Treatment Of Respiratory Distress Research Articles

Efficacy of a Low-Cost Bubble CPAP System in Treatment of Respiratory Distress in a Neonatal Ward in Malawi

BackgroundRespiratory failure is a leading cause of neonatal mortality in the developing world. Bubble continuous positive airway pressure (bCPAP) is a safe, effective intervention for infants with respiratory distress and is widely used in developed countries. Because of its high cost, bCPAP is not widely utilized in low-resource settings. We evaluated the performance of a new bCPAP system to treat severe respiratory distress in a low resource setting, comparing it to nasal oxygen therapy, the current standard of care.MethodsWe conducted a non-randomized convenience sample study to test the efficacy of a low-cost bCPAP system treating newborns with severe respiratory distress in the neonatal ward of Queen Elizabeth Central Hospital, in Blantyre, Malawi. Neonates weighing >1,000 g and presenting with severe respiratory distress who fulfilled inclusion criteria received nasal bCPAP if a device was available; if not, they received standard care. Clinical assessments were made during treatment and outcomes compared for the two groups.Findings87 neonates (62 bCPAP, 25 controls) were recruited. Survival rate for neonates receiving bCPAP was 71.0% (44/62) compared with 44.0% (11/25) for controls. 65.5% (19/29) of very low birth weight neonates receiving bCPAP survived to discharge compared to 15.4% (1/13) of controls. 64.6% (31/48) of neonates with respiratory distress syndrome (RDS) receiving bCPAP survived to discharge, compared to 23.5% (4/17) of controls. 61.5% (16/26) of neonates with sepsis receiving bCPAP survived to discharge, while none of the seven neonates with sepsis in the control group survived.InterpretationUse of a low-cost bCPAP system to treat neonatal respiratory distress resulted in 27% absolute improvement in survival. The beneficial effect was greater for neonates with very low birth weight, RDS, or sepsis. Implementing appropriate bCPAP devices could reduce neonatal mortality in developing countries.

Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension

High-dose intravenous nitroglycerin is a common in-hospital treatment for respiratory distress due to congestive heart failure (CHF) with hypertension. Intravenous (IV) nitroglycerin administration is impractical in the prehospital setting. In 2011, a new regional Emergency Medical Services (EMS) protocol was introduced allowing advanced providers to treat CHF with high-dose oral nitroglycerin. The protocol calls for patients to be treated with two sublingual tabs (0.8 mg) when systolic blood pressure (SBP) was >160 mm Hg, or three sublingual tabs (1.2 mg) when SBP was >200 mm Hg, every five minutes as needed. Hypothesis/Problem To assess the protocol's safety, the incidence of hypotension following prehospital administration of multiple simultaneous nitroglycerin (MSN) tabs by EMS providers was studied. This study was a retrospective cohort study of patients from a single commercial EMS agency over a 6-month period. Records from patients with at least one administration of MSN were reviewed. For each administration, the first documented vital signs pre- and post-administration were compared. Administrations were excluded if pre- or post-administration vital signs were missing. One hundred case-patients had at least one MSN administration by an advanced provider during the study period. Twenty-five case-patients were excluded due to incomplete vital signs. Seventy-five case-patients with 95 individual MSN administrations were included for analysis. There were 65 administrations of two tabs, 29 administrations of three tabs, and one administration of four tabs. The mean change in SBP following MSN was -14.7 mm Hg (SD = 30.7; range, +59 to -132). Three administrations had documented systolic hypotension in the post-administration vital signs (97/71, 78/50 and 66/47). All three patients were over 65 years old, were administered two tabs, had documented improved respiratory status, and had repeat SBP of at least 100. The incidence of hypotension following MSN administration was 3.2%. Discussion High-dose oral nitroglycerin administration is a practical alternative to IV nitroglycerin in the prehospital setting when administered by advanced providers. The prehospital protocol for high dose oral nitroglycerin was demonstrated to be safe in the cohort of patients studied. Limitations of the study include the relatively small sample size and the inability to identify hypotension that may have occurred following the cessation of data collection in the field. Hypotension was rare and self-limited in prehospital patients receiving MSN.

