Positive Pressure Ventilation Group Research Articles

Individualized dynamic PEEP (dynPEEP) vs. positive pressure ventilation in delivery room management: A retrospective cohort study.

Although nasal continuous positive airway pressure (nCPAP) is recommended in delivery room (DR) management for preterm infants, the effect of delivering nCPAP at 6-8 cmH2O is not satisfactory. Therefore, we conducted this retrospective cohort study to compare the effects of individualized dynamic positive end-expiratory pressure (dynPEEP) vs. positive pressure ventilation (PPV) in the DR on clinical outcomes. Preterm infants with a gestational age (GA) less than 30 weeks who received PPV (peak inspiratory pressure, PIP/PEEP 15-25/6-8 cmH2O) from August 2018 to July 2020 were included as Cohort 1 (PPV group, n = 55), and those who received dynPEEP (nCPAP 8-15 cmH2O) from June 2020 to April 2022 were included as Cohort 2 (dynPEEP group, n = 62). Primary outcomes included the DR intubation rate and the bronchopulmonary dysplasia (BPD) rate. The secondary outcomes included DR stabilization, transfer, admission, respiratory function, and other outcomes. The percentage of singleton infants was higher in the PPV group (63.6%) than in the dynPEEP group (22.6%, p = 0.000). The DR intubation and chest compression rates were higher in the PPV group (80.0% and 18.2%, respectively) than in the dynPEEP group (45.2%, p = 0.000; 3.0%, p = 0.008, respectively). The percentage of patients with 5-min Apgar scores < 5 was higher in the PPV group (9.1%) than in the dynPEEP group (0%, p = 0.016). The partial pressure of carbon dioxide was lower in the PPV group (49.77 ± 11.28) than in the dynPEEP group (56.44 ± 13.17, p = 0.004), and lactate levels were higher in the PPV group (3.60 (2.10, 5.90)) than in the dynPEEP group (2.25 (1.38, 3.33), p = 0.002). No significant differences in the BPD rate or other secondary outcomes were noted. In this retrospective cohort study, the dynPEEP strategy reduced the need for DR intubation compared with PPV. The dynPEEP strategy is feasible and potentially represents an alternative respiratory strategy to PPV. Nevertheless, a randomized control trial is needed to evaluate the dynPEEP strategy.

The long-term outcomes of preterm infants receiving non-invasive high-frequency oscillatory ventilation.

ObjectiveTo investigate the clinical outcomes of preterm infants who received non-invasive high-frequency oscillatory ventilation following extubation in a neonatal intensive care unit.MethodsInfants born between 25 and 34 weeks of gestation with a birth weight of <1,500 g, who were admitted into the neonatal intensive care unit of Guangxi Maternal and Child Health Hospital, Nanning, Guangxi, China, requiring mechanical ventilation on admission were randomized to the non-invasive high-frequency ventilation group, nasal intermittent positive pressure ventilation group, or nasal continuous positive airway pressure group following extubation. Their respiratory and neurodevelopmental outcomes were assessed at 12 and 24 months of corrected age.ResultsAmong 149 preterm infants who underwent randomization, 139 completed their treatment in the neonatal intensive care unit (45, 47, 47 in the non-invasive high-frequency ventilation group, nasal intermittent positive pressure ventilation group, or nasal continuous positive airway pressure group, respectively), 113 were assessed at 12-month corrected age, and 110 of 113 were assessed again at 24-month corrected age. There were no differences in the number of times bronchitis, pneumonia, wheezing episodes, and re-hospitalization rates appeared due to respiratory diseases among the three groups (P > 0.05); the pulmonary function tests at 12-month corrected age showed respiratory rate, tidal volume, inspiratory time/expiratory time, time to peak expiratory flow/expiratory time, volume at peak expiratory flow/expiratory volume, expiratory flow at 25, 50, and 75% tidal volume were all similar among infants from the 3 groups (P > 0.05). There were no differences in the rates of neurodevelopmental impairment among the three groups at 24-month corrected age (P > 0.05).ConclusionAs post-extubation respiratory support in preterm infants, non-invasive high-frequency ventilation did not increase the rates of long-term respiratory morbidities and neurodevelopmental impairment compared with nasal intermittent positive pressure ventilation and nasal continuous positive airway pressure.

