Use Of Positive Pressure Research Articles

Recruitment-Potential-Oriented Mechanical Ventilation Protocol and Narrative Review for Patients with Acute Respiratory Distress Syndrome.

Even though much progress has been made to improve clinical outcomes, acute respiratory distress syndrome (ARDS) remains a significant cause of acute respiratory failure. Protective mechanical ventilation is the backbone of supportive care for these patients; however, there are still many unresolved issues in its setting. The primary goal of mechanical ventilation is to improve oxygenation and ventilation. The use of positive pressure, especially positive end-expiratory pressure (PEEP), is mandatory in this approach. However, PEEP is a double-edged sword. How to safely set positive end-inspiratory pressure has long been elusive to clinicians. We hereby propose a pressure-volume curve measurement-based method to assess whether injured lungs are recruitable in order to set an appropriate PEEP. For the most severe form of ARDS, extracorporeal membrane oxygenation (ECMO) is considered as the salvage therapy. However, the high level of medical resources required and associated complications make its use in patients with severe ARDS controversial. Our proposed protocol also attempts to propose how to improve patient outcomes by balancing the possible overuse of resources with minimizing patient harm due to dangerous ventilator settings. A recruitment-potential-oriented evaluation-based protocol can effectively stabilize hypoxemic conditions quickly and screen out truly serious patients.

Diaphragmatic Ultrasound in Children With Asthma Exacerbations.

Asthma is a leading cause of pediatric emergency department visits, yet few tools exist to objectively measure asthma severity. Diaphragmatic ultrasound (DUS) is a novel method of assessing respiratory distress; however, data are lacking for children.Our primary aim was to determine if diaphragmatic excursion (DE), diaphragmatic thickening (DT), or diaphragmatic thickening fraction (TF) correlated with asthma severity as determined by the Pediatric Respiratory Assessment Measure (PRAM) score. Secondarily, we examined if these parameters correlated with need for respiratory support and evaluated interrater reliability. We conducted a prospective study of children 5-18 years presenting to a pediatric emergency department with an asthma exacerbation. Diaphragmatic ultrasound was performed by a trained pediatric emergency medicine sonologist in subcostal (DE) and midaxillary (DT). Thickening fraction was calculated from DT values as previously described in literature. To evaluate interrater reliability, a subset of subjects had DUS performed by a second sonologist. We enrolled 47 subjects for a total of 51 encounters. The mean age was 9.1 ± 3.7 years. Twenty-five (49%) had mild, 24 (47%) had moderate, and 2 (4%) had severe asthma. There was a significant difference in midaxillary DT and TF between children with mild and moderate asthma ( P = 0.02; mean difference, 0.2 mm; 95% confidence interval [CI], 0.03-0.4 and P = 0.02; mean difference, 0.11 mm; 95% CI, 0.02-0.2, respectively). No difference was found in subcostal DE ( P = 0.43; mean difference, 1.4 mm; 95% CI, -2.1 to 4.8). No association was found between use of positive pressure and DUS parameters. Fourteen encounters had 2 sonologists perform DUS, with strong interrater reliability found for midaxillary DT (Pearson correlation, 0.56) and poor association for subcostal DE (Pearson correlation, 0.18). In this pilot study, we conclude that DUS may be helpful in assessing severity of asthma. The midaxillary view assessment for DT and TF had the best correlation with asthma severity and the best interrater reliability. Future studies may benefit from focusing on the midaxillary view for DT and TF.

Positive versus negative pressure during removal of endotracheal-tube on prevention of post-extubation atelectasis in ventilated neonates: A randomized controlled trial

BackgroundPost-extubation-atelectasis (PEA) is a common problem after the removal of an endotracheal tube in neonates which increases the rate of extubation failure. Different techniques have been introduced for the prevention of PEA. One technique is the removal of the endotracheal tube by negative or positive gradients of pressure. No RCT has yet been done to compare the use of these two methods in neonates. So this study aimed to compare the role of positive and negative pressure during extubation of neonates on the prevention of PEA. Materials and methodsWe enrolled 100 newborns in this RCT that required at least 24 h of mechanical ventilation. The endotracheal tube in one group was removed by a T-Piece resuscitator at a PEEP level of 5 CmH2o while in another group extubation was done applying suction pressure of 100 mmHg by random selection. Prevalence of PEA in CXRs after extubation was compared between the two groups. ResultsThe prevalence of PEA in the extubation of the positive pressure group (24%) was significantly lower than that of the negative pressure group (46%) (p = 0.024). Extubation failure was found to be lower in the positive pressure group (6% versus 20% P = 0.037). No significant difference was observed between the two groups in the prevalence of apnea, pneumothorax, and death at 3 days after extubation. ConclusionThe use of positive pressure during removal of the endotracheal tube in newborn infants reduced the rate of PEA compared with the negative pressure so extubation by a positive pressure is recommended in neonates.

Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III)

The safety of endoscopist-directed nurse-administered propofol sedation (EDNAPS) has been demonstrated in low-risk patients (American Society of Anesthesiologists [ASA] class I and II). There are limited data regarding the safety of EDNAPS for endoscopic procedures in ASA class III patients. The purpose of this study was to determine the safety of EDNAPS for routine outpatient endoscopy in this population. We retrospectively reviewed all outpatient EGDs and colonoscopies performed with EDNAPS at the University of Utah from January 2015 to November 2018. Exclusion criteria were inpatient procedures, combined procedures, ASA IV or higher, use of continuous or bilevel positive airway pressure at the start of the procedure, or procedures performed by a nongastroenterologist. Major adverse events were defined as intubation or death. Minor adverse events were defined as hypoxia, hypotension, bradycardia, or need for airway interventions. Patients were stratified by procedure type and ASA I/II status and were compared with patients with ASA III status and matched according to age, gender, and the involvement of a fellow in a 3 to 1 fashion. The final sample size was 18,910 colonoscopy procedures (17,205 patients) and 9178 EGD procedures (6827 patients). In both colonoscopy and EGD procedures, there were no major adverse events such as intubation, need for resuscitation, or death. The rates of any airway intervention, jaw thrust, oral nasal airway, or use of positive pressure ventilation were low in both procedure types and not different between ASA I/II and ASA III patients. EDNAPS is safe in both ASA I/II and ASA class III patients undergoing routine outpatient endoscopy.

Improving Airways Patency and Ventilation Through Optimal Positive Pressure Identified by Noninvasive Mechanical Ventilation Titration in Mounier-Kuhn Syndrome: Protocol for an Interventional, Open-Label, Single-Arm Clinical Trial.

BackgroundMounier-Kuhn syndrome or congenital tracheobronchomegaly is a rare disease characterized by dilation of the trachea and the main bronchi within the thoracic cavity. The predominant signs and symptoms of the disease include coughing, purulent and abundant expectoration, dyspnea, snoring, wheezing, and recurrent respiratory infection. Symptoms of the disease in some patients are believed to be pathological manifestations arising due to resident tracheobronchomalacia. Although treatment options used for the management of this disease include inhaled bronchodilators, corticosteroids, and hypertonic solution, there is no consensus on the treatment. The use of continuous positive airway pressure (CPAP) has been reported as a potential therapeutic option for tracheobronchomalacia, but no prospective studies have demonstrated its efficacy in this condition.ObjectiveThe purpose of this is to identify the presence of tracheobronchomalacia and an optimal CPAP pressure that reduces the tracheobronchial collapse in patients with Mounier-Kuhn syndrome and to analyze the repercussion in pulmonary ventilation. In parallel, we aim to evaluate the prevalence of obstructive sleep apnea/hypopnea syndrome.MethodsThis interventional, open-label, single-arm clinical trial will enroll patients who are diagnosed Mounier-Kuhn syndrome. Patient evaluation will be conducted in an outpatient clinic and involve 3 visits. Visit 1 will involve the collection and registration of social demographic, clinical, and functional data. Visit 2 will entail polysomnography, bronchoscopy for the evaluation of tracheobronchomalacia, titration of the optimal pressure that reduces the degree of collapse of the airway, and electrical impedance tomography. In visit 3, patients exhibiting a reduction in collapse areas will be requested to undergo chest computed tomography during inspiration and forced expiration with and without positive pressure (titrated to determine optimal CPAP pressure).ResultsThis protocol is a doctorate project. The project was submitted to the institutional review board on January 24, 2017, and approval was granted on February 2, 2017 (Brazilian Research database number CAAE 64001317.4.000.0068). Patient evaluations started in April 2018. Planned recruitment is based on volunteers’ availability and clinical stability, and interventions will be conducted at least once a month to finish the project at the end of 2020. A preliminary analysis of each case will be performed after each intervention, but detailed results are expected to be reported in the first quarter of 2021.ConclusionsThere is no consensus on the best treatment options for managing Mounier-Kuhn syndrome. The use of positive pressure could maintain patency of the collapsed airways, functioning as a “pneumatic stent” to reduce the degree of airflow obstruction. This, in turn, could promote mobilization of thoracic secretion and improve pulmonary ventilation.Trial RegistrationClinicalTrails.gov NCT03101059; https://clinicaltrials.gov/ct2/show/NCT03101059.International Registered Report Identifier (IRRID)DERR1-10.2196/14786

