Neonatal Mechanical Ventilation Research Articles

Mammalian target of rapamycin inhibitors: A new-possible approach for in-utero medication therapy.

The mammalian/mechanistic target of rapamycin (mTOR) is a protein kinase that plays a crucial role in regulating cellular growth, metabolism, and survival. Although there is no absolute contraindication for the use of mTOR inhibitors during pregnancy, the specific fetal effects remain unknown. Available data from the past 2decades have examined the use of mTOR inhibitors during pregnancy in patients with solid organ transplantation, showing no clear link to fetal complications or structural abnormalities. Recently, a handful of case reports and series have described transplacental therapy of mTOR inhibitors to control symptomatic and complicated pathologies in the fetus. The effect of these agents includes a significant reduction in lesion size in the fetus and a reduced need for mechanical ventilation in neonates. In this context, we delve into the potential of mTOR inhibitors as in-utero therapy for fetal abnormalities, with a primary focus on lymphatic malformation (LM) and cardiac rhabdomyoma (CR). While preliminary reports underscore the efficacy of mTOR inhibitors for the treatment of fetal CR and fetal brain lesions associated with tuberous sclerosis complex, chylothorax, and LMs, additional investigation and clinical trials are essential to comprehensively assess the safety and efficacy of these medications.

A Flipped Classroom Pilot in Neonatal Mechanical Ventilation.

Pediatric residents frequently manage critically ill neonates but have limited systematic training in mechanical ventilation (MV). Competing demands, varying learner levels, and topic complexity contribute to inconsistent education. A blended learning approach may be ideally suited to achieve meaningful learning but has not been described for this topic and learner. To design, implement, and evaluate a flipped classroom for pediatric residents in neonatal MV. We used Kern's six-step framework for curricular development to create a flipped classroom curriculum in neonatal MV. Individual prework included interaction with six prerecorded animated whiteboard videos, while in-person learning occurred in small groups at the bedside of a ventilated infant. A mixed-methods evaluation included surveys, quantitative knowledge test scores (before, immediately after, and six months after course completion), and qualitative analysis of participant focus groups. Twenty-six learners participated in the curriculum. Mean knowledge test scores rose and were sustained after course completion (51% baseline, 82% immediate posttest, 90% retention; P < 0.001). Learners identified various design elements, technology affordances, and instructor factors as meaningful, and they identified unexpected impacts of the curriculum beyond knowledge acquisition, including effects on professional identities, interdisciplinary communication skills, and contribution to the culture of safety. This curriculum aligned with resident roles, was meaningful to learners, and led to long-term increases in knowledge scores and access to quality education; flipped classroom design using meaningful learning theory and leveraging animated whiteboard technology may be a useful strategy for other highly complex topics in graduate medical education.

Use of Induction of Labor and Emergency Cesarean Section and Perinatal Outcomes in English Maternity Services: A National Hospital-level Study

(BJOG. 2022;129:1899–906) Maternity services vary widely worldwide. A recent independent review of the National Health Service (NHS) in England looked at what may have been avoidable harm during births between 2000 and 2019. The review found that cesarean delivery (CD) rates were discouraged and intentionally kept low. In response, this study aimed to determine if there was an association between induction of labor and emergency CD in English hospitals and an increased risk of stillbirth, use of neonatal mechanical ventilation in babies born at term, and admission to a neonatal intensive care unit (ICU).

Lung ultrasound score as a predictor of ventilator use in preterm infants with dyspnea within 24h after dhospitalization.

