Duration Of Positive Pressure Ventilation Research Articles

Tracheostomy Timing During Pediatric Cardiac Intensive Care: Single Referral Center Retrospective Cohort.

To describe associations between the timing of tracheostomy and patient characteristics or outcomes in the cardiac ICU (CICU). Single-institution retrospective cohort study. Freestanding academic children's hospital. CICU patients with tracheostomy placed between July 1, 2011, and July 1, 2020. We compared patient characteristics and outcomes between early and late tracheostomy based on the duration of positive pressure ventilation (PPV) before tracheostomy placement, fitting a receiver operating characteristic curve for current survival to define a cutoff. Sixty-one patients underwent tracheostomy placement (0.5% of CICU admissions). Median age was 7.8 months. Eighteen patients (30%) had single ventricle physiology and 13 patients (21%) had pulmonary vein stenosis (PVS). Primary indications for tracheostomy were pulmonary/lower airway (41%), upper airway obstruction (UAO) (31%), cardiac (15%), neuromuscular (4%), or neurologic (4%). In-hospital mortality was 26% with 41% survival at the current follow-up (median 7.8 [interquartile range, IQR 2.6-30.0] mo). Late tracheostomy was defined as greater than or equal to 7 weeks of PPV which was equivalent to the median PPV duration pre-tracheostomy. Patients with late tracheostomy were more likely to be younger, have single ventricle physiology, and have greater respiratory severity. Patients with early tracheostomy were more likely to have UAO or genetic comorbidities. In multivariable analysis, late tracheostomy was associated with 4.2 times greater mortality (95% CI, 1.9-9.0). PVS was associated with higher mortality (adjusted hazard ratio [HR] 5.2; 95% CI, 2.5-10.9). UAO was associated with lower mortality (adjusted HR 0.2; 95% CI, 0.1-0.5). Late tracheostomy was also associated with greater cumulative opioid exposure. CICU patients who underwent tracheostomy had high in-hospital and longer-term mortality rates. Tracheostomy timing decisions are influenced by indication, disease, genetic comorbidities, illness severity, and age. Earlier tracheostomy was associated with lower sedative use and improved adjusted survival. Tracheostomy placement is a complex decision demanding individualized consideration of risk-benefit profiles and thoughtful family counseling.

Protocol of randomized controlled trial comparing T piece resuscitator versus self-inflating bag for resuscitation in the delivery room in preterm neonates

Background: Neonatal resuscitation is a critical process for a newborn with effective ventilation as its key component. Three manual ventilation devices, including self-inflating bags (SIB), flow-inflating bags (FIB), and T-piece resuscitator (TPR) are recommended for positive pressure ventilation (PPV) in the delivery room. To date, there is insufficient evidence regarding the optimal device for establishing effective ventilation in newborns. This study is planned to compare the effectiveness of TPR and SIB during resuscitation. Methods: This will be a single centre, open-label, randomized controlled trial. Study participants will be preterm ≤34 of gestation needing PPV at birth as per NRP algorithm. Newborns will be randomly assigned to two groups (TPR or SIB). SpO2 at 2 and 5 min, time to reach heart rate >100/min by pulse oximetry, and duration of PPV will be recorded. Primary outcome is need of delivery room intubation. Intention to treat analysis will be done using STATA version 17.0. A priori defined subgroup for purpose of analysis will be gestation ≤30 and 31-34 weeks. Trial will be done as per good clinical practice guidelines. Conclusions: If PPV with TPR is proven to be more efficacious in terms of less delivery room intubation, there would be a way towards finalizing the TPR as primary device for providing PPV during delivery room resuscitation at birth. This study has potential to bring down need of delivery room intubation with less duration of mechanical ventilation and morbidity in form of IVH, BPD and composite outcome of BPD and death. Trial registration: CTRI number: CTRI/2023/01/048660.