Placental Findings in Infants with Hypoxic-Ischemic Encephalopathy: The Importance of the Comparison Group

To determine the effect of 3 distinct comparison groups on associations between placental abnormalities and neonatal hypoxic-ischemic encephalopathy (HIE). This single-center, prospective case-control study of singletons of gestational age ≥36weeks with predefined criteria for HIE (n=30) and 3 control groups was conducted from June 2015 to January 2018. The control groups were infants born by repeat cesarean delivery (n=60), infants born small for gestational age (SGA; n=80), and infants receiving positive-pressure ventilation (PPV) at birth (n=70). One pathologist blinded to infant category reviewed placental sections using the Amsterdam Placental Workshop criteria. Logistic regression with group contrasts relative to HIE was used to analyze primary placental pathologies, and ORs with 95% CIs provided effect sizes. The odds of maternal vascular malperfusion were increased among HIE group placentas compared with placentas of the repeat cesarean delivery (OR, 4.50; 95% CI, 1.45-14.00) and PPV (3.88; 1.35-11.16) groups, but not those of the SGA group. The odds of fetal vascular malperfusion were increased in the HIE group compared with the SGA group (OR, 9.75; 95% CI, 1.85-51.51). The odds of acute chorioamnionitis were higher in the HIE group compared only with the repeat cesarean delivery group, reflecting a similar incidence of chorioamnionitis in SGA group and PPV group placentas. The absence of placental findings was lowest in the HIE group (6.7%), followed by the SGA (18.8%), PPV (31.4%), and repeat cesarean delivery (75%) groups. Associations with placental abnormalities among infants with HIE varied based on the specific placental abnormality and the control group. Potentially important associations between placental pathology and HIE may be obscured if control groups are not well designed.

Application of high frequency jet ventilation system in laryngopharyngeal and tracheal surgery

Objective:The effectiveness and safety of high frequency ventilation system in laryngopharyngeal and tracheal surgery is discussed. Methods:According to The American Society of Anesthesiologists Ⅰ-Ⅱ level, 60 cases of selective throat and tracheal surgery undering general anesthesia were randomly divided into high frequency jet ventilation group （group HFJV） and intermittent positive pressure ventilation group （IPPV group）, with 30 cases in each group. Group HFJV was treated with HFJV and group IPPV with a small caliber endotracheal tube connected to an anesthesia machine was treated with IPPV.Before anesthesia （T0）, after the success of the laryngoscope placed （T1）, 5 minites after ventilation （T2） and 5 minites after the laryngoscope removed （T3）, hemodynamic parameters were recorded at each time point , in T0, T2 and T3 record , arterial blood gas index, the patient's airway pressure, end-expiratory carbon dioxide concentration, surgical field quality and total blood loss, operating time and awakening time were recorded and compared between the two groups. Results:The average airway pressure and intraoperative average total blood loss of group HFJV were significantly lower than that of group IPPV（P<0.01）, and the average operative field quality of group HFJV was significantly better（P<0.01）, but there was no statistical significance in the effects on hemodynamics, arterial blood gas and other indicators compared with group IPPV（P>0.05）. No serious adverse events occurred in 2 groups. Conclusion:HFJV system can be used effectively in laryngopharyngeal and tracheal surgery, reducing intraoperative blood loss and improving surgical field of vision without obvious adverse reactions.

Noninvasive High-Frequency Shock Ventilation Based on Chest X-Ray Reconstruction Algorithm for Neonatal Respiratory Distress Syndrome

Objective. To explore the use of the noninvasive high-frequency oscillatory ventilation and CPAP ventilation mode in the treatment of neonatal respiratory distress syndrome and to compare the treatment effect and the incidence of complications and whether it can reduce the time to go to the hospital and the number of hospital stays. Methods. Seventy-four children with RDS treated in hospital were selected and divided into the noninvasive high-frequency group (NHFV group, 36 children) and noninvasive positive pressure ventilation group (NCPAP group, 38 cases), and they were compared with the changes in arterial blood gas, the occurrence of complications, and the time on the machine before and after the operation on 12, 24, 48, and 72 hours. Results. In the NHFV group, PO2, a/APO2, and SaO2 were higher than those in the NCPAP group at 12, 24, 48, and 72 h after the respiratory support was given, and the differences were statistically significant (all P &lt; 0.05 ). PaCO2 in the NHFV group was given respiratory support. After support, the results at 12, 24, 48, and 72 h were lower than those in the NCPAP group, and the difference was statistically significant (both P &lt; 0.05 ). The children in both groups were cured and discharged from the hospital, with air leakage, persistent pulmonary hypertension, and bronchopulmonary dysplasia; there were no statistically significant differences in the incidence of complications such as retinopathy, pulmonary hemorrhage, and intracranial hemorrhage ( P &gt; 0.05 ). The NHFV group had less tracheal intubation, operation time, and hospital stays than the NCPAP group. The differences were significant. Statistical significance was at P &lt; 0.05 . Conclusion. Noninvasive high-frequency ventilation is effective in the treatment of RDS, and compared with the CPAP ventilation mode, it can reduce CO2 retention, increase the oxygenation index, and reduce time of operation and length of hospital stay in children with RDS. It is worthy of clinical promotion and application.