Nasal Continuous Positive Airway Pressure

The purpose of this multisite study was to describe suctioning techniques of registered nurses (RNs) and respiratory therapists (RTs) caring for neonates requiring nasal continuous positive airway pressure (CPAP). The care practices investigated included suctioning frequency, assessment parameters, and techniques used to suction. A convenience sample of neonatal intensive care unit (NICU) RNs and practicing RTs at 8 Midwestern hospitals in the United States caring for neonates on nasal CPAP in a level II or III NICU were included. Eighty-five percent of respondents were RNs of which almost 89% (88.6%) were staff RNs, 63% were bachelor prepared, and 33% of the RNs had greater than 20 years of neonatal nursing experience. A cross-sectional descriptive comparative design was used for this study. An investigator-developed Web-based survey pertaining to current practice concerns was developed by the research team. The 31-item survey tool consisted of 4 sections. The first section addressed the frequency of suctioning. The second section addressed assessment parameters used to determine the need for suctioning. The third section addressed the technique used to suction, including gloving techniques, hyperoxygenation, and the use of catheters in nares and mouth and suctioning devices. Demographic data, including staff position, level of education, years of nursing, and NICU experience and certification, were collected in the fourth section. Descriptive statistics were used to characterize demographics and each item of the survey. Chi-square statistics (Pearson chi-square and Fisher Exact text) were used to compare RNs' and RTs' nasal CPAP suctioning practices. The results of this study indicated that decision making related to the need to suction was variable. In addition, the frequency of suctioning and nasopharyngeal and oropharyngeal suctioning techniques were highly variable for neonates requiring nasal CPAP. Despite the treatment of respiratory distress with nasal CPAP, there are no best practice guidelines for providing nasopharyngeal and oropharyngeal suctioning for maintenance of a patent airway. Future randomized controlled clinical trials are needed to develop best practices for nasal CPAP suctioning.

Neuropathischer und tumorbedingter Kopfschmerz

Cancer pain in the field of otolaryngology can be effectively alleviated. Only very few questions regarding the patient's history of pain are required to understand the type of pain being dealt with and to be able to make the correct selection of analgetic agents. It is particularly important to treat tumor breakthrough pain appropriately, for which a sufficient number of therapeutic agents are available. The present article comments on the various possibilities of specific drugs and interventional therapeutic approaches, as well as their specific characteristics within the field of otolaryngology, supplemented with various tricks for their practical application. Using these basic rules, most problems can be identified and specific treatments optimized. The progression of cancer pain may show wide dynamic ranges, and the therapeutic approach should always be adjusted to the current situation. Palliative care of a cancer patient may be particularly challenging in that, not only the treatment of pain, but also the treatment of respiratory distress is of key importance.

Mandibular Distraction Using Bone Morphogenic Protein and Rapid Distraction in Neonates With Pierre Robin Syndrome

Mandibular distraction is recognized as a treatment of respiratory distress in neonates with microretrognathia as seen in the Pierre Robin syndrome. However, mandibular distraction is a complex and lengthy treatment involving 2 to 4 weeks of distraction and another 4 to 12 weeks for bone consolidation. This study was performed to establish the safety and effectiveness of rapid protocol distraction osteogenesis with recombinant human bone morphogenetic protein 2 (rhBMP-2) in neonates with the Pierre Robin syndrome. A retrospective review of all patients treated in our department between February 2003 and February 2008 was performed. Three patients with the Pierre Robin syndrome who underwent distraction osteogenesis with rhBMP-2 were identified. Inpatient and outpatient charts were reviewed for time to completion of distraction, age at distraction, need for tracheostomy, and complications of the mandibular distraction. Three patients (6 hemimandibles) with Pierre Robin syndrome underwent rapid protocol distraction with rhBMP-2. Mean age at initial distraction was 17.3 days. Mean time from device placement to removal was 89.3 days. The complication rate was 16%, with 1 case of nonunion that required subsequent operative intervention. No patient required tracheostomy. Rapid protocol distraction with rhBMP-2 allows distraction of the hypoplastic mandible to class III occlusion during the initial operation and avoids the latency and distraction phases of standard mandibular distraction. This case series demonstrates the safety and effectiveness of rapid distraction in neonates with Pierre Robin syndrome. Larger studies and long-term follow-up are necessary; however, this study suggests that rapid protocol distraction with rhBMP-2 is effective in neonates with Pierre Robin syndrome.

