Duration Of Oxygen Dependency Research Articles

The role of clinical and immunological parameters in predicting the effectiveness of additional immunotropic therapy in oxygen-dependent patients with COVID-19 coronavirus disease

Aim. The purpose of the research is to find out the role of clinical and immunological parameters in predicting the effectiveness of additional immunotropic therapy in oxygen-dependent patients with the coronavirus disease COVID-19. Material and methods. 79 oxygen-dependent patients with COVID-19 were examined, who received additional therapy with tocilizumab according to current protocols. The patients were divided into groups: I group – 39 patients who recovered; group II – 40 patients with a fatal outcome of the disease. The content of ferritin (Monobind Inc., USA), interleukin (IL) IL-2 (Elabscience, USA), IL-6 (Invitrogen, Austria), monocyte chemotactic protein-1 (MCP-1) (Elabscience, USA) was determined in the blood serum of patients and persons of the control group by the method of immunoenzymatic analysis. Statistical processing of the obtained data was carried out in the program Statistica 13 for Windows (StatSoft Inc., No. JPZ804I382130ARCN10-J). Results. Threshold levels of immunological parameters at different stages of observation, which have prognostic value regarding the risk of a fatal outcome of COVID-19, have been established. After 5 days of tocilizumab administration, the preservation of the indicator of the absolute number of blood lymphocytes ≤1.2 × 109/l (AUC = 0.631, p = 0.039), CRP level >67.5 mg/l (AUC = 0.670, p = 0.020), IL-2 >309.45 pg/ml (AUC = 0.761, p = 0.013), IL-6 >4.66 pg/ml (AUC = 0.871, p < 0.001) indicated a high probability of developing a fatal outcome of the disease in patients with COVID-19. The analysis of the diagnostic significance of ferritin showed the informativeness of the level of its increase as at the time of the start of observation >548.02 ng/ml (AUC = 0.718, p = 0.004) and after 5 days the application of additional immunotropic therapy >443.55 ng/ml (AUC = 0.736, p = 0.026). It has been proven that, in addition to immunological parameters, when assessing the probability of a fatal outcome of COVID-19, such clinical parameters as the presence of febrile fever at the time of the appearance of oxygen dependence (p < 0.05) and the duration of oxygen dependence at the time of additional immunotropic therapy with tocilizumab are informative (p < 0.05). Under the conditions of additional immunotropic therapy with tocilizumab more than 4 days after the onset of oxygen dependence, the probability of ineffectiveness of the specified additional treatment was significant (AUC = 0.756, p < 0.001). Conclusions. The dynamics of immunological parameters in oxygen-dependent patients with COVID-19 during additional immunotropic therapy with tocilizumab has certain features with different treatment results. When predicting the probable risk of a fatal outcome of the disease, clinical parameters are informative, namely the appearance of febrile fever during the development of oxygen dependence and the duration of oxygen dependence until the moment of tocilizumab administration, and immunological parameters, namely the level of the absolute content of lymphocytes, ferritin, CRP, IL-2, IL-6 in the blood.

Impact of a Nursing Intervention Bundle of Care on Nasal-CPAP-Related Nasal Injuries in Preterm Infants: A Quality Improvement Initiative

AIM: The objective is to assess the effect of the application of a nasal injury prevention bundle on the incidence and severity of nasal-continuous positive airway pressure (nCPAP)-related nasal injuries in preterm infants. METHODS: We conducted a prospective controlled before-after study in a preterm neonate, <37 weeks gestation, who required nCPAP in the neonatal intensive care unit, at Mansoura University Children’s Hospital, between September 2018 through October 2019. After 2 months of nursing staff training, a nasal trauma prevention bundle was implemented. The nursing intervention bundle comprised nasal barrier dressing, regular focused checking for evolving nasal skin injury, and proper application of the CPAP device. nCPAP-related nasal injuries per 1000 days and grading of nasal injury severity were the primary outcomes. Time to onset of nasal injury after initiation of CPAP; duration of nCPAP use, duration of oxygen dependency; incidence of pneumothorax, broncho-pulmonary dysplasia; intraventricular hemorrhage; periventricular leukomalacia; late-onset sepsis; length of hospital stay; and in-hospital mortality were the secondary outcomes. RESULTS: Data from 62 preterm neonates were analyzed (31 in each group). The nasal trauma prevention bundle of care was associated with reduced nasal injury incidence per 1000 nCPAP-days (140 vs. 148.94, p = 0.03) with improved nasal injury severity staging (p = 0.003) compared to the pre-bundle era. Nasal injury developed earlier in the control group (1 [1–1] vs. 2 [1–3] days, p = 0.002) compared to the intervention group. No statistically significant differences were reported between groups regarding any of the other secondary outcomes. Longer duration of CPAP use (p = 0.009) and lack of bundle application (0.03) were the independent risk factors associated with nCPAP-related nasal injuries in preterm neonates. CONCLUSION: The implementation of a bundle of nursing interventions is associated with a substantially improved incidence and severity of nasal injuries in preterm infants receiving nCPAP.