A Novel Negative Pressure-Flow Waveform to Ventilate Lungs for Normothermic Ex Vivo Lung Perfusion.

Ex vivo lung perfusion (EVLP) is increasingly used to treat and assess lungs before transplant. Minimizing ventilator induced lung injury (VILI) during EVLP is an important clinical need, and negative pressure ventilation (NPV) may reduce VILI compared with conventional positive pressure ventilation (PPV). However, it is not clear if NPV is intrinsically lung protective or if differences in respiratory pressure-flow waveforms are responsible for reduced VILI during NPV. In this study, we quantified lung injury using novel pressure-flow waveforms during normothermic EVLP. Rat lungs were ventilated-perfused ex vivo for 2 hours using tidal volume, positive end-expiratory pressure (PEEP), and respiratory rate matched PPV or NPV protocols. Airway pressures and flow rates were measured in real time and lungs were assessed for changes in compliance, pulmonary vascular resistance, oxygenation, edema, and cytokine secretion. Negative pressure ventilation lungs demonstrated reduced proinflammatory cytokine secretion, reduced weight gain, and reduced pulmonary vascular resistance (p < 0.05). Compliance was higher in NPV lungs (p < 0.05), and there was no difference in oxygenation between the two groups. Respiratory pressure-flow waveforms during NPV and PPV were significantly different (p < 0.05), especially during the inspiratory phase, where the NPV group exhibited rapid time-dependent changes in pressure and airflow whereas the PPV group exhibited slower changes in airflow/pressures. Lungs ventilated with PPV also had a greater transpulmonary pressure (p < 0.05). Greater improvement in lung function during NPV EVLP may be caused by favorable airflow patterns and/or pressure dynamics, which may better mimic human respiratory patterns.

Management of apnea in infants with trisomy 18.

This case series aimed to characterize the clinical features, management, and outcomes of apnea in infants with trisomy 18. Participants in this study were infants with trisomy 18 who were born alive and admitted to the neonatal intensive care unit in Kyushu University Hospital from 2000 to 2018. Retrospective analysis was performed on clinical data recorded in our department. Twenty-seven infants with trisomy 18 were admitted to our hospital during the study period, of which 25 (nine males, 16 females) were enrolled as eligible participants in this study. Among them, 14 started presenting with apnea from median 3.5days of age (range 0-47d). In these infants with apnea, eight received respiratory support of positive pressure ventilation (PPV). The 1-year survival rate of infants in the PPV group was higher than that of non-PPV-supported infants (5 out of 8 vs 0 out of 6 infants). Five PPV-supported infants received a diagnosis of epilepsy, which was controlled by antiepileptic drugs. Postnatal respiratory intervention provides better prognosis in infants with trisomy 18. Improved survival leads to accurate diagnosis and treatment of apneic events in association with epilepsy. WHAT THIS PAPER ADDS: Respiratory support is effective against apnea in infants with trisomy 18. Intervention with ventilation provides a higher chance of prolonged survival. Improved survival leads to the accurate diagnosis and treatment of epilepsy-associated apnea.

Glucose Levels during the First 24 Hours following Perinatal Hypoxia.

