WORKSHEET for Evidence-Based Review of Science for Emergency Cardiac Care
Worksheet author(s)
HAN-SUK KIM, MD, PHD
Date Submitted for review (Day Month Year)
Clinical question
In newborns receiving ventilation during resuscitation (P), is using a T-piece resuscitator or a selfinflating bag with PEEP (I) better than using a self-inflating bag without PEEP (C) in achieving
spontaneous breathing, reducing incidence of pneumothoraces, BPD and mortality (O)?
Population: Newborns receiving ventilation (PPV) during resuscitation
Intervention: Using a T-piece resuscitator or a self-inflating bag with PEEP
Comparison: Using a self-inflating bag without PEEP
Outcomes: achieving spontaneous breathing (critical 7), reducing incidence of pneumothoraces
(critical 7), BPD (critical 7) and mortality (critical 9)
Is this question addressing an intervention/therapy, prognosis or diagnosis: Intervention
This is a new worksheet
Conflict of interest specific to this question
Do any of the authors listed above have conflict of interest disclosures relevant to this worksheet?


Commercial/industry;None
Potential intellectual conflicts;None
Search strategy
PubMed
Date Searched: April 24, 2014
Number of Results: 354
((((((((((((("Masks"[Mesh:NoExp]) OR Insufflation[MeSH Terms]) OR self-inflating bag[Title/Abstract])
OR bag valve mask[Title/Abstract]) OR Ambu bag[Title/Abstract]) OR manual
resuscitator*[Title/Abstract]) OR t-piece resuscitator*[Title/Abstract]) OR "Ventilators,
Mechanical"[Mesh:NoExp])) AND (((((Positive-Pressure Respiration[MeSH Terms]) OR positive end
expiratory pressure*[Title/Abstract]) OR PEEP[Title/Abstract]) OR positive pressure
respiration[Title/Abstract]) OR positive pressure ventilation[Title/Abstract]))) AND ((("Respiratory
Distress Syndrome, Newborn"[Mesh] OR "Bronchopulmonary Dysplasia"[Mesh] OR "Infant,
Newborn"[Mesh] OR "Delivery Rooms"[Mesh] OR "Gestational Age"[Mesh] OR "Premature
Birth"[Mesh] OR "Infant, Premature, Diseases"[Mesh:NoExp] OR "Term Birth"[Mesh] OR "Live
Birth"[Mesh] OR "Birth Injuries"[Mesh] OR "Birthing Centers"[Mesh] OR "Neonatal Nursing"[Mesh]
OR "Neonatal Screening"[Mesh] OR "Intensive Care, Neonatal"[Mesh] OR "Intensive Care Units,
Neonatal"[Mesh] OR "Animals, Newborn"[Mesh] OR "Transient Tachypnea of the Newborn"[Mesh]
OR "Persistent Fetal Circulation Syndrome"[Mesh] or newborn[TIAB] or neonatal[TIAB] or
neonate[TIAB] or neonates[TIAB] OR "Low Birth Weight "[TIAB] or "Small for Gestational Age"[TIAB]
or prematur*[TIAB] or preterm[TIAB] OR infant[TIAB] OR infants[TIAB] OR birth[TIAB] OR "delivery
room"[TIAB]))))) NOT ((animals[mh] NOT humans[mh]))
Cochrane
Date Searched: April 24, 2014
Number of Results: 48
([mh ^Masks] OR [mh Insufflation] OR [mh ^"Ventilators, Mechanical"] OR "self inflating bag":ab,ti
OR "bag valve mask":ab,ti OR "Ambu bag":ab,ti OR "manual resuscitator*":ab,ti OR "t-piece
resuscitator":ab,ti) AND ([mh "Positive-Pressure Respiration"] OR "positive end expiratory
pressure*":ab,ti OR PEEP:ab,ti OR "positive pressure respiration":ab,ti OR "positive pressure
ventilation":ab,ti) AND ([mh "Respiratory Distress Syndrome, Newborn"] or [mh "Bronchopulmonary
Dysplasia"] or [mh "Infant, Newborn"] or [mh "Delivery Rooms"] or [mh "Gestational Age"] or [mh
"Premature Birth"] or [mh ^"Infant, Premature, Diseases"] or [mh "Term Birth"] or [mh "Live Birth"]
or [mh "Neonatal Nursing"] or [mh "Neonatal Screening"] or [mh "Intensive Care, Neonatal"] or [mh
"Intensive Care Units, Neonatal"] or [mh "Animals, Newborn"] or [mh "Transient Tachypnea of the
Newborn"] or [mh "Persistent Fetal Circulation Syndrome"] or newborn:ti,ab or neonatal:ti,ab or
neonate:ti,ab or neonates:ti,ab or "Low Birth Weight ":ti,ab or "Small for Gestational Age":ti,ab or
prematur*:ti,ab or preterm:ti,ab or [mh "Birth Injuries"] or [mh "Birthing Centers"] or
Postmature:ti,ab or infant:ti,ab or infants:ti,ab or birth:ti,ab)
Embase
Date Searched: April 24, 2014
Number of Results: 207
'face mask'/exp OR 'mechanical ventilator'/de OR 'manual ventilation'/de OR 'self inflating bag':ab,ti
OR 'bag valve mask':ab,ti OR 'ambu bag':ab,ti OR (manual NEXT/1 resuscitator*):ab,ti OR ('t piece'
NEXT/1 resuscitator*):ab,ti AND ('positive end expiratory pressure'/de OR 'positive end expiratory
pressure':ab,ti OR 'positive end expiratory pressures':ab,ti OR peep:ab,ti OR 'positive pressure
respiration':ab,ti OR 'positive pressure ventilation':ab,ti) AND ('neonatal respiratory distress
syndrome'/exp OR 'newborn hypoxia'/exp OR 'prematurity'/exp OR 'newborn apnea attack'/exp OR
'newborn disease'/de OR 'neonatal stress'/exp OR 'lung dysplasia'/exp OR 'newborn'/exp OR 'low
birth weight'/exp OR 'newborn screening'/exp OR 'newborn monitoring'/exp OR 'newborn care'/exp
OR 'newborn period'/exp OR 'birth weight'/exp OR 'newborn morbidity'/exp OR 'live birth'/exp OR
'newborn death'/exp OR 'newborn mortality'/exp OR 'delivery room'/exp OR newborn OR 'low birth
weight':ab,ti OR 'small for gestational age':ab,ti OR prematur*:ab,ti OR preterm:ab,ti OR
postmature:ab,ti OR 'macrosomia'/exp) NOT ('animal'/exp NOT 'human'/exp) AND [embase]/lim
Search notes:
•
State inclusion and exclusion criteria

Included all studies with concurrent controls.
 Excluded review articles, studies with historical controls, animal studies, and studies
that did not specifically answer the question. Excluded unpublished studies, studies
only published in abstract form, unless accepted for publication.
Number of articles/sources meeting criteria for further review: 2 Articles Finally Evaluated
-Dawson JA, Schmölzer GM, Kamlin CO, Te Pas AB, O'Donnell CP, Donath SM, Davis PG, Morley CJ.
Oxygenation with T-piece versus self-inflating bag for ventilation of extremely preterm infants at
birth: a randomized controlled trial.
J Pediatr. 2011 Jun;158(6):912-918.e1-2.
--Szyld E, Aguilar A, Musante GA, Vain N, Prudent L, Fabres J, Carlo WA; Delivery Room Ventilation
Devices Trial Group. Comparison of Devices for Newborn Ventilation in the Delivery Room. J Pediatr.
2014 Aug;165(2):234-239.
Characteristics of included studies (alphabetical)
Dawson 2011, 912
Methods
This is a single-center, stratified, open-label randomized trial.
Infants were randomly allocated to PPV with the T-piece or SIB. Allocation was
stratified in gestational age groups (23 to 26 weeks and 27 to 28 weeks) and block
randomized with variable sized blocks (4 to 8). A sequentially numbered, sealed,
opaque envelope containing the allocation was opened by a researcher when the
resuscitation trolley was set-up and checked in the delivery room before the birth of
an eligible infant. A member of the research team ensured that the allocated
resuscitation equipment was available on the resuscitation trolley. The randomized
device was used when PPV was required in the first 5 minutes. Twins and triplets were
randomized as individuals. Caregivers were not masked to the allocated device. All
other resuscitative measures (eg, intubation, cardiac massage, and administration of
oxygen or other drugs) were at the discretion of the clinical staff involved, following a
standardized protocol. The alternative device was available when there was a failure
of the allocated device.
Infants received PPV with the allocated device, either the Neopuff T-piece (Neopuff
Infant Resuscitator Fisher & Paykel Healthcare, Auckland, New Zealand) or the Laerdal
240 mL self- inflating bag (Laerdal Silicone Resuscitator Preterm, Laerdal, Stavanger,
Norway) without a PEEP valve attached according to a standard protocol for that
device.
Participants
Infants born at <29 weeks gestation who received PPV in the delivery room in the first
5 minutes after birth because of inadequate respiration, a heart rate (HR) <100 bpm,
or both were eligible for enrollment. Infants were excluded when there was
uncertainty about their gestational age or when they had a congenital abnormality
that might have an adverse effect on breathing.
99 of 253 eligible infants were included and finally 80 infants were analyzed.
Interventions
Comparisons
Outcomes
Using T-piece resuscitator
Using SIB without PEEP
Primary outcome: SpO2 at 5 minutes afterbirth
Secondary outcomes: Respiratory variables and clinical outcomes including air leaks,
first 24 hr after birth, supplemental oxygen or respiratory support at 36 weeks PMA,
and death before hospital discharge.
Notes
Limitation
Randomization
Allocation
concealment
Reviewer’s
judgment of
risk
Low risk
Low risk
Support for judgment
Infants were randomly allocated to PPV with the T-piece or SIB.
Allocation was stratified in gestational age groups (23 to 26 weeks
and 27 to 28 weeks) and block randomized with variable sized blocks
(4 to 8).
A sequentially numbered, sealed, opaque envelope containing the
allocation was opened by a researcher when the resuscitation trolley
was set-up and checked in the delivery room before the birth of an
eligible infant.
Blinding
Incomplete
accounting and
outcomes
assessed
Severe
limitation
Low risk
Selective
outcome
reporting bias
Unlikely
Other
limitations
Not detected
This is an open label trial.
99 of 253 eligible infants were included and finally 80 infants were
analyzed. The reasons of post randomization exclusion were well
described; IPPV not given( n=10, T-piece: SIB=4:6), Oximeter
malfunction(n=3, , T-piece: SIB=2:1), no consent (n=6, , T-piece:
SIB=2:4)
Not detected
Szyld 2014, 234
Limitation
Randomization
Allocation
concealment
Blinding
Incomplete
accounting and
outcomes
assessed
Selective
outcome
reporting bias
Other
limitations
(carryover
effect in
crossover trial)
Reviewer’s
judgment of
risk
Low risk
Severe
limitation
Severe
limitation
Low risk
Support for judgment
The order of intervention was assigned at random, and the group
assignment was not submitted to the centers until study initiation.
This is a cluster-randomized trial.
This is an open-label trial.
1027 of 1032 enrolled infants were subjected to final analysis. The
reasons of post enrollment exclusion were informed consent
withdrawn (n=1, T-piece), unknown primary outcomes(n=4, T-piece:
SIB=3:1)
Unlikely
Unclear
There was an interval without intervention (washout period),
however no data was shown about carryover effect.
Risk of Bias in studies table
Study
Allocation
concealment
Blinding
Incomplete
accounting
Selective
outcome
reporting
bias
Other
limitations
Szyld
2014
Serious
limitation
Serious
limitation
No
unlikely
Not
detected
Dawson
2011
No
Serious
limitation
No
unlikely
Not
detected
Outcomes
to which
these
assessments
apply
-Achieving
spontaneous
breathing
- Air leaks
- BPD
- Survival to
hospital
discharge
-Achieving
spontaneous
breathing
- Air leaks
- BPD
- Survival to
hospital
discharge
Overall risk
of bias for
outcome(s)
for study
Moderate
risk
Low risk
Evidence finding Tables
1) Achieving spontaneous breathing (incidence of intubation in delivery room)
T-piece
SIB without PEEP
RR
95% CI
Dawson 2011
26/49
19/50
1.40
0.90-2.17
Szyld 2014
31/226
53/226
0.58
0.39-0.88
*Heterogeneity p=0.006, I2=87% (*There is difference in study population in mean
gestational age: Dawson; 27w GA, Szyld; 36w GA)
2) Air leaks
T-piece
Dawson 2011
Szyld 2014
1/41
6/226
SIB without PEEP
2/39
2/226
RR
0.48
3.00
95% CI
0.04-5.04
0.61-14.71
3) BPD
Dawson 2011
Szyld 2014
T-piece
15/41
9/30
SIB without PEEP
11/39
19/41
RR
1.30
0.65
95% CI
0.68-2.47
0.34-1.23
Szyld’s study: subgroup analysis in infants with born body weight <1,500 gr.
4) Survival to hospital discharge
T-piece
Szyld 2014
2/41
Dawson 2011
14/52
SIB without PEEP
6/39
6/43
RR
0.32
1.93
95% CI
0.07-1.48
0.81-4.59
Grade table
REVIEWER’S FINAL COMMENTS AND ASSESSMENT OF BENEFIT / RISK:
Conclusion
CONSENSUS ON SCIENCE:
Routine use of a T-piece resuscitator or a self-inflating bag with PEEP in comparison with a selfinflating bag without PEEP for newborns (preterm and term) receiving ventilation (PPV) during
delivery room resuscitation;
For the important outcome of “Achieving spontaneous breathing” or “ Reducing intubation in
delivery room”, we have identified very low evidence (downgraded for Risk of bias, inconsistency
and imprecision) from 2 RCTs enrolling 551 patients showing no benefit (RR 0.80, 95% CI 0.59 to
1.07).
For the critical outcome of “Air leaks” we have identified low evidence (downgraded for Risk of bias
and imprecision) from 2 RCTs enrolling 532 patients showing no benefit (RR 1.72, 95% CI 0.51 to
5.78).
For the important outcome of “BPD” we have identified low evidence (downgraded for Risk of bias
and imprecision) from 3 RCTs enrolling 151 patients showing no benefit (RR 0.92, 95% CI 0.59 to
1.43).
For the critical outcome of “Death before discharge” we have identified low evidence (downgraded
for Risk of bias and imprecision) from 2 RCTs enrolling 532 patients showing no benefit (OR 0.68,
95% CI 0.3 to 1.56).
TREATMENT RECOMMENDATION (including direction, quality of evidence and strength of
evidence grade*):
We suggest ventilation can be performed comparably with a self-inflating bag with PEEP, T-piece
resuscitator or a self-inflating bag without PEEP in newborns receiving ventilation (PPV) during
delivery room resuscitation (Weak recommendation, very low and low quality of evidence)
We recognized that use of T-piece resuscitator shows marginal but not statistical significant
benefits for clinical outcome of achieving spontaneous breathing. In making this suggestion, we also
place a value on impacts on resource use and feasibility in resource limited setting.
Acknowledgements:
* Strength of Recommendation
 Strong: the desirable effects of an intervention clearly outweigh the undesirable effects, or clearly do
not.
For patients—most people in your situation would want the recommended course of action and only a small
proportion would not; request discussion if the intervention is not offered
For clinicians—most patients should receive the recommended course of action

Weak: the trade-offs are less certain—either because of low quality evidence or because evidence
suggests that desirable and undesirable effects are closely balanced.
For patients—most people in your situation would want the recommended course of action, but many would
not
For clinicians—you should recognise that different choices will be appropriate for different patients and that
you must help each patient to arrive at a management decision consistent with her or his values and
preferences
Strength of Evidence Grade Definition
High: We are very confident that the true effect lies close to that of the estimate of the effect
Moderate: We are moderately confident in the effect estimate: The true effect is likely to be close to the
estimate of the effect, but there is a possibility that it is substantially different.
Low: Our confidence in the effect estimate is limited: The true effect may be substantially different from the
estimate of the effect.
Very low: We have very little confidence in the effect estimate: The true effect is likely to be substantially
different from the estimate of effect.
Citation lists
(Included: 2 articles)
Dawson, J. A., et al. (2011). "Oxygenation with T-piece versus self-inflating bag for
ventilation of extremely preterm infants at birth: a randomized controlled trial." The Journal
of pediatrics 158(6): 912-918.e911-912.
To investigate whether infants < 29 weeks gestation who receive positive pressure
ventilation (PPV) immediately after birth with a T-piece have higher oxygen saturation
(SpO��) measurements at 5 minutes than infants ventilated with a self inflating bag
(SIB).Randomized, controlled trial of T-piece or SIB ventilation in which SpO�� was
recorded immediately after birth from the right hand/wrist with a Masimo Radical pulse
oximeter, set at 2-second averaging and maximum sensitivity. All resuscitations started with
air.Forty-one infants received PPV with a T-piece and 39 infants received PPV with a SIB.
At 5 minutes after birth, there was no significant difference between the median (interquartile
range) SpO�� in the T-piece and SIB groups (61% [13% to 72%] versus 55% [42% to
67%]; P = .27). More infants in the T-piece group received oxygen during delivery room
resuscitation (41 [100%] versus 35 [90%], P = .04). There was no difference in the groups in
the use of continuous positive airway pressure, endotracheal intubation, or administration of
surfactant in the delivery room.There was no significant difference in SpO�� at 5 minutes
after birth in infants < 29 weeks gestation given PPV with a T-piece or a SIB as used in this
study.Crown Copyright ? 2011. Published by Mosby, Inc. All rights reserved.
Szyld, E., et al. (2014). "Comparison of Devices for Newborn Ventilation in the Delivery
Room." The Journal of pediatrics.