Clinical Implementation of the Use of Positive Pressure in Chest Drainage

Clinical Implementation of the Use of Positive Pressure in Chest Drainage

Failure of noninvasive ventilation in adult patients with acute asthma exacerbation.

Failure of noninvasive ventilation in adult patients with acute asthma exacerbation.

Incidence and Determinants of Port Occlusions in Cancer Outpatients: A Prospective Cohort Study.

Normal saline is considered a safe alternative for heparin as a locking solution in totally implantable venous access devices. The incidence rate of partial occlusion with the use of normal saline (easy injection, impossible aspiration) is estimated at 4%. The aim of this study was to investigate determinants of partial occlusions with the use of normal saline solution and the maintenance of positive pressure in the catheter. We enrolled 218 patients with different solid tumors who underwent pharmacologic treatment through the port with different frequencies: from once every week to at least once every month. The port was flushed with normal saline solution keeping a positive pressure in the catheter. We performed 4111 observations and documented normal port functioning in 99% of observations (n = 4057) and partial occlusions in 1% of observations (n = 54). Partial occlusions were significantly associated with frequency of port flushing (P < .05), chemotherapy (P < .001), and blood sample collection (P < .001). The use of positive pressure in addition to normal saline reduces the incidence rate of partial occlusions. The type of treatment, blood sample collection, and treatment schedule are important determinants of partial occlusions. Nurses play a key role in maintaining a functioning port using positive pressure during the flushing techniques. Certain risk factors must be monitored to prevent partial occlusions, and certain patients are more likely to present with port-related problems.

Validez y confiabilidad del instrumento “Medición de la autoeficacia percibida en apnea del sueño” - SEMSA. Versión en español

Objetivo: determinar la validez y la consistencia interna del instrumento “Medición de la autoeficacia percibida en apnea del sueño” - SEMSA, versión en español, diseñado por Weaver et al. Materiales y métodos: estudio de tipo descriptivo metodológico; se determinó la validez facial y de contenido con panel de expertos y un literato bilingüe. La muestra de la validez de constructo y consistencia interna fue de 151 pacientes con síndrome de apnea hipopnea del sueño que usaron el tratamiento de presión positiva continua en la vía aérea (CPAP). Resultados: la validez facial mostró un índice de aceptabilidad superior en las tres categorías evaluadas. En la validez de contenido, 23 ítems alcanzaron un nivel de aceptabilidad satisfactorio y los 4 ítems restantes fueron susceptibles de modificación. En la validez de constructo, el análisis factorial exploratorio determinó tres factores con una varianza total explicada de 52,2 %. La consistencia interna por el alfa de Cronbach fue 0,90 para la escala total y para cada dimensión mayor de 0,84. Discusión: la varianza total explicada comparándola con el estudio original fue mayor y el alfa de Cronbach fue similar tanto en la escala total como dimensional. Conclusión: el instrumento Self Efficacy Measure Sleep Apnea, válido y homogéneo en el contexto urbano colombiano, es una herramienta relevante y objetiva acerca de las perspectivas del paciente con síndrome de apnea hipopnea del sueño sobre los riesgos asociados, el beneficio del tratamiento y el cumplimiento en el uso de presión positiva (CPAP), a pesar de las barreras percibidas.