Selecting the correct ventilation strategy is crucial for the survival of preterm infants with dyspnea in NICU. Lung ultrasound score (LUSsc) is a potential predictor for respiratory support patterns in preterm infants. We prospectively included 857 preterm infants. LUS was performed in the first 2h after admission, and LUSsc was determined by two specialist sonographers. Participants were divided into two categories according to gestational age (<32+0 weeks and 32+0-36+6 weeks) and randomly divided into a training set and a validation set. There were two main outcomes: invasive and non-invasive respiratory support. In the training set, clinical factors were analyzed to find the best cut-off value of LUSsc, and consistency was verified in the verification set. The choice of invasive respiratory support was based on neonatal mechanical ventilation strategies. Preterm infants with invasive respiratory support had a higher LUSsc, greater use of Pulmonary Surfactant（PS）, and lower Oxygenation Index（OI）、birth weight than those with non-invasive support. In the <32+0 weeks group, the area under the curve (AUC) for the receiver operating characteristic curve plotted with 2-h LUSsc was 0.749 (95% CI: 0.689-0.809), the cut-off point of LUSsc was 8, and the sensitivity and specificity were 74.0% and 68.3%, respectively. In the 32+0-36+6 weeks group, the AUC was 0.863 (95% CI: 0.811-0.911), with a cut-off point of 7. Sensitivity and specificity were 75.3% and 0.836%, respectively. In the validation set, using the actual clinical respiratory support selection results for verification, the validation results showed for the <32+0 weeks group (Kappa value 0.660, P<0.05, McNemar test P>0.05) for preterm 32+0-36+6 weeks (Kappa value 0.779, P<0.05, McNemar test P>0.05). The LUSsc showed good reliability in predicting respiratory support mode for preterm infants with dyspnea. Registered at ClinicalTrials.gov (identifier: chiCTR1900023869).

Neonatal Mechanical Ventilation: Predictors of Mortality and Outcomes

Introduction: A large number of neonates in neonatal intensive care require mechanical ventilation and they have high fatality rate. Early identification of complications and factors influencing the outcome is important to improve the survival of ventilated neonates. Aims: To determine the predictors of fatality in ventilated neonates. Settings and Design: This prospective cohort study was conducted among the ventilated neonates in the department of Neonatal Intensive Care Unit (NICU), BSMMU. To identify factors affecting fatality clinical, biochemical and ventilator parameters were followed. The final outcome was recorded as “survivor” and “non-survivor” at discharged or death. Quantitative variables were compared by unpaired t-test; categorical variables were compared by chi-square test. To determine predictors of fatality, multivariate logistic regression analysis was performed. Results: A total 74 neonates were included, among them 23(31.1%) were survivors and 51(68.9%) were non-survivors. Mean gestational age (30.90 ± 5.20 weeks Vs 33.91 ± 2.52 weeks, p=0.010) and mean birth wt (1501 ± 623.38 g Vs 1873.04 ± 481.76 g, p=0.013) were significantly lower in non-survivor group. Shock (84.3% Vs 34.8%; p&lt;0.001), Pulmonary hemorrhage (15.7% Vs 0.00%; p=0.044), Acute kidney injury (58.8% Vs 30.4%; p=0.024), hyperglycemia (56.9% Vs 21.7%; p=0.005), hyponatremia (41.2% Vs 17.4%; p=0.045) were significantly higher in non-survivor group. Mean initial arterial pH (7.20 ± 0.117 Vs 7.31 ± 0.065; p&lt;0.001), highest PIP (16.51 ± 1.91 Vs 14.96 ± 1.33; p=0.001), highest FiO2 (0.93 ± 0.07 Vs 0.58 ± 0.083; p&lt;0.001), mean age of initiation of ventilation (8.53 ± 6.49 Vs 5.70 ± 4.15; p=027) were also significantly higher in non-survivor group then survivor group. Multivariate logistic regression analysis indicated the predictors of mortality were mean low birth weight (OR-0.997,95%CI0.995-1.00, p=0.00), AKI (OR-0.393,95% CI1.090-10.563, p=0.035), shock (OR-.507,95% CI 1.717-52.639,p=0.010), hyponatremia (OR-4.202, 95% CI 1.071-16.495, P=0.040), high FiO2 (OR-1.545, 95% CI 2.927-8.158, p=0.045) and high PIP (OR-2.122, 95% CI 1.273-3.537, p =0.004). Conclusion: The frequency of mortality in ventilated neonates was 68.9%. Low birth weight, shock, acute kidney injury, requirement of high PIP, high FiO2 and hyponatremia were associated with increased mortality.

