Duration Of Assisted Ventilation Research Articles

Risk factors in the development of retinopathy of prematurity: A 10-year retrospective study

ObjectiveTo evaluate Retinopathy of Prematurity (ROP) rate and risk factors in a large cohort of preterm newborns. MethodsSingle center retrospective study. All preterm inborn hospitalized at the Neonatal Intensive Care Unit of the Policlinico of Catania from January 1, 2009 till December 31, 2018, were included.ROP stage and location, treatments required, maternal and infant risk factors were evaluated. ResultsMedical records of 898 preterms were retrospectively examined (mean gestational age 32.9 ± 2.3 weeks). Of them 149 (16.6 %) developed bilateral ROP (92 stage 1, 44 stage 2 and 13 stage 3); 66 (7.3 %) received bilateral laser treatment. Six eyes of three patients affected by zone I ROP 1, with plus persistence 15 days after an optimal laser treatment, also received intravitreal ranibizumab injection. Risk factors for ROP development were gestational age (GA) (p < 0.001), birthweight (p < 0.001), assisted ventilation duration (p < 0.001), multiple birth (p = 0.003), erythropoietin (EPO) administration (p = 0.005) and persistence of tunica vasculosa lentis. The decision-tree analysis showed gestational age as the most significant predictive factor (P < 0.001); secondary predictive factors were EPO administration (p = 0.001) in newborns 29–31 weeks GA and birthweight lower than 2090 g (p < 0.001) in 32–34 weeks GA; in this latter group patent ductus arteriosus (PDA) was a tertiary predictive factor (p = 0.043). ConclusionsIn our study ROP incidence was 16,6 %; 7.3 % of the patients required laser treatment. Besides well-known factors, such as GA and birthweight, other factors like duration of assisted ventilation, EPO, multiple births, PDA, tunica vasculosa lentis persistence should be considered to tailor ophthalmic evaluation and follow-up.

Congenital Central Hypoventilation Syndrome: Diagnosis and Long-Term Ventilatory Outcomes.

Congenital central hypoventilation syndrome (CCHS), a rare disease caused by variants in the paired-like homeobox 2B (PHOX2B) gene, affects regulation of respiration necessitating lifelong assisted ventilation (AV). Most patients require full-time AV during infancy and some patients may sustain adequate spontaneous ventilation during wakefulness and change AV modalities at a later age. The aims of this study were to assess the changes in duration and modalities of AV, long-term respiratory outcomes, and to correlate them with PHOX2B genotypes. We conducted a retrospective study of patients with CCHS treated at our institution between January 1997 and May 2022. Results analyzed included: clinical presentation, PHOX2B genotype, modality and duration of AV at diagnosis and follow-up, survival, and transition to adult care. We identified 30 patients with CCHS-8 with PHOX2B nonpolyalanine repeat mutations (NPARMs), 21 with polyalanine repeat mutations (PARMs), and 1 with unknown PHOX2B genotype. The median age at presentation was 0.25 months (IQR 0.1-0.7 months). At diagnosis of CCHS, 24 (80%) patients required continuous AV and 28 (93%) received AV via tracheostomy. Twenty-six patients required sleep-only AV at a median age of 9 months (IQR 6-14 months). Nine patients requiring sleep-only AV underwent tracheostomy decannulation at a median age of 11.2 years (IQR 5.9-15.7 years) and used noninvasive positive pressure ventilation or diaphragm pacing. There was insufficient evidence to conclude that patients with PARMs and NPARMs differed by age at presentation (P = .39), tracheostomy (P = .06), and transition to sleep-only AV (P = .9). Six patients transitioned to adult care, 23 continued receiving pediatric care, and 1 patient died due to complications from Hirschsprung's disease. Our study demonstrates prolonged survival and good long-term respiratory outcomes possibly related to the early diagnosis of CCHS, optimizing AV strategies, and multidisciplinary care. The increasing number of patients attaining adulthood highlights the necessity for multidisciplinary care for adults with CCHS.

The Clinical and Prognostic Impact of the Choice of Surgical Approach to Fourth Ventricular Tumors in a Single-Center, Single-Surgeon Cohort of 92 Consecutive Pediatric Patients.