Tidal volumes during delivery room stabilization of (near) term infants

BackgroundWe sought to assess tidal volumes in (near) term infants during delivery room stabilization.MethodsSecondary analysis of a prospective study comparing two facemasks used for positive pressure ventilation (PPV) in newborn infants ≥ 34 weeks gestation. PPV was provided with a T-piece device with a PIP of 30 cmH2O and positive end-expiratory airway pressure of 5 cmH2O. Expired tidal volumes (Vt) were measured with a respiratory function monitor. Target range for Vt was defined to be 4 – 8 ml/kg.ResultsTwenty-three infants with a median (IQR) gestational age of 38.1 (36.4 – 39.0) weeks received 1828 inflations with a median Vt of 4.6 (3.3 – 6.2) ml/kg. Median Vt was in the target range in 12 infants (52%), lower in 9 (39%) and higher in 2 (9%). Thirty-six (25—27) % of the inflations were in the target rage over the duration of PPV while 42 (25 – 65) % and 10 (3 – 33) % were above and below target range.ConclusionsVariability of expiratory tidal volume delivered to term and late preterm infants was wide. Reliance on standard pressures and clinical signs may be insufficient to provide safe and effective ventilation in the delivery room.Trial registrationThis is a secondary analysis of a prospectively registered randomized controlled trial (ACTRN12616000768493).

Impact of immediate and continuous heart rate feedback by dry electrode ECG on time to initiation of ventilation after birth: protocol for a randomised controlled trial

Introduction3%–8% of newborns need positive pressure ventilation (PPV) after birth. Heart rate (HR) is considered the most sensitive indicator of the newborns’ condition and response to resuscitative interventions. According to...

Supraglottic Airways, Tennis, and Neonatal Resuscitation.

Supraglottic Airways, Tennis, and Neonatal Resuscitation.

Complications associated with long-term positive-pressure ventilation in dogs and cats: 67 cases.

To determine the complications associated with positive-pressure ventilation (PPV) in dogs and cats. Retrospective study from October 2009 to September 2013. University Teaching Hospital. Fifty-eight dogs and 9 cats. Medical records were retrospectively reviewed; signalment, complications associated with PPV, duration of PPV, and outcome were recorded. Complications most commonly recorded during PPV included hypothermia 41/67 (61%), hypotension 39/67 (58%), cardiac arrhythmias 33/67 (49%), a positive fluid balance 31/67 (46%), oral lesions 25/67 (37%), and corneal ulcerations 24/67 (36%). A definition of ventilator-associated events (VAE) extrapolated from the Center of Disease Control's criteria was applied to 21 cases that received PPV for at least 4 days in this study. Ventilator-associated conditions occurred in 5 of 21 (24%) of cases with infection-related ventilator-associated conditions and ventilator-associated pneumonia identified in 3 of 21 (14%) cases. Complications are common and diverse in dogs and cats receiving long-term PPV and emphasizes the importance of intensive, continuous patient monitoring and appropriate nursing care protocols. Many of the complications identified could be serious without intervention and suggests that appropriate equipment alarms could improve patient safety. Development of veterinary specific surveillance tools such as the VAE criteria would aid future investigations and allow for effective multicenter studies.

Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study.

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS.Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy.Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0–8.5] h vs. 1.0 [0.5–2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0–5.0] days vs. 2.0 [1.0–2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0–33.0] days vs. 9.0 [5.0–15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy.Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.

Lung histopathologic clusters in severe COVID-19: a link between clinical picture and tissue damage