To evaluate the effectiveness and safety of a T-piece resuscitator compared with a
self-inflating bag for providing mask ventilation to newborns at birth.Newborns at
��26?weeks gestational age receiving positive-pressure ventilation at birth were included
in this multicenter cluster-randomized 2-period crossover trial. Positive-pressure ventilation
was provided with either a self-inflating bag (self-inflating bag group) with or without a
positive end-expiratory pressure valve or a T-piece with a positive end-expiratory pressure
valve (T-piece group). Delivery room management followed American Academy of
Pediatrics and International Liaison Committee on Resuscitation guidelines. The primary
outcome was the proportion of newborns with heart rate (HR) ��100 bpm at 2?minutes
after birth.A total of 1027 newborns were included. There was no statistically significant
difference in the incidence of HR?��100 bpm at 2?minutes after birth between the T-piece
and self-inflating bag groups: 94% (479 of 511) and 90% (466 of 516), respectively (OR,
0.65; 95% CI, 0.41-1.05; P?=?.08). A total of 86 newborns (17%) in the T-piece group and
134 newborns (26%) in the self-inflating bag group were intubated in the delivery room (OR,
0.58; 95% CI, 0.4-0.8; P?=?.002). The mean?��?SD maximum positive inspiratory
pressure was 26?��?2?cm H2O in the T-piece group vs 28?��?5?cm H2O in the selfinflating bag group (P?<?.001). Air leaks, use of drugs/chest compressions, mortality, and
days on mechanical ventilation did not differ significantly between groups.There was no
difference between the T-piece resuscitator and a self-inflating bag in achieving an HR of
��100 bpm at 2?minutes in newborns ��26?weeks?gestational age resuscitated at birth.
However, use of the T-piece decreased the intubation rate and the maximum pressures
applied.Copyright ? 2014 Mosby, Inc. All rights reserved.
(Excluded by full text evaluation: 35 articles)
Finer, N. N., et al. (2004). "Delivery room continuous positive airway pressure/positive endexpiratory pressure in extremely low birth weight infants: a feasibility trial." Pediatrics
114(3): 651-657.
Although earlier studies have suggested that early continuous airway positive
pressure (CPAP) may be beneficial in reducing ventilator dependence and subsequent chronic
lung disease in the extremely low birth weight (ELBW) infant, the time of initiation of CPAP
has varied, and there are no prospective studies of infants who have received CPAP or
positive end-expiratory pressure (PEEP) from initial resuscitation in the delivery room (DR).
Current practice for the ELBW infant includes early intubation and the administration of
prophylactic surfactant, often in the DR. The feasibility of initiating CPAP in the DR and
continuing this therapy without intubation for surfactant has never been determined
prospectively in a population of ELBW infants. This study was designed to determine the
feasibility of randomizing ELBW infants of <28 weeks' gestation to CPAP/PEEP or no
CPAP/PEEP during resuscitation immediately after delivery, avoiding routine DR intubation
for surfactant administration, initiating CPAP on neonatal intensive care unit (NICU)
admission, and assessing compliance with subsequent intubation criteria.Infants who were of
<28 weeks' gestation, who were born in 5 National Institute of Child Health and Human
Development Neonatal Research Network NICUs from July 2002 to January 2003, and for
whom a decision had been made to provide full treatment after birth were randomized to
receive either CPAP/PEEP or not using a neonatal T-piece resuscitator (NeoPuff). Infants
would not be intubated for the sole purpose of surfactant administration in the DR. After
admission to the NICU, all nonintubated infants were placed on CPAP and were to be
intubated for surfactant administration only after meeting specific criteria: a fraction of
inspired oxygen of >0.3 with an oxygen saturation by pulse oximeter of <90% and/or an
arterial oxygen pressure of <45 mm Hg, an arterial partial pressure of carbon dioxide of >55
mm Hg, or apnea requiring bag and mask ventilation.A total of 104 infants were enrolled
over a 6-month period: 55 CPAP and 49 control infants. No infant was intubated in the DR
for the exclusive purpose of surfactant administration. Forty-seven infants were intubated for
resuscitation in the DR: 27 of 55 CPAP infants and 20 of 49 control infants. Only 4 of the 43
infants who had a birth weight of <700 g and 3 of the 37 infants of <25 weeks' gestation were
resuscitated successfully without positive pressure ventilation, and no difference was
observed between the treatment groups. All infants of 23 weeks' gestation required intubation
in the DR, irrespective of treatment group, whereas only 3 (14%) of 21 infants of 27 weeks'
required such intubation. For infants who were not intubated in the DR, 36 infants (16 CPAP
infants and 20 control infants) were subsequently intubated in the NICU by day 7, in
accordance with the protocol. Overall, 80% of studied infants required intubation within the
first 7 days of life. The care provided for 52 (95%) of 55 CPAP infants and 43 (88%) of the
49 control infants was in compliance with the study protocol, with an overall compliance of
91%.This study demonstrated that infants could be randomized successfully to a DR
intervention of CPAP/PEEP compared with no CPAP/PEEP, with intubation provided only
for resuscitation indications, and subsequent intubation for prespecified criteria. Forty-five
percent (47 of 104) of infants <28 weeks' gestation required intubation for resuscitation in the
DR. CPAP/PEEP in the DR did not affect the need for intubation at birth or during the
subsequent week. Overall, 20% of infants did not need intubation by 7 days of life. This
experience should be helpful in facilitating the design of subsequent prospective studies of
ventilatory support in ELBW infants.
Bassani, M. A., et al. (2012). "An evaluation of peak inspiratory pressure, tidal volume, and
ventilatory frequency during ventilation with a neonatal self-inflating bag resuscitator."
Respiratory Care 57(4): 525-530.
Although the self-inflating bag is widely used in the hospital setting, variability of
delivered ventilatory parameters is usually high, which might result in both hypoventilation
and lung injury. The aims of this study were to assess possible sources of the high variability
and to evaluate the adequacy of obtained values in relation to the recommended values for
neonatal resuscitation. METHODS: This was an experimental study in which 172 health
professionals (physicians, resident physicians, physiotherapists, nurses, and nursing
technicians) who work with neonatal intensive care manually ventilated a test lung (adjusted
to simulate the lungs of an intubated term newborn) with a self-inflating bag in 5 different
handling techniques, using 10, 5, 4, 3, and 2 fingers. Delivered values of peak inspiratory
pressure (PIP), tidal volume (VT), and ventilatory frequency (f) were compared, taking into
account the different handling modalities and professions by analysis of variance for repeated
measures. Chi-square, the Friedman test and the Fisher exact tests were performed to
compare the delivered and standard values. RESULTS: PIP and VT were significantly
affected by the handling technique, with higher values for a greater number of fingers used
for ventilation. Profession also influenced VT and f significantly: physiotherapists tended to
deliver higher volumes and lower rates. Nevertheless, we observed high variability of all
studied ventilatory parameters and overall inadequacy of obtained values. Most volunteers
delivered excessive pressures and volumes at insufficient ventilatory frequency.
CONCLUSIONS: Delivered values seem to depend on operators' individual and professional
differences, as well as on the number of fingers used to compress the bag. However, from the
clinical point of view, it is important to point out the high occurrence of inadequate delivered
values, regardless of handling technique and profession. (copyright) 2012 Daedalus
Enterprises.
Bassani, M. A., et al. (2009). "Peak pressure and tidal volume are affected by how the
neonatal self-inflating bag is handled." Jornal de Pediatria 85(3): 217-222.
Objective: To evaluate how different ways of handling the neonatal self-inflating bag
influence peak pressure and tidal volume. Methods: This is an experimental study involving
141 different professionals (physicians, resident physicians, physiotherapists, nurses, and
nursing technicians), who ventilated an artificial lung, adjusted to simulate the lung of a term
neonate, using a self-inflating bag. Each professional handled the ventilator in five different
ways: a) using both hands (10 fingers); and, with only one hand, b) five fingers, c) four
fingers, d) three fingers, and e) two fingers. Peak pressure and tidal volume data were
recorded by the artificial lung equipment. Results: Both variables showed high variability,
from 2.5 to 106.3 cmH2O (mean = 39.73 cmH2O; 95%CI 37.32-42.13) for peak pressure,
and from to 4 to 88 mL (mean = 39.56 mL; 95%CI 36.86-42.25) for tidal volume. There was
no significant influence of the profession on any of the variables (p > 0.05). However, bag
handling significantly influenced both peak pressure and tidal volume (p < 0.0001), which
were higher when the operator used both hands. Conclusion: The results indicate that most
professionals delivered excessively high peak pressures and tidal volumes, which could
increase the risk of barotrauma and volutrauma, especially when both hands were used to
ventilate. On the other hand, a small number of professionals delivered insufficient pressure
and volume for adequate lung expansion and ventilation. The delivery of inadequate
ventilation was not dependent on profession. Copyright (copyright) 2009 by Sociedade
Brasileira de Pediatria.
Bennett, S., et al. (2005). "A comparison of three neonatal resuscitation devices."
Resuscitation 67(1): 113-118.
Ventilation during neonatal resuscitation involves the use of self-inflating bags, flowinflating bags, and T-piece resuscitators. The ability of operators to deliver desired peak
inspiratory pressures (PIP), positive end expiratory pressures (PEEP), prolonged inflations
and the length of time to transition between different pressures has not been compared for all
three of these devices.To compare the ability of neonatal resuscitation personnel to deliver
predetermined ventilation interventions using these devices in advance of a clinical trial of
neonatal resuscitation.We studied 31 operators (neomatologists, neonatal respiratory
therapists, neonatal fellows, a pediatrician, pediatric residents, neonatal nurse practitioners,
and neonatal nurses) using a T-piece resuscitator (Neopuff), Fisher and Paykel Healthcare,
Auckland, New Zealand), a self-inflating bag (Baby Blue II, Vital Signs, Totowa, NJ), and a
flow-inflating bag (Model E191 Anesthesia Associates, San Marcos, CA). The self-inflating
bag was tested with and without the manufacturer's PEEP valve. Using a continuous pressure
recording system and a neonatal manikin, we evaluated the ability to deliver a consistent PIP
of 20 or 40 cmH2O and a PEEP of 5 cmH2O during 30 s of ventilation, the ability to
maintain a 5 s inflation at a PIP of 20 cmH2O and the time to transition from a PIP of 20 to
40 cmH2O. Each device was evaluated with and without a qualitative CO2 detector (Pedicap)
Nellcor Pleasanton, CA).The T-piece resuscitator delivered the desired PIP more precisely
and consistently compared with the self-inflating bag at a target of 20 cmH2O (maximum PIP
20.7 cmH2O, S.D.=0.8 versus 24.7 cmH2O, S.D.=2.8; p<0.001). At a target of 40 cmH2O,
the maximum pressure delivered with the T-piece resuscitator was significantly less than both
the flow-inflating bag and the self-inflating bag (39.7 cmH2O, S.D.=2.1 versus 44 cmH2O,
S.D.=3.3 versus 45.3 cmH2O, S.D.=4.7; p<0.001). It took significantly longer to increase the
PIP from 20 to 40 cmH2O using the T-piece resuscitator compared to the self-inflating bag or
the flow-inflating bag (5.7 s versus 2.2 s versus 1.8 s; p<0.001), and three operators could not
make the transition in the allotted 15 s time limit. During the 5 s prolonged inflation, the Tpiece resuscitator and the flow-inflating bag maintained a pressure greater than 18 cmH2O
for a longer time than the self-inflating bag (4 s versus 3.7 s versus 2.2 s; p<0.001). The selfinflating bag with the PEEP valve in place provided significantly less PEEP than both the Tpiece resuscitator and the flow-inflating bag (3.6 cmH2O versus 4.4 cmH2O versus 4.4
cmH2O; p<0.005). The Pedicap did not significantly affect any of the observed results, and
there were no consistent operator differences between different disciplines or years of
experience.The T-piece resuscitator delivered the desired pressures more accurately, but
required greater time to increase the PIP from 20 to 40 cmH2O. It was difficult to maintain a
prolonged inflation and deliver the desired PEEP with the self-inflating bag even with the
PEEP valve in place. There is a need for improvement in the design and function of current
manual resuscitation devices and for prospective trials to evaluate the optimal method of bag
and mask ventilation during resuscitation of the newborn infant.
Dawson, J. A., et al. (2011). "Providing PEEP during neonatal resuscitation: which device is
best?" Journal of Paediatrics and Child Health 47(10): 698-703.
The study aims to compare three commonly used neonatal resuscitation devices, the
Laerdal self-inflating bag with a positive end expiratory pressure (PEEP) valve, a T-piece
resuscitator (T-piece) and a flow-inflating bag to provide peak inflation pressure (PIP) and
PEEP.Participants were asked to use each device to give positive pressure ventilation to a
modified neonatal mannequin via a face mask to achieve 40-60 inflations per minute, aiming
for a PIP/PEEP of 30/5 cm H��O. A manometer was visible to participants with each
device. PIP, PEEP, percentage leak at the face mask and expired tidal volume were measured
using a hot-wire anemometer. We analysed 20 inflations from each participant for each
device.Fifty participants provided PIP and PEEP with each device. The T-piece was the most
accurate and consistent. The flow-inflating bag had the most variation. The leak was lowest
with the self-inflating bag and PEEP and highest with the flow-inflating bag, but all had wide
variation.Each device was able to provide PIP and PEEP when used appropriately. When
compared with other resuscitation devices, the T-piece provided the most accurate and
consistent PIP and PEEP.? 2011 The Authors. Journal of Paediatrics and Child Health ? 2011
Paediatrics and Child Health Division (Royal Australasian College of Physicians).
Greenough, A. "Respiratory support techniques for prematurely born infants: new advances
and perspectives." Acta paediatrica Taiwanica = Taiwan er ke yi xue hui za zhi 42(4): 201206.
A variety of respiratory techniques have been introduced into the neonatal intensive
care unit. High frequency positive pressure ventilation (HFPPV) compared to slow rate
ventilation significantly reduced the incidence of airleaks, but this has yet to be confirmed in
infants routinely exposed to antenatal steroids and postnatal surfactant. Continuous positive
airways pressure (CPAP) is useful for infants with obstructive or mixed apnoea and reduces
the need for extra respiratory support following extubation, whether it reduces chronic lung
disease (CLD) remains to be appropriately tested. Randomised trials have failed to identify
long term benefits of patient triggered ventilation (PTV) in infants with acute respiratory
distress; but it is the most efficacious mode of weaning. High volume strategy, high
frequency oscillation (HFO), if commenced within 24 hours of birth, lowers the CLD rate,
but may increase airleak and intracranial pathology. Nitric oxide (NO) can improve
oxygenation in preterm infants with suspected pulmonary hypertension, but does not appear
to influence outcome. Liquid ventilation is a promising, but relatively untested technique in
preterm infants. Ventilator techniques have not been rigorously examined in infants
developing or with established CLD. It is essential that the relative merits of new respiratory
support techniques are compared in well designed studies which include infants with acute
and chronic respiratory distress, only then can their appropriate roles in the management of
prematurely born infants be identified.
Hartung, J. C., et al. (2013). "Time to Adjust to Changes in Ventilation Settings Varies
Significantly between Different T-Piece Resuscitators, Self-Inflating Bags, and Manometer
Equipped Self-Inflating Bags." American journal of perinatology.
Objective Resuscitation guidelines give no preference over use of self-inflating bags
(SIBs) or T-piece resuscitators (TPR) for manual neonatal ventilation. We speculated that
devices would differ significantly regarding time required to adjust to changed ventilation
settings.Study Design This was a laboratory study. Time to adjust from baseline peak
inflation pressure (PIP) (20 cmH2O) to target PIP (25 and 40 cmH2O), ability to adhere to
predefined ventilation settings (PIP, PEEP, and inflation rate [IR]), and the variability within
and between operators were assessed for a SIB without manometer, SIB with manometer
(SIBM), and two TPRs.Results Adjustment time was significantly longer with TPRs,
compared with SIB and SIBM. The SIBM and TPRs were < 5% (median) off target PIP, and
the SIB was 14% off target PIP. Significant variability between operators (interquartile range
[IQR]: 71%) was seen with SIBs.Conclusion PIP adjustment takes longer with TPRs,
compared with SIB/SIBM. TPRs and SIBM allow satisfactory adherence to ventilation
parameters. SIBs should only be used with manometer attached.Thieme Medical Publishers
333 Seventh Avenue, New York, NY 10001, USA.
Hawkes, C. P., et al. (2012). "Comparison of the T-piece resuscitator with other neonatal
manual ventilation devices: a qualitative review." Resuscitation 83(7): 797-802.
To review the literature surrounding various aspects of T-piece resuscitator use, with
particular emphasis on the evidence comparing the device to other manual ventilation devices
in neonatal resuscitation.The Medline, EMBASE, Cochrane databases were searched in April
2011. Ongoing trials were identified using www.clinicaltrials.gov and www.controlledtrials.com. Additional studies from reference lists of eligible articles were considered. All
studies including T-piece resuscitator use were eligible for inclusion.Thirty studies were
included. There were two randomised controlled trials in newborn infants comparing the
devices, one of which addressed short and intermediate term morbidity and mortality
outcomes and found no difference between the T-piece resuscitator and self inflating bag.
From manikin studies, advantages to the T-piece resuscitator include the delivery of inflating
pressures closer to predetermined target pressures with least variation, the ability to provide
prolonged inflation breaths and more consistent tidal volumes. Disadvantages include a
technically more difficult setup, more time required to adjust pressures during resuscitation, a
larger mask leak and less ability to detect changes in compliance.There is a need for
appropriately designed randomised controlled trials in neonates to highlight the efficacy of
one device over another. Until these are performed, healthcare providers should be
appropriately trained in the use of the device available in their departments, and be aware of
its own limitations.Copyright ? 2012 Elsevier Ireland Ltd. All rights reserved.
Kattwinkel, J., et al. (2009). "Responding to compliance changes in a lung model during
manual ventilation: perhaps volume, rather than pressure, should be displayed." Pediatrics
123(3): e465-470.