ObjectiveA single-institution cohort of 92 consecutive pediatric patients harboring tumors involving the fourth ventricle, surgically treated via the telovelar or transvermian approach, was retrospectively reviewed in order to analyze the impact of surgical route on surgery-related outcomes and cumulative survival.MethodsClinical, radiological, surgical, and pathology details were retrospectively analyzed. We selected n = 6 surgery-related clinical and radiological outcomes: transient and permanent neurological deficits, duration of assisted ventilation, postoperative new onset medical events, postoperative cerebellar mutism, and extent of resection. We built univariate and multivariate logistic models to analyze the significance of relationships between the surgical routes and the outcomes. Cumulative survival (CS) was estimated by the cohort approach.ResultsThere were 53 girls and 39 boys (mean age, 83 months). Telovelar approach was performed in 51 cases and transvermian approach in 41 cases. Early postoperative MRI studies showed complete removal in 57 cases (62%) and measurable residual tumor in 35 cases (38%). The average tumor residual volume was 1,316 cm3 (range, 0.016–4.231 cm3; median value, 0.9875 cm3). Residual disease was more often detected on immediate postop MRI after telovelar approach, but the difference was not significant. Cerebellar mutism was observed in 10 cases (11%). No significant difference in the onset of cerebellar mutism was detected between telovelar and transvermian approach. The choice of surgical approach did not significantly modify any other postoperative outcome and 1-/3-year CS of high-grade surgically treated tumors.ConclusionsWith the limitation of a single-center, single-surgeon retrospective series, our findings offer significant data to reconsider the real impact of the choice of the surgical route to the fourth ventricle on the incidence of cerebellar mutism and surgery-related morbidity. This seems to be in line with some recent reports in the literature. Surgical approach to the fourth ventricle should be individualized according to the location of the tumor, degree of vermian infiltration, and lateral and upward extension. Telovelar and transvermian approaches should not be considered alternative but complementary. Pediatric neurosurgeons should fully master both approaches and choose the one that they consider the best for the patient based on a thorough and careful evaluation of pre-operative imaging.

Annual Respiratory Evaluations in Congenital Central Hypoventilation Syndrome and Changes in Ventilatory Management.

Background: Annual in-hospital respiratory evaluations (AREs) during wakefulness and sleep are recommended to assess ventilatory requirements in patients with congenital central hypoventilation syndrome (CCHS) aged ≥2-3 years based on expert consensus. This study aimed to determine if AREs in patients with CCHS led to changes in ventilatory management. Methods: Retrospective review of patients with CCHS who underwent AREs with or without polysomnography between 2017 and 2019 was conducted. Clinical symptoms, results of AREs, and subsequent changes in ventilatory management were analyzed. Results: We identified 10 patients with CCHS aged 4-20 years. All patients required assisted ventilation (AV) only during sleep delivered by positive pressure ventilation via tracheostomy (n = 7) or diaphragm pacing (n = 3). In total, 7 (70%) patients had abnormal oxygenation and/or ventilation requiring changes in ventilator settings or duration of AV. Six patients required an increase in settings and/or duration of AV, and only 1 patient required a decrease in ventilator settings. Two patients had awake hypercapnia during a routine outpatient visit that improved following increase in ventilator settings and a period of continuous AV. One patient who was previously ventilator-dependent only during sleep was identified to require 16 h per day of AV. All patients (n = 3) who reported symptoms such as headache or oxygen desaturations during sleep required an increase in ventilator settings. Conclusion: We report a high prevalence of changes in AV management following an ARE. Our results demonstrate the importance of regular AREs in patients with CCHS to assess their ventilatory requirements and optimize AV.

Relationship between Epigenetic Maturity and Respiratory Morbidity in Preterm Infants

To assess associations between epigenetic maturity of extremely preterm babies (born at less than 28 weeks of gestation), neonatal interventions, and respiratory outcomes, including the administration of surfactant and postnatal corticosteroids, duration of assisted ventilation, and development of bronchopulmonary dysplasia (BPD). DNA was extracted from neonatal blood spots collected after birth from 143 extremely preterm infants born 1991-1992 in Victoria, Australia and used to determined DNA methylation (DNAm). A DNAm based gestational age was determined using our previously published method. The residual of DNAm gestational age and clinically estimated gestational age (referred to as "gestational age acceleration") was used as a measure to assess developmental maturity. Associations between gestational age acceleration and respiratory interventions and morbidities were determined. Infants with higher gestational age acceleration were less likely to receive surfactant (P = .009) or postnatal corticosteroids (P = .008), had fewer days of assisted ventilation (P = .01), and had less BPD (P = .02). Respiratory measures are known to correlate with gestational age; however, models comparing each with clinically estimated gestational age were improved by the addition of the gestational age acceleration measure in the model. Gestational age acceleration correlates with respiratory interventions and outcomes of extremely preterm babies. Surfactant and postnatal corticosteroid use, assisted ventilation days, and BPD rates were all lower in babies who were epigenetically more mature than their obstetrically estimated gestational age. This suggests that gestational age acceleration is a clinically relevant metric of developmental maturity.