Leflunomide treatment for patients hospitalised with COVID-19: DEFEAT-COVID randomised controlled trial

ObjectiveTo evaluate the clinical efficacy and safety of leflunomide (L) added to the standard-of-care (SOC) treatment in COVID-19 patients hospitalised with moderate/critical clinical symptoms.DesignProspective, open-label, multicentre, stratified, randomised clinical trial.SettingFive...

The Difference in Potential Harms between Whole Blood and Component Blood Transfusion in major Bleeding: A Rapid Systematic Review and Meta-Analysis of RCTs.

Our aim was to assess whether there is a difference in outcomes of potential "all-cause" harm in the transfusion of whole blood (WB) compared to blood components (BC) for any bleeding patient regardless of age or clinical condition. We searched multiple electronic databases using a pre-defined search strategy from inception to 2nd March 2021. 1 reviewer screened, extracted, and analysed data, with verification by a second reviewer of all decisions. We used Cochrane ROB1 and GRADE to assess the quality of the evidence. We used predefined subgroups of trauma and non-trauma studies in the analysis. We included six RCTs (618 participants) which compared WB and BC transfusion therapy in major bleeding, one trauma trial (n=107), and 5 surgical trials (non-trauma) (n=511). We GRADED evidence as very-low for all outcomes (downgraded for high and unclear risk of bias, small sample size, and wide confidence intervals around the estimate). Our primary outcome (all-cause mortality at 24-hours and 30-days) was reported in 3 out of 6 included trials. There was no evidence of a difference in mortality of WB compared to BC therapy (very-low certainty evidence). There may be a benefit of WB therapy compared to BC therapy in the non-trauma subgroup, with a reduction in the duration of oxygen dependence (1 study; n=60; mean difference 5.9 fewer hours [95% Confidence Interval [CI] -10.83, -0.99] in WB group), and a reduction in hospital stay (1 study, n=64, median difference 6 fewer days in WB group) (very-low certainty evidence). For the remaining outcomes (organ injury, mechanical ventilation and intensive care unit requirement, infection, arterial/venous thrombotic events, and haemolytic transfusion reaction) there was no difference between WB and BC therapy (wide CI, crossing line of no effect), though many of these outcomes were based on small single studies (very-low certainty evidence). In conclusion, there appears to be little to no difference in harms between WB and BC therapy, based on small studies with very low certainty of the evidence. Further large trials are required to establish the overall safety of WB compared to BC, and to assess differences between trauma and non-trauma patients.

Association of Maternal Hypertensive Disorders During Pregnancy With Severe Bronchopulmonary Dysplasia: A Systematic Review and Meta-Analysis

BackgroundThis meta-analysis was performed to examine the association between maternal hypertension during pregnancy (HDP) and neonatal bronchopulmonary dysplasia (BPD).MethodsWe systematically searched PubMed, EMBASE, the Cochrane Library, and the KoreaMed database for relevant studies. We used the Newcastle-Ottawa Scale for quality assessment of all included studies. The meta-analysis was performed using Comprehensive Meta-Analysis software (version 3.3).ResultsWe included 35 studies that fulfilled the inclusion criteria; the total number of infants evaluated came to 97,399 through review process. Maternal HDP was not significantly associated with any definition of BPD, i.e., oxygen dependency at 36 weeks of gestation (odds ratio [OR], 1.162; 95% confidence interval [CI], 0.991–1.362; P = 0.064) in pooled analysis of 29 studies or oxygen dependency at 28 days of age (OR, 1.084; 95% CI, 0.660–1.780; P = 0.751) in pooled analysis of 8 studies. Maternal HDP was significantly associated only with severe BPD (OR, 2.341; 95% CI, 1.726–3.174; P < 0.001). BPD was not associated with HDP in the overall analysis (OR, 1.131; 95% CI, 0.977–1.309; P = 0.100) or subgroup analysis according to the definition of HDP.ConclusionMaternal HDP was not associated with neonatal BPD defined by the duration of oxygen dependency (at either 36 weeks of gestation or 28 days of life) but was associated with severe BPD.