The standard technique for positive-pressure ventilation is to regulate the breath size
by varying the pressure applied to the bag. Investigators have argued that consistency of peak
inspiratory pressure is important. However, research shows that excessive tidal volume
delivered with excessive pressure injures preterm lungs, which suggests that inspiratory
pressure should be varied during times of changing compliance, such as resuscitation of
newborns or treatment after surfactant delivery.We modified a computerized lung model
(ASL5000 [IngMar Medical, Pittsburgh, PA]) to simulate the functional residual capacity of a
3-kg neonate with apnea and programmed it to change compliance during ventilation. Fortyfive professionals were blinded to randomized compliance changes while using a flowinflating bag, a self-inflating bag, and a T-piece resuscitator. We instructed subjects to
maintain a constant inflation volume, first while blinded to delivered volume and then with
volume displayed, with all 3 devices.Subjects adapted to compliance changes by adjusting
inflation pressure more effectively when delivered volume was displayed. When only
pressure was displayed, sensing of compliance changes occurred only with the self-inflating
bag. When volume was displayed, adjustments to compliance changes occurred with all 3
devices, although the self-inflating bag was superior.In this lung model, volume display
permitted far better detection of compliance changes compared with display of only pressure.
Devices for administration of positive-pressure ventilation should display volume rather than
pressure.
Kaufman, J., et al. (2013). "Mask ventilation of preterm infants in the delivery room."
Archives of disease in childhood. Fetal and neonatal edition 98(5): F405-410.
To measure tidal volumes (VT) and describe the interactions between spontaneous
breaths and positive pressure ventilation (PPV) inflations during stabilisation of preterm
infants in the delivery room (DR). We used a respiratory function monitor (RFM) to evaluate
the first 5 min of mask respiratory support provided to preterm infants.An observational study
of infants <32 weeks gestation, born in a single tertiary perinatal centre receiving mask PPV
in the DR. PPV was delivered with a round silicone facemask connected to a T-piece device
and RFM. The RFM display was not visible to the resuscitator. Respiratory function
parameters in the first 5 min after birth were analysed by breath-type (inflations, assisted
inflations, spontaneous breaths between PPV, and breaths during continuous positive airway
pressure (CPAP)). Parameters measured included VT, peak inspiratory pressure, peak end
expiratory pressure and mask leak.A total of 2605 inflations and breaths from 29 subjects
were analysed. Substantial leak was observed during all four breath types with median leaks
ranging from 24% to 59%. Median tidal volumes were greater during inflations (8.3 ml/kg)
and assisted inflations (9.3 ml/kg) than spontaneous breaths between PPV (3.2 ml/kg) and
breaths during CPAP (3.3 ml/kg).Facemask leak is large during resuscitation of preterm
infants using round silicone masks. Tidal volumes delivered during PPV inflations are much
higher than those generated during spontaneous breathing by an infant on CPAP.
Kelm, M., et al. (2009). "Reliability of two common PEEP-generating devices used in
neonatal resuscitation." Klinische P?diatrie 221(7): 415-418.
Approximately 15% of neonates require respiratory support at birth, the demand of
which increases with decreasing gestational age. Positive end-expiratory pressure (PEEP)
stabilizes the airways and improves both pulmonary functional residual capacity and
compliance. Self-inflating bags, which can be used with and without a PEEP-valve, are most
commonly used for neonatal resuscitation, pressure limited T-piece resuscitators are
becoming increasingly popular. The aim of the study was to investigate the reliability of
PEEP provision of both systems.An intubated, leak free mannequin (equivalent to 1 kg
neonate, pulmonary compliance 0.2 ml*cmH (2)O (-1)) was used for testing both devices.
Eleven PEEP-valves attached to a 240 ml self-inflating bag and 5 T-piece resuscitators were
investigated. Provision of a PEEP of 5 cmH (2)O (gas flow of 8l/min) at manual ventilation
at breaths 40/min was investigated. Data were recorded using a standard
pneumotachograph.Only 1/11 PEEP-valves provided a PEEP of 5 cmH (2)O (mean (SD) 2.95
(1.82) cmH (2)O, CV 0.62%), in 5/11 (45%) PEEP was <3 cmH (2)O, in 2 of the PEEPvalves produced a PEEP below 0.3 cmH (2)O. All T-piece resuscitators provided a PEEP >5
cmH (2)O (mean 5.59 (0.32) cmH (2)O, CV 0.06%). Significant differences in individual
performance per device (p<0.05) and between systems (p=0.007) were found.Self-inflating
bags did not reliably provide the desired PEEP of 5 cmH (2)O, whereas T-piece resuscitators
did reliably provide the set PEEP-level, with less variability. When using self-inflating bags
with PEEP-valves, neonatologists should check the equipment regarding the reliability of
PEEP provision.(c) Georg Thieme Verlag KG Stuttgart New York.
Krauss, A. N. (1980). "Assisted ventilation: a critical review." Clinics in Perinatology 7(1):
61-74.
Assisted ventilation is a complex technique that has been responsible for much of the
improvement in neonatal morbidity and mortality during the last 10 to 15 years. In unskilled
hands, however, it can be dangerous. Complications run as high as 30% in some series.
Assisted ventilation requires a constantly available medical and nursing team that can
supervise the care of a critically ill infant around the clock. It cannot be done from a remote
office, but must be carried out by intensivists on the spot. A large investment in time, labor,
and skill is needed to reap the benefits without paying an excessive price in terms of
morbidity among surviving infants. While the community-based pediatrician must become
expert at recognizing the signs of neonatal respiratory distress and initiating the first steps to
diagnose and stabilize sick infants, it is not to be expected that the definitive care of such
infants can take place in every locality. Therefore local hospitals must recognize their
limitations of staff and financial commitment to the care of these infants and form close
clinical and educational links with tertiary hospitals capable of long-term care of infants with
respiratory distress who require assisted ventilation.
Lamberska, T., et al. (2013). "Efficacy of FiO2 increase during the initial resuscitation of
premature infants < 29 weeks: An observational study." Pediatrics and Neonatology 54(6):
373-379.
Objective To evaluate the heart rate (HR) and oxygen saturation (SpO 2) at 15second intervals within 60 seconds after incremental increases of fractional inspired oxygen
(FiO2) during resuscitation of infants younger than 29 weeks requiring two different forms of
ventilatory support. Study design Retrospective observational study. Methods Forty-three
infants were stabilized, 14 by continuous positive airway pressure exclusively (CPAP group),
and 29 by positive pressure ventilation (PPV group). Both groups received ventilatory
support in a special bed with two cameras enabling the evaluation of all interventions
including HR, SpO2, FiO2, positive inflation pressure, and positive end-expiratory pressure
values. FiO2 was commenced at 0.30 and titrated in 0.1-0.2 increments every 30-60 seconds.
The relationships between the incremental increases of FiO 2 and related SpO2 and HR
changes were evaluated. Results Although there was an inverse correlation between initial
FiO2 and SpO2 in both groups, a significant positive correlation between the incremental
increase of FiO2 and SpO2 changes after 30 seconds was found only in the CPAP group.
Only higher initial levels of FiO 2 had a positive effect on the improvement in SpO2 in the
PPV group. Conclusion The efficacy of FiO2 titration in 0.1-0.2 increments may be
attenuated and delayed in extremely preterm infants required PPV during the first 6 minutes
of life. Copyright (copyright) 2013, Taiwan Pediatric Association. Published by Elsevier
Taiwan LLC. All rights reserved.
Leone, T. A., et al. (2006). "A survey of delivery room resuscitation practices in the United
States." Pediatrics 117(2): e164-175.
To determine current resuscitation practices of neonatologists in the United States.A
15-question survey was developed and mailed to neonatal directors in May 2004.Of the total
of 797 surveys mailed, 84 were returned undeliverable or unanswered and 450 were returned
completed (63% response rate). Respondents were mainly (70%) from level III NICUs. Most
programs resuscitate newborns in the delivery room (83%), rather than in a separate room.
The number and background of individuals attending deliveries vary greatly, with 31% of
programs having <3 individuals attending deliveries. Flow-inflating bags are most commonly
used (51%), followed by self-inflating bags (40%) and T-piece resuscitators (14%). Pulse
oximeters are used during resuscitation by 52% of programs, and 23% of respondents
indicated that there was a useful signal within 1 minute after application. Blenders are
available for 42% of programs, of which 77% use pure oxygen for the initial resuscitation and
68% use oximeters to alter the fraction of inspired oxygen. Thirty-two percent of programs
use carbon dioxide detectors to confirm intubation, 48% routinely and 43% when there is
difficulty confirming intubation. Preterm infants are wrapped with plastic wrap to prevent
heat loss in 29% of programs, of which 77% dry the infant before wrap application. A
majority of programs (76%) attempt to provide continuous positive airway pressure or
positive end expiratory pressure (PEEP) during resuscitation, most commonly with a flowinflating bag (58%), followed by a self-inflating bag with PEEP valve (19%) and T-piece
resuscitator (16%). A level of 5 cm H2O is used by 55% of programs.Substantial variations
exist in neonatal resuscitation practices, some of which are not addressed in standard
guidelines. Future guidelines should include recommendations regarding the use of blenders,
oximeters, continuous positive airway pressure/PEEP, and plastic wrap during resuscitation.
Lista, G., et al. (2013). "Sustained lung inflation to manage preterm infants (25-29 weeks'
gestation) in the delivery room: The Italian SLI study." Early Human Development
89(SUPPL4): S115-S116.
There is not a conclusive role of Sustained Lung Inflation (SLI) in the management
of preterm infants at risk for RDS in the delivery room. This strategy would permit lung
recruitment immediately after birth through delivery of brief peak pressure to the infant
airways via a nasopharyngeal tube or mask allowing preterm infants to achieve FRC and
reduce need of mechanical ventilation. We planned in Italy a randomized controlled trial
(RCT) to confirm or refute these findings. (copyright) 2013 Elsevier Ireland Ltd.
McHale, S., et al. (2008). "Variation in inspiratory time and tidal volume with T-piece
neonatal resuscitator: association with operator experience and distraction." Resuscitation
79(2): 230-233.
The most recent Neonatal Resuscitation Programme (NRP 5th edition) guidelines
recognise the T-piece resuscitator (Neopuff) device as an acceptable method of administering
a pre-selected peak inspiratory pressure (PIP) and positive end expiratory pressure (PEEP).
While these are constant, other parameters are operator-dependent. Although in widespread
clinical use, there is little published data on the use of the T-piece resuscitator in neonatal
resuscitation. This study showed that despite fixed inflating pressures, less experienced
operators used prolonged inspiratory times. Wide variation in mean airway pressure and tidal
volume were seen in all operators.
Menakaya, J., et al. (2004). "A randomised comparison of resuscitation with an anaesthetic
rebreathing circuit or an infant ventilator in very preterm infants." Archives of disease in
childhood. Fetal and neonatal edition 89(6): F494-496.
Twenty four preterm infants (< 27 weeks gestation) were randomised to resuscitation
with an anaesthetic rebreathing circuit or a ventilator with volume guarantee. There was no
difference in weight or gestation between the groups. End expiratory pressures were higher
and less variable with the ventilator. This pilot study shows that very preterm infants can be
safely and effectively resuscitated using a ventilator.
Milner, A. (2001). "The importance of ventilation to effective resuscitation in the term and
preterm infant." Seminars in Neonatology 6(3): 219-224.
Although resuscitation at birth often has a successful outcome, there is very little data
available on the optimal method. Face mask/bag resuscitation is relatively ineffective, rarely
producing adequate alveolar ventilation before lung expansion has occurred, probably
depending on the Head's Paradoxical Reflex to stimulate inspiratory efforts. The T-piece/face
mask technique is easier to use and more effective as the inflation pressure can be maintained
for longer. Standard T-piece/endotracheal tube resuscitation produces inflation volumes of
less than half of those generated by spontaneously breathing infants, and the functional
residual capacity is not formed for several breaths. This can be overcome by maintaining the
first inflation for 3 s. More studies are urgently required in very preterm infants as these are
particularly vulnerable to volutrauma immediately after delivery. (copyright) 2001 Harcourt
Publishers Ltd.
Moran, P. M., et al. (2013). "T-piece gas flow palpation as a clinical indicator of endotracheal
intubation in neonates." European Journal of Pediatrics 172(4): 509-512.
We aimed to determine if providers could detect simulated spontaneous respirations
of an intubated neonate by palpating gas flow changes at the positive end expiratory pressure
valve of a T-piece resuscitation device in an in vitro setting. We also aimed to demonstrate
whether the sensitivity of this methodology was related to the exhaled tidal volumes and/or
the gas flow settings on the resuscitation device. A T-piece resuscitator (Neopuff��) circuit
was connected to a neonatal silicon test lung. Expiratory tidal volumes of 5, 10 and 15 ml
were provided via the test lung, with the Neopuff�� set at gas flow rates of 5, 10 and 15
L/min. Physician volunteers were asked to identify whether they could detect expiratory gas
from the test lung at the circuit T-piece with the volar surface of their wrist, at different tidal
volumes and gas flows. Ten doctors detected 315 of 450 expirations; 95, 73 and 42 % of tidal
volumes of 15, 10 and 5 ml, respectively, were detected with an overall positive predictive
value of 98.7 %. Detection of exhalations was similar at different gas flow rates for each tidal
volume. No exhalations were detected at zero gas flow. We concluded that T-piece gas flow
palpation may be a useful and previously unreported clinical sign, which may help to reassure
clinicians that they have successfully intubated the trachea. As with any clinical sign, it
should not be considered in isolation but within the context of the clinical picture.
Morley, C. J., et al. (2010). "The effect of a PEEP valve on a Laerdal neonatal self-inflating
resuscitation bag." Journal of Paediatrics and Child Health 46(02-Jan): 51-56.
Self-inflating bags are used to provide ventilation during neonatal resuscitation.
However, they cannot provide positive end expiratory pressure (PEEP) unless a PEEP valve
is attached. The ability of Laerdal neonatal self-inflating bags fitted with PEEP valves to
reliably deliver PEEP is unclear. The aim of this study was to measure the delivered PEEP at
different set PEEP levels and inflation rates.We connected disposable and non-disposable 240
mL Laerdal self-inflating resuscitation bags fitted with PEEP valves to a leak-free test lung.
We measured PEEP delivered with the valve set at 5, 7 and 10 cm H(2)O whilst inflating the
test lung at rates of 20, 40 and 60 min. Studies were done with 8 L/min of gas flow and with
no gas flow.The PEEP delivered was close to the set level immediately after inflation but
declined rapidly between inflations. The mean PEEP was higher with faster ventilation rates.
When PEEP was set at 7 cm H(2)O, using a non-disposable bag, and an inflation rate of
60/min the mean (SD) PEEP was 5.4 (0.19) cm H(2)O. The PEEP delivered was unrelated to
the gas flow into the device.The 240 mL Laerdal self-inflating bag with a PEEP valve
delivers PEEP that loses pressure quickly. The level of PEEP delivered is less than that set,
particularly at rates below 40/min.
Murthy, V., et al. (2010). "Analysis of inflation breaths during face mask resuscitation in
preterm infants." Resuscitation 81(2): S4-.
Purpose of the study: Positive pressure ventilation with a prolonged inspiratory time
is recommended to establish a functional residual capacity and deliver appropriate tidal
volume at preterm resuscitation. The aim of the studywas to analyse the peak inspiratory
pressure (PIP), tidal volume (TV), inspiratory time (Ti) and face mask leak during the first
five inflation breaths at preterm resuscitation. Patientand methods: The studyused
respiratoryfunction monitor (NM3, Respironics) and a computer laptop with recording and
analysis software (Spectra, Groove medical, UK) to analyse the flow, pressure and volume
traces. The monitoring equipment recorded data at resuscitation of preterm infants born
before 34 weeks of gestation. The study was conducted between March and July 2010 at
King's College Hospital, London. Clinicians involved in preterm resuscitation were trained
and certified in newborn life support (Resuscitation council, UK). Parental consentwas
obtained for analysis of the data and the study was approved by Outer North London ethics
committee. Results: A total of 100 inflation breaths from 21 preterm resuscitations were
analysed. Median peak inspiratory pressure (PIP) was 25.1; range 19.7-38cm H2O, expired
tidal volume (TVe) was 3.3 ml/kg; range 0.2-19.8 ml/kg, face mask leak was 43.1%; range 196%, inspiratory time was 1.1 s; range 0.2-3.2 s. Face mask leak was calculated from the
inspired and expired tidal volume. Significant correlation was noted between PIP and TVe
(r=0.36). Conclusion: Inspiratory time achieved during the first five inflation breaths at
preterm resuscitation is significantly lower than that recommended (2-3 s) by the
resuscitation council. Usinglonger inspiratorytimes and minimisingface maskleak mayhelp to
achieve optimal tidal volumes during preterm resuscitation.
O'Donnell, C. P. F., et al. (2004). "Positive pressure ventilation at neonatal resuscitation:
Review of equipment and international survey of practice." Acta Paediatrica, International
Journal of Paediatrics 93(5): 583-588.
Background: The equipment used to provide positive pressure ventilation to
newborns needing resuscitation at delivery varies between institutions. Devices were
reviewed and their use surveyed in a sample of neonatal centres worldwide. Aim: To
determine which equipment is used to resuscitate newborns at delivery in a sample of
teaching hospitals around the world. Methods: A questionnaire was sent via e-mail to a
neonatologist at each of 46 NICUs in 23 countries on five continents, asking which
resuscitation equipment they used. If it was not returned, follow-up was by e-mail. Results:
Data were obtained from 40 (87%) centres representing 19 countries. Round face masks are
used at 34 (85%) centres, anatomically shaped masks are used exclusively at six (15%) and a
mixture of types are used at 11 (28%). Straight endotracheal tubes are used exclusively at 36
(90%) centres; shouldered tubes are used infrequently at three of the four centres that have
them. The self-inflating bag is the most commonly used manual ventilation device (used at 33
(83%) centres), the Laerdal Infant Resuscitator(trademark) the most popular model. Flowinflating bags are used at 10 (25%) centres. The Neopuff Infant Resuscitator(trademark) is
used at 12 (30%) centres. Varying oxygen concentrations are provided during neonatal
resuscitation at half of the centres, while 100% oxygen is routinely used at the other half.