Use of Induction of Labour and Emergency Cesarean Section and Perinatal Outcomes in English Maternity Services: A National Hospital-Level Study

ABSTRACT Care provided by maternity services requires a fine balance between support for the physiological process of birth and clinical intervention when needed. Yet, clinical guidelines for maternity care vary widely within and between countries. For singleton babies born at term in 149 hospitals of the National Health Service (NHS) in the United Kingdom alone, the rate of induction of labor varied from 16% to 44%, and the overall rate of cesarean delivery (CD) varied from 17% to 35% between April 2016 and March 2017. This suggests a lack of consensus around the indications for interventions, such as induction of labor and emergency CD. The debate often focuses on either the safety of childbirth or the women's experience to deliver good maternity care. The aim of this study was to examine the association between the rates of induction of labor and emergency CD with the risks of stillbirth, neonatal intensive care unit (NICU) admission, and need for mechanical ventilation in neonates born at term. This was a national study using data collected from electronic maternity records between 2015 and 2017. Included were singleton pregnancies delivered in NHS hospitals providing maternity care. The primary outcomes were stillbirth, NICU admission, and mechanical ventilation. The entire cohort included 1,131,719 term, singleton births in 131 hospitals. The risks of stillbirth, NICU admission, and need for mechanical ventilation in the baby were 0.15%, 5.4%, and 0.54%, respectively. Between hospitals, the rate of induction of labor ranged from 17.5% to 40.7% (interquartile range, 24.6%–32.1%), and the rate of emergency CD ranged from 5.6% to 17.1% (interquartile range, 9.4%–11.8%). In hospitals with higher induction rates, the risk of adverse perinatal outcomes was lower, but the association was statistically significant only between the rate of induction and rates of stillbirth (P = 0.002) and mechanical ventilation (P = 0.001). For each 5%-point increase in the rate of induction at a hospital, there was a 9% decrease in the risk of stillbirth (odds ratio [OR], 0.91; 95% confidence interval [CI], 3%–15%) and a 14% decrease in the risk of mechanical ventilation (OR, 0.86; 95% CI, 6%–21%). There was no association between the rate of emergency CD and the primary outcomes (all P &gt; 0.05). In the United Kingdom, the rates of induction of labor and emergency CD varied considerably between hospitals. Those hospitals with higher rates of induction had lower risks of adverse perinatal outcomes, but not for emergency CD.

Incidence of nasal trauma in nasal continuous positive airway pressure versus heated humidified high flow nasal cannula in neonates, our experience in Government Medical College Srinagar

Background: The nCPAP (nasal continuous positive airway pressure) is noninvasive mode of ventilation that decreases the need for mechanical ventilation in neonates. The newer device heated humidified high flow nasal cannula (HHHFNC) delivers heated (to body temperature, 37 °C) and humidified (near 100% relative humidity) gas at flow rates of more than 1 liter/min through small bi-nasal prongs, that is more physiological. Methods: This was a retrospective study conducted in neonatal intensive care unit. The eligible neonates who were put on HHHFNC or nCPAP depending upon the availability of any of these devices at the time of admission. The details regarding complications were recorded from the admission files of these patients from medical record section of the hospital. Results: There was no statistically significant difference in complications like shock, NEC, pulmonary air leak, apnea, PDA, ROP, IVH or PVL for nCPAP or HHHFNC. However, nasal trauma was present in 18 (18%) patients in nCPAP group but in no patient in HHHFNC. Conclusions: There is no significant differences in complication in nCPAP vs HHHFNC except nasal trauma which is more common in nCPAP.