123 A COMPARISON STUDY BETWEEN PRISMASOL SOLUTION AND SELF-IMPROVISED REGIME USING NORMAL SALINE, HARTMANN SOLUTION AND DEXTROSED BASED LACTATE SOLUTION IN CONTINUOUS RENAL REPLACEMENT THERAPY

NMRR-16-694-29424 Category: RRT Technique Characteristics Presenter: Dr KENG-HEE KOH Keyword: Prismasol; self-improvised regime; CRRT Corresponding Author: Koh Keng Hee (email: [email protected]) Continuous Renal Replacement Therapy (CRRT) for critically ill and hemodynamically unstable patients with Primasol solutions are well established regime. We used self-improvised regime as a substitute of prismasol solution after finishing stock of prismasol. Our self improvised regime utilizes normal saline, dextrose based lactate solution, hartmann solution and bicarbonate infusion. To compare the survival rate of self-revised CRRT compared to conventional CRRT. To compare blood pressure, carbon dioxide and bicarbonate retention, risk of hypoglycemia and duration of assisted ventilation with different CRRT regime. All adult cases with history of admission to intensive care unit and had undergone CVVH from January 2016 till April 2017 were identified and a retrospective study is performed. In this study, 72 patients were admitted to intensive care unit and undergone CRRT between January 2016 and April 2017. We only managed to retrieve 52 medical case notes from the medical record unit. There were 36 males and 16 females in this study with the median age of 54 years old. Majority of the patients (n=41,78.9%) were having sepsis, remaining of the patients was diagnosed to have intracranial bleeding (n=4, 7.7%), perforated viscus(n=3, 5.8%), polytrauma (n=2, 3.9%) and others. Out of the 40 patients who have survived more than 24 hours, 22 and 18 of them received prismasol and self-revised regime respectively. Comparisons of the outcome show that there was no difference in regards to bicarbonate level, blood pressure measurement nor risk of hypoglycemia in both group (Table 1). It showed that mean carbon dioxide level was higher in the prismasol group (mean=51.0mmHg/kPa) than the self-revised group (mean=42.7mmHg/kPa) though it was not statistically significant. Nevertheless, there was not much difference in terms of assisted ventilation duration with mean reading of 8 days and 10 days respectively. Overall, there were 19/24 subjects (79%) died in the prismasol group and 24/28 subjects (86%) died in the second group (p=0.716). Both cohorts have no differences in term of Sequential Organ Failure Assessment (SOFA) score, age, Hb and albumin levels. Although initial urea level is higher in prismasol versus self-improvised regime, adjusted univariate analysis (of survived versus fatal patients) followed by multivariate logistic regression shows that the both CRRT regime did not have differences in survival. In these cohorts, there is no much difference between prismasol and self-improvised regime group in terms of survival rate and pCO2 retention, or risk of hypoglycemia. In case of resources limitation, self improvised regime is a viable option but one need to perform surveillance to ensure acceptable survival outcome.Table 1Comparison of Outcomes between Prismasol regime and Self-improvised regimePrismasol regimeSelf-improvised regimep-valueSystolic Blood pressure (mmHg)Pre-CRRT115±21118±180.663Post-CRRT115±19125±160.076Bicarbonate level (mmol/L)Pre-CRRT12.8±4.411.3±4.70.303Post-CRRT17.3±4.815.1±5.10.135Glucose level (mmol/L)Pre-CRRT10.5±5.09.5±5.20.535Post-CRRT8.8±3.38±2.90.432Carbon dioxide level (mmHg/kPa)Pre-CRRT43.8±12.933.2±15.30.022Post-CRRT51±42.742.3±14.90.932Duration of assisted ventilation after CRRT initiation (days)8±610±90.411mean ± standard deviation are shown and comparison is with t-test.Note: Post level was taken a day after CRRT commencement Open table in a new tab

Fluid restriction for treatment of preterm infants with chronic lung disease.

Fluid restriction is often recommended as part of the management of infants with early or established bronchopulmonary dysplasia (BPD). To determine whether fluid restriction as part of the therapeutic intervention for early or established BPD improves clinical outcomes. We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1) in the Cochrane Library (searched 16 February 2016), MEDLINE via PubMed (1966 to 16 February 2016), Embase (1980 to 16 February 2016), and CINAHL (1982 to 16 February 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. Prospective randomised clinical trials comparing two distinct fluid administration volumes in preterm infants with early or established BPD. We used the standard methods of Cochrane Neonatal. For the included trial, we extracted data and assessed the risk of bias, and used GRADE methods to assess the quality of the evidence. The outcomes considered in this review are effects on mortality or requirement for oxygen at 36 weeks' postmenstrual age (primary outcome measure), the duration of supplemental oxygen therapy, proportion of infants discharged from hospital on oxygen, duration of assisted ventilation, duration of hospitalisation, weight gain, feeding tolerance, apnoea, necrotizing enterocolitis, renal dysfunction or nephrocalcinosis, lung mechanics, and use of diuretic therapy (secondary outcome measures). One trial was found, including 60 preterm infants at 28 days of age with persistent oxygen requirements. Infants were randomised to either 180 mL/kg/day of standard formula or 145 mL/kg/day of concentrated formula. This single study did not provide data regarding our primary outcome. No effects of the intervention were found on any of our secondary outcomes. The quality of the evidence from this study was graded low. There is no evidence to support the practice of fluid restriction in infants with early or established BPD.