Hypoglycemia is a significant risk factor for perinatal brain injury and adverse outcomes, particularly in infants requiring resuscitation following hypoxic ischemic (HI) insult. We aimed to study blood glucose (BG) levels in physiologically stressed infants in the presence or absence of epinephrine (Epi) administration at resuscitation in the first 24 hours after birth. A retrospective chart review of all infants with heart rate (HR) < 100/min at 1 minute requiring positive pressure ventilation (PPV) at birth was performed. Infants were classified into two groups as follows: (1) PPV group: infants' HR improved with PPV only at resuscitation, and Epi group: infants received Epi at resuscitation for persistent bradycardia. Serial measurements of BG levels collected and glucose infusion rate (GIR) calculated at 24 hours. By design, infants in the Epi group had lower cord pH and higher base deficit. BG was significantly lower overtime in premature infants ≤32 weeks of gestation in the Epi group. The BG was markedly higher in near-term and term infants in the Epi group compared with the PPV group. Hypoglycemia was more common despite administration of higher GIR in premature infants ≤32 weeks of gestation. In the presence of physiological stress, premature infants are more at risk for hypoglycemia than term infants.

Emulating a Novel Clinical Trial Using Existing Observational Data. Predicting Results of the PreVent Study.

Rationale: "Target trial emulation" has been proposed as an observational method to answer comparative effectiveness questions, but it has rarely been attempted concurrently with a randomized clinical trial (RCT).Objectives: We tested the hypothesis that blinded analysts applying target trial emulation to existing observational data could predict the results of an RCT.Methods: PreVent (Preventing Hypoxemia with Manual Ventilation during Endotracheal Intubation) was a multicenter RCT examining the effects of positive-pressure ventilation during tracheal intubation on oxygen saturation and severe hypoxemia. Analysts unaware of PreVent's results used patient-level data from three previous trials evaluating airway management interventions to emulate PreVent's eligibility criteria, randomization procedure, and statistical analysis. After PreVent's release, results of this blinded observational analysis were compared with those of the RCT. Difference-in-differences estimates for comparison of treatment effects between the observational analysis and the PreVent trial are reported on the absolute scale.Results: Using observational data, we were able to emulate PreVent's randomization procedure to produce balanced groups for comparison. The lowest oxygen saturation during intubation was higher in the positive-pressure ventilation group than the no positive-pressure ventilation group in the observational analysis (n = 360; mean difference = 1.8%; 95% confidence interval [CI] = -1.0 to 4.6) and in the PreVent trial (n = 401; mean difference = 3.9%; 95% CI = 1.4 to 6.4), though the observational analysis could not exclude no difference. Difference-in-differences estimates comparing treatment effects showed reasonable agreement for lowest oxygen saturation between the observational analysis and the PreVent trial (mean difference = -2.1%; 95% CI = -5.9 to 1.7). Positive-pressure ventilation resulted in lower rates of severe hypoxemia in both the observational analysis (risk ratio = 0.60; 95% CI = 0.38 to 0.93) and in the PreVent trial (risk ratio = 0.48; 95% CI = 0.30 to 0.77). The absolute reduction in the incidence of severe hypoxemia with positive-pressure ventilation was similar in the observational analysis (9.4%) and the PreVent trial (12.0%), though the difference between these estimates had wide CIs (mean difference = 2.5%; 95% CI = -8.0 to 13.6%).Conclusions: Applying target trial emulation methods to existing observational data for the evaluation of a novel intervention produced results similar to those of a randomized trial. These findings support the use of target trial emulation for comparative effectiveness research.