Supporting all breaths versus supporting some breaths during synchronised mechanical ventilation in neonates: a systematic review and meta-analysis

BackgroundNational Institute for Health and Clinical Effectiveness (NICE), UK, guideline published in 2019 recommends the use of volume-targeted ventilation (VTV). It recommends synchronised intermittent mandatory ventilation (SIMV) over the modes...

Positive fluid balance and diuretic therapy are associated with mechanical ventilation and mortality in preterm neonates in the first fourteen postnatal days.

Fluid overload leads to poor neonatal outcomes. Diuretics may lower the rates of mechanical ventilation (MV) and mortality in neonates with fluid overload. This is a retrospective study of preterm neonates ≤ 36weeks of gestational age (GA) in the first 14 postnatal days in a level IV NICU in 2014-2020. We evaluated the epidemiology of fluid balance in the first 14 postnatal days and its association with MV and mortality and studied the association of diuretics with fluid balance, MV, and mortality. In 1383 included neonates, the overall median lowest and peak fluid balances were - 7.8% (IQR: - 11.7, - 4.6) and 8% (3, 16) on days 3 (2, 5) and 13 (5, 14), respectively. Fluid balance distribution varied significantly by GA. Peak fluid balance of ≥ 10% was associated with increased odds of MV on days 7 and 14 with highest odds ratios (OR) of MV in neonates with fluid balance ≥ 15%. Peak fluid balance of ≥ 15% was associated with the greatest odds of mortality. Diuretics were used more frequently in neonates with younger GA, smaller birthweight, positive fluid balance, and those on MV. Positive fluid balance negatively impacts pulmonary status. The odds of MV and death increase significantly as peak fluid balance percentage increases in all GA groups. The impact of diuretics on MV and death in preterm neonates needs further evaluation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Endotracheal Tube Cuffs for Neonates: Novel cuff design to minimise tracheal damage

Neonatal mechanical ventilation (MV) is complex and its efficiency is limited due to leakage of air around the endotracheal tube (ETT). Adult ETT cuffs cannot be used in neonatal patients to block reverse flow as they cause damage to delicate throat tissues. A novel design and testing method for a non-contact neonatal ETT cuff was developed and validated. The goal was to minimise cuff surface area and contact, while creating resistance to airflow using turbulence to reduce ventilator leakage and increase efficacy of treatment for neonatal patients. Several cuff designs were generated based on testing results. Cuffs were tested using flow visualisation methods to assess leak performance in a fluid dynamically scaled experimental test setup. Final cuff designs utilised successful elements from several cuff design iterations. Overall, leakage was reduced by an average of 77.8% from an uncuffed baseline. By increasing the efficacy of healthcare solutions for neonatal patients it is hoped the burden on New Zealand's NICUs will be reduced, and quality of care increased to improve overall patient outcomes.

The Role of Postoperative Mechanical Ventilation in Neonates with Tracheoesophageal Fistula

Background: Many advances have been made in managing neonates with esophageal atresia/tracheoesophageal fistula (EA/TEF). This resulted in a progressive decrease in mortality as a result of improved neonatal intensive care and neonatal mechanical ventilation; however, this is not the case in developing countries. Objectives: We aimed to evaluate the efficacy of postoperative ventilation in neonates with EA/TEF in Iraq as a developing country. Materials and Methods: It is a prospective study for all neonates with EA and/or TEF admitted to the pediatric intensive care unit (PICU) in Alkhansaa Teaching Hospital between December 2012 to December 2014. Forty operated neonates were randomly divided into two groups according to the record number of presentations (even = G1, odd = G2): Twenty patients (group l) had been assigned to be post-operatively on a ventilator as a routine protocol. While group 2 planned to be extubated in the theater. We evaluated the complications and mortality rates in two groups. Results: For 24 months, 40 neonates with EA/TEF were admitted to PICU; Thirty-two were operated on within 24 hours of life. There were no significant differences between the two groups regarding fetal maturity (p-value 0.490), gender, and weight. The mean period for mechanical ventilation was four days. Six neonates had tube mal-positioning complications, leading to lung collapse, hypoxia, and pneumonia (p-value 0.250). Anastomotic leaks occur in 10 neonates (five in each group) (p-value 0.642), which sometimes leads to sepsis (p-value 0.347). Trachea-malacia was recorded after weaning in 5 intubated patients (p-value 0.078). The mortality rate in G1 was 35%, while in group 2 was 25% (p-value 0.366). Conclusions: Although the study’s sample is small, it is recommended to avoid mechanical ventilation in the postoperative care of neonates with EA and/or TEF.