Effects of biocompatible extracorporeal bypass circuit coating Bioline in cardiac surgery patients

Biocompatibility of heparin-based coating for extracorporeal circuits, the Bioline, was evaluated in cardiac surgery setting. Thirty six CABG pts, aged from 30 to 69 yrs, were randomly perfused with a circuit containing Bioline-coated Quadrox oxygenator (Bioline, n=18) or with a similar non-coated circuit (control, n=18). Leukocyte and platelet counts, levels of tumor necrosis factor, interleukin-6 and fibrinogen were assessed in arterial blood before, during and after cardiopulmonary bypass (CPB). Oxygenation and ventilation indices before and after surgery, post-operative chest tube drainage and transfusion volume as well as the duration of assisted ventilation were also measured. A platelet count and fibrinogen dropped less in the Bioline group significantly compared with that in control at the end of CPB (p&lt;0,05) and after protamine administration (p&lt;0,05). A leukocyte count and an interleukin-6 level increased more in controls after CPB (p&lt;0,05) as well as oxygenation and ventilation indices, bleeding volume and intubation time (all p&lt;0,05). Our results suggest surface heparinization with Bioline coating limited to the oxygenator ameliorates the inflammatory response, preserves fibrinogen and platelets, reduces blood loss postoperatively and improves lung function during CPB.

Impact of the systematic introduction of low-cost bubble nasal CPAP in a NICU of a developing country: a prospective pre- and post-intervention study

BackgroundThe use of Nasal Continuous Positive Airway Pressure Ventilation (NCPAP) has begun to increase and is progressively replacing conventional mechanical ventilation (MV), becoming the cornerstone treatment for newborn respiratory distress syndrome (RDS). Howerver, NCPAP use in Lower-Middle Income Countries (LMICs) is poor. Moreover, bubble NCPAP (bNCPAP), for efficacy, cost effectiveness, and ease of use, should be the primary assistance technique employed in newborns with RDS.Objective: To measure the impact on in-hospital newborn mortality of using a bNCPAP device as the first intervention on newborns requiring ventilatory assistance.MethodsDesign: Prospective pre-intervention and post-intervention study.Setting: The largest Neonatal Intensive Care Unit (NICU) in Nicaragua.Participants: In all, 230 (2006) and 383 (2008) patients were included.Intervention: In May 2006, a strategy was introduced to promote the systematic use of bNCPAP to avoid intubation and MV in newborns requiring ventilatory assistance. Data regarding gestation, delivery, postnatal course, mortality, length of hospitalisation, and duration of ventilatory assistance were collected for infants assisted between May and December 2006, before the project began, and between May and December 2008, two years afterwards.Outcome measures: The pre- vs post-intervention proportion of newborns who died in-hospital was the primary end point. Secondary endpoints included rate of intubation and duration of NICU stay.ResultsSignificant differences were found in the rate of intubation (72 vs 39%; p < 0.0001) and the proportion of patients treated exclusively with bNCPAP (27% vs 61%; p <0.0001). Mortality rate was significantly reduced (40 vs 23%; p < 0.0001); however, an increase in the mean duration of NICU stay was observed (14.6 days in 2006 and 17.5 days in 2008, p = 0.0481).The findings contribute to the evidence that NCPAP, particularly bNCPAP, is the first-line standard of care for efficacy, cost effectiveness, and ease of use in newborns with respiratory distress in LMICs.ConclusionsThis is the first extensive survey performed in a large NICU from a LMICs, proving the efficacy of the systematic use of a bNCPAP device in reducing newborn mortality. These findings are an incentive for considering bNCPAP as an elective strategy to treat newborns with respiratory insufficiency in LMICs.

Surfactant for meconium aspiration syndrome in term and late preterm infants.