The Breathing Effort of Very Preterm Infants at Birth

To compare the respiratory effort of very preterm infants receiving positive pressure ventilation (PPV) with infants breathing on continuous positive airway pressure (CPAP), directly after birth. Recorded resuscitations of very preterm infants receiving PPV or CPAP after birth were analyzed retrospectively. The respiratory effort (minute volume and recruitment breaths [>8 mL/kg], heart rate, oxygen saturation, and oxygen requirement were analyzed for the first 2 minutes and in the fifth minute after birth. Respiratory effort was analyzed in 118 infants, 87 infants receiving PPV and 31 infants receiving CPAP (median gestational age, 28 weeks [IQR, 26-29] vs 29 weeks [IQR, 29-30; P < .001); birth weight, 1059 g [IQR, 795-1300] vs 1205 g [IQR, 956-1418; P = .06]). The minute volume of spontaneous breaths of infants receiving PPV was lower at 2 minutes (37 mL/kg/minute [IQR, 15-69] vs 188 mL/kg/minute [IQR, 128-297; P < .001]) and at 5 minutes (112 mL/kg/minute [IQR, 46-229] vs 205 mL/kg/minute [IQR, 174-327; P < .001]). Recruitment breaths occurred less in the PPV group at 2 minutes (0 breaths/minute [IQR, 0-1] vs 4 breaths/minute [IQR, 1-8; P < .001]) and 5 minutes (0 breaths/minute [IQR, 0-3] vs 2 breaths/minute [IQR, 0-11; P = .01). The heart rate was lower in the PPV group (94 beats/minute [IQR, 68-128] vs 124 beats/minute [IQR, 100-144; P = .02]) as was oxygen saturation (50% [IQR, 35%-66%] vs 67% [IQR, 34%-80%; P = .04]), but not different at 5 minutes (heart rate, 149 beats/minute [IQR, 131-162] vs 150 beats/minute [IQR, 132-160; P = NS]; oxygen saturation , 91% [IQR, 80%-95%] vs 92% [IQR, 89%-97%; P = NS]). The oxygen requirement was higher (at 2 minutes, 30% [IQR, 21%-53%] vs 21% [IQR, 21%-29%; P = .05]; at 5 minutes, 39% [IQR, 22%-91%] vs 22% [IQR, 21%-31%; P = .003]). Very preterm infants breathe at birth when receiving PPV, but the respiratory effort was significantly lower when compared with infants receiving CPAP only. The reduced breathing effort observed likely justified applying PPV in most infants.

Using exhaled CO2 to guide initial respiratory support at birth: a randomised controlled trial

ImportanceA sustained inflation (SI) provided at birth might reduce bronchopulmonary dysplasia (BPD).ObjectiveThis study aims to examine whether an SI-guided exhaled carbon dioxide (ECO2) compared with positive pressure ventilation (PPV) alone...

Resuscitation and risk factors of tracheal intubation of neonates born from high risk mothers

Objective To understand the whole situation of neonatal resuscitation in high risk deliveries. Methods Totally, 3 420 neonates born from high risk pregnant mothers in Tianjin Central Obstetrics and Gynecology Hospital from September 2013 to November 2014 were recruited and divided into four groups according the needs of resuscitation, including no resuscitation group (Group A), initial resuscitation group (Group B), initial resuscitation plus bag-and-mask or T-piece ventilation (positive pressure ventilation group, Group C), tracheal intubation and/or external chest compression and/or epinephrine administation (tracheal intubation group, Group D). Variance analysis, Chi-square test and Logistic regression analysis were applied to compare the differences of clinical conditions among these groups and to analyze risk factors of tracheal intubation requirement for extensive resuscitation. Results Among the 3 420 newborns, 2 360(69.0%) were assigned to Group A, 565 (16.5%) to Group B, 408 (11.9%) to Group C and 87 (2.5%) to Group D. Statistical differences were shown in the gestational age [(35.5±4.1), (33.0±4.3) and (32.1±4.8) weeks], birth weight [(2 593.8±663.6), (2 063.3±973.9) and (1 839.0±977.9) g], and the incidence of multiple births [66(11.7%), 65(15.9%) and 23(26.4%)], abruptio placentae [15(2.7%), 35(8.6%) and 9(10.3%)], umbilical cord prolapse [0(0.0%), 2(0.5%), and 10(11.5%)], abnormal fetal heart rate in labor [28(5.0%), 45(11.0%) and 46(52.9%)], prolonged labor [36(6.4%), 35(8.6%), and 20(23.0%)], meconium stained liquor [32(5.7%), 0(0.0%), and 8(9.2%)], and congenital anomaly [8(1.4%), 12(2.9%) and 7(8.0%)] among Group B, C and D (F or χ2=233.188, 105.050, 14.535, 19.934, 91.434, 149.366, 26.525, 28.602 and 13.765, all P<0.05). Multiple regression analysis revealed that gestational age <28 weeks (OR=1.290,95% CI:1.167-1.425), abnormal fetal heart rate in labor (OR=1.350,95%CI: 1.184-6.862) and meconium stained liquor (OR=1.397, 95%CI: 1.051-6.825) were independent risk factors for endotracheal intubation requirement (all P<0.05). Conclusions More newborns born from high risk mothers may need resuscitation, especially for those in small gestational age, with abnormal fetal heart rate during labor and meconium-stained liquor, thus close monitoring and management are necessary. Key words: Infant,premature; Resuscitation; Intubation,intratracheal; Infant,extremely low birth weight