Is fresh, leucodepleted, whole blood transfusion superior to blood component transfusion in pediatric patients undergoing spinal deformity surgeries? A prospective, randomized study analyzing postoperative serological parameters and clinical recovery.

PurposeTo compare the effectiveness of fresh whole blood (FWB) and blood component transfusion in improving clinical outcome and serological parameters in the early postoperative period following spinal deformity surgery.MethodsPatients undergoing major spinal deformity surgeries involving ≥ 6 levels of fusion and expected blood loss ≥ 750 ml between September 2017 and August 2018 were included in the study. The patients were randomized into two groups: FWBG and CG, receiving fresh whole blood and component transfusions, respectively.ResultsA total of 65 patients with spinal deformities of different etiologies were included. The mean age was 14.0 and 14.9 years in FWB and CG, respectively. All other preoperative parameters were comparable. The mean fusion levels and surgical time were 11.1 and 221.20 min in FWB, as compared with 10.70 and 208.74minutes in CG, respectively. Intraoperative blood losses were 929 ml (FWBG) and 847 ml(CG), and the mean volumes of transfusion were 1.90 (FWBG) and 1.65 units (CG). FWBG was significantly superior to CG in the following clinical and laboratory parameters: duration of oxygen dependence [36.43 (FWBG) vs. 43.45 h (CG); P = 0.0256], mean arterial pH [7.442 (FWBG) vs. 7.394 (CG); p < 0.001], interleukin-6 [30.04 (FWBG) vs. 35.10 (CG); p < 0.019], mean duration of HDU stay [40.6 hours (FWBG) vs 46.51 hours (CG); p = 0.0234] and postoperative facial puffiness [7/30 in FWBG vs. 18/35 (CG) (P < 0.02)].ConclusionFWB transfusion can potentially improve the immediate postoperative outcome in patients undergoing major spinal deformity surgeries by reducing the duration of intensive care unit stay and oxygen dependence. The other potential benefits of this practice, based on our study, include a reduced inflammatory response (reduced lactate and IL-6) and postoperative facial puffiness. However, further large-scale validation studies in future are necessary to precisely determine the role of FWB in spine surgeries.Level of evidence IIDiagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

Comparison of the effects of bosentan and sildenafil in the treatment of persistent pulmonary arterial hypertension in infants

Background: Persistent pulmonary hypertension (PPHN) is a life-threatening condition in neonates. In developing countries, mortality is estimated to be around 10%–20% due to lack of access to the main drug, inhaled nitric oxide. Bosentan as an endothelin type A and B receptor antagonist and sildenafil as a phosphodiesterase inhibitor type 5 are effective in reducing pulmonary vascular resistance and pulmonary artery pressure (PAP). Materials and Methods: A double-blind clinical trial was conducted at the intensive care unit of Akbarabadi Hospital Tehran between October 2017 and September 2019. The efficacy, safety, and possible side effects of bosentan and sildenafil were evaluated in neonates suffering from PPHN. Echocardiographic findings, duration of oxygen dependency, invasive ventilation support requirement, duration of medication, short-term outcomes including blood pressure, white blood cell, and hemoglobin counts were compared between the two groups. Results: Bosentan is as effective as sildenafil in reducing PAP and improving cardiac output. The duration of treatment with bosentan was significantly shorter than that of sildenafil (P = 0.002). The time of oxygen demand was similar between both the groups, ranging from 15 to 17 days (P = 0.198). The need for invasive ventilation support was similar in both the groups (P = 0.989). Although PAP and the severity of tricuspid valve insufficiency were higher before treatment, the third echocardiographic findings such as pulmonic insufficiency (P = 0.194), tricuspid regurgitation (P = 0.368), and ejection fraction (P = 0.160) were similar in bosentan and sildenafil groups. The need for supportive inotropic drugs was similar in both the groups. There was no statistically significant difference in the mean of blood pressure, white blood cell, and hemoglobin counts between the two groups.Conclusion: Bosentan is effective in the treatment of PPHN in neonates and reduces it over a shorter period of time. It is more efficient in reducing PAP and decreases the severity of tricuspid valve insufficiency in a shorter time compared to sildenafil.