Surfactant replacement therapy has been proven beneficial in the prevention and treatment of neonatal respiratory distress syndrome (RDS). The deficiency of surfactant or surfactant dysfunction may contribute to respiratory failure in a broader group of disorders, including meconium aspiration syndrome (MAS). To evaluate the effect of surfactant administration in the treatment of late preterm and term infants with meconium aspiration syndrome. We searched The Cochrane Library (Issue 4, 2006), MEDLINE and EMBASE (1985 to December 2006), previous reviews including cross-references, abstracts, conference and symposia proceedings, expert informants, and journal handsearching, without language restrictions. We contacted study authors for additional data.We ran an updated search in November 2014 and searched the following sites for ongoing or recently completed trials: www.clinicaltrials.gov; www.controlled-trials.com; and www.who.int/ictrp. Randomised controlled trials which evaluated the effect of surfactant administration in late preterm and term infants with meconium aspiration syndrome are included in the analyses. We extracted data on clinical outcomes including mortality, treatment with extracorporeal membrane oxygenation (ECMO), pneumothorax, duration of assisted ventilation, duration of supplemental oxygen, intraventricular haemorrhage (any grade and severe IVH), and chronic lung disease. We conducted data analyses in accordance with the standards of the Cochrane Neonatal Review Group. Four randomised controlled trials met our inclusion criteria. The meta-analysis of four trials (326 infants) showed no statistically significant effect on mortality [typical risk ratio (RR) 0.98, 95% confidence interval (CI) 0.41 to 2.39; typical risk difference (RD) -0.00, 95% CI -0.05 to 0.05]. There was no heterogeneity for this outcome (I² = 0% for both RR and RD). The risk of requiring extracorporeal membrane oxygenation was significantly reduced in a meta-analysis of two trials (n = 208); [typical RR 0.64, 95% CI 0.46 to 0.91; typical RD -0.17, 95% CI -0.30 to -0.04; number needed to treat for an additional beneficial outcome (NNTB) 6, 95% CI 3 to 25]. There was no heterogeneity for RR (1² = 0%) but moderate heterogeneity for RD (I² = 50%). One trial (n = 40) reported a statistically significant reduction in the length of hospital stay (mean difference -8 days, 95% CI -14 to -3 days; test for heterogeneity not applicable). There were no statistically significant reductions in any other outcomes studied (duration of assisted ventilation, duration of supplemental oxygen, pneumothorax, pulmonary interstitial emphysema, air leaks, chronic lung disease, need for oxygen at discharge or intraventricular haemorrhage). In infants with MAS, surfactant administration may reduce the severity of respiratory illness and decrease the number of infants with progressive respiratory failure requiring support with ECMO. The relative efficacy of surfactant therapy compared to, or in conjunction with, other approaches to treatment including inhaled nitric oxide, liquid ventilation, surfactant lavage and high frequency ventilation remains to be tested.

Outcome of Patients with Cholinergic Insecticide Poisoning Treated with Gastric Lavage: A Prospective Observational Cohort Study

Background: Gastric lavage (GL) is one of the most commonly used decontamination method for cholinergic insecticide ingestion in developing countries despite lack of supporting evidence. This study was designed to evaluate the outcome of patients with cholinergic insecticide poisoning treated with GL in regards to timing and frequency of the procedure. Methods: In this prospective observational cohort study, GL was planned to be administered to patients with cholinergic insecticide poisoning after initial stabilization irrespective of lavage given in peripheral hospitals. Therefore, some patients received one procedure (single GL) and some received more than one procedure (multiple GL). Early GL was defined as GL given within one hour of poison exposure and late GL was referred to performing the procedure after one hour. Results: During the study period, 238 patients with cholinergic insecticide poisoning received GL comprising of 93 who received early, 145 who received late, 127 who received single and 111 who received multiple GL. Seventy-six GL treated patients (31.9%) died. Mortality, early RF and duration of assisted ventilation were not significantly different between patients receiving early and late, or single and multiple GL. Patients receiving multiple GL compared to those who received single GL developed late RF (9.0% vs. 20.5%, P = 0.01) and IMS (9.9% vs. 23.6%, P = 0.005) in significantly lesser extents. In multiple logistic regression analysis, effect of multiple GL on IMS and late RF remained significant (P = 0.04). Conclusion: Number or timing of GL does not show any association with mortality while multiple GL had protective effect against development of late RF and IMS. Hence, GL might be beneficial in cholinergic insecticide poisoning.

Optimization of Initial Anesthesia in a One-Day Surgical Hospital

Objective: to modify initial sevorane anesthesia so that the incidence of excitement and apnoea should be reduced. Subjects and methods. Seven hundred and sixty-three patients were examined and divided into 4 groups: total intravenous anesthesia (TIA) with propofol and fentanyl and 3 inhalational sevorane-based anesthesia modes; one of them was modified by the authors. Initial anesthesia modes were compared by the following criteria: the time of consciousness loss (sec); that of creating the favorable conditions for laryngeal mask airway instillation (sec); the incidence of apnoea (% of the number of patients in this group); the duration of assisted ventilation (sec); excitement (% of the number of patients in this group); cough (% of the number of patients in this group). Results. The use of sevorane excludes the need for successive induction or breathing circuit prefilling. However, initial sevorane anesthesia is somewhat longer than intravenous induction with propofol and fentanyl and is more frequently accompanied by episodes of excitement, although the latter is insignificant. TIA in turn results in the development of apnoea more frequently, which is undesirable if anesthesia with preserved spontaneous breathing is to be further performed. The use of the subnarcotic doses of propofol (0.5 mg/kg) and fentanyl (50-^g bolus) during inhalation induction permits excitement to be prevented and a patient&#8217;s spontaneous breathing to be maintained. TIA modes and the authors&#8217; modified inhalation induction procedure are comparable in the time of falling asleep and creating the optimal conditions for laryngeal mask airway instillation. Key words: inhalational anesthesia, sevofluorane, induction.