Use of positive pressure in preoperative and intraoperative of bariatric surgery and its effect on the time of extubation

Background and objectiveTo investigate the influence of intraoperative and preoperative positive pressure in the time of extubation in patients undergoing bariatric surgery. MethodRandomized clinical trial, in which 40 individuals with a body mass index between 40 and 55kg/m2, age between 25 and 55 years, nonsmokers, underwent bariatric surgery type Roux-en-Y gastric bypass by laparotomy and with normal preoperative pulmonary function were randomized into the following groups: G-pre (n=10): individuals who received treatment with noninvasive positive pressure before surgery for 1h; G-intra (n=10): individuals who received positive end-expiratory pressure of 10cm H2O throughout the surgical procedure; and G-control (n=20): not received any preoperative or intraoperative intervention. Following were recorded: time between induction of anesthesia and extubation, between the end of anesthesia and extubation, duration of mechanical ventilation, and time between extubation and discharge from the post-anesthetic recovery. ResultsThere was no statistical difference between groups. However, when applied to the Cohen coefficient, the use of positive end-expiratory pressure of 10cm H2O during surgery showed a large effect on the time between the end of anesthesia and extubation. About this same time, the treatment performed preoperatively showed moderate effect. ConclusionThe use of positive end-expiratory pressure of 10cm H2O in the intraoperative and positive pressure preoperatively, influenced the time of extubation of patients undergoing bariatric surgery.

Use of positive pressure in the bariatric surgery and effects on pulmonary function and prevalence of atelectasis: randomized and blinded clinical trial.

BackgroundIn surgical procedures, obesity is a risk factor for the onset of intra and postoperative respiratory complications.AimDetermine what moment of application of positive pressure brings better benefits on lung function, incidence of atelectasis and diaphragmatic excursion, in the preoperative, intraoperative or immediate postoperative period.MethodRandomized, controlled, blinded study, conducted in a hospital and included subjects with BMI between 40 and 55 kg/m2, 25 and 55 years, underwent bariatric surgery by laparotomy. They were underwent preoperative and postoperative evaluations. They were allocated into four different groups: 1) Gpre: treated with positive pressure in the BiPAP mode (Bi-Level Positive Airway Pressure) before surgery for one hour; 2) Gpos: BIPAP after surgery for one hour; 3) Gintra: PEEP (Positive End Expiratory Pressure) at 10 cmH2O during the surgery; 4) Gcontrol: only conventional respiratory physiotherapy. The evaluation consisted of anthropometric data, pulmonary function tests and chest radiography.ResultsWere allocated 40 patients, 10 in each group. There were significant differences for the expiratory reserve volume and percentage of the predicted expiratory reserve volume, in which the groups that received treatment showed a smaller loss in expiratory reserve volume from the preoperative to postoperative stages. The postoperative radiographic analysis showed a 25% prevalence of atelectasis for Gcontrol, 11.1% for Gintra, 10% for Gpre, and 0% for Gpos. There was no significant difference in diaphragmatic mobility amongst the groups.ConclusionThe optimal time of application of positive pressure is in the immediate postoperative period, immediately after extubation, because it reduces the incidence of atelectasis and there is reduction of loss of expiratory reserve volume.

Complications of Laryngeal Masks in Children

Complications of Laryngeal Masks in Children

Drug-induced sleep endoscopy in adults with sleep-disordered breathing: Technique and the VOTE Classification system

Drug-induced sleep endoscopy (DISE) offers an unique evaluation of the upper airway. After pharmacologic induction of unconscious sedation, it is possible to evaluate endoscopically the structures contributing to upper airway obstruction in sleep disordered breathing. The authors describe DISE techniques and the VOTE classification system for reporting of DISE findings. The VOTE classification focuses on the primary structures that contribute to upper airway obstruction and represents a common language to describe the patterns of obstruction during DISE. The latter can facilitate the scientific evaluation of DISE, including its role in directing treatment.

Negative Pressure Ventilation as a Therapy for Post-operative Complications in a Patient with Single Ventricle Physiology

To report the use of negative pressure ventilation as a therapeutic rescue in a patient with post-operative complications of Kawashima procedure. Case report. Paediatric cardiac critical care unit in a tertiary care teaching hospital. Nine month-old patient with single ventricle physiology developed complications after Kawashima procedure that were worsened by use of positive pressure ventilation. Utilisation of negative pressure ventilation due to its unique cardiopulmonary interactions and haemodynamic effects. There was gradual and persistent improvement in the passive diastolic pulmonary blood flow through the Kawashima circuit along with improvement in oxygenation and ventilation. The patient was successfully weaned off ventilator support and discharged to home. Patients with single ventricle physiology depend on passive diastolic blood flow to the lungs through surgical pathways such as Fontan or Kawashima circuits. Prolonged use of positive pressure ventilation can significantly affect this forward flow and result in haemodynamic compromise. Use of negative pressure ventilation with its unique cardiopulmonary interactions can be an effective rescue as demonstrated in our case.

