Effects of High-Frequency Oscillatory Ventilation With Volume Guarantee During Surfactant Treatment in Extremely Low Gestational Age Newborns With Respiratory Distress Syndrome: An Observational Study.

Milena Tana,Simonetta Costa,Eloisa Tiberi,Roberta Pastorino,Angela Paladini,Claudia Aurilia,Giovanni Vento,Anthea Bottoni,Alessandra Lio,Chiara Tirone

doi:10.3389/fped.2021.804807

Abstract

ObjectiveTo evaluate the effect of volume guarantee (VG) combined with high-frequency oscillatory ventilation (HFOV) on respiratory and other physiological parameters immediately after lung recruitment and surfactant administration in HFOV elective ventilated extremely low gestational age newborns (ELGAN) with respiratory distress syndrome (RDS).DesignObservational study.SettingTertiary neonatal intensive care unit.PatientsTwenty-two ELGANs of 25.5 ± 1.1 weeks of gestational age requiring invasive mechanical ventilation and surfactant administration for RDS during the first 6 h of life.InterventionsAll infants intubated in delivery room, were managed with elective HFOV and received surfactant after a lung recruitment manoeuver. Eleven infants received HFOV + VG and were compared with a control group of 11 infants receiving HFOV alone. HFOV was delivered in both groups by Dräger Babylog VN500 ventilator (Dräger, Lubeck, Germany).Main Outcome MeasuresVariations and fluctuations of delivered high-frequency tidal volume (VThf), fluctuation of pressure amplitude (ΔP) and partial pressure of CO2 (pCO2) levels after recruitment manoeuver and immediately after surfactant administration, in HFOV + VG vs. HFOV ventilated infants.ResultsThere were no significant differences in the two groups at starting ventilation with or without VG. The mean applied VThf per kg was 1.7 ± 0.3 ml/kg in the HFOV group and 1.7 ± 0.1 ml/kg in the HFOV + VG group. Thirty minutes after surfactant administration, HFOV group had a significant higher VThf/Kg than HFOV + VG (2.1 ± 0.3 vs. 1.6 ± 0.1 ml/kg, p < 0.0001) with significantly lower pCO2 levels (43.1 ± 3.8 vs. 46.8 ± 1.5 mmHg, p = 0.01), 54.4% of patients having pCO2 below 45 mmHg. Measured post-surfactant ΔP values were higher in HFOV group (17 ± 3 cmH2O) than in HFOV + VG group (13 ± 3 cmH2O, p = 0.01).ConclusionHFOV + VG maintains pCO2 levels within target range and reduces VThf delivered variations more consistently than HFOV alone after surfactant administration.

Highlights

Despite a shift toward non-invasive respiratory support, mechanical ventilation and surfactant administration in the first hours of life may be life-saving in preterm infants with respiratory distress syndrome (RDS), especially in extremely low gestational age newborns (ELGAN) [1, 2]
Between 1 June 2016 and 30 June 2018, a total of 68 inborn ELGAN with a diagnosis of RDS requiring on-going intensive care were admitted to our neonatal intensive care unit (NICU)
Data on weight corrected gas transport coefficient (DCO2) in the high-frequency oscillatory ventilation (HFOV) and HFOV + Volume guarantee (VG) groups show a mean DCO2 measurement significantly different, with higher values in HFOV both pre-surfactant (51.6 ± 16.3 vs. 39.4 ± 5.1; p = 0.03) and post-surfactant (69.5 ± 16.4 vs. 39.5 ± 5.8; p < 0.0001). This is the first paper of comparison between HFOV and HFOV + VG during surfactant administration in extremely preterm neonates with RDS electively HFOV ventilated

Summary

Introduction

Despite a shift toward non-invasive respiratory support, mechanical ventilation and surfactant administration in the first hours of life may be life-saving in preterm infants with respiratory distress syndrome (RDS), especially in extremely low gestational age newborns (ELGAN) (gestational age ≤ 27 weeks) [1, 2]. High-frequency oscillatory ventilation (HFOV) has been increasingly used in preterm infants with RDS, because early HFOV could reduce risk of bronchopulmonary dysplasia (BPD) [3], especially if associated with an open lung strategy [4, 5]. The CO2 diffusion (gas transport) coefficient (DCO2) is a vital variable in HFOV and is calculated as frequency times the square of tidal volume during HFOV (VThf) [8, 9]. VThf is crucial for CO2 elimination with a larger impact in comparison to tidal volume during conventional mechanical ventilation. As the same P can be associated with very different level of chest oscillations and VThf in different babies, and even in the same baby over the course of pulmonary disease, the same P can result in very large variations of VThf and unexpected variations of CO2 removal [11, 12]

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