Effect of Invasive Mechanical Ventilation at Birth on Lung Function Later in Childhood.

BackgroundDespite recent neonatal care improvements, mechanical ventilation still remains a major cause of lung injury and inflammation. There is growing literature on short- and long-term respiratory outcomes in infants born prematurely in the post-surfactant era, but the exclusive role of mechanical ventilation at birth in lung function impairment is still unclear. The aim of this study was to assess the effect of neonatal mechanical ventilation on lung function parameters in children born ≤ 32 weeks of gestational age at 11 years of age.Materials and MethodsIn total, 55 ex-preterm children born between January 1, 2006 and December 31, 2007 were enrolled at 11 years of age. Neonatal information was obtained from medical records. Information about family and personal clinical history was collected by questionnaires. At 11 years of age, we measured spirometry parameters, lung volumes, diffusing lung capacity, and fractional exhaled nitric oxide. In addition, an allergy evaluation by skin prick test and eosinophil blood count were performed. A multivariable linear or logistic regression analysis was performed to examine the associations of mechanical ventilation with respiratory outcomes, adjusting for confounders (maternal smoking during pregnancy, gestational age, surfactant replacement therapy, and BMI).ResultsNo difference in lung function evaluation between ventilated and unventilated children were found. No association was also found between mechanical ventilation with lung function parameters.ConclusionMechanical ventilation for a short period at birth in preterm children was not associated with lung function impairment at 11 years of age in our study sample. It remains to define if ventilation may have a short-term effect on lung function, not evident at 11 years of age.

Risk factors for prolonged mechanical ventilation in neonates following gastrointestinal surgery.

BackgroundProlonged mechanical ventilation (MV) should be avoided in neonates. Noninvasive ventilation (NIV) can facilitate weaning from MV but has risks for patients immediately following foregut surgery due to the potential risk of anastomotic leak. We evaluated the risk factors for prolonged MV following intestinal surgery in neonates.MethodsWe retrospectively reviewed 253 neonates undergoing intestinal surgery in 2017-2018 to identify risk factors for prolonged MV, and determine the correlation between NIV and anastomotic leak in a tertiary neonatal intensive care unit that performs the greatest number of neonatal surgeries in Ontario.ResultsThe most common diagnoses were necrotizing enterocolitis/spontaneous intestinal perforation (NEC/SIP) 21%, intestinal atresia 16%, esophageal atresia/tracheoesophageal fistula 14%, ano-rectal malformation 13%, malrotation/volvulus 11%, gastroschisis 9% and omphalocele 4%. The median (IQR) duration of MV post-surgery was 3 (1–8) days with 25.7 % (n=65) of neonates on MV for >7 days. Compared to infants on MV post-surgery for ≤7 days, those with MV>7 days were of lower gestational age, birth weight and weight at surgery, but a higher proportion underwent stoma creation, had a longer duration of opioid administration and higher rates of moderate to severe bronchopulmonary dysplasia (BPD) and mortality (P<0.05). Generalized linear regression analysis showed lower gestational age (GA) and longer opioid administration were associated with longer duration of MV (P<0.001), but indication for surgery, weight at surgery and stoma creation didn’t correlate with longer duration of MV (P>0.05). Of the 122 patients handled by one-stage resection with primary anastomosis, 22.1% (n=27) received NIV with 74.1% (n=20) commenced on NIV after 7 days post-surgery, anastomotic leak was detected in 2.5 % (3/122) patients and didn’t correlate with NIV.ConclusionsLower GA and longer opioid administration were risk factors for prolonged MV in neonates following intestinal surgery. Further research is needed to investigate modifiable practices around pain assessment/ventilation in these patients, and the correlation between NIV and anastomotic leak.