BackgroundAutoptic pulmonary findings have been described in severe COVID-19 patients, but evidence regarding the correlation between clinical picture and lung histopathologic patterns is still weak.MethodsThis was a retrospective cohort observational study conducted at the referral center for infectious diseases in northern Italy. Full lung autoptic findings and clinical data of patients who died from COVID-19 were analyzed. Lung histopathologic patterns were scored according to the extent of tissue damage. To consider coexisting histopathologic patterns, hierarchical clustering of histopathologic findings was applied.ResultsWhole pulmonary examination was available in 75 out of 92 full autopsies. Forty-eight hospitalized patients (64%), 44 from ICU and four from the medical ward, had complete clinical data. The histopathologic patterns had a time-dependent distribution with considerable overlap among patterns. Duration of positive-pressure ventilation (p < 0.0001), mean positive end-expiratory pressure (PEEP) (p = 0.007), worst serum albumin (p = 0.017), interleukin 6 (p = 0.047), and kidney SOFA (p = 0.001) differed among histopathologic clusters. The amount of PEEP for long-lasting ventilatory treatment was associated with the cluster showing the largest areas of early and late proliferative diffuse alveolar damage. No pharmacologic interventions or comorbidities affected the lung histopathology.ConclusionsOur study draws a comprehensive link between the clinical and pulmonary histopathologic findings in a large cohort of COVID-19 patients. These results highlight that the positive end-expiratory pressures and the duration of the ventilatory treatment correlate with lung histopathologic patterns, providing new clues to the knowledge of the pathophysiology of severe SARS-CoV-2 pneumonia.

Electrocardiogram for heart rate evaluation during preterm resuscitation at birth: a randomized trial.

BackgroundAlthough electrocardiogram (ECG) can detect heart rate (HR) faster compared to pulse oximetry, it remains unknown if routine use of ECG for delivery room (DR) resuscitation reduces the time to stabilization in preterm infants.MethodsNeonates <31 weeks’ gestation were randomized to either an ECG-displayed or an ECG-blinded HR assessment in the DR. HR, oxygen saturation, resuscitation interventions, and clinical outcomes were compared.ResultsDuring the study period, 51 neonates were enrolled. The mean gestational age in both groups was 28 ± 2 weeks. The time to stabilization, defined as the time from birth to achieve HR ≥100 b.p.m., as well as oxygen saturation within goal range, was not different between the ECG-displayed and the ECG-blinded groups [360 (269, 435) vs 345 (240, 475) s, p = 1.00]. There was also no difference in the time to HR ≥100 b.p.m. [100 (75, 228) vs 138 (88, 220) s, p = 0.40] or duration of positive pressure ventilation (PPV) [345 (120, 558) vs 196 (150, 273) s, p = 0.36]. Clinical outcomes were also similar between groups.ConclusionsAlthough feasible and safe, the use of ECG in the DR during preterm resuscitation did not reduce time to stabilization.Impact Although feasible and apparently safe, routine use of the ECG in the DR did not decrease time to HR >100 b.p.m., time to stabilization, or use of resuscitation interventions such as PPV for preterm infants <31 weeks’ gestational age.This article adds to the limited randomized controlled trial evidence regarding the impact of routine use of ECG during preterm resuscitation on DR clinical outcomes.Such evidence is important when considering recommendations for routine use of the ECG in the DR worldwide as such a recommendation comes with a significant cost burden.

Enteral lactoferrin supplementation for prevention of sepsis and necrotizing enterocolitis in preterm infants.