Improved Care and Growth Outcomes by Using Hybrid Humidified Incubators in Very Preterm Infants

To identify changes in temperature, fluid and electrolyte management, growth, and short-term outcome in extremely low birth weight (ELBW) infants nursed in humidified hybrid incubators (HI group) compared with a cohort of patients cared for in nonhumidified conventional incubators (CI group). Body temperature (BT), fluid and electrolyte balance, and growth velocity (GV) were collected retrospectively on 182 ELBW infants. The CI group included ELBW infants cared for with radiant warmers followed by an incubator without humidity. The HI group included ELBW infants cared for in the radiant warmer mode in a Giraffe OmniBed, followed by the incubator mode using high humidity. The CI group included more multiple births (50.6%) than the HI group (35.8%; P < .05), but there was no difference in demographic characteristics. BT was similar during the first week. The HI group had less fluid intake, urine output, and insensible water loss, less maximum weight loss, and a lower incidence of hypernatremia during the first week than did the CI group (P < .05). The HI group also had a lower frequency of electrolyte sampling and packed red cell transfusion (P < .05), a higher incidence of hyponatremia on postnatal day 1 than the CI group (P < .05), and a higher GV than the CI group (15.2 +/- 5.0 vs 13.5 +/- 4.8 g/kg per day), especially among those with a birth weight of <or=749 g (P < .01). There was no difference in sepsis, necrotizing enterocolitis, intraventricular hemorrhage, and all bronchopulmonary dysplasia (BPD), but there was a decreased incidence of severe BPD (5.1% [HI] vs 16.4% [CI]; P < .05) and duration of assisted ventilation in the HI group compared with the CI group (15.5 +/- 2.1 vs 19.6 +/- 2.4 days, respectively; P = .068). Use of a humidified hybrid incubator improved care for ELBW infants by making it possible to decrease fluid intake, improve electrolyte balance, and enhance GV without a disturbance of BT compared with conventional care. By adjusting fluid intake when using these devices, benefits may be enhanced and the risk of BPD and severe BPD may be reduced.

L-Arginine treatment for severe vascular fetal intrauterine growth restriction: A randomized double-bind controlled trial

Infants born with severe IUGR are exposed to higher neonatal mortality and morbidity rates, as compared with appropriate-for-gestational-age. They are exposed to a higher risk of developing chronic disease such as hypertension, coronary artery disease, obesity, and type 2 diabetes in adulthood. L-Arginine is a precursor of nitric oxide (NO) and may play a role in placental vascular mediation or local vasodilatation. The current study was designed to determine whether oral supplementation of gravid patients suffering from severe intrauterine growth restriction (IUGR) with L-arginine, would enhance birth weight and/or decrease neonatal morbidity. Forty-four patients with a singleton pregnancy who had been referred for IUGR detected by ultrasonic examination were included. Vascular IUGR was defined by fetal abdominal circumference less than or equal to the 3rd percentile, associated with abnormal uterine Doppler. After double-blind randomization, patients received either 14 g/day of L-arginine, or a placebo. The characteristics of the two groups of patients (IUGR with L-arginine vs IUGR with placebo) were similar upon randomization. There was no significant difference between the two groups concerning birth weight (1042+/-476 vs. 1068+/-452 g). At delivery, maternal and neonatal characteristics were similar in the two groups. There was no difference in the Clinical Risk Index for Babies (CRIB) score, the duration of ventilatory assistance, nor the delay between birth and full enteral feeding between the two groups. In this study which is, at the best of our knowledge, the first double-bind, multicenter, randomized trial in this condition, L-arginine is not an effective treatment for severe vascular growth restriction.

Prenatal prediction of neonatal morbidity in survivors with congenital diaphragmatic hernia: a multicenter study

To investigate the value of the observed to expected fetal lung area to head circumference ratio (o/e LHR) and liver position in the prediction of neonatal morbidity in survivors with congenital diaphragmatic hernia (CDH). Neonatal morbidity was recorded in 100 consecutive cases with isolated CDH diagnosed in fetal medicine units, which were expectantly managed in the prenatal period, were delivered after 30 weeks and survived until discharge from hospital. Regression analysis was used to identify the significant predictors of morbidity, including prenatal and immediate neonatal findings. The o/e LHR provided significant prediction of the need for prosthetic patch repair, duration of assisted ventilation, need for supplemental oxygen at 28 days, and incidence of feeding problems. An additional independent prenatal predictor of the need for patch repair was the presence of fetal liver in the chest. In isolated CDH the prenatally assessed size of the contralateral lung is a significant predictor of the need for prosthetic patch repair, the functional consequences of impaired lung development and occurrence of feeding problems.

