelopmental outcomes. Although early (in the first week of life) postnatal steroid treatment facilitates earlier extubation and reduces the risk of chronic lung disease, it is associated with adverse effects, such as hyperglycemia, hypertension, gastrointestinal bleeding and perforation, hypertrophic cardiomyopathy, growth failure, and cerebral palsy, and cannot be recommended. Early treatment with hydrocortisone may also improve survival without chronic lung disease, but concerns remain about possible adverse effects such as gastrointestinal perforation and sepsis, particularly in very preterm infants. Early inhaled budesonide also reduces the incidence of chronic lung disease but there are concerns that this may occur at the expense of increased risk of death. More studies of early low-dose steroids with adequate long-term follow-up are needed before they can be recommended for the prevention of chronic lung disease. Late (after the first week of life) postnatal steroids may have a better benefit-to-harm ratio than early steroids. A Cochrane Review shows that late steroid treatment reduces chronic lung disease, the combination of death and chronic lung disease at both 28 days and 36 weeks' corrected age, and the need for later rescue dexamethasone. Adverse effects include hyperglycemia, hypertension, hypertrophic cardiomyopathy, and severe retinopathy of prematurity but without an increase in blindness. Long-term neurodevelopmental effects are not significantly increased by late postnatal steroid treatment. Current recommendations are that postnatal steroid treatment should be reserved for preterm infants who are ventilator-dependent after the first 7-14 days of life and any course should be low dose and of short duration to facilitate endotracheal extubation. Budesonide/surfactant mixtures show some promise as a means of reducing chronic lung disease in preterm infants with severe respiratory distress syndrome, but further larger studies with long-term follow-up are needed before this treatment can be recommended as a routine intervention. [ABSTRACT FROM AUTHOR]