Lactoferrin, a normal component of human colostrum and milk, can enhance host defenses and may be effective for prevention of sepsis and necrotizing enterocolitis (NEC) in preterm neonates. To assess the safety and effectiveness of lactoferrin supplementation to enteral feeds for prevention of sepsis and NEC in preterm neonates. Secondarily, we assessed the effects of lactoferrin supplementation to enteral feeds on the duration of positive-pressure ventilation, development of chronic lung disease (CLD) or periventricular leukomalacia (PVL), length of hospital stay to discharge among survivors, and adverse neurological outcomes at two years of age or later. We used the standard search strategy of Cochrane Neonatal to update our search. We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 9), MEDLINE via PubMed (1966 to 20 January 2020), PREMEDLINE (1996 to 20 January 2020), Embase (1980 to 20 January 2020), and CINAHL (1982 to 20 January 2020). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials and quasi-randomized trials. In our search, we included randomized controlled trials (RCTs) evaluating enteral lactoferrin supplementation at any dose or duration to prevent sepsis or NEC in preterm neonates. We used the standard methods of Cochrane Neonatal and the GRADE approach to assess the certainty of evidence. Meta-analysis of data from twelve randomized controlled trials showed that lactoferrin supplementation to enteral feeds decreased late-onset sepsis (typical RR 0.82, 95% CI 0.74 to 0.91; typical RD -0.04, 95% CI, -0.06, -0.02; NNTB 25, 95% CI 17 to 50; 12 studies, 5425 participants, low-certainty evidence) and decreased length of hospital stay (MD -2.38, 95% CI, -4.67, -0.09; 3 studies, 1079 participants, low-certainty evidence). Sensitivity analysis including only good methodological certainty studies suggested a decrease in late-onset sepsis with enteral lactoferrin supplementation (typical RR 0.87, 95% CI, 0.78, 0.97; typical RD -0.03, 95% CI, -0.05, -0.0; 9 studies, 4702 participants, low-certainty evidence). There were no differences in NEC stage II or III (typical RR 1.10, 95% CI, 0.86, 1.41; typical RD -0.00, 95% CI, -0.02, 0.01; 7 studies, 4874 participants; low-certainty evidence) or 'all-cause mortality' (typical RR 0.90, 95% CI 0.69, 1.17; typical RD -0.00, 95% CI, -0.01, 0.01; 11 studies, 5510 participants; moderate-certainty evidence). One study reported no differences in neurodevelopmental testing by Mullen's or Bayley III at 24 months of age after enteral lactoferrin supplementation (one study, 292 participants, low-certainty evidence). Lactoferrin supplementation to enteral feeds with probiotics decreased late-onset sepsis (RR 0.25, 95% CI 0.14 to 0.46; RD -0.13, 95% CI -0.18 to -0.08; NNTB 8, 95% CI 6 to 13; 3 studies, 564 participants; low-certainty evidence) and NEC stage II or III (RR 0.04, 95% CI 0.00 to 0.62; RD -0.05, 95% CI -0.08 to -0.03; NNTB 20, 95% CI 12.5 to 33.3; 1 study, 496 participants; very low-certainty evidence), but not 'all-cause mortality' (very low-certainty evidence). Lactoferrin supplementation to enteral feeds with or without probiotics had no effect on CLD, duration of mechanical ventilation or threshold retinopathy of prematurity (low-certainty evidence). Investigators reported no adverse effects in the included studies. We found low-certainty evidence from studies of good methodological quality that lactoferrin supplementation of enteral feeds decreases late-onset sepsis but not NEC ≥ stage II or 'all cause mortality' or neurodevelopmental outcomes at 24 months of age in preterm infants without adverse effects. Low- to very low-certainty evidence suggests that lactoferrin supplementation of enteral feeds in combination with probiotics decreases late-onset sepsis and NEC ≥ stage II in preterm infants without adverse effects, however, there were few included studies of poor methodological quality. The presence of publication bias and small studies of poor methodology that may inflate the effect size make recommendations for clinical practice difficult.

Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study

ObjectivesTo determine the incidence and characteristics of resuscitative interventions at different gestational ages and short-term outcomes after resuscitation.Design, setting and patientsA prospective observational study in an unselected population at Stavanger...

Analysis of using of citicoline in term newborns during the acute period of hypoxic ischemic encephalopathy