International Perspectives

> The following article in our International Perspectives series differs somewhat from the usual format. Most of these pieces either cover what is happening in a particular country or provide a regional viewpoint on a selected topic. The report of this seminar was suggested by one of our International Advisory Board members (Dr Mats Blennow from Stockholm, Sweden) and provides some insight into what is currently considered to be important by influential neonatologists in Europe. It also provides direction for future research activity in several different areas, which may stimulate some of our North American readers (as well as our European colleagues). Not all references provided by the speakers are included with this report. The complete list of references may be obtained by contacting Dr Roehr at cristoph-roehr@charite.de. Publication of this report should not be seen as an open invitation to submit the proceedings of all such meetings to NeoReviews. However, there might be a place for other reports of international seminars/symposia, if they deal with topics that are considered to be of general interest and have not been covered in recent issues of the journal. > > — Alistair G.S. Philip, MD Editor-in-Chief , NeoReviewsThis seminar originated as a sponsored research seminar, initiated by the European Respiratory Society (ERS) and the Charite Universitasmedizin Berlin, Germany. At the invitation of the organizing committee (C. Roehr/R. Wauer/A. Greenough/H. Verder), an international panel of expert neonatologists and researchers in neonatal medicine presented the latest data on managing extremely low gestational age neonates (ELGANs) with continuous positive airway pressure (CPAP) and surfactant. The presentations focused on the pathophysiology of neonatal lung disease and the prevention and treatment of respiratory distress in ELGANs. The international audience comprised respirologists, physicians, physiologists, and neonatal practitioners. Aims of the seminar were to: 1) Discuss the best available evidence regarding the use of surfactant and CPAP in …

Shortness of breath prehospital treatment of respiratory distress.

Shortness of breath prehospital treatment of respiratory distress.

Children With Respiratory Distress Treated With High-Flow Nasal Cannula

High-flow nasal cannula (HFNC) therapy is a treatment for respiratory distress in neonates and children. In the present study, we assessed its effectiveness, comfort, and possible mechanism of action. We reviewed records of 46 patients treated with HFNC and estimated the modified COMFORT score (7 to 35 units), the respiratory clinical scale (0 to 12 units), and the oxygen saturation level. Data were collected at time 0 (before the use of high-flow), time 2 (60 to 90 min post-application), and at time 3 (8 to 12 hours post-application). Furthermore, we measured the nasopharyngeal pressure while on continuous positive air pressure (CPAP) as well as the differences in ''lung expansion'' demonstrated by the prestudy and post-study chest x-ray. There were significant improvements in the modified COMFORT score (F(1,45) = 40.03, P < .05), respiratory clinical scale (F(1.69,76.15) = 121.19, P < .05), and oxygen saturation (F(2,90) = 101.54, P < .05). Application of HFNC therapy created a significant average positive expiratory pressure of 4.0 +/- 1.99 (SE) cm H(2)O. X-rays taken after initiation of HFNC showed either improved aeration of the lungs or no changes in 40 of 46 patients. Mechanical ventilation was needed in 5 of 46 patients. Our study indicates that high-flow nasal cannula improves the respiratory scale score, the oxygen saturation, and the patient's COMFORT scale. Its mechanism of action is application of mild positive airway pressure and lung volume recruitment.

Importance of effective collaboration between pediatric intensive care and emergency departments

Pediatric critical care and pediatric emergency medicine are disciplines that share responsibility for providing care for acutely injured or critically ill children. In many parts of the developed world, these disciplines are recognized subspecialties of pediatrics with excellent training programs, a welldefined body of knowledge, sufficient practitioners at the senior level and a track record of clinical and academic productivity [1,2]. Indeed, from modest beginnings in the 1960s, pediatric critical care medicine has evolved and can boast dramatic major advances in the areas of lung injury, sepsis, traumatic brain injury and postoperative care. Pediatric emergency medicine has also made significant advances in the evaluation and treatment of respiratory distress, asthma, croup, epiglottitis, traumatic injuries, poisonings, cardiopulmonary resuscitation and sepsis. Both pediatric emergency medicine and pediatric critical care have developed impressive and aggressive research programs both in the USA and Canada [101–104]. What these disciplines share in common is their expertise to render care to patients with the greatest physiological instability. For many of these children, critical illness first occurs in diverse settings outside the hospital environment, and early recognition and early aggressive therapy can lead to improved outcomes. Furthermore, the best outcome can be guaranteed if there is good communication and a seamless continuum of care starting in the pre-hospital setting, which is linked to an efficient transport system and tertiary pediatric emergency and tertiary pediatric critical care teams (Figure 1).

Increasing incidence of respiratory distress in neonates

To document the change in the incidence of respiratory distress (RD), related interventions and mortality in neonates admitted to primary, secondary and tertiary neonatal units within a geographically defined population over a period of 30 years. RD was defined as a clinical picture irrespective of the etiology. Information was collected retrospectively for 1974, 1984, 1994 and 2004 from all neonatal units in Switzerland. In the 30 years studied the proportion of infants hospitalized with RD increased from 1.9% to 3.8% of the whole neonatal population and from 30% to 53% of all infants admitted to a neonatal unit. Treatment of RD changed significantly. Mechanical ventilation decreased from 31% to 16%, nasal CPAP increased from almost 0% to 26% and surfactant administration increased from 0% to 53% in infants with hyaline membrane disease. Overall mortality decreased in infants with RD from 15.5% to 3.5%. The incidence of RD in infants admitted to neonatal units doubled over the last 30 years in a geographically defined neonatal population. This rise can predominantly be ascribed to infants with birth weight >2500 g and may reflect the corresponding increase in the rate of caesarean section.