Totally Implantable Port Management: Impact of Positive Pressure during Needle Withdrawal on Catheter Tip Occlusion (An Experimental Study)

Totally implanted ports (TIP) have become a standard part of patient care, providing long-term central venous access for treatment administration and other procedures. Despite overall the safety and effectiveness of TIP, complications still occur. Negative pressure created during needle withdrawal induces blood reflux and subsequent catheter occlusion. Application of positive pressure during needle withdrawal is thought to largely prevent such reflux, but supporting data are limited. To quantify the role of positive pressure, using a test model designed to simulate physiological conditions. Reflux associated with needle withdrawal with and without applied positive pressure was tested using various TIP models from different manufacturers mounted on a specially designed test bench. In addition to the presence or absence of positive pressure during needle withdrawal, study variables comprised of needle type (safety and standard), needle gauge and port septum diameter. Application of positive pressure during needle withdrawal reduced the incidence of reflux during needle withdrawal by nearly 80% (22% vs. 99%, p<0.001). When reflux did occur, the mean residual volume was half that observed without positive pressure. In the absence of positive pressure, mean reflux increased with septum diameter and needle gauge to a statistically significant extent. None of these variables significantly affected reflux in the context of needle withdrawal under positive pressure. The results of this study support the use of positive pressure during needle withdrawal to prevent blood reflux potentially leading to catheter tip occlusion.

Barotrauma Not Related to Type of Positive Pressure Ventilation During Severe Asthma Exacerbations in Children

Background: Children with impending respiratory failure due to severe asthma may be treated with endotracheal intubation and mechanical ventilation. Barotrauma occurs in a significant number of these children. Non-invasive positive pressure ventilation (NPPV) has been used as an alternative intermediary therapy and potentially prevents intubation. However, the comparative risk of barotrauma associated with the use of NPPV has not been evaluated in this population. Objective: To determine if the mode of positive pressure delivery per se affects the likelihood of development of barotrauma. Methods: We retrospectively examined data from all children older than 2 years of age admitted to the Intensive Care Unit (ICU) with an asthma exacerbation between April 1997 and August 2006. Results: Of the 293 children admitted to the ICU with asthma, 45 (17%) received treatment with positive pressure ventilation: 11 received only NPPV, 29 were intubated and mechanically ventilated, and 7 children received both of these therapies. Compared with those not requiring positive pressure, children receiving positive pressure were significantly more likely to develop barotrauma during hospitalization (OR 8.9; 95% CI 2.4–32.7). However, the incidence of barotrauma did not significantly differ according to the mode of positive pressure delivery: 9% in those who received only NPPV, 14% in those who were intubated, and 14% in those who received both therapies (p = 0.92). Conclusions: The use of positive pressure is associated with an increased risk of barotrauma in children with asthma, regardless of the mode of delivery.

POSITIVE PRESSURE AND THE DEVELOPMENT OF EXTRAPULMONARY AIR LEAKS IN PEDIATRIC STATUS ASTHMATICUS

PURPOSE: Endotracheal intubation and mechanical ventilation are frequently undertaken in children with status asthmaticus and impending respiratory failure. However, the use of positive pressure for pediatric status asthmaticus is thought to be associated with the development of extrapulmonary air leaks. Non-invasive positive pressure ventilation (NPPV) has been used as an alternative intermediary therapy in some children. The purpose of this study was to determine if the mode of positive pressure delivery per se affects the likelihood of development of an extrapulmonary air leak.

1564 ORAL Substitution of the heparinized solution with the use of positive pressure and a normal saline solution when washing indwelling ports in oncological patients

Although the use of peripherally inserted central catheters (PICCs) has increased in burn patient treatment, little is known about the subjective experiences of these patients with PICCs. These experiences may be similar to those of other patients, particularly cancer patients receiving long term care but it is not clear if this is the case. Burn patients’ exposure to skin injury may result in pain and apprehension similar but different from that felt by cancer patients. The aim of this study was to explore the subjective experiences of PICC insertion procedures among burn patients treated and managed in a burn center in South Korea.A qualitative descriptive study was conducted using focus group interviews. Twenty-two participants who experienced of PICC insertion procedures participated in audio-taped focus groups sessions. Qualitative content analysis was used to identify categories of discussion depicting participants’ subjective experience with PICC procedures.Three categories of PICC subjective experience were identified: (a) distress: painful burn treatments and repeated venipunctures, (b) PICC insertion: short and endurable, and (c) use of PICC: lots of pros and a few cons.The major findings from our focus group interviews were that frequent venipunctures are a significant sources of distress for burn patients. However, most participants reported that PICC provided a very convenient route for venous infiltration and for that they were generally positive about the procedure. This knowledge may enable clinicians to better the needs of their patients when undergoing PICC insertion and management.