Hypoxic ischemic encephalopathy occurs in 1.5 to 4 per 1,000 births in developed countries, and in as many as 26 per 1,000 live births in resource-limited settings. Therapeutic hypothermia significantly reduces the combined outcome of death or severe neurodevelopmental impairment from 65% to 40-50%. While the benefits of therapeutic hypothermia provide proof of concept that outcomes can be improved, additional pharmacological agents for neonatal neuroprotection for further improve outcomes of hypoxic ischemic encephalopathy are needed.Objective.To determine the potential neuroprotective influence of citicoline interm neonatesduring the acute period of hypoxic-ischemic encephalopathy.Materials and methods.A prospective, single-centered, randomized, controlled study of the citicolineimpact on acute period after perinatal hypoxia-ischemia performed in 205 full-term infant, were treated in the neonatal intensive care unit inbabiessustained of hypoxic ischemic encephalopathy in 2012-2017. Citicoline was administered basingon simple randomization in dose of 200 mg once daily intravenously for the first 5 days of treatment. Endpoints included indicators such as duration of positive pressure ventilation, total days of intensive care and the morbidity of cerebral leukomalacia, as well as frequency of the development of seizures. During all the days of the study, a standard neurosonography was performedtoevaluateresistant and pulsatile indexes in the anterior cerebral artery.Results.After randomization 31 babieswere collectedinthe groupof citicoline, remaining 174 infants were at the control group. The obtained data showed no significant differences between citicoline and control groupsin Doppler indexes on the first day of treatment, mean blood pressure, terms of extubation, and the total duration of respiratory support, both invasive and non-invasive. Interestingly, there was a significant difference on the 3rd day of treatment with the resistantindex (p=0.026) and pulsatile index (p = 0.036) measured in the anterior cerebral arteries. However, despite the more prognostic, more positive values in the citicoline group, this did not lead to a decrease in the incidence of cerebral leukomalacia, which was even lower in the control group (10.9% vs. 19.4%), but this difference was not reliable (p=0.186). On the other hand, we paid our attention to the higher frequency of the development of seizuresin the citicoline group on the 1st(p=0.005) and 2nd(p <0.001) and 3rd days of the study (p=0.003).Conclusions.Among term neonates the use of citicoline duringthe acute period of HIEdid not show neuroprotective properties.

Suction Mask vs Conventional Mask Ventilation in Term and Near-Term Infants in the Delivery Room: A Randomized Controlled Trial

To compare the suction mask, a new facemask that uses suction to create a seal between the mask and the infant's face, with a conventional soft, round silicone mask during positive pressure ventilation (PPV) in the delivery room in newborn infants >34 weeks of gestation. Single-center randomized controlled trial in the delivery room. The primary outcome was mask leak. Forty-five infants were studied at a median gestational age of 38.1 weeks (IQR, 36.4-39.0 weeks); 22 were randomized to the suction mask and 23 to the conventional mask. The suction mask did not reduce mask leak (49.9%; IQR, 11.0%-92.7%) compared with the conventional mask (30.5%; IQR, 10.6%-48.8%; P = .51). The suction mask delivered lower peak inspiratory pressure (27.2 cm H2O [IQR, 25.0-28.7 cm H2O] vs 30.4 cm H2O [IQR, 29.4-32.5 cm H2O]; P < .05) and lower positive end expiratory pressure (3.7 cm H2O [IQR, 3.1-4.5 cm H2O] vs 5.1 cm H2O [IQR, 4.2-5.7 cm H2O ]; P < .05). There was no difference in the duration of PPV or rates of intubation or admission to the neonatal intensive care unit. In 5 infants (23%), the clinician switched from the suction to the conventional mask, 2 owing to intermittently low peak inspiratory pressure, 2 owing to failure to respond to PPV, and 1 owing to marked facial bruising after 6 minutes of PPV. The use of the suction mask to provide PPV in newborn infants did not reduce facemask leak. Adverse effects such as the inability to achieve the set pressures and transient skin discoloration are concerning. Australian and New Zealand Clinical Trial Registry ACTRN12616000768493.

Enteral lactoferrin supplementation for prevention of sepsis and necrotizing enterocolitis in preterm infants.