Effect Of Nebulized Budesonide In Improving The Clinical Outcome Of Neonates With Meconium Aspiration Syndrome

Aim and Objective: To study the effect of nebulized steroid in improving the clinical outcome in terms of morbidity and mortality in neonates with meconium aspiration syndrome. Patients: Full term babies with clinical diagnosis of Meconium aspiration syndrome(MAS) admitted in the NICU of cheluvamba hospital attached to Mysore medical college and research institute were included in the study. Intervention: Administration of nebulized budesonide(Budecort,Cipla) in a dose of 50µg in 2.5ml normal saline through jet nebulizer every 12hourly from second day of life till 7days or clinical recovery whichever is earlier. Results: 40 patients were randomized into 20 in control group(Group-A) and 20 in budesonide group(Group-B). The baseline clinical profile of both the groups were similar. Duration of respiratory distress in days (2.63vs5.24 p=0.0493), duration of oxygen dependency(2.37vs4.94 p=0.0406), duration of hospital stay(7.58vs10.47 p=0.0430), time taken for achievement of full feeds(3.79vs8.76 p=0.0002) and the need for mechanical ventilation(0vs0.2 p=0.0356) were statistically less in budesonide treated group as compared to the controls. Complications were similar in both the groups. Four patients died during the hospital stay, three in the control group and one in the case group. Out of them, two patients died due to pneumothorax and both of them belong to the control group, other two patients died due to sepsis with disseminated intravascular coagulation(DIC), representing one each from control and case group. Conclusion:Nebulized budesonide improves the short term respiratory outcome and is relatively safe, however long term follow-up is needed to recommend inhalation route of steroids as safe and effective.

Efficacy analysis of surgical ligation in very low birth weight infant with hemodynamic significant patent ductus arteriosus

Objective To evaluate the efficacy of surgical ligation in very low birth weight infant(VLBWI) with hemodynamic significant patent ductus arteriosus (hsPDA), and further investigate the indication, timing and safety of surgical intervention of VLBWI with hsPDA. Methods Retrospective analysis was performed for the medical records of 11 cases of VLBWI with hsPDA confirmed by echocardiography who received operation between January 2006 and December 2010 in Guangdong General Hospital.The indications of PDA ligation were patients with invalid medical treatment combined with different kinds of complication of hsPDA. Results All infants' median gestational age was 29 weeks (26-32 weeks), mean birth weight was (1166.8±283.9) g, and the hsPDA diameter ranged from 2.0-5.5 mm.The most common complication of operation was ventilator-associated pneumonia.The operation mortality was 0, the mean hospital stay was (67.1±36.1) days, and duration of oxygen dependence was (60.9±28.0) days.Total duration of mechanical ventilation dependence was (33.6±13.2) days.After ligation, duration of mechanical ventilation dependence was (11.4±6.9) days, which was significantly shorter than before ligation[(22.9±9.3) days](P<0.05). The incidence of apnea, broncho pulmonary dysplasia, metabolic acidosis, septicemia, retinopathy of prematurity, necrotizing enterocolitis, intraventricular haemorrhage and pulmonary hemorrhage were 81.8%, 63.6%, 45.5%, 36.4%, 36.4%, 27.3%, 27.3% and 18.2% respectively.Followed up to 44 months after surgery, there was only 1 infant who died of accidental asphyxia, so total survival rate was 90.9%. Conclusion Surgical ligation was an effective therapy of VLBWI with hsPDA, as it can lessen the duration of mechanical ventilation dependence, treatment cost and decrease the mortality. Key words: Patent ductus arteriosus; Very low birth weight infant; Surgical ligation; Echocardiography; Complication

Randomized, Controlled Trial Comparing Synchronized Intermittent Mandatory Ventilation and Synchronized Intermittent Mandatory Ventilation Plus Pressure Support in Preterm Infants