Conclusions: This survey shows considerable variation in practice, reflecting this lack of
evidence and consequent uncertainty among clinicians. Comparison of the two most popular
manual ventilation devices, the Laerdal Infant Resuscitator and the Neopuff Infant
Resuscitator, is urgently required.
Okulu, E., et al. (2012). "How safe are delivery room manegements to prevent early
hypocarbia?" Archives of Disease in Childhood 97: A504-.
Background and Aim Clinically determining appropriate respiratory support from the
point of delivery to the NICU is difficult and inadvertent overventilation may be common.
The aim of the study was to determine whether delivery room managements done by skilled
team will produce 'normocarbic' blood gas values in <29 weeks' preterm infants. Method A
prospective cohort study was designed and infants born before 29 weeks' from January 2009
to December 2011 were enrolled. All infants received 100 mg/kg prophylactic surfactant in
delivery room. During resuscitation, stabilization, surfactant administration and transport
infants were ventilated with a T-piece resuscitator. If respiratory drive was present, infants
were extubated to nasal CPAP through short binasal prong. FiO2 was adjusted to achive
SaO2 of 88-92% which was monitored by pulse oxymeter. Carbon dioxide (CO2) levels on
admission and early NICU hours (0-6 hours) were evaluated. Results Fifty nine infants were
included with a mean gestation age of 26.2(plus or minus)1.7 (23-28.6) weeks and a birth
weight of 857(plus or minus)237 (400- 1470). The mean pCO2 levels of the first blood gas
analysis was 45.3(plus or minus)9.8 (range 30.4-71.2). Four (6.8%) infants had hypocarbia
(pCO2 < 35 mmHg). Conclusion To prevent both hyperoxia and hypocarbia from the point of
delivery to the NICU is a challenge. More caution is required to prevent hypocarbia and
hyperoxia.
PF, O. D. C., et al. (2004). "Sustained inflations for neonatal resuscitation." Cochrane
Database of Systematic Reviews(4).
This is the protocol for a review and there is no abstract. The objectives are as
follows:In newly born infants resuscitated with intermittent positive pressure ventilation does
the provision of initial sustained (greater than 1 second duration) inflations reduce mortality
and morbidity?Subgroup analysis will be performed to determine the safety and efficacy of
sustained inflations during resuscitation in subgroups of term (37 weeks gestation and above)
and preterm (less than 37 weeks) infants the safety and efficacy of sustained inflations during
resuscitation in subgroups determined by the type of ventilation device used (self-inflating
bag, flow-inflating bag, T-piece, mechanical ventilator) the safety and efficacy of sustained
inflations during resuscitation in subgroups determined by the interface (ie. face mask,
endotracheal tube, nasopharyngeal tube) used the safety and efficacy of sustained inflations
during resuscitation in subgroups determined by the duration of the sustained inflation - ie.
greater than one second to five seconds, greater than five seconds
Poulton, D. A., et al. (2011). "Assessment of chest rise during mask ventilation of preterm
infants in the delivery room." Resuscitation 82(2): 175-179.
Background: Current neonatal resuscitation guidelines recommend using visual
assessment of chest wall movements to guide the choice of inflating pressure during positive
pressure ventilation (PPV) in the delivery room. The accuracy of this assessment has not been
tested. We compared the assessment of chest rise made by observers standing at the infants'
head and at the infants' side with measurements of tidal volume. Methods: Airway pressures
and expiratory tidal volume (VTe) were measured during neonatal resuscitation using a
respiratory function monitor. After 60s of PPV, resuscitators standing at the infants' head
(head view) and at the side of the infant (side view) were asked to assess chest rise and
estimate VTe. These estimates were compared with VTe measurements taken during the
previous 30s. Result: We studied 20 infants who received a mean (SD) of 23 (4) inflations
during the 30s. Some observer felt unable to assess chest rise both from the head view (6/20)
and from the side view (3/20). Observers from both head and side tended to underestimate
tidal volume by 3.5mL and 3.3mL respectively. Agreement between clinical assessment and
measured VTe was generally poor. Conclusion: During mask ventilation, resuscitators were
unable to accurately assess chest wall movement visually from either head or side view.
(copyright) 2010 Elsevier Ireland Ltd.
Richards-Kortum, R. and M. Oden (2013). "Devices for low-resource health care." Science
342(6162): 1055-1057.
Devices designed for low-resource settings can improve access to life-saving health
care around the world.
Roegholt, E., et al. (2013). "Do We Deliver the Pressures We Intend to When Using a TPiece Resuscitator?" PLoS ONE 8(5): -.
Background:A T-piece resuscitator (TPR) uses a built-in manometer to set the
inflation pressures, but we are not informed what pressures are actually delivered distally.
Aim of this study was to measure the proximal and distal pressures under different gas
conditions when using a TPR.Methodology/Findings:A test lung was ventilated using a TPR
(PIP 25 cmH2O, PEEP 5 cmH2O) with a gas flow rate of 8 L/min. A) Pressure delivered by
six different TPRs was tested. To test variability 20 participants were asked to set PEEP and
PIP pressures to 25/5 cmH2O. B) PIP and PEEP were measured proximal and distal of the
TPR when using standard tubing or heated tubing with or without a humidifier. In experiment
A mean (SD) proximal PIP and PEEP of the TPRs were respectively 20.3 (0.3) cmH2O
(19.9-20.6 cmH2O) and 4.9 (0.1) cmH2O. When 20 participants set pressures; PIP 26.7 (0.5)
cm H2O and PEEP 5.9 (0.44) cmH2O were measured. Experiment B showed that the
decrease of PIP between proximal and distal pressures was not clinically significant.
However there was a significant decrease of PEEP using the standard tubing (5.1 (0.1)
cmH2O proximally versus 4.8 (0.2) cmH2O distally; p<0.001) compared to, when using a
humidifier with associated tubing and the humidifier turned on, 5.1 (0.1) proximally versus
3.9 (0.2) cmH2O distally; (p<0.001).Conclusion/Significance:The accuracy of the built-in
manometer of a TPR is acceptable. Most pressures set proximally are comparable to the
actual pressures delivered distally. However, when using tubing associated with the
humidifier PEEP decreases distally by 1.1-1.2 cmH2O and users should anticipate on this.
(copyright) 2013 Roegholt et al.
Roehr, C. C., et al. (2010). "Manual ventilation devices in neonatal resuscitation: tidal
volume and positive pressure-provision." Resuscitation 81(2): 202-205.
Excessive peak inspiratory pressures (PIP) and high tidal volumes (Vt) during
manual ventilation can be detrimental to the neonatal lung. We compared the influence of
different manual ventilation devices and individual professional experience on the extent of
applied Vt and PIP in simulated neonatal resuscitation.One hundred and twenty medical
professionals were studied. An intubated mannequin (equivalent to 1.0 kg neonate) was
ventilated using two different devices: a self-inflating bag and a T-piece resuscitator. Target
value was a PIP of 20 cm H(2)O. Applied PIP and the resulting Vt were recorded
continuously using a respiratory function monitor (CO(2)SMO(+), Novametrix, USA).Vt and
PIP provision was significantly higher in SI-bags, compared to T-piece devices: median
(interquartile range) PIP 25.6 (18.2) cm H(2)O vs 19.7 (3.2) cm H(2)O (p<0.0005), and Vt
5.1(3.2) ml vs Vt 3.6 (0.8) ml (p<0.0005) respectively. The intersubject variability of Vt and
PIP provision was distinctly higher in SI-bags, compared to T-piece devices. Professional
experience had no significant impact on the level and the variability of Vt or PIP
provided.Use of T-piece devices guarantees reliable and constant Vt and PIP provision,
irrespective of individual, operator dependent variables. Methods to measure and to avoid
excessive tidal volumes in neonatal resuscitation need to be developed.Copyright 2009
Elsevier Ireland Ltd. All rights reserved.
Roehr, C. C., et al. (2010). "Equipment and operator training denote manual ventilation
performance in neonatal resuscitation." American journal of perinatology 27(9): 753-758.
High peak inspiratory pressure (PIP) and tidal volume (V(T)) from manual
ventilation are hazardous to the neonatal lung. We investigated the influence of operator
training on the extent of applied PIP and V(T) between two manual ventilation devices. We
performed a prospective, crossover study of 84 medical professionals using a neonatal
mannequin. Participants were classified into four groups, according to experience in neonatal
resuscitation and previous training in manual ventilation. Provision of PIP, V(T), and
inspiratory time (Ti) were compared between groups and equipment used, either a selfinflating bag (SI-bag) or a T-piece resuscitator (Neopuff). Using SI-bags, operator training
significantly affected provision of PIP ( P?<?0.001), V(T) ( P?<?0.001), and Ti ( P?=?0.048).
Using a T-piece device, PIP and V(T) provision was independent of operator training
( P?=?0.55 and P?=?0.66, respectively). Twenty-five participants (30%) had previous
experience with T-piece devices; this correlated significantly with lower PIP and lower V(T)
provision ( P?>?0.001 for PIP and V(T)). Operator training level and device-specific
experience had a significant impact on PIP and V(T) provision when using SI-bags for
manual ventilation. For operators with no specific training in manual ventilation, use of Tpiece devices is advised to control for excessive PIP and V(T) application.? Thieme Medical
Publishers.
Sandberg, K. L. and O. Hjalmarson (2012). "CPAP of 4 cm H2O has no short-term benefit at
term in infants with BPD." Neonatology 102(4): 282-286.
Background: Lung development and function is compromised at term in infants with
bronchopulmonary dysplasia (BPD), characterized by reduced functional residual capacity
(FRC) and impaired gas-mixing efficiency in distal airways. Objective: To determine whether
continuous positive airway pressure (CPAP) improves FRC, ventilation, distal airway
function, and gas exchange in spontaneously breathing infants with BPD. Design/Methods:
Twenty-one infants with BPD (median birth weight 0.72 kg (range 0.50-1.27) and median
gestational age 26 weeks (range 23-28)) were studied before and after CPAP of 4 cm H 2O
was applied by a facemask system. A multiple-breath nitrogen washout method was used to
assess FRC, ventilation, and gas-mixing efficiency. Moment analysis and lung clearance
index was calculated from the nitrogen-decay curve for assessment of gas-mixing efficiency.
Transcutaneous (Tc) PO 2/PCO2 was monitored during stable infant conditions before each
washout test. Results: When CPAP was raised from 0 to 4 cm H 2O, FRC increased
significantly together with a significant increase in moment ratios (M1/M0 and M2/M0). Tc
PO2 decreased significantly and the breathing pattern changed, with significantly reduced
respiratory rate, minute ventilation, and alveolar ventilation. There was also an increase in
tidal volume and dead space. Conclusions: CPAP of 4 cm H2O applied with a facemask at
term to infants with BPD did not improve ventilation, gas-mixing efficiency in distal airways,
or oxygenation despite an increase in FRC. We speculate that instead of promoting
recruitment of unventilated lung volumes, increasing the end-expiratory pressure in infants
with BPD may lead to an overexpansion of already ventilated parts of the lung, causing
further compromise of lung function. Copyright (copyright) 2012 S. Karger AG, Basel.
Schilleman, K., et al. (2013). "Evaluating manual inflations and breathing during mask
ventilation in preterm infants at birth." The Journal of pediatrics 162(3): 457-463.
To investigate inflations (initial sustained inflations and consecutive inflations) and
breathing during mask ventilation in preterm infants at birth.Resuscitation of infants <32
weeks' gestation receiving mask ventilation at birth were recorded. Recorded waveforms
were divided into inflations (sustained and consecutive inflations), breaths in between
inflations, breaths coinciding with an inflation, and breaths on continuous positive airway
pressure (during evaluation moments in between and after ventilation) and expiratory tidal
volume (V(Te)) was compared. Inflations were analyzed for leak, low V(Te) (<2.5 mL/kg),
high V(Te) (>15 mL/kg in sustained inflations, >10 mL/kg in consecutive inflations), and
airway obstruction.In 27 infants, we analyzed 1643 inflations, 110 breaths in between
inflations, 133 breaths coinciding with an inflation, and 1676 breaths on continuous positive
airway pressure. A large mask leak frequently resulted in low V(Te). Breathing during
positive pressure ventilation occurred in 24 of 27 infants (89%). Median (IQR) V(Te) of
inflations, breaths in between inflations, and breaths coinciding with an inflation were 0.8
mL/kg (0.0-5.6 mL/kg), 2.8 mL/kg (0.7-4.6 mL/kg), and 3.9 mL/kg (0.0-7.7 mL/kg) during
sustained inflations and 3.7 mL/kg (1.4-6.7 mL/kg), 3.3?mL/kg (2.1-6.6 mL/kg), and 4.6
mL/kg (2.1-7.8 mL/kg) during consecutive inflations, respectively. The V(Te) of breaths
were significantly lower than the V(Te) of inflations or breaths coinciding with an
inflation.We often observed large leak and low V(Te), especially during sustained inflations.
Most preterm infants breathe when receiving mask ventilation and this probably contributed
to the stabilization of the infants after birth.Copyright ? 2013 Mosby, Inc. All rights reserved.
Te Pas, A. B., et al. (2008). "Spontaneous breathing patterns of very preterm infants treated
with continuous positive airway pressure at birth." Pediatric Research 64(3): 281-285.
There are no data describing how very preterm infants breathe spontaneously
immediately after birth. We studied a convenience sample of spontaneously breathing infants
(less-than or equal to)32 wk' gestation treated with facemask continuous positive airway
pressure at birth. Airway pressure and flow were measured and each breath analyzed. Twelve
infants had 792 breaths suitable for analysis. Results are given as mean (SD). Gestational age
and birth weight were 29 (1.9) wk and 1220 (412) g. Recordings were started 159 (77) s after
birth. The inspiratory pattern and duration was similar in all breaths at 0.36 (0.11) s. There
were five expiratory patterns; most infants had more than one. In 79% of breaths expiratory
duration (1.6 (1.1) s) was slowed or held by interruption or braking of expiratory flow. It was
braked in 47% to a complete expiratory hold, in 22% by grunting or crying, and in 10% by
slow or interrupted expiration. In 21% of the breaths, expiration was not interrupted and
lasted 0.53 (0.13) s. Half of these breaths represented a panting pattern (rate >60 /min).
Immediately after birth, most very preterm infants, treated with continuous positive airway
pressure, frequently prolong their expiration by braking the expiratory flow. (copyright) 2008
International Pediatric Research Foundation, Inc.
te Pas, A. B. and F. J. Walther (2007). "A randomized, controlled trial of delivery-room
respiratory management in very preterm infants." Pediatrics 120(2): 322-329.
Initial ventilation strategy may play an important role in the development of
bronchopulmonary dysplasia in very preterm infants. Early nasal continuous positive airway
pressure is an accepted approach, but randomized clinical trials are lacking. Our aim was to
determine whether early nasal continuous positive airway pressure, preceded by a sustained
inflation, is more effective and less injurious in very preterm infants than conventional
intervention.Two hundred seven very preterm infants were assigned randomly in the delivery
room to either a sustained inflation through a nasopharyngeal tube followed by early nasal
continuous positive airway pressure (early functional residual capacity intervention) or
repeated manual inflations with a self-inflating bag and mask followed by nasal continuous
positive airway pressure, if necessary, after arrival at the NICU. The primary outcome
measure was intubation <72 hours of age and bronchopulmonary dysplasia at 36 weeks was
used as secondary outcome. This trial was registered as an early functional residual capacity
intervention trial (ISRCTN 12757724).In the early functional residual capacity intervention
group, fewer infants were intubated at <72 hours of age or received >1 dose of surfactant, and
the average duration of ventilatory support was less. Infants in the early functional residual
capacity intervention group developed bronchopulmonary dysplasia less frequently.A
sustained inflation followed by early nasal continuous positive airway pressure, delivered
through a nasopharyngeal tube, is a more efficient strategy than repeated manual inflations
with a self-inflating bag and mask followed by nasal continuous positive airway pressure on
admission to the NICU.
Tracy, M. B., et al. (2010). "Neopuff T-piece mask resuscitator: is mask leak related to
watching the pressure dial?" Acta paediatrica (Oslo, Norway : 1992) 99(9): 1314-1318.
The aim of the study is to compare mask leak and delivered ventilation during
Neopuff (NP) mask ventilation in two modes: (i) with NP pressure dial hidden and
resuscitator watching chest wall (CW) rise with, (ii) CW movement hidden and resuscitator
watching NP pressure dial.Thirty-six participants gave mask ventilation to a modified
manikin designed to measure mask leak and delivered ventilation for two minutes in each
mode randomly assigned. Paired t-tests were used to analyse differences in mean values.
Linear regression was used to determine the association of mask leak with delivered
ventilation.Of 7277 inflations analysed, 3621 were observing chest wall mode (CWM) and
3656 observing NP mode (NPM). Mask leak was similar between the groups; 31.6% for
CWM and 31.5% (p = 0.56) for NPM. There were no significant differences in airways
pressures and expired tidal volumes (TVe) between modes. Mask leak was strongly
associated with TVe (R = -0.86 p < 0.0001) and with peak inspiratory pressure (PIP) (R = 0.51 p < 0.0001). TVe was associated with PIP (R = 0.51 p < 0.0001).This study provides
reassurance that NP mask leak is not greater when resuscitators watch the NP pressure dial.
Mask leak is related to TVe. Mask ventilation training with manikins should include tidal
volume measurements.? 2010 The Author(s)/Journal Compilation ? 2010 Foundation Acta
Paediatrica.
Trevisanuto, D., et al. (2013). "Oxygen delivery using a neonatal self-inflating resuscitation
bag: effect of oxygen flow." Pediatrics 131(4): e1144-1149.