Bubble Continuous Positive Airway Pressure Enhances Lung Volume and Gas Exchange in Preterm Lambs

The technique used to provide continuous positive airway pressure (CPAP) to the newborn may influence lung function and breathing efficiency. To compare differences in gas exchange physiology and lung injury resulting from treatment of respiratory distress with either bubble or constant pressure CPAP and to determine if the applied flow influences short-term outcomes. Lambs (133 d gestation; term is 150 d) born via cesarean section were weighed, intubated, and treated with CPAP for 3 hours. Two groups were treated with 8 L/minute applied flow using the bubble (n = 12) or the constant pressure (n = 12) technique. A third group (n = 10) received the bubble method with 12 L/minute bias flow. Measurements at study completion included arterial blood gases, oxygraphy, capnography, tidal flow, multiple breath washout, lung mechanics, static pressure-volume curves, and bronchoalveolar lavage fluid protein. Birth weight and arterial gas variables at 15 minutes were comparable. Flow (8 or 12 L/min) did not influence the 3-hour outcomes in the bubble group. Bubble technique was associated with a higher pH, Pa(O2), oxygen uptake, and area under the flow-volume curve, and a decreased alveolar protein, respiratory quotient, Pa(CO2), and ventilation inhomogeneity compared with the constant pressure group. Compared with constant pressure technique, bubble CPAP promotes enhanced airway patency during treatment of acute postnatal respiratory disease in preterm lambs and may offer protection against lung injury.

Use of silfenadil for treatment of respiratory distress after pneumonectomy for bronchogenic carcinoma

Post-pneumonectomy respiratory failure is a devastating complication of resection for lung cancer. As proven therapy is limited, we successfully employed a novel medication silfenadil that has been effective in the treatment of pulmonary hypertension.

Oxygen and resuscitation: beyond the myth.

Perhaps nothing in medicine is more steeped in myth than oxygen. From its initial success in treating pulmonary tuberculosis to its failure in treating cholera, oxygen has fallen in and out of style. Only gradually did oxygen gain favor as a treatment for respiratory distress with even the likes of Osler doubting its effectiveness. But by the early 1900s, treatment of patients with pulmonary parenchymal disease was so convincing that a lack of appreciation for oxygen’s potentially harmful effects led to its eventual widespread acceptance.a We started using oxygen for resuscitation because it seemed like a good idea. Now we use it because we always have. The use of 100% oxygen in resuscitation is intuitively appealing. Maximizing the gradient driving oxygen into hypoxic cells may speed recovery. However, it is well known that long-term exposure to 100% oxygen is toxic. The proponents of oxygen therapy argue that toxicity simply does not occur during the short period of resuscitation. Although this may be true with respect to effects like fibrosis and pulmonary edema, the real concern is for reperfusion injury. In reperfusion injury, hypoxic cells appear to undergo metabolic changes that prime them to create free radicals when oxygen is reintroduced.1–3 Experimental resuscitation with 100% oxygen has been associated with a variety of concerning physiologic changes when compared with room air resuscitation. They include increased generation of oxygen radicals,4 decreased central nervous system sodium-potassium ATPase function,5 and decreased dopamine metabolism.6 Although there is no data on the safety or danger of short-term exposure to 100% oxygen, the reperfusion injury literature suggests that resuscitation from hypoperfusion states (ie, sudden cardiac arrest, hypovolemic, or distributive shock) is precisely the time when oxygen toxicity from free radicals is likely to occur. Given the potential harm of supplemental … Address correspondence to William Lefkowitz, MD, Department of Pediatrics, Room C-1066, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD 20814. E-mail: wlefkowitz{at}usuhs.mil

A CASE OF MYELODYSPLASTIC SYNDROME COMPLICATED BY PULMONARY ALVEOLAR PROTEINOSIS WITH A HIGH SERUM KL-6 LEVEL

Serious hematological diseases often cause respiratory disorders. Because these are related to the prognoses of patients with hematological diseases, their early diagnosis is necessary. This study describes a 6-year-old girl with myelodysplastic syndrome complicated by pulmonary alveolar proteinosis who showed a remarkable increase in her serum KL-6 level. Three years and 2 months after the end of therapy for neonatal melanoma, a diagnosis of myelodysplastic syndrome with leukemic change was made. Ten months after the onset of leukemia, she had respiratory distress with an increased serum KL-6 level of 75,000 U/mL (reference range; < 500 U/mL). Despite various treatments for pulmonary complications, she died 3 months after developing respiratory distress. A diagnosis of pulmonary alveolar proteinosis was made at autopsy. Earlier treatment of respiratory distress could be achieved if serum KL-6 levels were examined earlier.