Prolonged mechanical ventilation is associated with lung injury in preterm infants. In these infants, weaning from synchronized intermittent mandatory ventilation may be delayed by their inability to cope with increased respiratory loads. The addition of pressure support to synchronized intermittent mandatory ventilation can offset these loads and may facilitate weaning. The purpose of this work was to compare synchronized intermittent mandatory ventilation and synchronized intermittent mandatory ventilation plus pressure support in weaning from mechanical ventilation and the duration of supplemental oxygen dependency in preterm infants with respiratory failure. Preterm infants weighing 500 to 1000 g at birth who required mechanical ventilation during the first postnatal week were randomly assigned to synchronized intermittent mandatory ventilation or synchronized intermittent mandatory ventilation plus pressure support. In both groups, weaning followed a set protocol during the first 28 days. Outcomes were assessed during the first 28 days and until discharge or death. There were 107 infants enrolled (53 synchronized intermittent mandatory ventilation plus pressure support and 54 synchronized intermittent mandatory ventilation). Demographic and perinatal data, mortality, and morbidity did not differ between groups. During the first 28 days, infants in the synchronized intermittent mandatory ventilation plus pressure support group reached minimal ventilator settings and were extubated earlier than infants in the synchronized intermittent mandatory ventilation group. Total duration of mechanical ventilation, duration of oxygen dependency, and oxygen need at 36 weeks' postmenstrual age alone or combined with death did not differ between groups. However, infants in synchronized intermittent mandatory ventilation plus pressure support within the 700- to 1000-g birth weight strata had a shorter oxygen dependency. The results of this study suggest that the addition of pressure support as a supplement to synchronized intermittent mandatory ventilation during the first 28 days may play a role in reducing the duration of mechanical ventilation in extremely low birth-weight infants, and it may lead to a reduced oxygen dependency in the 700- to 1000-g birth weight strata.

The Effect of Steroids on the Clinical Course and Outcome of Neonates with Meconium Aspiration Syndrome

Meconium Aspiration Syndrome (MAS) is an important cause of neonatal morbidity and mortality. The present study was undertaken to evaluate the role of steroids in the management of MAS. This was a double blinded randomized controlled trial and a prospective Interventional Study over one-year period in the neonatal unit of the Lady Hardinge Medical College and associated Kalawati Saran Children's hospital. Fifty-one babies of MAS which were randomly distributed into three groups, Control, systemic and nebulized steroids. Methyl prednisolone was given i.v. in dose of 0.5 mg/kg/day in two divided doses. Budecort was given by nebulization in dose of 50 microgram 12 hourly. Infants were assessed in terms of duration of stay, oxygen dependence, X-ray clearances and also assessed for short term adverse effects. There was a statistically significant difference in the duration of stay, duration of oxygen dependence and radiological clearance. The use of steroids was not associated with an increased incidence of sepsis. The conclusion is that steroids alter the course of Meconium Aspiration Syndrome and favorably affect the outcome.

Outcome following patent ductus arteriosus ligation in premature infants: a retrospective cohort analysis

BackgroundThe patent ductus arteriosus (PDA) is an important problem in premature infants. Surgical PDA ligation is usually only be considered when medical treatment has either failed or was contraindicated. The aims of our study were to determine the mortality and morbidity following patent ductus arteriosus ligation in premature infants, and whether prostaglandin synthetase inhibitor (PSI) use prior to ligation affects outcome.MethodsA retrospective case note review study to determine the outcome of premature infants undergoing patent ductus arteriosus ligation in one tertiary neonatal intensive care unit and two paediatric cardiothoracic centres.ResultsWe had follow-up data on 87 infants. Cumulative mortality rates at 7 days, 30 days and at hospital discharge were 2%, 8% and 20% respectively. The incidence of chronic lung disease, intraventricular haemorrhage, necrotising enterocolitis and retinopathy of prematurity were 77%, 39%, 26% and 28% respectively. There was no difference in mortality, incidence of chronic lung disease or duration of oxygen dependence between those who had and those who had not received a PSI prior to surgical ligation. In those who had received 2 or more courses of PSI prior to surgical ligation, there was a trend to increase in the duration of oxygen therapy and chronic lung disease, but no difference in mortality.ConclusionThis study shows that patent ductus arteriosus ligation is a relatively safe procedure (30 day survival 92%) but there is substantial late mortality and a high incidence of morbidity in the survivors. 2 or more courses of PSI prior to surgical ligation trends to increased oxygen dependence and chronic lung disease. This high risk population requires careful follow-up. A definitive prospective cohort study is lacking.