Serum Enzymes in Predicting the Severity of Meconium Aspiration Syndrome in Newborn

Purpose: Meconium aspiration syndrome (MAS), often progresses to respiratory failure and its’ serious com­ plication, persistent pulmonary hypertension of the newborn (PPHN) is a major cause of neonatal mortality. Early recognition of infants at the risk for respiratory failure in MAS patients is necessary for treatment. So we aimed to identify serum enzymes such as lactate dehydrogenase (LDH), aspartate transaminase (AST), and alanine transaminase (ALT) as serum biologic marker for early detection of respiratory failure in MAS patients. Methods: Infants admitted within 24 hours after birth to Neonatal Intensive Care Unit of Dongguk University Ilsan Hospital and diagnosed with MAS from August 2005 to March 2014 were analyzed retrospectively. Serum enzymes were measured on admission. Results: Of the total 60 patients diagnosed with MAS, 28 were in the positive pressure ventilation (PPV) group and 32 were in the non­PPV group. Six patients progressed to PPHN. Only serum LDH was significantly higher in the PPV group than the non­PPV group (median 1,123 vs. 831, P=0.01). Using the ROC curves, the cut­off value of 964 U/L for LDH offered the best predictive value for PPV requirement (sensitivity 61% and specificity 81%). Serum LDH was significantly higher in MAS with PPHN group than MAS without PPHN group (median 1,791 vs. 904, P=0.013). But serum AST, ALT were not predicting factor for the requirement of respiratory support and development of PPHN among MAS patients. Conclusion: LDH might be a good predicting factor for the requirement of respiratory support and develop­ ment of PPHN among MAS patients.

Post-resuscitation care for neonates receiving positive pressure ventilation at birth.

To investigate if postresuscitation care (PRC) is indicated for all infants ≥35 weeks' gestation who receive positive pressure ventilation (PPV) at birth, explore the aspects of this care and the factors most predictive of it. Our hospital admits any infant who requires PPV at birth to special (intermediate/intensive) neonatal care unit (SNCU) for observation for at least 6 hours. All infants ≥35 weeks' gestation born between 1994 and 2013, who received PPV at birth, were reviewed. We examined perinatal factors that could predict the need for PRC after short (<1 minute) and prolonged (≥1 minute) PPV, admission course, neonatal morbidities, and the aspects of care given. Among 87 464 infants born, 3658 (4.2%) had PPV at birth with 3305 (90%) admitted for PRC. Of those, 1558 (42.6%) were in the short PPV group and 2100 (57.4%) in the prolonged PPV group. Approximately 59% of infants who received short PPV stayed in the SNCU for ≥1 day. Infants who received prolonged PPV were more likely to have morbidities and require special neonatal care. Multiple logistic regression analysis revealed the risk factors of placental abruption, assisted delivery, small-for-dates, gestational age <37 weeks, low 5-minute Apgar score, and need for intubation at birth to be independent predictors for SNCU stay ≥1 day and need for assisted ventilation, central lines, and parenteral nutrition. Our data support the need for PRC even for infants receiving short PPV at birth.

Monitoring lung aeration during respiratory support in preterm infants at birth.

BackgroundIf infants fail to initiate spontaneous breathing, resuscitation guidelines recommend respiratory support with positive pressure ventilation (PPV). The purpose of PPV is to establish functional residual capacity and deliver an adequate tidal volume (VT) to achieve gas exchange.ObjectiveThe aim of our pilot study was to measure changes in exhaled carbon dioxide (ECO2), VT, and rate of carbon dioxide elimination (VCO2) to assess lung aeration in preterm infants requiring respiratory support immediately after birth.MethodA prospective observational study was performed between March and July 2013. Infants born at <37 weeks gestational age who received continuous positive airway pressure (CPAP) or PPV immediately after birth had VT delivery and ECO2 continuously recorded using a sensor attached to the facemask.ResultsFifty-one preterm infants (mean (SD) gestational age 29 (3) weeks and birth weight 1425 (592 g)) receiving respiratory support in the delivery room were included. Infants in the CPAP group (n = 31) had higher ECO2 values during the first 10 min after birth compared to infants receiving PPV (n = 20) (ranging between 18–30 vs. 13–18 mmHg, p<0.05, respectively). At 10 min no significant difference in ECO2 values was observed. VT was lower in the CPAP group compared to the PPV group over the first 10 min ranging between 5.2–6.6 vs. and 7.2–11.3 mL/kg (p<0.05), respectively.ConclusionsImmediately after birth, spontaneously breathing preterm infants supported via CPAP achieved better lung aeration compared to infants requiring PPV. PPV guided by VT and ECO2 potentially optimize lung aeration without excessive VT administered.