Lung ultrasound guided pulmonary recruitment during mechanical ventilation in neonates: A case series.

Recently, the first report of lung ultrasound (LUS) guided recruitment during open lung ventilation in neonates has been published. LUS guided recruitment can change the approach to open lung ventilation, which is currently performed without any measure of lung function/lung expansion in the neonatal population. We included all the newborn infants that underwent a LUS-guided recruitment maneuver during mechanical ventilation as a rescue attempt for an extremely severe respiratory condition with oxygen saturation/fraction of inspired oxygen (SpO2/FIO2) ratio below 130 or the inability to wean off mechanical ventilation. We report a case series describing 4 LUS guided recruitment maneuvers, underlying crucial aspects of this technique that can improve the effectiveness of the procedure. In particular, we describe a novel pattern (the S-pattern) that allows us to distinguish the recruitable from the unrecruitable lung and guide the pressure titration phase. Additionally, we describe the optimal LUS-guided patient positioning. We believe that the inclusion of specifications regarding patient positioning and the S-pattern in the LUS-guided protocol may be beneficial for the success of the procedure.

Ventilation-induced epithelial injury drives biological onset of lung trauma in vitro and is mitigated with prophylactic anti-inflammatory therapeutics.

Mortality rates among patients suffering from acute respiratory failure remain perplexingly high despite the maintenance of blood oxygen homeostasis during ventilatory support. The biotrauma hypothesis advocates that mechanical forces from invasive ventilation trigger immunological mediators that spread systemically. Yet, how these forces elicit an immune response remains unclear. Here, a biomimetic in vitro three‐dimensional (3D) upper airways model allows to recapitulate lung injury and immune responses induced during invasive mechanical ventilation in neonates. Under such ventilatory support, flow‐induced stresses injure the bronchial epithelium of the intubated airways model and directly modulate epithelial cell inflammatory cytokine secretion associated with pulmonary injury. Fluorescence microscopy and biochemical analyses reveal site‐specific susceptibility to epithelial erosion in airways from jet‐flow impaction and are linked to increases in cell apoptosis and modulated secretions of cytokines IL‐6, ‐8, and ‐10. In an effort to mitigate the onset of biotrauma, prophylactic pharmacological treatment with Montelukast, a leukotriene receptor antagonist, reduces apoptosis and pro‐inflammatory signaling during invasive ventilation of the in vitro model. This 3D airway platform points to a previously overlooked origin of lung injury and showcases translational opportunities in preclinical pulmonary research toward protective therapies and improved protocols for patient care.

Use of lung ultrasound and and aEEG patterns to predict the need for mechanical ventilation and the readiness for extubation in neonates with respiratory distress