Diurétiques et prématuré

Diuretics are frequently used in preterm infants in various situations such as patent ductus arteriosus, respiratory distress syndrome, bronchopulmonary dysplasia or neonatal renal insufficiency. However, the beneficial effects reported in the literature are usually transient, without any obvious effect on important parameters such as duration of oxygen dependency, ventilator dependency, length of hospital stay, long-term outcome, or mortality. Moreover, these drugs may induce water-electrolyte disorders especially when used for a long-term period. Thus, we recommend a systematic analysis of the beneficial/risk ratio before any use of these drugs.

Inhaled versus systemic corticosteroids for the treatment of chronic lung disease in ventilated very low birth weight preterm infants.

Chronic lung disease (CLD) remains a serious and common problem among very low birth weight infants despite the use of antenatal steroids and postnatal surfactant therapy to decrease the incidence and severity of respiratory distress syndrome. Corticosteroids have been widely used to treat or prevent CLD due to their anti-inflammatory properties. However, the use of systemic steroids has been associated with serious short and long term adverse effects. Administration of corticosteroids topically through the respiratory tract might result in beneficial effects on the pulmonary system with fewer undesirable systemic side effects. To compare the effectiveness of inhaled versus systemic corticosteroids administered to ventilator dependent preterm neonates with birth weight </= 1500 grams or gestational age </= 32 weeks after two weeks of life for the treatment of evolving CLD. Randomized and quasi-randomized trials were identified by searching the Cochrane Controlled Trials Register (The Cochrane Library, Issue 3, 2002), MEDLINE (1966 - September 2002), EMBASE (1980 - September 2002), CINAHL (1982 - September 2002), reference lists of published trials and abstracts published in Pediatric Research (1990 - April 2002) from the Society for Pediatric Research/Pediatric Academic Societies' Annual Meetings. Randomized or quasi-randomized trials comparing inhaled versus systemic corticosteroid therapy (irrespective of the dose and duration of therapy) starting after the first two weeks of life in ventilator dependent very low birth weight preterm neonates. Data were extracted regarding clinical outcomes including CLD at 28 days or 36 weeks corrected gestational age (CGA), mortality, combined outcome of death or CLD at 28 days or 36 weeks CGA, other pulmonary outcomes and adverse effects. All data were analyzed using RevMan 4.1. When appropriate, meta-analysis was performed using relative risk (RR), risk difference (RD), and weighted mean difference (WMD) along with their 95% confidence intervals (CI). If RD was statistically significant, number needed to treat (NNT) was calculated. Five trials comparing inhaled versus systemic corticosteroids in the treatment of CLD were identified. Two trials were excluded as both included non ventilator dependent patients. One trial is awaiting assessment and clarification of published data. Two trials qualified for inclusion in this review. Halliday et al (Halliday 2001a) randomized infants < 72 hours, while Suchomski et al (Suchomski 2002) randomized at 12-21 days. Although the steroids were commenced after the first 2 weeks of life in both the trials, the outcomes were measured over different time periods, from the age at randomization in each trial, making it inappropriate to combine results. In neither trial was there a statistically significant difference between the groups in the incidence of CLD at 36 weeks CGA amongst all randomized infants. The estimates for the trial by Halliday et al (Halliday 2001a) were RR 1.10 (95% CI 0.82, 1.47), RD 0.03 (95% CI -0.08, 0.15); number of infants (n) = 292 and for the trial by Suchomski et al (Suchomski 2002) RR 0.90 (95% CI 0.79, 1.02), RD -0.10 (95% CI -0.22, 0.02; n = 78 ). There were no statistically significant differences between the groups in either trial for oxygen dependency at 28 days, death by 28 days or 36 weeks, the combined outcome of death or CLD by 28 days or 36 weeks CGA, duration of intubation, duration of oxygen dependence, or adverse effects. Information on the long term neurodevelopmental outcomes was not available. This review found no evidence that inhaled corticosteroids confer net advantages over systemic corticosteroids in the management of ventilator dependent preterm infants. Neither inhaled steroids, nor systemic steroids, can be recommended as standard treatment for ventilated preterm infants. There was no evidence of difference in effectiveness or side-effect profiles for inhaled versus systemic steroids. A better delivery system guaranteeing selective delivery of inhaled steroids to the alveoli might result in beneficial clinical effects without increasing side-effects. To resolve this issue, studies are needed to identify the risk/benefit ratio of different delivery techniques and dosing schedules for the administration of these medications. The long term effects of inhaled steroids, with particular attention to neurodevelopmental outcome, should be addressed in future studies.