The Administration of 100% Oxygen and Respiratory Drive in Very Preterm Infants at Birth

AimTo retrospectively investigate the changes of SpO2 and respiratory drive in preterm infants at birth after administration of 100% oxygen.MethodsRespiratory parameters, FiO2 and oximetry of infants <32 weeks gestation before and after receiving FiO2 1.0 were reviewed during continuous positive airway pressure (CPAP) or positive pressure ventilation (PPV).ResultsResults are given as median (IQR) or percentages where appropriate. Suitable recordings were made in 50 infants (GA 27 (26–29) weeks), 17 received CPAP and 33 PPV. SpO2 increased rapidly in the first minute after FiO2 1.0 and remained stable. The duration of FiO2 1.0 tended to be shorter in the CPAP group than in the PPV group (CPAP vs. PPV: 65 (33–105) vs. 100 (40–280) s; p = 0.05), SpO2 >95% occurred more often in PPV group (53% vs. 69%) and lasted longer (70(40–95) vs. 120(50–202) s). In CPAP group, minute volume increased from 134 (76–265) mL/kg/min 1 minute before to 240 (157–370) mL/kg/min (p<0.01) 1 minute after start FiO2 1.0 and remained stable at 2 minutes (252 (135–376) mL/kg/min; ns). The rate of rise to maximum tidal volume increased (from 13.8 (8.0–22.4) mL/kg/s to 18.2 (11.0–27.5) mL/kg/s; p<0.0001) to 18.8 (11.8–27.8) mL/kg/s; ns). In the PPV group respiratory rate increased from 0(0–4) to 9(0–20) at 1 minute (p<0.001) to 23 (0–34) breaths per minute at 2 minutes (p<0.01).ConclusionIn preterm infants at birth, a rapid increase in oxygenation, resulting from a transient increase to 100% oxygen might improve respiratory drive, but increases the risk for hyperoxia.

Extubation Success in Premature Infants With Respiratory Distress Syndrome Treated With Bi-Level Nasal Continuous Positive Airway Pressure Versus Nasal Intermittent Positive Pressure Ventilation

Infants born prematurely with respiratory distress syndrome are at high risk for complications from mechanical ventilation. Strategies are needed to minimize their days on the ventilator. The purpose of this study was to compare extubation success rates in infants treated with 2 different types of continuous positive airway pressure devices. A retrospective cohort study design was used. Data were retrieved from electronic medical records for patients in a large, metropolitan, level III neonatal intensive care unit. A sample of 194 premature infants with respiratory distress syndrome was selected, 124 of whom were treated with nasal intermittent positive pressure ventilation and 70 with bi-level variable flow nasal continuous positive airway pressure (bi-level nasal continuous positive airway pressure). Infants in both groups had high extubation success rates (79% of nasal intermittent positive pressure ventilation group and 77% of bi-level nasal continuous positive airway pressure group). Although infants in the bi-level nasal continuous positive airway pressure group were extubated sooner, there was no difference in duration of oxygen therapy between the 2 groups. Promoting early extubation and extubation success is a vital strategy to reduce complications of mechanical ventilation that adversely affect premature infants with respiratory distress syndrome.

Safety, efficacy, and tolerability of early initiation of noninvasive positive pressure ventilation in pediatric patients admitted with status asthmaticus