Objective. The aim of the study was to establish if lung ultrasound findings could anticipate the need for intubation and mechanical ventilation in neonates with respiratory distress and if lung ultrasound and aEEG criteria could be used in appreciation of the readiness for extubation of the neonatal patients resulting in a decrease of the rate of extubation failure. Material and method. There were analyzed the cases of 50 late preterm and early term neonates presenting with respiratory distress. Lung ultrasound was performed during the first 4 hours after delivery in all the neonates and then as clinically indicated in the case of ventilated patients. A lung ultrasound was performed in all the ventilated patients before extubation. 12 of the 25 ventilated patients were also monitored by aEEG. The decisions regarding the intubation and mechanical ventilation and the moment of extubation of the patients were taken by the clinicians in accordance with the local and international guidelines. The extubation failure was defined as the need to re-intubate the patient in the first 24 hours after the extubation. The lung ultrasound pattern was considered as normal if the image was consisting of A lines with rare B lines or ”double lung point” as in the case of the delayed absorption of fetal lung fluid and abnormal in the case of “white lung” appearance (coalescent B lines) or an image of consolidation. A normal aEEG was defined as the presence of a continuous normal voltage pattern with sleep-wake cycles present and an abnormal aEEG as either discontinuous normal voltage, burst-suppression, low voltage or flat background patterns. The lung ultrasound patterns in the first hours of life were compared between patients that needed intubation and those that did not need mechanical ventilation. The lung ultrasound and aEEG patterns before extubation were compared between the patients that did not need re-intubation and those with extubation failure. Results. An abnormal image on lung ultrasound was significantly associated with the risk of intubation (p &lt; 0.001) (sensitivity 84%, specificity 100%, positive predictive value 100% and negative predictive value 86.2%) An abnormal lung ultrasound pattern before extubation was associated with a significant risk of extubation failure (p &lt; 0.049) (sensitivity 75%, specificity 85%, positive predictive value 50%, negative predictive value 94.7%). In the case of the subset of patients in which aEEG was performed, an abnormal aEEG pattern was significantly associated with extubation failure (p &lt; 0.034) (sensitivity 100%, specificity 88%, positive predictive value 75%, negative predictive value 100%). In the case of association of the two parameters (lung ultrasound and aEEG pattern) there was again a statistically significant association between the abnormal patterns and extubation failure. Conclusions. An abnormal lung ultrasound during the first hours of life is a strong predictor for the need of intubation and mechanical ventilation in the neonates with respiratory distress. The normal lung ultrasound pattern just before extubation is predictive of a good evolution without the need for re-intubation of the patient. A normal aEEG pattern at the same time is associated also with a decreased risk of extubation failure.

Methylene Blue for the Treatment of COVID-19 in Pediatrics

Letter to the Editor Despite vaccination against SARS-CoV-2, the COVID-19 pandemic continues to expand worldwide. Early reports suggested that only a minor proportion of pediatric population is affected by COVID-19 in comparison to adult population. Three percent of pediatric population needed admission to intensive care units, and only a small number of deaths have been reported. Available literature suggests that infants (children under 1 year) seem to be more vulnerable to COVID-19 virus infection with a higher severity of illness compared with other pediatric ages. Requirement for neonatal mechanical ventilation is 20%–22.4% (vs. 4% in children). (1)

Neurodevelopmental Outcomes after Neonatal Mechanical Ventilation

Abstract Background A majority of extremely preterm infants are treated with mechanical ventilation, which is associated with an increased risk for future development of chronic lung disease, neonatal brain damage, and neurodevelopmental impairments. Objectives The aim of the current study was to evaluate the current and follow up neurodevelopmental status of an Egyptian sample of newly and previously discharged mechanically ventilated infants following them up for a period of 6 months for the earlier group and a year for the latter. Patients and Methods The current study was designed to be a descriptive study with retrospective (50 infants) and prospective (50 infants) domains. It was carried out on 100 neonates who were recruited from the Pediatric Neonatology Clinic, Children's Hospital and Neonatal Intensive Care Unit, Ain Shams University using clinical evaluation, Bayley Scales of Infant Development, and Childhood Autism Rating Scale (CARS).. Results There was statistically significant negative correlation between CARS score and Bayley Scale by using Composite Score (Cognitive, Language and Motor) on first assessment and follow up in the Prospective group while no correlation was found in the retrospective group. The study results showed that there was no statistical significant difference between two groups as regards gestational age, gender, residency, consanguinity, maternal disease, maturity, mode of delivery, respiratory distress, duration of stay in NICU, duration on mechanical ventilation, weight on admission, audiometry and fundus examination (P &amp;gt; 0.05). Conclusion Using a mechanical ventilator in the neonatal period for a prolonged duration increased the risk for ASD and neurodevelopmental delay. Future studies on large samples are recommended from multicenters to confirm the validity of such findings, Bayley scale is a predicative for neurodevelopmental delay in neonates with long duration stay at NICU especially preterms with low birth weight.