We evaluated the effect of oxygen (O��) flow rate on the corresponding delivered
fraction of oxygen (FiO��) during positive pressure ventilation (PPV) when using a
neonatal self-inflating bag (SIB).Fifteen health care professionals administered PPV at a
respiratory rate of 40 to 60 breaths per minute and at peak inspiratory pressures of 25 and 35
cm?H��O to a manikin by using a SIB with reservoir connected to an O�� source
equipped with a flowmeter (flow rates: 0-10 L/min). The FiO�� corresponding to each
flow rate was measured at the inflow to the facial mask for 60 seconds.In total, 2520 FiO��
data points were collected. At every O�� flow rate, the FiO�� gradually increased from
time 0 seconds to time 60 seconds, both at 25 cm?H��O and at 35 cm?H��O. After 1
minute of PPV at 25 cm?H��O, the delivered FiO�� was 31.5% �� 2.1% and 43.1%
�� 3.1% at O�� flow rates of 0.1 and 0.5 L/min, respectively. After 1 minute of PPV at
35 cm?H��O, the delivered FiO�� was 29.4% �� 2.0% and 42.1% �� 4.6% at
O�� flow rates of 0.1 and 0.5 L/min, respectively. At all O�� flow rates >5 L/min, the
delivered FiO�� was >85% and >95%, after 1 minute of PPV at 25 and 35 cm?H��O,
respectively.Delivered FiO�� during PPV depends on 3 factors: oxygen flow rate, peak
inspiratory pressures, and time elapsed. These data can be used to develop a scheme
correlating the oxygen flow rate and the corresponding delivered FiO�� when using a
neonatal SIB.
(Excluded by title and abstract: 475 articles)
"Evaluation of ventilator alarms." Journal of medical engineering & technology 8(6): 270276.
An evaluation of ventilator alarms is being carried out for the DHSS within the
Welsh National School of Medicine. The technical performance and safety assessments are
being made within the Department of Anaesthetics and clinical trials within the South
Glamorgan Area Health Authority. For this evaluation (published in 'Health Equipment
Information' ['HEI'] No. 124 [June 1984]) one example of each model was assessed (Penlon
IDP, Draeger, Medix Ventimonitor 101, BOC Medishield, East Ventilarm, Cape TTL) and
the conclusions are based on the assumption that the sample was typical of normal production.
This is a continuing programme and the next report will evaluate a group of infant ventilators.
For full details of the evaluation findings, readers should consult 'HEI' 124. The following are
extracts from the report.
(1971). "Intensive care and therapy of the newborn." Progress in pediatric surgery 3: 113-120.
(1994). "AARC (American Association for Respiratory Care) clinical practice guideline.
Neonatal time-triggered, pressure-limited, time-cycled mechanical ventilation." Respiratory
Care 39(8): 808-816.
(1994). "AARC (American Association for Respiratory Care). Application of continuous
positive airway pressure to neonates via nasal prongs or nasopharyngeal tube." Respiratory
Care 39(8): 817-823.
(2011). "Airway management and mask ventilation of the newborn infant. ARC and NZRC
Guideline 2010." EMA - Emergency Medicine Australasia 23(4): 428-435.
(2011). "The resuscitation of the newborn infant in special circumstances. ARC and NZRC
Guideline 2010." EMA - Emergency Medicine Australasia 23(4): 445-447.
(2011). "Techniques in paediatric advanced life support. ARC and NZRC Guideline 2010."
EMA - Emergency Medicine Australasia 23(4): 412-416.
(2011). "Tracheal intubation and ventilation of the newborn infant. ARC and NZRC
Guideline 2010." EMA - Emergency Medicine Australasia 23(4): 436-439.
(2013). "Editor's commentary." Respiratory Care 58(7): 1113-.
(2006). "2005 American Heart Association (AHA) guidelines for cardiopulmonary
resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal
patients: pediatric basic life support." Pediatrics 117(5): e989-1004.
This publication presents the 2005 American Heart Association (AHA) guidelines for
cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the
pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and
ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005
International Consensus Conference on Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care Science With Treatment Recommendations, hosted by the American
Heart Association in Dallas, Texas, January 23-30, 2005. The 2005 AHA Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care contain
recommendations designed to improve survival from sudden cardiac arrest and acute lifethreatening cardiopulmonary problems. The evidence evaluation process that was the basis
for these guidelines was accomplished in collaboration with the International Liaison
Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the
International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science With Treatment Recommendations. The recommendations in the 2005 AHA
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care confirm
the safety and effectiveness of many approaches, acknowledge that other approaches may not
be optimal, and recommend new treatments that have undergone evidence evaluation. These
new recommendations do not imply that care involving the use of earlier guidelines is unsafe.
In addition, it is important to note that these guidelines will not apply to all rescuers and all
victims in all situations. The leader of a resuscitation attempt may need to adapt application
of the guidelines to unique circumstances. The following are the major pediatric advanced
life support changes in the 2005 guidelines: There is further caution about the use of
endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced
providers. Cuffed endotracheal tubes may be used in infants (except newborns) and children
in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O. Confirmation
of tube placement requires clinical assessment and assessment of exhaled carbon dioxide
(CO2); esophageal detector devices may be considered for use in children weighing >20 kg
who have a perfusing rhythm. Correct placement must be verified when the tube is inserted,
during transport, and whenever the patient is moved. During CPR with an advanced airway in
place, rescuers will no longer perform cycles of CPR. Instead, the rescuer performing chest
compressions will perform them continuously at a rate of 100/minute without pauses for
ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath
approximately every 6-8 seconds). Timing of 1 shock, CPR, and drug administration during
pulseless arrest has changed and now is identical to that for advanced cardiac life support.
Routine use of high-dose epinephrine is not recommended. Lidocaine is de-emphasized, but it
can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if
amiodarone is not available. Induced hypothermia (32-34 degrees C for 12-24 hours) may be
considered if the child remains comatose after resuscitation. Indications for the use of
inodilators are mentioned in the postresuscitation section. Termination of resuscitative efforts
is discussed. It is noted that intact survival has been reported following prolonged
resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine. The
following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary
oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation;
free-flow oxygen should be administered to infants who are breathing but have central
cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is
reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start
with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation
with room air, it is recommended that supplementary oxygen be available to use if there is no
appreciable improvement within 90 seconds after birth. In situations where supplementary
oxygen is not readily available, positive-pressure ventilation should be administered with
room air. Current recommendations no longer advise routine intrapartum oropharyngeal and
nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic
fluid. Endotracheal suctioning for infants who are not vigorous should be performed
immediately after birth. A self-inflating bag, a flow-inflating bag, or a T-piece (a valved
mechanical device designed to regulate pressure and limit flow) can be used to ventilate a
newborn. An increase in heart rate is the primary sign of improved ventilation during
resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm
correct endotracheal tube placement when a prompt increase in heart rate does not occur after
intubation. The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per
dose. Higher IV doses are not recommended, and IV administration is the preferred route.
Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through
the endotracheal tube may be considered. It is possible to identify conditions associated with
high mortality and poor outcome in which withholding resuscitative efforts may be
considered reasonable, particularly when there has been the opportunity for parental
agreement. The following guidelines must be interpreted according to current regional
outcomes: When gestation, birth weight, or congenital anomalies are associated with almost
certain early death and when unacceptably high morbidity is likely among the rare survivors,
resuscitation is not indicated. Examples are provided in the guidelines. In conditions
associated with a high rate of survival and acceptable morbidity, resuscitation is nearly
always indicated. In conditions associated with uncertain prognosis in which survival is
borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high,
parental desires concerning initiation of resuscitation should be supported. Infants without
signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show
either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of
continuous and adequate resuscitative efforts, discontinuation of resuscitation may be
justified if there are no signs of life.
AA, F., et al. (1973). "Controlled trial of continuous negative external pressure in the
treatment of severe respiratory distress syndrome." Journal of Pediatrics 82(6): 921-928.
AB, F., et al. (1987). "High-frequency oscillatory ventilation in premature infants with
respiratory failure: a preliminary report." Anesthesia and Analgesia 66(9): 814-824.
High-frequency ventilation has been used successfully to manage life-threatening
complications in premature infants with lung disease. Here we report a preliminary
assessment of the efficacy and safety of high-frequency oscillatory ventilation-(HFO-A, A =
active expiratory phase) when used as a primary ventilator in 11 infants of 24-34 weeks
gestation who required ventilatory support. HFO-A was initiated after no more than 5.5 hr of
conventional mechanical ventilation (CMV). HFO-A at 15 Hz was used for 12-203 hr
following a protocol designed for rapid reduction of FI02 requirements. CO2 elimination was
easily achieved in all infants. Oxygenation was satisfactory, except in one infant with
congenital pneumonia. There were four deaths during HFO-A: two pulmonary (one
congenital pneumonia; one pulmonary hemorrhage) and two nonpulmonary. The HFO-A
protocol utilized lung volume recruitment maneuvers plus mean airway pressures (MAwP)
greater than those generally used early in the course of CMV. Therefore, in a subset of infants
less than or equal to 29 weeks' gestation with respiratory distress syndrome (RDS), ventilator
pressures and gas exchange were compared in infants treated with either HFO-A or CMV.
Maximum MAwP levels were reached earlier in six infants on HFO-A (5.2 +/- 2.5 hr; mean
+/- SD) than in a comparable group of 9 CMV-treated infants (36 +/- 1 hr). This earlier use of
high MAwP lowered the FI02 to less than 0.4 by 18.9 +/- 11 hr with HFO-A as compared
with 64 +/- 6 hr using CMV, without any evidence of an increase in pulmonary complications.
There were 17 complications in the nine CMV-treated infants; and four in the six HFO-A
treated ones. We conclude that HFO-A, instituted early and used with a protocol designed for
early reduction in FI02 requirements, demonstrates sufficient efficacy and safety to warrant
further clinical trials in the routine management of infant RDS.
Aberdeen, E. and J. J. Downes (1974). "Artificial airways in children." The Surgical clinics
of North America 54(5): 1155-1170.
Abrahams, N., et al. (1975). "Evaluation of infant ventilators." Anaesthesia and Intensive
Care 3(1): 11-Jun.
A method of evaluating the performance of paediatric ventilators under simulated
clinical conditions is described, together with the results of this evaluation of the prototypes
of two ventilators designed specifically for use with infants and small children.
Ackerman, B. D., et al. (1974). "Continuous positive airway pressure applied by means of a
tight fitting face mask." Journal of Pediatrics 85(3): 408-411.
The authors describe their experience with 10 patients treated for hyaline membrane
disease with continuous positive airway pressure applied by a face mask technique, with
particular reference to the ability to lower the inspired oxygen concentration required to
maintain adequate oxygenation.
Adams, A. P. and J. D. Henville (1977). "A new generation of anaesthetic ventilators. The
Pneupac and Penlon A-P." Anaesthesia 32(1): 34-40.
A new range of ventilators which can be used during anaesthesia for infants, children
and adults is described. The ventilators work on the moving-part fluid logic principle and are
simple, inexpensive and robust; the patient valve can be autoclaved at standard temperatures
(140 degrees C). There are facilities for providing PEEP, attachment of a scavenging system
and for relief of over-pressure. The unit is 'fail-safe'. The ventilators, being constant flow
generators, have a high specification and equal the performance of other machines which are
five times the cost. The weight and size are such that servicing can be provided on a
replacement exchange basis through the post.
Adegbite, M., et al. (2006). "Non invasive respiratory support in neonates: A review."
Perinatology 8(1): 46-52.
Admani, M., et al. (1985). "Prevention of gastric inflation during mask ventilation in
newborn infants." Critical care medicine 13(7): 592-593.
Ten premature infants who had recovered from the respiratory distress syndrome
were subjected to cricoid compression during mask ventilation. Each infant was ventilated
with an AMBU face mask for 3 min with the nasogastric (NG) tube, without the NG tube,
and without the NG tube but applying cricoid pressure during ventilation. The results of the
study indicated that, similar to insertion of an NG tube, cricoid compression can prevent
gastric inflation during mask ventilation.
Ahlstr?m, H. (1975). "Pulmonary mechanics in infants surviving severe neonatal respiratory
insufficiency." Acta paediatrica Scandinavica 64(1): 69-80.
Pulmonary mechanics was studied in 24 survivors of severe neonatal ventilatory
insufficiency, 15 infants had idiopathic respiratory distress syndrome (IRDS), 6 recurrent
severe apnoeic spells, and 3 postasphyxia syndrome. Of the infants with IRDS, 5 were treated
with intermittent positive pressure ventilation (IPPV), 3 with continuous positive airway
pressure (CPAP) via an endotracheal tube and 7 with CPAP applied via a face chamber. The
other infants were all treated with IPPV. IPPV-treated infants generally had lower than
expected values of dynamic compliance and pulmonary conductance, particularly after
prolonged treatment. All infants treated with CPAP via a face chamber had normal mechanics,
but a trend towards obstruction of the airways after varying periods of time was observed in
most infants, irrespective of diagnosis or treatment. One infant treated with CPAP via an
endotracheal tube and given pure oxygen for a long time had gross abnormalities suggesting
bronchopulmonary dysplasia. Measurement of pulmonary conductance appears to be a
reliable prognostic tool as concerns pulmonary symptoms later in infancy.
Ahluwalia, J. S., et al. (1998). "Infant Flow Driver or single prong nasal continuous positive
airway pressure: short-term physiological effects." Acta paediatrica (Oslo, Norway : 1992)
87(3): 325-327.
The effectiveness of single prong nasal continuous positive airway pressure (CPAP)
was compared with the Infant Flow Driver (IFD) in a crossover study in 20 neonates treated
with > or = 30% oxygen by nasal CPAP. They were randomized to the device used at the
start of the study. Each infant was studied for four consecutive 2-h periods alternating
between single prong nasal CPAP and the IFD. The FiO2 from the IFD read 0.02 higher than
the same setting on the ventilators used for single prong nasal CPAP. The IFD improved the
mean (95% CI) of the FiO2 by 0.05 (0.02-0.08), p = 0.008. Taking into account the
systematic error in the FiO2 between the devices the real mean improvement in FiO2
produced by the IFD was 0.03 (-0.005 to 0.06), p=0.09. There were no significant differences
in respiratory rate, heart rate, blood pressure or comfort score of infants during periods of
single nasal prong CPAP compared with periods on the IFD.
AI, M., et al. (1970). "Mechanical ventilation in the respiratory distress syndrome: a
controlled trial." Archives of Disease in Childhood 45(243): 624-633.
Al-alami, A. A., et al. (2009). "Pediatric laryngospasm: Prevention and treatment." Current
Opinion in Anaesthesiology 22(3): 388-395.
Identifying the risk factors and taking the necesary precautions are the key points in
prevention of laryngospasm. An experienced anesthesiologist is asociated with lower
incidence of laryngospasm. Airway management is the most essential part of treatment of
laryngospasm. Drugs can be used as an adjunct in treatment of laryngospasm, especially
when anesthesia is administered by beginners.
Alarkon, E., et al. (2013). "Dynamics of respiratory disorders in premature infants who
received CPAP with gradual reduction in pressure." Journal of Perinatal Medicine 41: -.
Creating and maintaining a continuous positive airway pressure at birth is an
essential element of early stabilization of preterm infants. After the procedure of the sustained
inflation all patients need to transfer to NICU with CPAP pressure level of 4-6 cm H2O. The
purpose of this study - to analyze the dynamics of respiratory distress and safety within the
first 72 hours of life in preterm infants after sustained inflation in the delivery room,
receiving therapy with CPAP open CPAP system with valve Benveniste with a gradual
stepwise reduction in airway pressure. Design of these study is pilot, prospective. We
included 12 preterm infants with gestational age 27-30 weeks, mean body weight was 1075
(plus or minus) 215, length - 37 (plus or minus) 3,09, which had an independent spontaneous
breathing and heart rate of over 100 per minute. All premature since the first minute of life
was performed by prolonged inflation with face mask with PEEP = 20 cm H2O during 15-20
seconds. Later all babies were transferred to the intensive care unit where the pressure drop
was carried out step by step with the CPAP valve Benveniste from 12 cmH2O to 4 cm H2O
in increments of 2 cm H2O. The reason for reducing of pressure indicators were SpO2 over
92%. We excluded newborns who needed in intubation under 20 minutes of life. Average
starting rates inhaled oxygen fraction (FiO2) in the delivery room were 0,38 (plus or minus)
0,21. In all cases, immediately after admission from delivery room we continued respiratory
support. Demanded the transfer to the ventilator 4 from 12 children followed by the
introduction of surfactant in age from one to four hours of life on a background of increased
demand for oxygen with INSURE strategy. In 8 of the 12 premature babies we were able to
successfully reduce the FiO2 within the first 72 hours of life to 0.21, and the escape from
CPAP therapy. Stepwise reduction of pressure during nasal CPAP with a valve Benveniste or
another device after procedure of sustained inflation may be safe and effective preventive
strategy for avoid of the respiratory insufficiency in preterm infants 27-30 weeks' suffer from
RDS.
Allen, L. P., et al. (1975). "Continuous positive airway pressure and mechanical ventilation
by face mask in newborn infants." British Medical Journal 4(5989): 137-139.
During a 9 month period 24 newborn infants were treated with continuous positive
airway pressure (CPAP) or mechanical ventilation delivered through a facemask. The mask
was held in place in a way that minimised trauma and distortion of the head. The median
birth weight of the infants was 1096 g and their median gestational age 29 wk. The usual
reason for treatment was hyaline membrane disease or recurrent apnoea due to inadequate
control of breathing. Twenty one of the infants survived. The technique was simple to apply
and complications were minimal. We suggest that it may have advantages over other methods
of applying CPAP or mechanical ventilation to infants mildly affected by respiratory illnesses
and that it should be useful in avoiding endotracheal intubation or reducing the length of time
that infants with more serious illnesses are intubated.
Allen, L. P., et al. (1975). "Continuous positive airway pressure and mechanical ventilation
by facemask in newborn infants." British Medical Journal 4(5989): 137-139.
During a nine-month period 24 newborn infants were treated with continuous
positive airway pressure (CPAP) or mechanical ventilation delivered through a facemask.