Diuretics acting on the distal renal tubule for preterm infants with (or developing) chronic lung disease.

The aim of this review is to assess the risks and benefits of diuretics acting on distal segments of the renal tubule (distal diuretics) in preterm infants with or developing chronic lung disease (CLD). Primary objectives are to assess changes in need for oxygen or ventilatory support and effects on long-term outcome, and secondary objectives are to assess changes in pulmonary mechanics and potential complications of therapy. We used the standard method of the Cochrane Neonatal Review Group. We used the following keywords: ¿<bronchopulmonary dysplasia> or <chronic lung disease>¿ and <explode diuretics>, limited to <human> and limited to <infant, newborn> or <infant>. We searched Medline (1966-1998), Embase (1974-1998) and the Cochrane Controlled Trials Register (CCTR) from the Cochrane Library (1999, issue 2). In addition, we hand searched several abstract books of national and international American and European Societies. We included in this analysis trials in which preterm infants with or developing CLD and at least five days of age were all randomly allocated to receive a distal diuretic (i.e., a diuretic acting on the distal renal tubule). Eligible studies needed to assess at least one of the outcome variables defined a priori for this systematic review. Primary outcome variables included changes in need for respiratory support and oxygen supplementation, mortality, bronchopulmonary dysplasia (BPD), death or BPD, chronic lung disease at 36 weeks of postconceptional age (gestational age + postnatal age), length of stay, and number of rehospitalizations during the first year of life. Secondary outcome variables included pulmonary mechanics and potential complications of therapy. We used the standard method for the Cochrane Collaboration which is described in the Cochrane Collaboration Handbook. Two investigators extracted, assessed and coded separately all data for each study, using a form that was designed specifically for this review. Any disagreement was resolved by discussion. We combined parallel and cross-over trials and, whenever possible, transformed baseline and final outcome data measured on a continuous scale into change scores using Follmann's formula. Of six studies fulfilling entry criteria, most focused on pathophysiological parameters and did not assess effects on important clinical outcomes defined in this review, or the potential complications of diuretic therapy. In preterm infants > 3 weeks of age with CLD, a four-week treatment with thiazide and spironolactone improved lung compliance and reduced the need for furosemide. Thiazide and spironolactone decreased the risk of death and tended to decrease the risk for lack of extubation after 8 weeks in intubated infants. There is no evidence to support the hypothesis that adding spironolactone to thiazide or that adding metolazone to furosemide improves the outcome of preterm infants with CLD. In preterm infants > 3 weeks of age with CLD, acute and chronic administration of distal diuretics improve pulmonary mechanics. Chronic administration of diuretics (thiazide with spironolactone) reduces mortality in intubated patients. Large studies are needed to assess (1) whether chronic diuretic administration improves mortality, duration of oxygen dependency, ventilator dependency, length of hospital stay and long-term outcome in patients without long-term toxicity and (2) whether adding spironolactone to thiazides or adding metolazone to furosemide has any beneficial effect.

Ureaplasmapneumonien und Nachweis von Ureaplasma urealyticum im Tubussekret bei Früh- und Neugeborenen