Efficiency of Noninvasive Ventilation in Acute Heart Failure

Objective: to evaluate the efficiency of noninvasive supporting ventilation in patients with acute cardiorespiratory failure in the early postoperative period after cardiac surgery under extracorporeal circulation. Methods. Case histories of patients operated on the heart under extracorporeal circulation, who postoperatively developed acute car-diorespiratory failure requiring repeated artificial ventilation (AV), were retrospectively studied. According to the AV mode, the patients were divided into 2 groups. Non-invasive AV was carried out in Group 1 (a study group). In Group 2 (a control group), tracheal intubation and mechanical ventilation were performed when respiratory indices deteriorated. In both groups, anesthesia was maintained without deviating from the clinically accepted protocol. The indications for extubation were routine. Following 24—72 hours after extubation, the health status of patients became worse, as manifested in decreased circulatory performance, requiring that they be switched to AV. Clinical and laboratory findings were used to define indications for AV switching. The conditions for noninvasive ventilation were the close cooperation of a patient with medical personnel, the absence of significant hyperthermia, injury, operation or facial abnormally, which excluded intimate mating. Results. Analysis of gas exchange changes suggests that there are no differences between the groups both just after surgery and within 24 postperfusion hours after extubation. When the condition deteriorated, no differences in oxygen exchange and delivery were observed in the study and control groups. In the control group, PaO2, oxygenation index, and oxygen delivery index were significantly less than those in the study group. Analysis of the duration of assisted ventilation revealed that the study group patients were on a respirator significantly less than the controls. The length of intensive care unit stay also increased greatly in Group 2. All patients with normal gas exchange parameters were transferred to a specialized unit. Complications, such as insignificant skin damages at the site of intimate mask mating, were observed in the study group, while in the control group, ventilator-associated pneumonia was seen in 3 cases. Conclusion. The present study has provided evidence that noninvasive AV may be effective in the occurrence of acute cardiorespiratory failure requiring the correction of gas exchange parameters after surgery under extracorporeal circulation. Key words: noninvasive supporting ventilation, cardiosurgery, extracorporeal circulation.

Risk factors for gastroesophageal reflux disease in very low birth weight infants with bronchopulmonary dysplasia

To assess risk factors for gastroesophageal reflux disease (GERD) in very low birth weight infants with bronchopulmonary dysplasia. A case-control study was carried out in 23 cases and 23 control subjects with bronchopulmonary dysplasia submitted to 24-hour esophageal pH monitoring between January 2001 and October 2005. Cases and controls were compared for gestational age, birth weight, gender, use of antenatal steroids, duration of assisted ventilation, duration of oxygen therapy, length of gastric tube use, administration of xanthines, postconceptual age, and weight at esophageal pH monitoring. Multiple logistic regression analysis was used to establish the odds ratio (OR) with a 95% confidence interval (95%CI). None of the groups (with and without GERD) showed statistically significant differences in terms of demographic variables and postnatal outcome, use of antenatal and postnatal corticosteroids, or in terms of caffeine use and duration of mechanical ventilation and oxygen therapy. However, feeding intolerance (OR = 6.55; 95%CI 1.05-40.8) and length of gastric tube use (OR = 1.67; 95%CI 1.11-2.51) turned out to be risk factors for GERD. Postconceptual age at the time of pH monitoring (OR = 0.02; 95%CI < 0.001-0.38) was regarded as a protective factor against GERD. The data obtained allow inferring that prolonged gastric tube use and feeding intolerance increase the risk for GERD. On the other hand, older postconceptual age at the time of pH monitoring reduces the risk for GERD in preterm infants with bronchopulmonary dysplasia weighing less than 1,500 g.

The pulmonary outcome of long-term survivors after congenital diaphragmatic hernia repair.

Congenital diaphragmatic hernia (CDH) represents a chronic condition with significant pulmonary and non-pulmonary complications. The main aim of the present study was to determine the pulmonary outcome in a group of long-term survivors of CDH. Clinical records of 46 patients with CDH admitted to the University Children's Hospital Zurich between 1991 and 2001 were reviewed retrospectively. Survivors underwent clinical examination, lung function tests and measurements of exhaled nitric oxide. 30 of 46 (65%) patients survived after repair of CDH and 19 children participated in a follow-up study at the mean age of 7.9 (2.8) years. At least one wheezy episode requiring inhaled bronchodilators was reported by 9/19 (47%) children and 4/19 (21%) children complained of recurrent wheezy episodes. Nine children showed lung function impairment in spirometry as well as in oscillatory resistance. Neither duration of assisted ventilation nor the length of hospitalisation appeared to correlate with lung function. Exhaled nitric oxide was within normal range in our group of CDH survivors. Measurement of respiratory system resistance using a forced oscillation technique detected those CDH survivors, who showed abnormal pattern in spirometry. However, no correlation between oscillatory resistance and specific airway resistance measured by whole body plethysmography was found. Despite the presence of rather insignificant symptoms, we found mild to moderate pulmonary functional impairment in children surviving CDH repair.