Doxapram treatment for apnea in preterm infants.

Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia which may be severe enough to require resuscitation including use of positive pressure ventilation. Doxapram has been used to stimulate breathing and so prevent apnea and its consequences. In preterm infants with recurrent apnea, does treatment with Doxapram lead to a clinically important reduction in apnea and use of intermittent positive airways pressure (IPPV), without clinically important side effects? Searches were made of the Oxford Database of Perinatal trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), MEDLINE from 1966 - June 2004, EMBASE from 1980 - June 2001, CINAHL from 1982- June 2004. Text words 'doxapram', 'apnea or apnoea' and the MeSH term 'infant, premature' were used. Previous reviews including cross references, abstracts from conferences and symposia proceedings were also examined. Abstracts of the Society for Pediatric Research were searched from 1996 - 2004 inclusive. All trials utilising random or quasi-random patient allocation, in which doxapram was used for the treatment of apnea in preterm infants were included. Each author evaluated the papers for quality and inclusion criteria. Independent data extraction was carried out. Only one trial, which randomized 11 infants to intravenous doxapram and 10 infants to placebo, was found. There were fewer treatment failures after 48 hours in the group of preterm infants treated with doxapram (4/11) compared with the group treated with placebo (8/10). The wide confidence intervals made this result non-significant [RR 0.45 (0.20, 1.05)]. Only one infant, who was from the placebo group, was given IPPV. Of the seven responders by 48 hours in the group of 11 who received doxapram, five failed to respond between 48 hours and seven days after commencement of therapy. This gives a late failure rate of 9/11, similar to the short term failure rate in the placebo group of 8/10. It is not possible to evaluate the late responses of all those in the placebo group since they crossed over to a treatment arm. Although intravenous Doxapram might reduce apnea within the first 48 hours of treatment, there are insufficient data to evaluate the precision of this result or to assess potential adverse effects. No long term outcomes have been measured. Further studies are needed to determine the role of this treatment in clinical practice.

Doxapram treatment for apnea in preterm infants.

Recurrent apnea is common in preterm infants, particularly at very early gestational ages. These episodes of loss of effective breathing can lead to hypoxemia and bradycardia which may be severe enough to require resuscitation including use of positive pressure ventilation. Doxapram has been used to stimulate breathing and so prevent apnea and its consequences. In preterm infants with recurrent apnea, does treatment with doxapram lead to a clinically important reduction in apnea and use of Intermittent positive airways pressure (IPPV), without clinically important side effects? Searches were made of the Oxford Database of Perinatal trials, the Cochrane Collaboration Clinical Trials Register, MEDLINE (using text words 'doxapram', 'apnea or apnoea' and Mesh term 'infant, premature') previous reviews including cross references, abstracts, conferences and symposia proceedings, expert informants, mainly in the English language. Also an expert informant's search in the Japanese language was made by Prof. Y. Ogawa in 1996. All trials utilising random or quasi-random patient allocation, in which doxapram was used for the treatment of apnea in preterm infants were included. Each author evaluated the papers for quality and inclusion criteria. Independent data extraction was carried out. Only one trial, which randomized 11 infants to intravenous doxapram and 10 infants to placebo, was found. There were fewer treatment failures after 48 hours in the group of preterm infants treated with doxapram (4/11) compared with the group treated with placebo (8/10). The wide confidence intervals made this result non-significant [RR 0.45 (0.20, 1.05)]. Only one infant, who was from the placebo group, was given IPPV. Of the seven responders by 48 hours in the group of 11 who received doxapram, five failed to respond between 48 hours and seven days after commencement of therapy. This gives a late failure rate of 9/11, similar to the short term failure rate in the placebo group of 8/10. It is not possible to evaluate the late responses of all those in the placebo group since they crossed over to a treatment arm. Although intravenous doxapram might reduce apnea within the first 48 hours of treatment, there are insufficient data to evaluate the precision of this result or to assess potential adverse effects. No longterm outcomes have been measured. Further studies are needed to determine the role of this treatment in clinical practice.