Lactoferrin, a normal component of human colostrum and milk, can enhance host defenses and may be effective for prevention of sepsis and necrotizing enterocolitis (NEC) in preterm neonates. Primary objective 1. To assess the safety and effectiveness of lactoferrin supplementation to enteral feeds for prevention of sepsis and NEC in preterm neonates Secondary objectives 1. To determine the effects of lactoferrin supplementation to enteral feeds to prevent neonatal sepsis and/or NEC on duration of positive-pressure ventilation, development of chronic lung disease (CLD) or periventricular leukomalacia (PVL), length of hospital stay to discharge among survivors, and adverse neurological outcomes at two years of age or later2. To determine the adverse effects of lactoferrin supplementation for prophylaxis of neonatal sepsis and/or NECWhen data were available, we analyzed the following subgroups.1. Gestational age < 32 weeks and 32 to 36 weeks2. Birth weight < 1000 g (extremely low birth weight (ELBW) infants) and birth weight < 1500 g (very low birth weight (VLBW) infants)3. Type of feeding: breast milk versus formula milk SEARCH METHODS: We used the search strategy of the Cochrane Neonatal Review Group (CNRG) to update our search in December 2016. We searched the databases Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PREMEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL), as well as trial registries and conference proceedings. Randomized controlled trials (RCTs) evaluating oral lactoferrin at any dose or duration to prevent sepsis or NEC in preterm neonates. Review authors used standard methods of the CNRG. This review includes six RCTs. Trial results show that lactoferrin supplementation to enteral feeds decreased late-onset sepsis (typical risk ratio (RR) 0.59, 95% confidence interval (CI) 0.40 to 0.87; typical risk difference (RD) -0.06, 95% CI -0.10 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) 17, 95% CI 10 to 50; six trials, 886 participants; low-quality evidence) and NEC stage II or III (typical RR 0.40, 95% CI 0.18 to 0.86; typical RD -0.04, 95% CI -0.06 to -0.01; NNTB 25, 95% CI 17 to 100; four studies, 750 participants; low-quality evidence). Lactoferrin supplementation did not have an effect on "all-cause mortality" (typical RR 0.65, 95% CI 0.37 to 1.11; typical RD -0.02, 95% CI -0.05 to 0; six studies, 1041 participants; low-quality evidence).Lactoferrin supplementation to enteral feeds with probiotics decreased late-onset sepsis (RR 0.27, 95% CI 0.12 to 0.60; RD -0.13, 95% CI -0.19 to -0.06; NNTB 8, 95% CI 5 to 17; one study, 321 participants; low-quality evidence) and NEC stage II or III (RR 0.04, 95% CI 0.00 to 0.62; RD -0.05, 95% CI -0.08 to -0.03; NNTB 20, 95% CI 12.5 to 33.3; one study, 496 participants; low-quality evidence), but not "all-cause mortality" (low-quality evidence).Lactoferrin supplementation to enteral feeds with or without probiotics decreased bacterial and fungal sepsis but not CLD or length of hospital stay (low-quality evidence). Investigators reported no adverse effects and did not evaluate long-term neurological outcomes and PVL. Evidence of low quality suggests that lactoferrin supplementation to enteral feeds with or without probiotics decreases late-onset sepsis and NEC stage II or III in preterm infants without adverse effects. Completed ongoing trials will provide data from more than 6000 preterm neonates, which may enhance the quality of the evidence. Clarification regarding optimal dosing regimens, types of lactoferrin (human or bovine), and long-term outcomes is needed.

The advantage of early plication in children diagnosed with diaphragm paresis

BackgroundIn this single-center study, we sought to determine the frequency of phrenic nerve injury leading to diaphragm paresis (DP) in children following open cardiac surgery over the last 10 years, and to identify possible variables that predict the need for plication and associated clinical outcomes. MethodsPatients diagnosed with DP were identified from departmental databases and a review of clinical diaphragm ultrasound images. A cohort was analyzed for predictors of diaphragm plication and associations with clinical outcomes. Cumulative proportion graphs modeled the association between plication and length of stay. ResultsDP was diagnosed in 161 of 6448 patients (2.5%) seen between January 2002 and December 2012. All diagnoses but 1 were confirmed by ultrasound. Plication of the diaphragm was performed in 30 patients (19%); compared with patients who did not undergo plication, these patients were younger (median age, 10 days vs 138 days; P < .001), more likely to have undergone deep hypothermic circulatory arrest (47% vs 18%; P = .005), had a longer duration of positive pressure ventilation (median, 15 days vs 7 days; P < .001), and had longer lengths of stay in both the intensive care unit (median, 23 days vs 8 days; P < .0001) and the hospital (median, 37 days vs 15 days; P < .0001). Early plication was associated with reduction in all intervals of care. ConclusionsEarly plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.

Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital

IntroductionThe Neonatal Resuscitation Program (NRP) guidelines recommend positive pressure ventilation (PPV) in the first 60s of life to support perinatal transition in non-breathing newborns. Our aim was to describe the incidence and characteristics of newborn PPV using real-time observation in the delivery unit. MethodsProspective, observational, quality improvement study conducted at a tertiary academic hospital. Deliveries during randomized weekday/evening 8-h shifts were attended by a trained observer. Intervention data were recorded for all newborns with gestational age (GA) ≥34wks that received PPV. Descriptive summaries and Kruskal-Wallis test for continuous variables and Fisher’s exact test for categorical variables were used to compare characteristics. ResultsOf 1135 live deliveries directly observed over 18mos, 64 (6%) newborns with a mean GA 39±2wks received PPV: Median time from birth to warmer was 20s (IQR 15–22s); PPV was initiated within 60s of life in 29 (45%) and between 60 and 90s of life in 17 (27%). PPV duration was <120s in 38 (60%). Seven/21 (33%) newborns that received PPV after vaginal delivery were not pre-identified and resuscitation team was alerted after delivery. We found no association between PPV start time and duration of PPV (p=0.86). ConclusionWe observed that most (94%) term newborns spontaneously initiate respirations. In over half observed deliveries receiving PPV, time to initiation of PPV was greater than 60s (longer than recommended). Compliance with current NRP guidelines is difficult, and it’s not clear whether it is the recommendations or the training to achieve PPV recommendations that should be modified.

T-piece or self inflating bag for positive pressure ventilation during delivery room resuscitation: An RCT

ObjectiveTo compare the duration of positive pressure ventilation (PPV) during delivery room resuscitation in neonates resuscitated with self-inflating bag (SIB) and T-piece resuscitator (TPR). DesignRandomized control trial. SettingDelivery room and neonatal intensive care unit of a tertiary care center in northern India. PatientsConsecutively born neonates more than 26 weeks of gestation requiring PPV at birth. InterventionEligible neonates were randomized to two groups, SIB and TPR. Outcome measuresDuration of PPV, intubation rates in delivery room, incidence of respiratory distress, need for mechanical ventilation during first 48h and its duration, need for surfactant replacement therapy and mortality during NICU stay. ResultsFifty neonates received PPV with a SIB and 40 received PPV with a TPR. The mean (SD) birth weight and gestational age of neonates in SIB and TPR groups were 2264 (872) and 2065 (814)g; 35.1 (3.6) and 34.3 (3.7) weeks, respectively. The median (IQR) duration of PPV in delivery room was significantly less in TPR group as compared to SIB; 30 (30–60)s vs. 60 (30–90)s, respectively; (p<0.001). A higher proportion of neonates required delivery room intubation in SIB group as compared to TPR group (34% vs. 15%, p=0.04). In the TPR group, a higher proportion of neonates could be resuscitated with room air only (72.5% vs. 38%, p=0.001). Other outcomes were comparable in the two groups. Similar findings were observed in neonates <34 weeks, except that fewer neonates resuscitated with TPR required invasive ventilation (31.6% vs. 77.8%, p=0.008). ConclusionUse of TPR during delivery room resuscitation resulted in shorter duration of PPV and lesser rates of intubation as compared to SIB. More infants in this group could be resuscitated with room air only (CTRI/2010/091/002946).

Outcome of positive-pressure ventilation in dogs and cats with congestive heart failure: 16 cases (1992-2012).