Terbutaline vs Albuterol for Out‐of‐hospital Respiratory Distress: Randomized, Double‐blind Trial

To determine the efficacy and safety of single doses of subcutaneous terbutaline (TERB) or nebulized albuterol (ALB) during out-of-hospital treatment for respiratory distress from asthma or chronic obstructive pulmonary disease. Patients aged > 18 years who had respiratory distress were enrolled in a double-placebo, double-blind, randomized trial. Paramedics measured respiratory severity using an empiric score [respiratory rate, wheezing, speech, and peak expiratory flow rate (PEFR)], and the patients rated their own respiratory distress using a visual analog scale (VAS). The patients received O2 plus ALB (2.5 mg) and saline injection (n = 40) or TERB (0.25 mg) and saline aerosol (n = 43). The groups were similar with respect to age, gender, initial empiric scores (median score 9 for both groups), PEFRs (89 +/- 84 L/min, mean +/- SD, for ALB vs 97 +/- 84 L/min for TERB), and respiratory distress VAS scores. Both groups showed significant improvement in their respiratory distress VAS scores by the time of ED arrival. The ALB group had a greater improvement in respiratory distress VAS score than did the TERB group (p < 0.05). Empiric scores, PEFR scores, and hospital admission frequencies were not significantly different. No complication was observed. The out-of-hospital administration of either aerosolized ALB or subcutaneous TERB reduced respiratory severity. Albuterol provided greater subjective improvement in respiratory distress.

Biomimetic pulmonary surfactants

Considerable progress has been made in the development of defined mixtures of proteins or peptides with phospholipids which mimic the activity of natural pulmonary surfactants. Several of these biomimetic surfactants are active in animal models and clinical syndromes of surfactant deficiency. This review summarizes the structure and composition of natural surfactants and the development of defined mixtures of peptides and lipids that may be useful in the treatment of respiratory distress.

The prevention and treatment of perinatal sepsis in a neonatal intensive care unit

We report our experience with 345 premature infants weighing less than 1,500 g admitted to the neonatal intensive care unit during 1990–1993. The improved survival of the very-low-birth-weight patients was related mainly to the routine use of surfactant in the treatment of respiratory distress. In addition, as a result of several preventive precautions, early diagnosis, and appropriate antimicrobial therapy, a decrease in neonatal sepsis was observed. The decrease in the ratio between the number of septic episodes to the number of septic patients is another indication of the efficacy of our current preventive and therapeutic protocols.

Role of Bronchoscopy in the Treatment of Respiratory Distress Caused by Massive Esophagogastric Dilatation

Role of Bronchoscopy in the Treatment of Respiratory Distress Caused by Massive Esophagogastric Dilatation

Physicians?? Prognoses about the Quality of Life for Infants with Intraventricular Hemorrhage

There is an absence of definitive information concerning the long-term outcome of children born with intraventricular hemorrhage (IVH). Physicians, however, are called on to prognosticate about the future quality of life of these children. Our study examined pediatricians' and neonatologists' prognoses for infants with grade I- and grade-IV IVH and the impact of those prognoses on recommendations for treatment. A national random survey of 289 pediatricians and 283 neonatologists found that both groups expected infants with grade-I IVH to have slight impairments to future development, whereas infants with grade-IV IVH were expected to have severe impairments. Physicians prognosticated that infants with grade-IV IVH would function at a moderate to severe level of mental retardation, incapable of any employment, and residing in an institution. Furthermore, physicians would encourage parents to seek medical treatment of respiratory distress for the infant with grade-I IVH but were neutral or would discourage parents from seeking treatment for the infant with grade-IV IVH. Lastly, physicians' prognoses were significantly related to their recommendations for treatment. Several differences in physicians' prognoses and recommendations were found to be related to their discipline and training.

Pulmonary Surfactant: Biochemistry, Physiology, and Pathology

The material that lines the alveoli of the lung, known as pulmonary surfactant, plays a crucial role in lung function. Its composition and biosynthesis are rather well known, but its mechanism of action and its primary role in the etiology of neonatal respiratory distress remain controversial. Surfactant replacement for the treatment of respiratory distress nevertheless appears useful.