The mask was held in place in a way that minimised trauma and distortion of the head. The
median birth weight of the infants was 1096 g and their median gestational age 29 weeks.
The usual reason for treatment was hyaline membrane disease or recurrent apnoea due to
inadequate control of breathing. Twenty-one of the infants survived. The technique was
simple to apply and complications were minimal. We suggest that it may have advantages
over other methods of applying CPAP or mechanical ventilation to infants mildly affected by
respiratory illnesses and that it should be useful in avoiding endotracheal intubation or
reducing the length of time that infants with more serious illnesses are intubated.
Allen, L. P., et al. (1977). "Controlled trial of continuous positive airway pressure given by
face mask for hyaline membrane disease." Archives of Disease in Childhood 52(5): 373-378.
A controlled trial of elective intervention with continuous positive airway pressure
(CPAP) was performed on 24 infants with hyaline membrane disease whose arterial oxygen
tension (Pao2) fell below 8kPa (60 mmHg) while they were breathing a fractional inspired
oxygen concentration (F1O2) greater than 0.60. A face mask was used to apply the CPAP.
The progress of the 12 infants who were treated on entry to the trial was compared with that
of 12 infants who were treated later. All 12 infants in the early-intervention group and 8
infants in the late-intervention group survived. When CPAP was started, Pao2 increased and
the early-treated infants breathed high concentrations of oxygen for a shorter period than the
late-treated infants. The 4 infants in the early-intervention group who required mechanical
ventilation needed lower mean airway pressures to achieve satisfactory gas exchange than the
7 ventilated infants in the late-intervention group. We conclude that a Pao2 less than 8 kPa
while breathing an F1o2 greater than 0.60 is an adequate indication for giving CPAP in
hyaline membrane disease, and that early intervention with CPAP allows infants who go on
to require mechanical ventilation to be ventilated at lower pressures.
Altemeyer, K. H., et al. (1979). "[Causes and treatment possibilities of acute respiratory
insufficiency in premature infants]." Klinische An?sthesiologie und Intensivtherapie 20: 254274.
Amin, R. S. and C. M. Fitton (2003). "Tracheostomy and home ventilation in children."
Seminars in Neonatology 8(2): 127-135.
The last 30 years have brought a significant emphasis on home care for ventilatordependent children. While the movement was driven by the desire to minimize healthcare
costs, the advancements in medical knowledge and technology, and the change in the
perception of a ventilator-dependent child have offered a fertile environment for the
development of programs that support the chronic care of ventilator-dependent children at
home (N. Engl. J. Med. 309(21) (1983) 1319; J. Pediatr. 106(5) (1985) 850; N. Engl. J. Med.
310(17) (1984) 1126; JAMA 258(23) (1987) 3398). In addition, the advances in medical and
nursing care have led to the steady increase in the number of children with chronic
respiratory failure and development of multi -disciplinary teams experienced and dedicated to
the care of these children. Another trend that has also contributed to the rise in the number of
pediatric patients using long-term mechanical ventilation is the parental expectation of longterm survival of their child. This parental expectation continues to grow as the effect of longterm mechanical ventilation on quality of life and longer survival becomes more evident. The
primary indication for use of home mechanical ventilation is chronic respiratory failure (CRF)
as indicated by hypoxemia and or hypercapnia. CRF is considered to be a condition persisting
for greater than 1 month and requiring mechanical ventilation during part or all of the day to
provide adequate gas exchange for the support of vital function (Chest 103(5) (1993) 1463).
(copyright) 2003 Elsevier Science Ltd. All rights reserved.
Arnaudova, R., et al. (1977). "[Treatment of the depressive state (asphyxia) in the newborn]."
Akusherstvo i ginekologii?a 16(4): 306-314.
Arndt, G. A., et al. (2012). "Wire-guided (Seldinger technique) intubation through a face
mask in urgent, difficult and grossly distorted airways." Saudi Journal of Anaesthesia 6(3):
292-294.
We report two cases of successful urgent intubation using a Seldinger technique for
airway management through an anesthesia facemask, while maintaining ventilation in
patients with difficult airways and grossly distorted airway anatomy. In both cases,
conventional airway management techniques were predicted to be difficult or impossible, and
a high likelihood for a surgical airway was present. This technique was chosen as it allows
tracheal tube placement through the nares during spontaneous ventilation with the airway
stented open and oxygen delivery with either continuous positive airway pressure and/or
pressure support ventilation. This unhurried technique may allow intubation when other
techniques are unsuitable, while maintaining control of the airway.
Arrica, M. and M. W. Crawford (2006). "Complete upper airway obstruction after induction
of anesthesia in a child with undiagnosed lingual tonsil hypertrophy." Paediatric Anaesthesia
16(5): 584-587.
We present a case of a 9-year-old patient with previously undiagnosed lingual tonsil
hypertrophy (LTH) that caused sudden and complete airway obstruction and inability to
ventilate on induction of anesthesia. More frequently described in adults than in children,
LTH can complicate mask ventilation, intubation or both, with the potential for catastrophic
consequences. (copyright) 2005 Blackwell Publishing Ltd.
Aune, H. and J. Stovner (1974). "[Respiratory failure in children treated with continuous
positive airway pressure]." Tidsskrift for den Norske l��geforening : tidsskrift for praktisk
medicin, ny r��kke 94(24): 1445-1447.
Avent, M. L., et al. (1999). "Comparing the delivery of albuterol metered-dose inhaler via an
adapter and spacer device in an in vitro infant ventilator lung model." The Annals of
pharmacotherapy 33(2): 141-143.
To compare the delivery of an albuterol metered-dose inhaler (MDI) (Ventolin) via
an Aerochamber (Monaghan) with an inline adapter (Medicomp Straight Swivel) in an in
vitro infant lung model.An in vitro infant lung model was modified to compare the delivery
of albuterol MDI 10 inhalations via an Aerochamber with an inline adapter. The adapter and
Aerochamber were placed at the endotracheal tube. A 1000 mL intravenous bag filled with
500 mL deionized water was attached to a 3.5 mm endotracheal tube (10 cm length). An
Infant Bear Cub ventilator was used at the following settings: positive inspiratory pressure 20
cm H2O, intermittent mandatory ventilation 40 breaths/min, positive end expiratory pressure
4 cm H2O, and inspiratory time 0.5 second. Each device was run at least 10 times and
assayed in duplicate by HPLC. An unpaired Student's t-test was used to analyze the statistical
significance of the data.There was significantly greater delivery of albuterol with the
Aerochamber (19.49 +/- 7.23 microg; 2.17% +/- 0.8%) as compared with an inline adapter
(1.0625 +/- 1.36 microg; 0.12% +/- 0.15%) (p = 0.001).The Aerochamber provides a greater
delivery of albuterol metered-dose inhalations to the lung than the inline adapter in an in vitro
infant lung model.
Avent, M. L., et al. (1999). "Evaluating the delivery of nebulized and metered-dose inhalers
in an in vitro infant ventilator lung model." The Annals of pharmacotherapy 33(2): 144-148.
To evaluate drug delivery to the lungs of nebulized and metered-dose inhalers (MDIs)
in an in vitro infant lung model.An in vitro lung model was modified to study drug delivery.
A 1000 mL intravenous bag filled with 500 mL deionized water was attached to a 3.5 mm (12
cm length) endotracheal tube. An inline Marquest Whisper Jet infant circuit nebulizer system
delivered 2.5 mg/3 mL albuterol sulfate inhalation solution (Ventolin nebules) at a flow rate
of 5 L/min. An Aerochamber (Monaghan) was placed at the endotracheal tube for the
delivery of the MDIs. Albuterol MDI (Ventolin) 10 inhalations and beclomethasone MDI
(Beclovent) 20 inhalations were delivered. A Servo 900C (Siemens-Elma) was used at the
following ventilator settings: positive inspiratory pressure 30 cm H2O), intermittent
mandatory ventilation 40 breaths/min, positive end expiratory pressure 4 cm H2O, inspiratory
time 0.4 sec. Each formulation was run at least 10 times and assayed in duplicate by HPLC.
An unpaired Student's t-test was used to analyze the statistical significance of the data.There
was a significantly greater percentage of drug delivery with MDI albuterol (1.96 +/- 0.50) as
compared with nebulized albuterol (1.26 +/- 0.37) (p = 0.002) or beclomethasone
diproprionate (0.51 +/- 0.24) (p = 0.001).Albuterol MDI provides a more efficient delivery of
drug to the lung as compared with nebulized albuterol and MDI beclomethasone
diproprionate.
Axelin, A., et al. (2009). "Promoting shorter duration of ventilator treatment decreases the
number of painful procedures in preterm infants." Acta paediatrica (Oslo, Norway : 1992)
98(11): 1751-1755.
To investigate whether promoting shorter ventilator treatment decreases the number
of painful procedures and the use of analgesics in preterm infants.Retrospective patient chart
review of all preterm infants in one Neonatal Intensive Care Unit (NICU) was carried out in
2000 (n = 240) and 2005 (n = 206). Between these cohorts, early nasal continuous positive
airway pressure (nCPAP) application and early extubation policy were introduced.Fewer
infants were intubated (22 vs. 32%, p = 0.03), the duration of ventilator treatment decreased
(6.7 SD 11.3 vs. 9.0 SD 11.1 days, p < 0.001) and nCPAP treatment became more common
(41 vs. 25%, p < 0.001) in 2005 than in 2000. Similarly, the infants' exposure to painful
procedures did not decrease significantly (61.9 SD 98.5 vs. 67.1 SD 104.3 procedures, p =
0.32) but the procedures related to respiratory support were fewer (45.2 SD 79.5 vs. 68.9 SD
91.1 procedures, p < 0.001) in 2005 than in 2000. In addition, the amount of pain medication
used was significantly lower in 2005 than in 2000. One day on a ventilator included more
painful procedures than a day on nCPAP (11.2 95% CI: 11.0-11.5 vs. 4.2 95% CI: 4.1-4.4
procedures, p < 0.001) during both study years.Early nCPAP and early extubation policies
were successfully implemented in an NICU resulting in less invasive respiratory support.
This was associated with fewer painful procedures and less pain medication in the preterm
infants who required respiratory support. Despite this positive effect, the number of painful
procedures in all preterm infants stayed at the same level. Our results provide further support
for the use of nCPAP in preterm infants.
B, M., et al. (2007). "A recruitment manoeuvre performed after endotracheal suction does not
increase dynamic compliance in ventilated paediatric patients: a randomised controlled trial."
Australian journal of physiotherapy 53(3): 163-169.
QUESTION: Does a recruitment manoeuvre after suctioning have any immediate or
short-term effect on ventilation and gas exchange in mechanically-ventilated paediatric
patients? DESIGN: Randomised controlled trial with concealed allocation, assessor blinding,
and intention-to-treat analysis. PARTICIPANTS: Forty-eight paediatric patients with
heterogeneous lung pathology. Fourteen patients were subsequently excluded from analysis
due to large leaks around the endotracheal tube. INTERVENTION: The experimental group
received a single standardised suctioning procedure followed five minutes later by a
standardised recruitment manoeuvre. The control group received only the single suctioning
procedure. OUTCOME MEASURES: Measurements of ventilation (dynamic lung
compliance, expiratory airway resistance, mechanical and spontaneous expired tidal volume,
respiratory rate) and gas exchange (transcutaneous oxygen saturation) were recorded, on
three occasions before and on two occasions after the recruitment manoeuvre, using a
respiratory profile monitor. RESULTS: There was no difference between the experimental
and the control group in dynamic compliance, expired airway resistance, or oxygen saturation
either immediately after the recruitment manoeuvre, or after 25 minutes. The experimental
group decreased mechanical expired tidal volume by 0.3 ml/kg (95% CI 0.1 to 0.6), increased
spontaneous expired tidal volume by 0.3 ml/kg (95% CI 0.0 to 0.6), and increased total
respiratory rate by 3 bpm (95% CI 1 to 4) immediately after the recruitment manoeuvre
compared with the control group, but these differences disappeared after 25 minutes.
CONCLUSION: There is insufficient evidence to support performing recruitment
manoeuvres after suctioning infants and children.
Bach, K. P., et al. (2009). "Ventilator gas flow rates affect inspiratory time and ventilator
efficiency index in term lambs." Neonatology 96(4): 259-264.
Despite increasing survival in the smallest preterm infants, the incidence of chronic
lung disease has not decreased. Research into ventilatory strategies has concentrated on
minimising barotrauma, volutrauma and atelectotrauma, but little attention has been paid to
the role of bias gas flow rates and the potential for rheotrauma or shear stress injury.
Ventilated preterm infants frequently receive relatively high gas flow rates.We hypothesised
that altering bias gas flow rates would change the efficiency of ventilation and thereby affect
ventilatory parameters.We tested this hypothesis using an artificial lung followed by
ventilation of 8 term lambs.Between flows of 2 and 15 l/min, inflation time (Ti) in the
artificial lung was inversely related to the bias gas flow rate. In the ventilated lambs, Ti was
inversely related to flow rates up to 10 l/min, with no statistically significant effect at flow
rates >10 l/min. There were no adverse effects on gas exchange or cardiovascular parameters
until a flow rate of 3 l/min was used, when inadequate gas exchange occurred.Ti is inversely
associated with the bias gas flow rate. Flow rates much lower than those used in many
neonatal units seem to provide adequate ventilation. We suggest that the role of ventilator gas
flow rates, which may potentially influence shear stress in ventilator-induced lung injury,
merits further investigation.Copyright 2009 S. Karger AG, Basel.
Bagshaw, O. N. and C. G. Stack (1999). "A comparison of halothane and isoflurane for
gaseous induction of anaesthesia in infants." Paediatric Anaesthesia 9(1): 25-29.
Sixty-four ASA 1 and 2 infants between the ages of 44 weeks postconceptual age and
one year presenting for routine, elective surgery were randomly anaesthetized with either 3%
halothane in oxygen (Group H) or 5% isoflurane in oxygen (Group I). Patients in Group I
took a mean (SD) time of 70.1(13.6) s to loss of eyelash reflex and 80.0 (13.5) s to tolerating
the face mask, compared with 80.2 (17.7) s and 93.4 (20.5) s in Group H (P=0.028 and
0.0072, respectively). There were no significant differences between the groups for
preinduction or induction state, lowest oxygen saturation, or the incidence of airway related
complications or interventions. This study demonstrates that 5% isoflurane in oxygen induces
anaesthesia in infants more quickly than 3% halothane in oxygen, without any increase in the
incidence or severity of airway-related complications.
Bain, J. A. and D. Reid (1975). "A simple way to ventilate babies utilizing a Mark VII Bird
Ventilator and a Modified Mapleson D Breathing Circuit." Canadian Anaesthetists' Society
journal 22(2): 202-207.
Baird, J. S., et al. "Noninvasive ventilation during pediatric interhospital ground transport."
Prehospital emergency care : official journal of the National Association of EMS Physicians
and the National Association of State EMS Directors 13(2): 198-202.
We report our use of noninvasive ventilation (NIV) during pediatric interhospital
ground transport.We retrospectively reviewed transport and hospital records for nonneonatal
patients <or= 18 years old transferred into or out of our children's hospital between January
2005 and June 2006 while receiving continuous positive airway pressure (CPAP) or bilevel
positive airway pressure (BiPAP). Transport paramedics have extensive experience and
supplemental training in NIV and advanced pediatric airway skills.NIV was used during 31
transports of 25 patients (CPAP: 18 transports for 16 patients; BiPAP: 13 transports for nine
patients). Nine patients (36%) were NIV-dependent prior to transport. Diagnoses included
neurologic disease (n = 10), pulmonary disease (n = 10), congenital heart disease (n = 4), and
other (n = 1). Oxygen saturation (SpO(2)) improved to or remained greater than 93% during
all transports. Neither tracheal intubation nor cardiopulmonary resuscitation was required
during or for one hour following any transport-though airway suctioning and/or bag-valvemask ventilation was required during eight of 31 (26%) transports. Six of 17 patients
transferred into our hospital while receiving NIV required tracheal intubation at three to 84
hours after transport; none of these patients developed aspiration pneumonia.Though the use
of NIV during pediatric interhospital ground transports was not associated with serious outof-hospital complications, advanced pediatric airway skills were frequently required.
Baltzan, M. A., et al. (2009). "Evidence of interrelated side effects with reduced compliance
in patients treated with nasal continuous positive airway pressure." Sleep Medicine 10(2):
198-205.
Patients treated for obstructive sleep apnea syndrome (OSAS) with nasal continuous
positive airway pressure (nCPAP) often have side effects and poor compliance. Our
objectives were to explore their side effects when treated with nCPAP and to validate the
association of a side effect syndrome with the outcomes of sleep quality, daytime sleepiness
and nCPAP compliance.Prospective exploratory and subsequent validation study using
questionnaires was performed in a tertiary-care sleep-disorders clinic. Consecutive patients
with polysomnographic diagnosis and nCPAP titrations treated at least 3 months with singlepressure nCPAP were studied. In the first survey, 114 patients were questioned of whom 89
(78%) qualified for exploratory analysis. In the validation survey of 122 patients, 104 (85%)
were studied. Subjects were interviewed and their nCPAP meters were queried.In the first
survey, 3 side effects were often found together and each found to be correlated to
compliance: mouth leak with nCPAP, nasal congestion, and taking off the mask prematurely.
In the validation study, 34% of participants met a syndrome definition with at least 2 of 3
major side effects. Mean (SD) compliance was lower in patients with the syndrome: 4.97
(1.98) vs. 6.42 (1.56) hours per night (p=0.0001). Poor sleep quality and lower satisfaction
with nCPAP were associated with the syndrome.The syndrome of mouth leak, taking off the
nCPAP mask prematurely and nasal congestion is frequent in patients treated with nCPAP.
This is associated with lower compliance and poor sleep quality.
Bannister, D. G. and C. I. Haines (1975). "Letter: Continuous positive airway pressure by
facemask in newborn infants." British Medical Journal 4(5999): 758.