To describe the indications, duration of ventilation, underlying cardiac diseases, and outcome of dogs and cats undergoing positive-pressure ventilation (PPV) for treatment of congestive heart failure (CHF). Two-site retrospective study (1992-2012). Two university small animal teaching hospitals. Six cats and 10 dogs undergoing PPV for CHF. None. Medical records were searched to identify patients requiring PPV for treatment of pulmonary edema secondary to CHF. Sixteen animals fulfilled these criteria. Patient signalment, duration of PPV, underlying cardiac disease, arterial or venous blood gas values, pharmacologic therapy before, during, and after PPV, anesthetic drugs, complications, and outcome were recorded. Overall survival to discharge was 62.5% (10/16). Mean (±SD) duration of PPV was 30.8 ± 21.3 hours and average time from presentation for CHF to initiation of PPV was 5.9 ± 6.4 hours. Azotemia at the time of initiation of ventilation, development of anuria or oliguria, and use of pentobarbital for anesthesia were negatively associated with survival (P = 0.011, P = 0.036, and P = 0.036, respectively). Survival-to-discharge rate was 77% (10/13) for patients treated after 2005 and those not receiving pentobarbital. There was no significant effect attributed to age, sex, weight, species, nature of heart disease, furosemide dose, length of ventilation, use of vasopressors, first-time CHF events, or plasma lactate concentration on survival to discharge. Dogs and cats requiring PPV for CHF have a good overall prognosis for hospital discharge and require PPV for a relatively short duration. Azotemia, oliguria or anuria, and the use of pentobarbital are negatively associated with outcome.

Laryngeal Mask Airway as Primary Mode in Neonatal Resuscitation –Does it Reduce Need of Positive Pressure Ventilation?

In neonatal resuscitation, Laryngeal Mask Airway (LMA) is usually recommended as an alternate airway when endotracheal intubation is not possible. However, it can be used to give positive pressure breaths in place of Bag and Mask (BM) and may even be easier to use than the latter. A study was undertaken to determine if the use of LMA as a primary mode of giving positive pressure breaths decreased the duration of positive pressure ventilation in neonates requiring resuscitation in delivery room. Methodology: 67 babies > 36 weeks and > 2000 gms requiring resuscitation at birth were quasi-randomized into two groups - BM or LMA - as the primary mode of administering positive pressure breaths. Resuscitation was as per standard protocols. 6 trained Resident doctors in their 2 nd or 3 rd year of residency performed the resuscitation in all cases. Primary outcomes were required for positive pressure ventilation in the first 5 minutes and for endotracheal intubation. Secondary outcomes were the duration of hospital stay and mortality. Results : Birth weight and gestational age were similar in both groups. Requirement of positive pressure ventilation (in seconds) in the first 5 minutes was less in the LMA group (95.31 (23.22) vs. 180.86 (37.83) secs), as was the number of babies who needed endotracheal intubation (5/32 vs. 12/35). There was no difference in the duration of hospital stay or mortality in the two groups. There were no complications noted with the use of LMA. Conclusion: LMA is safe and efficacious in neonatal resuscitation and appears to decrease the duration of resuscitation.

Outcomes of tracheostomy following congenital heart surgery: a contemporary experience.

Following congenital heart surgery, pediatric patients may experience persistent respiratory failure that requires tracheostomy placement. Currently, definitive knowledge of the optimal timing for tracheostomy placement in this patient population is lacking. An 8-year retrospective review of 17 pediatric patients who underwent congenital heart surgery and subsequently required tracheostomy placement was performed. Patients were evaluated with regard to the timing of tracheostomy and mortality. The overall study mortality was 24%. The median duration of intubation prior to tracheostomy was 60 days (interquartile range: 19-90 days); there was no difference in the average time between intubation and tracheostomy for survivors compared with nonsurvivors (51 vs. 73 days, P = .37). No difference was observed in the overall duration of positive pressure ventilation when tracheostomy was performed within 30 days of intubation compared with greater than 30 days following intubation (481 vs. 451 days, P = .88). Overall, 18% of patients were successfully weaned from the ventilator after a median duration of positive pressure ventilation of 212 days. The timing of tracheostomy placement may be an important factor in clinical outcomes for pediatric patients with persistent dependence on mechanical ventilatory support following congenital heart surgery. A larger, multi-institution study may help further elucidate our observed clinical findings in this patient population.