The pulmonary outcome of long-term survivors after congenital diaphragmatic hernia repair.

Congenital diaphragmatic hernia (CDH) represents a chronic condition with significant pulmonary and non-pulmonary complications. The main aim of the present study was to determine the pulmonary outcome in a group of long-term survivors of CDH. Clinical records of 46 patients with CDH admitted to the University Children's Hospital Zurich between 1991 and 2001 were reviewed retrospectively. Survivors underwent clinical examination, lung function tests and measurements of exhaled nitric oxide. 30 of 46 (65%) patients survived after repair of CDH and 19 children participated in a follow-up study at the mean age of 7.9 (2.8) years. At least one wheezy episode requiring inhaled bronchodilators was reported by 9/19 (47%) children and 4/19 (21%) children complained of recurrent wheezy episodes. Nine children showed lung function impairment in spirometry as well as in oscillatory resistance. Neither duration of assisted ventilation nor the length of hospitalisation appeared to correlate with lung function. Exhaled nitric oxide was within normal range in our group of CDH survivors. Measurement of respiratory system resistance using a forced oscillation technique detected those CDH survivors, who showed abnormal pattern in spirometry. However, no correlation between oscillatory resistance and specific airway resistance measured by whole body plethysmography was found. Despite the presence of rather insignificant symptoms, we found mild to moderate pulmonary functional impairment in children surviving CDH repair.

NIPSV for acute cardiogenic pulmonary oedema does not increase the risk of myocardial infarction compared to CPAP

Acute cardiogenic pulmonary oedema (ACPO) can be managed with either non-invasive pressure support ventilation (NIPSV) or non-invasive continuous positive airway pressure (CPAP). Does management with NIPSV increase the risk of myocardial infarction compared to management with CPAP? Randomised controlled trial with concealed allocation. High-dependency unit of a hospital emergency department in Turin, Italy. 52 adults with severe ACPO, defined as acute dyspnoea, > 30 breaths per minute, use of accessory respiratory muscles, oxygen saturation (SpO 2 ) < 90% with F i O 2 60%, and radiological signs of ACPO. Patients with signs of acute coronary syndrome (ACS) on hospital admission were excluded from the study. All patients received standard medications (diuretic, nitroglycerin, morphine) and oxygen. NIPSV was applied by a Pulmonetics Systems LTV 1000 ventilator. CPAP was administered by means of a flow generator (Whisper-Flow) with an expiratory (PEEP) valve. Patients randomised to NIPSV (n = 25) received sufficient inspiratory pressure (IPAP) to generate a tidal volume of ∼7 mL/kg, and oxygen to maintain SpO 2 at ∼93%, via an oronasal mask. Expiratory pressure (EPAP) was gradually increased until SpO 2 ≥ 96% (maximum of 12 cmH 2 O). Those randomised to CPAP (n = 27) commenced at 5 cmH 2 O via an oronasal mask with oxygen to maintain SpO 2 at ∼93%. The CPAP was gradually increased until SpO 2 ≥ 96% (maximum of 12 cmH 2 O). Treatment failure was defined as cardiac arrest, respiratory distress and arterial blood gas deterioration for > 60 min, PaO 2 /F i O 2 < 100 mmHg, coma or psychomotor agitation, haemodynamic instability, or life-threatening arrhythmias. Otherwise, treatment continued until the participant met objective criteria of recovery. The primary outcome was the rate of acute myocardial infarction (AMI). Secondary outcomes included rate of endotracheal intubation, death, duration of ventilatory assistance, and lengths of stay in the hospital and high-dependency unit. In the NIPSV group, the average EPAP and IPAP applied were 7 ± 1 and 15 ± 3 cm H 2 O, respectively. In the CPAP group, the mean pressure applied was 9 ± 2 cm H 2 O. AMI occurred in four patients on NIPSV and eight patients on CPAP, which was not significantly different, absolute risk reduction (ARR) 0.14, 95% CI –0.10 to 0.34. Also not significantly different were the number of intubations with only one in the NIPSV group, ARR –0.04, 95% CI –0.20 to 0.09, and the number of deaths with three in the NIPSV group and two in the CPAP group, ARR –0.05, 95% CI –0.23 to 0.13. The lengths of stay in hospital and in the high-dependency unit also did not significantly differ between the groups. This study demonstrated no significant difference in AMI among patients with ACPO managed with NIPSV versus CPAP.