Baraka, A., et al. (1969). "Rebreathing in a double T-piece system." British journal of
anaesthesia 41(1): 47-53.
Barrie, H. (1971). "Continuous positive airway pressure in respiratory-distress syndrome."
Lancet 2(7739): 1427.
Barrington, K. J. and S. C. Muttitt (1998). "Randomized, controlled, blinded trial of
doxapram for extubation of the very low birthweight infant." Acta Paediatrica, International
Journal of Paediatrics 87(2): 191-194.
The objective of the study was to determine whether administering doxapram by
infusion to the very low birthweight infant, prior to extubation during the first 3 weeks of life,
would increase the incidence of successful extubation. The study patients, 56 infants of less
than 1251 g birthweight and less than 30 weeks' gestation, were entered in the first 3 weeks
of life when lung disease had started to improve. A randomized blinded trial was performed,
with infants receiving 3.5 mg kg-1 doxapram bolus, followed by an infusion at 1 mg kg-1 h 1, or placebo. Weaning from positive pressure ventilation was standardized and extubation
occurred after a 12 h trial of an intermittent mandatory ventilation (IMV) rate of 6 breaths
min-1, if PCO2 < 55 mmHg, pH > 7.26, and FiO2 < 0.45. Study drug was continued for 48 h
postextubation, and the infants were placed on nasopharyngeal continuous positive airway
pressure (CPAP) for 72h postextubation. Extubation failure within the first 72 h after
extubation was objectively defined in terms of acidosis (pH < 7.26), hypercarbia (PCO2 > 55
mmHg), excessive oxygen requirement (FiO2 > 0.8) or frequent apnoea (more than three in
12 h, or more than two requiring face mask IMV in 24 h). No difference was noted in the
frequency of successful extubation between the groups. Fifteen infants in each group were
successfully extubated before the 10th day of the study. In conclusion, when given in
accordance with this protocol doxapram does not increase the likelihood of successful
extubation in the very low birthweight infant. Increasing successful extubations in this group
of infants will require other strategies.
Bateman, S. T. and J. H. Arnold (2000). "Acute respiratory failure in children." Current
Opinion in Pediatrics 12(3): 233-237.
Recent studies in the treatment of acute respiratory failure in children have been
targeted at reducing ventilator-induced lung injury, providing treatment adjuncts to
mechanical ventilation, and assessing innovative therapies directed at immunomodulation.
Ventilator-associated lung injury has been demonstrated in animal models during the delivery
of moderate-to-large tidal volumes and has also been described in adult populations.
Subsequently, a significant survival benefit of a low tidal volume, high positive end
expiratory pressure strategy on the ventilatory was found in adults. Investigation of the
effects of inhaled nitric oxide in acute respiratory failure patients continues to show transient
improvements in oxygenation, but no evidence of improved outcomes. The use of
intratracheal surfactant within 24 hours of intubation in pediatric respiratory failure may be
beneficial in reducing the days of mechanical ventilation. Neutrophil oxidative damage has
been demonstrated, but therapies directed at decreasing neutrophil adherence have failed to
demonstrate improvements. Enteral anti-inflammatory and antioxidant therapy may be
promising, because these modalities have been shown to improve a number of surrogate
outcomes in patients with respiratory failure. The use of corticosteroids in the late stages of
lung injury has also recently been shown to have promise.
Battersby, E. F. (1971). "The results of long-term positive pressure ventilation in newborn
surgical patients." Progress in pediatric surgery 3: 105-111.
Belenky, D. A., et al. (1976). "Is continuous transpulmonary pressure better than
conventional respiratory management of hyaline membrane disease? A controlled study."
Pediatrics 58(6): 800-808.
The influence of continuous positive airway pressure (CPAP) and positive endexpiratory pressure (PEEP) on mortality and complication rates in severe hyaline membrane
disease (HMD) was evaluated in a randomized, prospective study. Patients were admitted to
the study if the Po2 was less than 50 mm Hg with FiO2 greater than 0.6. Twenty-four patients
in each of three weight groups were equally divided between treatment and control groups.
The treatment regimen included CPAP (6 to 14 cm H2O) for spontaneously breathing
patients and PEEP for patients requiring mechanical ventilation for apnea or hypercapnia
(Pco2 greater than 65 mm Hg). Control patients received oxygen and were mechanically
ventilated if they had apnea, hypercapnia, or Po2 less than 50 mm Hg with FiO2 greater than
0.8. Oxygenation improved after the start of CPAP or PEEP; however, Pco2 rose after CPAP
was initiated. There was no significant difference between treatment and control groups in
mortality, requirement for mechanical ventilation, or incidence of pulmonary sequelae. The
incidence of pulmonary air-leak was increased with Peep. the findings suggest that CPAP and
PEEP have not significantly altered the outcome of HMD.
Bellani, G., et al. (2008). "The use of helmets to deliver non-invasive continuous positive
airway pressure in hypoxemic acute respiratory failure." Minerva anestesiologica 74(11):
651-656.
Non-invasive continuous positive airway pressure (CPAP) is a useful tool for
managing patients with acute respiratory failure. The head helmet is a relatively novel
interface that is as effective as the traditionally employed face-mask in delivering CPAP and
can possibly be characterized as better for the patient's tolerance and, consequently, a longer
duration of treatment. This review focuses on the main properties of the helmet and the issues
related to its use, as shown by the physiological and bench studies. Clinical experience, both
personal and reported in the literature, for the treatment of both cardiogenic and noncardiogenic pulmonary edema is reviewed as well.
Bellini, C. and F. Campone (2008). "A neonate with acute renal failure: Question." Pediatric
Nephrology 23(1): 49-50.
Bellini, C., et al. (2013). "Simultaneous transport of twin newborns." Air Medical Journal
32(6): 334-337.
Bernath, M. A. and R. Henning (1997). "Tracheal gas insufflation reduces requirements for
mechanical ventilation in a rabbit model of respiratory distress syndrome." Anaesthesia and
Intensive Care 25(1): 15-22.
Tracheal gas insufflation is known to lower PaCO2 in larger animal models of
respiratory distress syndrome, but its ability to reduce the ventilator pressures and tidal
volume needed to achieve an acceptable PaCO2 has not been examined in small animals
using modes of ventilation employed in neonatal intensive care. In this study, the effect of
insufflating humidified gas into the lower trachea was examined in a saline lung lavage
model of respiratory distress syndrome in rabbits, while the peak airway pressure during
conventional pressure-limited ventilation was adjusted to keep the PaCO2 approximately
constant. Tracheal gas insufflation significantly reduced the peak airway pressure required
and reduced the delivered tidal volume but did not affect the AaDO2. The effects were more
marked at a ventilator rate of 30 breaths per minute than at 60 bpm and more during
continuous insufflation than when gas was insufflated only during expiration. These results
suggest that tracheal gas insufflation may reduce the risk of ventilation-induced lung disease
in the newborn.
Bernstein, G., et al. (1993). "Response time and reliability of three neonatal patient-triggered
ventilators." The American review of respiratory disease 148(2): 358-364.
We studied the response time (RT) and reliability of three neonatal patient-triggered
ventilator (PTV) systems: the Draeger Babylog 8000, the Bear Cub enhancement module
(CEM), and the Infrasonics Star Sync. In 10 adult rabbits, airway flow and pressure
recordings showed the RT of the Star Sync to be shorter than that of the Bear CEM (53 +/- 13
versus 65 +/- 15 ms, p < 0.05), and both were shorter than that of the Babylog (95 +/- 24 ms,
p < 0.01) by ANOVA. The RT of the Bear CEM and the Babylog increased significantly at
decreased trigger sensitivity settings. All ventilators triggered successfully on assist-control
(A/C). However, the Babylog had a higher rate of asynchrony on SIMV (30 +/- 25%) than
the Bear CEM (1.1 +/- 0.3%) and the Star Sync (1.2 +/- 0.4%), p < 0.01. In 10 infants with
respiratory failure, recordings of airway flow and pressure were made at ventilator inspiratory
time (Ti) settings of 0.3, 0.4, and 0.5 s on assist-control and on SIMV at rates of 15, 30, 45,
and 60 breaths/min. The Star Sync and Bear CEM triggered successfully on A/C (100%) and
had low rates of asynchrony on SIMV (1 to 3%). The Babylog had a lower success rate on
A/C (70 +/- 12%) and a higher rate of asynchrony on SIMV (29 +/- 30%) than the other two
ventilators; p < 0.01. The lower reliability of the Babylog was due to its variable refractory
period (0.2 to 0.5 s, to equal the set Ti).(ABSTRACT TRUNCATED AT 250 WORDS)
Berry, R. B. and A. J. Block (1984). "Positive nasal airway pressure eliminates snoring as
well as obstructive sleep apnea." Chest 85(1): 15-20.
Nine men who were habitual snorers were studied during a control and a treatment
night (in random order) to assess the effect of nasal continuous positive airway pressure
(CPAP) on snoring, sleep-disordered breathing, and nocturnal oxygen desaturation. Four
subjects had symptoms suggestive of the sleep apnea syndrome, but the other five were
asymptomatic. Polysomnography and recordings of snores were obtained on both nights. On
the treatment night, the subjects wore a customized infant anesthesia mask over their noses,
and CPAP was applied and adjusted upward from 4 cm H2O to a level that obliterated
snoring. Nasal CPAP (range 4 to 13 cm H2O) reduced the mean number of snores per night
from 1,015 per subject to 23 per subject (p less than 0.01). Mean numbers of episodes of
apnea, hypopnea, and desaturation were also significantly reduced. Analysis of sleep
structure showed no significant differences in sleep period time, total sleep time, or the
percentages of stages 3 and 4 sleep. The percentage of stages 1 and 2 was significantly
greater on control nights, and the percentage of REM sleep was greater on treatment nights.
On the control nights, snoring was common in stages 3 and 4 and least common during REM
sleep.
Bhandari, V. (2013). "The potential of non-invasive ventilation to decrease BPD." Seminars
in Perinatology 37(2): 108-114.
Bronchopulmonary dysplasia (BPD), the most common chronic lung disease in
infancy, has serious long-term pulmonary and neurodevelopmental consequences right up to
adulthood, and is associated with significant healthcare costs. BPD is a multifactorial disease,
with genetic and environmental factors interacting to culminate in the characteristic clinical
and pathological phenotype. Among the environmental factors, invasive endotracheal tube
ventilation is considered a critical contributing factor to the pathogenesis of BPD. Since BPD
currently has no specific preventive or effective therapy, considerable interest has focused on
the use of non-invasive ventilation as a means to potentially decrease the incidence of BPD.
This article reviews the progress made in the last 5 years in the use of nasal continuous
positive airways pressure (NCPAP) and nasal intermittent positive pressure ventilation
(NIPPV) as it pertains to impacting on BPD rates. Research efforts are summarized, and
some guidelines are suggested for clinical use of these techniques in neonates. (copyright)
2013 Elsevier Inc.
Binder, C., et al. (2014). "Human or monitor feedback to improve mask ventilation during
simulated neonatal cardiopulmonary resuscitation." Archives of disease in childhood. Fetal
and neonatal edition 99(2): F120-123.
To investigate if external chest compressions (ECC) increase mask leak, and if
human or technical feedback improves mask ventilation during simulated neonatal
cardiopulmonary resuscitation (CPR).In this observational study, 32 participants delivered
positive pressure ventilation (PPV) to a modified, leak-free manikin via facemask. Mask leak,
tidal volume (VT), positive end expiratory pressure (PEEP) and respiratory rate (RR) were
measured with a respiratory function monitor (RFM). Participants had to perform four studies.
In the first study, participants performed PPV alone as baseline. Thereafter, three studies
were performed in random order. In the PPV+ECC+manometer group, participants had to
observe the manometer while the RFM was covered; in the PPV+ECC+RFM group, the RFM
was used while the manometer was covered; and in the PPV+ECC+verbal feedback group,
the RFM and manometer were covered while a team leader viewed the RFM and provided
verbal feedback to the participants.Median (IQR) mask leak of all studies was 15% (5-47%).
Comparing the studies, PPV+ECC+RFM and PPV+ECC+verbal feedback had significantly
less mask leak than PPV+ECC+manometer. Mean (SD) VT of all studies was 9.5��3.5 mL.
Comparing all studies, PPV+ECC+RFM had a significantly higher VT than PPV and
PPV+ECC+manometer. As well, PPV+ECC+verbal feedback had a significantly higher VT
than PPV. PEEP and RR were within our target, mean (SD) PEEP was 6��2 cmH2O and
RR was 36��13/min.During simulated neonatal CPR, ECCs did not influence mask leak,
and a RFM and verbal feedback were helpful methods to reduce mask leak and increase VT
significantly.
Binder, C., et al. (2013). "Cerebral and peripheral regional oxygen saturation during postnatal
transition in preterm neonates." The Journal of pediatrics 163(2): 394-399.
To evaluate peripheral regional oxygen saturation (rpSO��) and cerebral regional
oxygen saturation (rcSO��) during the immediate postnatal transition in late preterm
infants with and without the need for respiratory support.This was a prospective
observational study using near-infrared spectroscopy to evaluate changes in rpSO�� and
rcSO��. These variables were measured during the first 15 minutes of life after elective
cesarean delivery. Peripheral oxygen saturation (SpO��) and heart rate were measured
continuously by pulse oximetry, and cerebral fractional tissue oxygen extraction (cFTOE)
was calculated. Two groups were compared based on their need for respiratory support: a
respiratory support group and a normal transition group. Positive-pressure ventilation was
delivered with a T-piece resuscitator, and oxygen was adjusted based on SpO�� values. A
Florian respiratory function monitor was used to record the ventilation variables.There were
21 infants in the normal transition group and 21 infants in the respiratory support group.
Changes in heart rate over time were similar in the 2 groups. SpO��, rcSO��, and
rpSO�� values were consistently higher in the normal transition group. In the respiratory
support group, cFTOE values remained significantly elevated for a longer period.This
systematic analysis of rpSO��, rcSO��, and cFTOE in late preterm infants found
significantly lower oxygen saturation values in infants who received respiratory support
compared with a normal transition group. We hypothesize that the elevated cFTOE values in
the respiratory support group represent compensation for lower oxygen delivery.Copyright ?
2013 Mosby, Inc. All rights reserved.
Bingham, R. M., et al. (1986). "Assisted ventilation and the Servo ventilator in infants. An
assessment of three systems used for CPAP/IMV." Anaesthesia 41(2): 168-172.
A laboratory assessment was made of systems used for Continuous Positive Airway
Pressure/Intermittent Mandatory Ventilation (CPAP/IMV) with the Servo 900B and 900C
ventilators. Pressure-volume loops recorded during sine wave oscillation using an external
CPAP/IMV system were similar to those found during normal respiration. Pressure-volume
loops using the systems based on the ventilator's inbuilt trigger mechanism were very
different, particularly for the 900B. The results were confirmed by measurements in two
infants. The implications of these findings with reference to the weaning of infants from
mechanical ventilation are discussed.
Biro, P., et al. (1995). "Anesthetic management of a patient with obstructive sleep apnea
syndrome and difficult airway access." Journal of Clinical Anesthesia 7(5): 417-421.
Patients with the obstructive sleep apnea syndrome (OSAS) are predisposed to
respiratory complications under the influence of sedative and anesthetic drugs because of
these drugs' alternation of respiratory control with a tendency for upper airway collapse.
Additional difficulties for airway management during anesthesia may arise if fixed anatomic
obstacles block the upper airway. We present a case of a patient with OSAS scheduled for
general anesthesia for nasal polypectomy and correction of a deviated septum. Preoperative
evaluation revealed several factors known to be associated with difficult intubation and
ventilation: nasal obstruction, maxillofacial malformation (micrognathia), reduced
temporomandibular joint mobility, and obesity. An individualized strategy of airway
management based on published standards was developed and successfully applied. It
involved fiberoptic guided intubation through a laryngeal mask airway. This case illustrates
the management of patients with OSAS and additional conditions that reduce upper airway
patency.
Bizzle, T. L. and R. V. Kotas (1983). "Positive pressure hand ventilation: potential errors in
estimating inflation pressures." Pediatrics 72(1): 122-125.
Black, C. (2010). "CPAP, yes! But how?" Respiratory Care 55(5): 638-639.
Blake, A. M., et al. (1973). "Simplified mechanical ventilation for hyaline-membrane
disease." Lancet 2(7839): 1176-1178.
Bohn, D. (2001). "Lung salvage and protection ventilatory techniques." Pediatric clinics of
North America 48(3): 553-572.
Physicians are in the beginning of an era in intensive care medicine in which they
finally are starting to see improved outcomes in patients with AHRF. At the same time,
intensivists are presented with a bewildering choice of ventilator options and adjunctive
therapies. Trying to sort out which are cosmetic, that is, improve the blood gases as opposed
to influencing the outcome, remains a challenge and will be resolved only with additional
RCTs. Principles of ventilator management that are driven by mimicking normal physiology
are inappropriate and must be rethought.
Bordessoule, A., et al. (2012). "Neurally adjusted ventilatory assist improves
patient?ventilator interaction in infants as compared with conventional ventilation." Pediatric
Research 72(2): 194-202.
Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation controlled by
the electrical activity of the diaphragm (Edi). The aim was to evaluate patient-ventilator
interaction in infants during NAVA as compared with conventional ventilation.Infants were
successively ventilated with NAVA, pressure control ventilation (PCV), and pressure support
ventilation (PSV). Edi and ventilator pressure (Pvent) waveforms were compared and their
variability was assessed by coefficients of variation.Ten patients (mean age 4.3 �� 2.4 mo
and weight 5.9 �� 2.2 kg) were studied. In PCV and PSV, 4 �� 4.6% and 6.5 �� 7.7%
of the neural efforts failed to trigger the ventilator. This did not occur during NAVA. Trigger
delays were shorter with NAVA as compared with PCV and PSV (93 �� 20 ms vs. 193
�� 87 ms and 135 �� 29 ms). During PCV and PSV, the ventilator cycled off before the
end of neural inspiration in 12 �� 13% and 21 �� 19% of the breaths (0 �� 0% during
NAVA). During PCV and PSV, 24 �� 11% and 25 �� 9% of the neural breath cycle was
asynchronous with the ventilator as compared with 11 �� 3% with NAVA. A large
variability was observed for Edi in all modes, which was transmitted into Pvent during
NAVA (coefficient of variation: 24 �� 8%) and not in PCV (coefficient of variation 2 ��
1%) or PSV (2 �� 2%).NAVA improves patient-ventilator interaction and delivers
adequate ventilation with variable pressure in infants.