Long-Term Mechanical Ventilation in Neonates: A 10-Year Overview and Predictive Model.

Objectives: Significant resources are devoted to neonatal prolonged mechanical ventilation (NPMV), but little is known about the outcomes in those children. Our primary objective was to describe the NPMV respiratory, digestive, and neurological outcomes at 18 months corrected age. Our second objective was on the early identification of which patients, among the NPMV cohort, will need to be ventilated for ≥125 days, which corresponded to the 75th percentile in the preliminary data, and to describe that subgroup.Methods: In this retrospective cohort study, we included all children born between 2004 and 2013 who had a NPMV (≥21 days of invasive or noninvasive respiratory support reached between 40 and 44 weeks of postconceptional age). We used random forests, logistic regression with penalization, naive Bayes, and XGBoost to predict which patients will need ≥125 days of ventilation. We used a Monte Carlo cross validation.Results: We included 164 patients. Of which, 40% (n = 66) were female, and the median gestational age was 29 weeks [interquartile range (IQR): 26–36 weeks] with a bimodal distribution. Median ventilation days were 104 (IQR: 66–139 days). The most frequently associated diagnoses were pulmonary hypertension (43%), early pulmonary dysplasia (41%), and lobar emphysema (37%). At 18 months corrected age, 29% (n = 47) had died, 59% (n = 97) were free of any respiratory support, and 45% (n = 74) were exclusively orally fed. A moderate area under the ROC curve of 0.65 (95% CI: 0.54–0.72) for identifying patients in need of ≥125 days of ventilation at inclusion was achieved by random forests classifiers. Among the 26 measured at inclusion, the most contributive ones were PCO2, inspired O2 concentration, and gestational age. At 18 months corrected age, patients ventilated for ≥125 days had a lower respiratory weaning success (76 vs. 87%, P = 0.05), lower exclusive oral feeding proportion (51 vs. 84%, P < 0.001), and a higher neurological impairment (median Pediatric Cerebral Performance Category score 3 vs. 2, P = 0.008) than patients ventilated for < 125 days.Conclusion: NPMV is a severe condition with a high risk of mortality, neurological impairment, and oral feed delay at 18 months. Most survivors are weaned of any respiratory support. We identified the risk factors that allow for the early identification of the most at-risk children of long-term ventilation with a moderate discrimination.

Effect of muscle relaxants on the prognosis of neonates with congenital esophageal atresia-tracheoesophageal fistula after surgery

OBJECTIVE To summarize the experience in the application of muscle relaxants in the perioperative period in neonates with congenital esophageal atresia-tracheoesophageal fistula (EA-TEF). METHODS A retrospective analysis was performed on the medical data of 58 previously untreated neonates with EA-TEF who were treated in the Neonatal Center of Beijing Children's Hospital, Capital Medical University from 2017 to 2019. The incidence rate of anastomotic leak was compared between the neonates receiving muscle relaxants for different durations after surgery (≤ 5 days and > 5 days). The correlation between the duration of postoperative use of muscle relaxants and the duration of mechanical ventilation was evaluated. RESULTS Among the 58 neonates with EA-TEF, 44 underwent surgery, among whom 35 with type III EA-TEF underwent thoracoscopic surgery. Among these 35 neonates, 30 (86%) received muscle relaxants after surgery, with a median duration of 4.75 days, and 6 (18%) experienced anastomotic leak. There was no significant difference in the incidence rate of anastomosis leak between the ≤ 5 days and > 5 days groups (P > 0.05). The duration of postoperative invasive mechanical ventilation was positively correlated with the duration of the use of muscle relaxants (rs=0.548, P < 0.05). CONCLUSIONS Prolonged use of muscle relaxants after surgery cannot significantly reduce the incidence of anastomotic leak, but can prolong the duration of invasive mechanical ventilation in neonates with EA-TEF. Therefore, prolonged use of muscle relaxants is not recommended after surgery.