Bei wie vielen Frühgeborenen ≤1250 g und bei wie vielen Neugeborenen >1250 g mit klinischer Symptomatik Ureaplasma urealyticum im Tubussekret nachweisbar war und bei wie vielen eine Pneumonie auftrat. Methodik: Die Patienten wurden in zwei Gruppen unterteilt (Gruppe 1: Geburtsgewicht ≤1250 g, n = 25; Gruppe 2: Geburtsgewicht >1250 g, n = 45) und diese wiederum in zwei Subgruppen (Subgruppe a: U. urealyticum im Tubussekret ohne Pneumonie; Subgruppe b: U. urealyticum im Tubussekret mit Pneumonie). Ergebnisse: Bei 9 Patienten der Gruppe 1 (36%) konnte U. urealyticum nachgewiesen werden, und 5 dieser Patienten (20%) hatten eine Pneumonie (Gruppe 1b). Frühgeborene mit einer Ureaplasmapneumonie hatten im Vergleich zu jenen mit einer blossen Ureaplasmabesiedelung signifikant höhere Beatmungsparameter, eine längere Beatmungsdauer und einen grösseren Sauerstoffbedarf. Bei 6 Patienten der Gruppe 2 (13%) konnte U. urealyticum nachgewiesen werden, und 2 von ihnen (4,4%) hatten eine Pneumonie. Schlussfolgerungen: Bei neonatalen Pneumonien bei sehr kleinen Frühgeborenen, aber auch bei reifen Neugeborenen, sollte stets U. urealyticum in die Differentialdiagnose miteinbezogen werden.

Chylothorax after repair of congenital diaphragmatic hernia—Risk factors and morbidity

Background/Purpose: Chylothoraces have been reported rarely after congenital diaphragmatic hernia (CDH) repair, but that is contrary to the authors' experience. The aim of this study was to audit the outcome of antenatally diagnosed CDH cases to determine the incidence, possible risk factors, and morbidity associated with chylothorax in CDH patents. Methods: Twenty-four of 35 consecutive infants with CDH (69%) underwent surgical repair and survived the immediate postoperative period. Results: Effusions developed in all 22 for whom chest radiographs were available. Six of the eight infants whose effusions required drainage had a chylothorax. Those six infants required a mean of 8 days of thoracentesis, during which a mean total volume of 358 mL/kg of fluid was removed. The infants remained on a medium-chain triglyceride (MCT) formula for a mean of 81 days. The six infants with a chylothorax differed from the rest with respect to their duration of oxygen dependence (a median of 28.5 versus 15 days, P<.05) and hospital stay (a median of 5.5 versus 4 weeks, P<.05), but no significant risk factors for the development of a chylothorax were identified. Conclusion: Chylothorax is a relatively common cause of effusion after CDH repair and is associated with increased morbidity.

Hospitalization as a measure of morbidity among very low birth weight infants with chronic lung disease

OBJECTIVE: To examine the spectrum of hospitalization and rehospitalization among very low birth weight (VLBW, <1500 gm) infants with severe chronic lung disease during the first 2 years of life. POPULATION: All 124 VLBW infants admitted to our center from October 1988 to September 1990 who were oxygen and ventilator dependent at 21 days of age. One hundred infants survived to discharge, of whom two subsequently died. The 98 surviving infants are the subject of this report. METHODS: The duration of the neonatal stay, the use of a long-term care facility, and rehospitalizations were recorded to a postnatal age of 24 months. The duration of these hospitalizations and the total duration of hospitalization during the first year of life were correlated with demographic and perinatal risk factors and 20-month outcome. RESULTS: The 98 infants spent a median of 125 days (range, 44 to 365) of their first year hospitalized; the neonatal stay accounted for 85% of this time. Forty-nine of the infants (50%) were rehospitalized in their first year (median stay, 14 days), and 36 (37%) were rehospitalized in their second year (median stay, 7 days). Long-term care facility stay and rehospitalizations accounted for 6% and 9% of the first-year hospitalizations, respectively. A median of 9 days (range, 1 to 365) of the second year of life were spent in hospital. The infants rehospitalized during their first year of life did not differ significantly from those not requiring rehospitalization with regard to maternal demographic descriptors, birth data, severity of chronic lung disease, or measures of 20-month outcome. Both duration of neonatal stay and total hospital stay during the first year were significantly associated with all measures of chronic lung disease severity and with 20-month neurodevelopmental outcome measures, whereas the duration of rehospitalization was associated only with duration of oxygen dependence. CONCLUSION: Among infants with severe chronic lung disease, the total duration of hospitalization during the first year of life provides a better index of morbidity than the number or duration of rehospitalizations alone. (J P EDIATR 1996;128:447-52 )

Does the duration of oxygen dependence after birth influence subsequent respiratory morbidity?

Does the duration of oxygen dependence after birth influence subsequent respiratory morbidity?