Although noninvasive positive pressure ventilation is increasingly used for respiratory distress, there is not much data supporting its use in children with status asthmaticus. The objective of this study was to determine safety, tolerability, and efficacy of early initiation of noninvasive positive pressure ventilation in addition to standard of care in the management of children admitted with status asthmaticus. A prospective, randomized, controlled, clinical trial. Twenty patients (1-18 yrs old) admitted to the pediatric intensive care unit with status asthmaticus. Children were randomized to receive either noninvasive positive pressure ventilation plus standard of care (noninvasive positive pressure ventilation group) or standard of care alone (standard group). Improvement in clinical asthma score was significantly greater in noninvasive positive pressure ventilation group compared to standard group at 2 hrs, 4-8 hrs, 12-16 hrs, and 24 hrs after initiation of interventions (p < .01). A significant decrease in respiratory rate at ≥ 24 hrs oxygen requirement after 2 hrs was noted in noninvasive positive pressure ventilation group as compared to standard group (p = .01 and p = .03, respectively). Although statistically not significant, fewer children in the noninvasive positive pressure ventilation group required adjunct therapy compared to standard group (11% vs. 50%; p = .07). There were no major adverse events related to noninvasive positive pressure ventilation. Nine out of ten patients tolerated noninvasive positive pressure ventilation through the duration of the study; noninvasive positive pressure ventilation had to be discontinued in one patient because of persistent cough. Early initiation of noninvasive positive pressure ventilation, along with short acting β-agonists and systemic steroids, can be safe, well-tolerated, and effective in the management of children with status asthmaticus.

Early use of noninvasive positive pressure ventilation for acute lung injury

Noninvasive positive pressure ventilation is beneficial for patients with acute respiratory failure. However, its possible benefit for patients with acute lung injury (200 mm Hg < PaO(2)/FIO(2) ≤300 mm Hg) remains unclear. Our aim was to assess the safety and efficacy of noninvasive positive pressure ventilation for patients with acute lung injury and compare this with high-concentration oxygen therapy. A multicentered randomized controlled trial. Ten multipurpose intensive care units. Forty patients who fulfilled the criteria for acute lung injury were included in this study. Patients were randomly allocated to receive either noninvasive positive pressure ventilation (noninvasive positive pressure ventilation group) or high-concentration oxygen therapy through a Venturi mask (control group). Twenty-one patients were assigned to the noninvasive positive pressure ventilation group and 19 were in the control group. At study entry, the patients' characteristics in the two groups were similar. Noninvasive positive pressure ventilation application decreased the respiratory rate and improved PaO(2)/FIO(2) with time. The proportion of patients requiring intubation and the actual number of intubations in the noninvasive positive pressure ventilation group were significantly less than in the control group (one of 21 vs. seven of 19; p = .02, and one of 21 vs. four of 19; p = .04, respectively). Noninvasive positive pressure ventilation showed a trend for reducing inhospital mortality (one of 21 vs. five of 19; p = .09). The total number of organ failures in the noninvasive positive pressure ventilation group was significantly lower than in the control group (three vs. 14; p < .001). Noninvasive positive pressure ventilation is safe for selected patients with acute lung injury. However, a larger randomized trial with need for intubation and mortality as the outcomes of interest is required.

Tracheal fluid leakage in benchtop trials: comparison of static versus dynamic ventilation model with and without lubrication

Longitudinal folds in tracheal tube (TT) cuffs cause leakage of pooled secretions past the tube cuff, and the most common in vitro method to test the efficacy of a new tube is a benchtop model using an artificial rigid trachea. This study compared the potential of a static and dynamic ventilation benchtop model and cuff lubrication in testing the tracheal sealing properties of a given TT cuff. Static trial Six brands of 7.5 mm internal diameter (ID) cuffed TT (n = 8) with high volume-low pressure cuffs were inflated in an artificial trachea (18 mm ID) without and with lubrication. Dynamic trial The same tube cuffs, without lubrication, were subjected to positive pressure ventilation (PPV) + positive end-expiratory pressure (PEEP) of 5cmH(2)O or to PPV alone (without PEEP) or to PEEP alone (without PPV). Clear water (5 ml) was placed above the tube cuff, and fluid leakage (ml) was measured up to 60 min. Gel lubrication, PEEP alone and PPV + PEEP completely prevented fluid leakage across the tube cuffs in all six TT brands tested within 60 min when compared to the static unlubricated model (0% leak versus 100% leak; P < 0.01). Fluid leakage in the static unlubricated model and the PPV group was 1.38-4.76 ml and 0.23-4.47 ml, respectively. Gel lubrication, PEEP alone, and PPV + PEEP in the benchtop model had a much stronger protective effect than PPV alone on fluid leakage. Studies testing the fluid sealing efficiency of tube cuffs might be more conclusive in a static benchtop model without lubrication than in a dynamic model.