Boros, S. J. and A. A. Orgill (1978). "Mortality and morbidity associated with pressure- and
volume-limited infant ventilators." American journal of diseases of children (1960) 132(9):
865-869.
The effect of pressure-limited (PL) and volume-limited (VL) ventilation on mortality
and morbidity in infants with severe hyaline membrane disease (HMD) was examined in a
prospective controlled study. Criteria for mechanical ventilation were PaO2 value of 50 mm
Hg or less or a Paco2 value of 70 mm Hg or greater, while the infant was receiving nasal
continuous positive airway pressure (CPAP) at oxygen concentrations (FIO2) of 0.8 or
greater and CPAP of 8 cm H2O or greater; HMD associated with severe perinatal asphyxia
requiring mechanical ventilation in the delivery room. Consecutive patients were alternately
assigned to receive either PL or VL ventilation. Twenty infants were ventilated with PL
machines using low peak inspiratory pressures (mean maximum inspiratory pressure of 28
cm H2O) and prolonged inspiratory times. Twenty other infants were ventilated with VL
machines, using essentially unlimited peak inspiratory pressures (mean maximum inspiratory
pressure of 62 mm H2O) and prolonged expiratory times. There were no significant
differences in survival, incidence of pneumothorax or pulmonary interstitial emphysema, or
noteworthy bronchopulmonary dysplasia.
Boros, S. J. and J. W. Reynolds (1975). "Hyaline membrane disease treated with early nasal
end-expiratory pressure: one year's experience." Pediatrics 56(2): 218-223.
This report describes one year's experience treating hyaline membrane disease (HMD)
with nasal end-expiratory pressure (NEEP). During the 12 months from July 1, 1973 through
June 30, 1974, 119 children with HMD were admitted to the Intensive Care Unit of St. Paul
Children's Hospital. Sixty-nine infants were treated early in the course of their disease with
NEEP. The survival, incidence of complications, and the number of endotracheal intubations
are reported and compared to our experience during a similar time period prior to the use of
NEEP (1971-1972). Since the advent of the early application of modest amounts of endexpiratory pressure by nasopharyngeal tube, there has been an increase in the survival of all
admissions with HMD, but the increase was statistically significant (P less than .01) only in
those weighing 1,501 to 2,000 gm. There was a significant decrease (P less than .025) in the
total number of children with HMD requiring endotracheal intubation. There was no change
in the incidence of pneumothoraces or bronchopulmonary dysplasia. NEEP is a simple and
effective technique for creating continuous airway distending pressure. Its effectiveness and
ready availability make the routine endotracheal intubation of infants requiring only
continuous airway distending pressure no longer justifiable.
Bowman, T. A., et al. (2012). "Sensing and responding to compliance changes during manual
ventilation using a lung model: can we teach healthcare providers to improve?" The Journal
of pediatrics 160(3): 372-376.e371.
To test the hypothesis that an educational intervention would improve the
resuscitator's ability to provide on-target volume ventilation during pulmonary compliance
changes.Neonatal professionals (n = 27) ventilated an electromechanical lung model
simulating a 3-kg baby while targeting a tidal volume of 4-6 mL/kg. In this preintervention
and postintervention study, a one-on-one educational intervention aimed to improve the
primary outcome of on-target tidal volume delivery during high and low compliance.
Seventeen subjects were retested 8 months later.When only pressure was displayed, and using
a self-inflating bag, participants improved from a mean of 6% of breaths on-target to 21%
immediately after education (P < .01). Using a flow-inflating bag, participants improved from
1% to 7% of breaths on-target (P < .01). Eight-month retention testing demonstrated no
difference compared with baseline. With volume displayed, the mean baseline success rate
was 84% with the self-inflating bag and 68% with the flow-inflating bag. There was no
significant change after education or at 8-month follow-up.When pressure is displayed,
resuscitators can improve their ability to respond to changes in compliance after an
educational intervention. When volume is displayed, performance is markedly better at
baseline, but not improved after the intervention. Our findings reconfirm that resuscitation
bags should have volume displays.Copyright ?? 2012 Mosby, Inc. All rights reserved.
Boynton, B. R., et al. (1984). "Combined high-frequency oscillatory ventilation and
intermittent mandatory ventilation in critically ill neonates." The Journal of pediatrics 105(2):
297-302.
Combined high-frequency oscillatory ventilation (HFOV) and intermittent
mandatory ventilation (IMV) was used in 12 neonates with inadequate gas exchange with
conventional IMV. Diagnoses included diaphragmatic hernia with hypoplastic lungs,
pneumonia, persistent fetal circulation, and severe respiratory distress syndrome. In most
patients there was severe air leak. Within 10 hours of beginning HFOV-IMV the mean
arterial PCO2 fell from 60 +/- 5 (means +/- SEM) to 38 +/- 2 mm Hg (P less than 0.01) and
the mean IMV rate was reduced from 96 +/- 8 to 17 +/- 4 breaths per minute (P less than
0.001). The mean arterial-alveolar oxygen tension ratio rose from 0.05 +/- 0.01 to 0.09 +/0.01 (P less than 0.005). Mean airway pressure in the trachea was reduced from 16 +/- 2 to 10
+/- 3 cm H2O (P less than 0.05). Four patients died, three of whom had diaphragmatic
hernias with hypoplastic lungs. Five of the eight survivors had mild bronchopulmonary
dysplasia requiring supplemental oxygen. These studies demonstrate that in some neonates
with respiratory failure who fail to respond to conventional IMV, combined HFOV-IMV can
be successful.
Braima, O. and C. A. Ryan (2008). "Neonatal resuscitation program guidelines 2006: ready,
steady, can't go!" Irish Medical Journal 101(5): 142-144.
New evidence-based guidelines have been launched with recommendations that may
impact how resuscitations, particularly of LBW infants, are enacted.to determine current
resuscitation practices in Maternity units in Ireland and benchmarked these results to a recent
study in the United States.A 20-question survey was developed and mailed to a lead
neonatologist/paediatrician in each of 19 maternity units in Ireland in May 2006.There was
84% response rate to the surveys mailed which included 10 level II and 6 level III units. NRP
qualification was considered obligatory for all paediatrics doctors in all units, with 14/16
units running at least one NRP course per year (range 1-9). Self inflating bags were more
commonly used (44%), followed by T-piece resuscitators (31%) and flow inflating bags
(25%). Pulse oximeters to alter the fraction of inspired oxygen were used by (25%) of units
during the management of very low birth weigh infants, with a useful signal being achieved
in one minute in most cases. Air/oxygen blenders were available for (44%) of units; however,
all units use 100% O2 for initial resuscitation. CO2 detectors for ETT position were used in
only 2 units (12%). A third of units (31%) used plastic wrap to prevent heat loss in VLBW
infants. CPAP/PEEP were used by 44% of the surveyed units, generally with initiating
pressure of 5 cm H2O.NRP is now an obligatory feature in all NICU's in Ireland compared to
the 1990s when resuscitation training was disorganized and inconsistent. Variations in
resuscitation practices still exist among different units. Many units may not be able to apply
2006 NRP guidelines especially for VLBW infants unless there is a significant investment in
air/oxygen blenders, pulse oximeters, CO2 detectors and resuscitators that control peak
pressures and CPAP/PEEP.
Brambrink, A. M. and U. Braun (2005). "Airway management in infants and children." Best
Practice and Research: Clinical Anaesthesiology 19(4): 675-697.
Anaesthesiologists, paediatricians, paediatric intensivists and emergency physicians
are routinely challenged with airway management in children and infants. There are
important differences from adult airway management as a result of specific features of
paediatric anatomy and physiology, which are more relevant the younger the child. In
addition, a number of inherited and acquired pathological syndromes have significant impact
on airway management in this age group. Several new devices - e.g. different types of
laryngeal mask airways in various sizes, small fibre-endoscopes - have been introduced into
clinical practice with the intention of improving airway management in this age group.
Important new studies have gathered evidence about risks and benefits of certain confounding
variables for airway problems and specific techniques for solving them. Airway-related
morbidity and mortality in children and infants during the perioperative period are still high,
and only a thorough risk determination prior to and continuous attention during the procedure
can reduce these risks. Appropriate preparation of the available equipment and frequent
training in management algorithms for all personnel involved appear to be very important.
(copyright) 2005 Elsevier Ltd. All rights reserved.
Braun, N. M. (1988). "Intermittent mechanical ventilation." Clinics in chest medicine 9(1):
153-162.
More than 150 years have passed since the birth of the idea of intermittent
mechanical ventilation. Many types of ventilatory disorders can result in excessive loading of
the respiratory muscles, thus causing them to fail. We now have several types of ventilatory
assist devices to choose from so that we can select a system that fulfills the physical,
physiologic, and psychological needs of patients and return them to a more satisfactory level
of living in the home. This is successful when the care team and the patient and family set
realistic goals and maintain close clinical supervision. Much more study is needed to
determine the optimal times for respiratory muscle rest. Future technologic designs for
ventilatory systems should aim to decrease cost and increase efficiency, ease of use, and
durability.
Bumstead, D. (1984). "A modification of the Laerdal infant resuscitator for the simple and
safe delivery of CPAP and PEEP." Respiratory Care 29(3): 270-272.
A Laerdal infant resuscitator was modified to permit simple delivery of continuous
positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP) in both
stationary and transport situations. The device is useful for pulmonary support of critically ill
infants when they are off mechanical ventilators and for ventilation of infants with respiratory
distress in the delivery room. It has been used successfully at The Johns Hopkins Hospital
since early 1981.
Calderini, E., et al. (2010). "What are the current indications for noninvasive ventilation in
children?" Current Opinion in Anaesthesiology 23(3): 368-374.
The aims of this paper are to examine the physiological rationale for noninvasive
respiratory support (NRS) in children older than 1 month with acute respiratory failure, to
review clinical available data and to give some practical recommendations for the safe
application of NRS.NRS is the delivery of ventilatory support without the need for an
invasive airway. Two types of NRS are commonly used in the pediatric population:
noninvasive continuous positive airway pressure and noninvasive positive pressure
ventilation. In general, the evidence to support the use of NRS in children with acute
respiratory failure is scarce. However, two randomized studies have been recently published
suggesting that noninvasive positive pressure ventilation ameliorates clinical signs and gas
exchange while reducing the need for endotracheal intubation. Moreover, noninvasive
continuous positive airway pressure and heliox may improve clinical scores and carbon
dioxide washout in infants with severe bronchiolitis, without major complications. Data from
noncontrolled studies show that NRS unloads the respiratory muscles and that the helmet can
be a valid alternative to a facial and/or nasal mask when noninvasive continuous positive
airway pressure is administered to children in the early stage of acute respiratory
failure.Preliminary clinical data show that NRS is safe and effective in children with acute
respiratory failure.
Capasso, L., et al. (2005). "A randomized trial comparing oxygen delivery on intermittent
positive pressure with nasal cannulae versus facial mask in neonatal primary resuscitation."
Acta paediatrica (Oslo, Norway : 1992) 94(2): 197-200.
To compare, in a prospective clinical trial, oxygen delivery on intermittent positive
pressure with nasal cannulae versus facial mask in primary resuscitation of the newborn with
moderate asphyxia.617 neonates with moderate asphyxia at birth were randomized: 303 were
resuscitated by oxygen on intermittent positive pressure with nasal cannuale and 314
neonates by mask. Resuscitation followed the Neonatal Resuscitation Program guidelines of
the American Academy of Pediatrics, 3rd edition.Resuscitation through the nasal route less
frequently requires chest compressions and intubations (26 neonates needed chest
compression and 20 needed intubation out of 314 resuscitated by mask; five neonates needed
chest compression and two needed intubation out of 303 resuscitated by nasal cannulae).
Apgar scores, admission rates to neonatal intensive care units, air-leak syndromes,
birthweight, gestational age, use of prenatal steroids and deaths did not differ between
groups.Oxygen delivery on intermittent positive pressure with nasal cannulae in primary
resuscitation of the newborn with moderate asphyxia is a less aggressive and potentially
advantageous alternative to the traditional oral route.
Carlisle, H. R., et al. (2010). "Oral continuous positive airway pressure (CPAP) following
nasal injury in a preterm infant." Archives of Disease in Childhood: Fetal and Neonatal
Edition 95(2): F142-F143.
Non-invasive respiratory support is increasingly popular but is associated with
complications including nasal trauma. The present report describes a novel method of oral
continuous positive airway pressure (CPAP) delivery in an extremely premature infant with
severe nasal septum erosion. The distal end of a cut down endotracheal tube was passed
through a small hole made in the teat of a dummy (infant pacifi er) and sutured in place. The
dummy was secured in the infant's mouth and CPAP was delivered to the pharynx. The
device was well tolerated and the infant was successfully managed using this technique for 48
days, avoiding endotracheal intubation and ventilation.
Carlo, W. A. and R. J. Martin (1986). "Principles of neonatal assisted ventilation." Pediatric
clinics of North America 33(1): 221-237.
Based on the current knowledge of pulmonary mechanics and the results of clinical
studies, we have reviewed principles that govern gas exchange during assisted ventilation in
infants with RDS. Guidelines for changes in ventilator settings have been presented with
respect to their specific effects on CO2 elimination and O2 uptake. In addition, their possible
mechanisms of action and potential side effects have been addressed. General strategies have
been presented, but they must be employed with caution. All infants will not exhibit the
expected response to changes in ventilator setting, and thus their ventilatory management, as
well as their general medical care, will need to be individualized.
Cauley, R. P., et al. (2013). "Pulmonary support on Day 30 as a predictor of morbidity and
mortality in congenital diaphragmatic hernia." Journal of Pediatric Surgery 48(6): 1183-1189.
Purpose Congenital diaphragmatic hernia (CDH) is associated with significant inhospital mortality, morbidity and length-of-stay (LOS). We hypothesized that the degree of
pulmonary support on hospital day-30 may predict in-hospital mortality, LOS, and discharge
oxygen needs and could be useful for risk prediction and counseling. Methods 862 patients in
the CDH Study Group registry with a LOS (greater-than or equal to) 30 days were analyzed
(2007-2010). Pulmonary support was defined as (1) room-air (n = 320) (2) noninvasive
supplementation (n = 244) (3) mechanical ventilation (n = 279) and (4) extracorporeal
membrane oxygenation (ECMO, n = 19). Cox Proportional hazards and logistic regression
models were used to determine the case-mix adjusted association of oxygen requirements on
day-30 with mortality and oxygen requirements at discharge. Results On multivariate analysis,
use of ventilator (HR 5.1, p =.003) or ECMO (HR 19.6, p <.001) was a significant predictor
of in-patient mortality. Need for non-invasive supplementation or ventilator on day-30 was
associated with a respective 22-fold (p <.001) and 43-fold (p <.001) increased odds of
oxygen use at discharge compared to those on room-air. Conclusions Pulmonary support on
Day-30 is a strong predictor of length of stay, oxygen requirements at discharge and inpatient mortality and may be used as a simple prognostic indicator for family counseling,
discharge planning, and identification of high-risk infants.
Cegrell, L. and N. W. Svenningsen (1975). "Successfully treated pneumopericardium in a
newborn infant during IPPV." Acta paediatrica Scandinavica 64(1): 135-137.
The successful treatment of pneumopericardium and cardiac tamponade in a newborn
infant is presented in this case report. Alert recognition of this complication in newborn
infants on intermittent positive pressure ventilation (IPPV) is of the utmost importance as
prompt and adequate treatment is life-saving.
Chakrabarti, M. K., et al. (1990). "A new infant oscillatory ventilator." British journal of
anaesthesia 64(3): 374-378.
A new, simple and inexpensive oscillatory ventilator is described in which a rotating
jet mounted in the breathing duct generates cyclically positive and negative pressures in the
airway with a sinusoidal flow waveform. Unlike conventional oscillatory ventilators it is free
from restrictions to inspiratory or expiratory gas flows and open to atmosphere at all times,
making it intrinsically a safe system for ventilation. A prototype rotating jet oscillatory
ventilator designed for application in infants was evaluated in rabbits (mean weight 3.8 kg).
The positive peak and mean airway pressures were significantly less during oscillatory
ventilation at 300 and 420 b.p.m. compared with normal and high frequency positive pressure
ventilation at 30 and 300 b.p.m., respectively, while maintaining blood-gas tensions within
the normal range. An increase in the oscillatory frequency from 300 to 420 b.p.m. provided
no further benefit in terms of airway pressure, tidal volume or blood-gas tensions.
Chakrabarti, M. K. and J. G. Whitwam (1988). "A new infant ventilator for normal and highfrequency ventilation: influence of tracheal tube on distal airway pressure during highfrequency ventilation." Critical care medicine 16(11): 1142-1146.
A new infant ventilator for both normal and high-frequency ventilation is described.
High pressure gas delivered via a jet in the breathing limb of a T-piece, in which there are no
valves, drives respiratory fresh gas (RFG), supplied to the tracheal tube from any low
pressure source, into the lungs. Observations on anesthetized rabbits showed that after setting
up for a PaCO2 of 36 torr at 30 cycle/min, it remained around 36 torr when the ventilation
frequency was progressively increased to 200 cycle/min. The mean peak proximal airway and
tracheal pressures were 13 and 12, 11 and 7, and 13 cm H2O (PEEP 2.1 cm H2O) and 7.4 cm
H2O (PEEP 3.1 cm H2O) at 30, 100 and 200 cycle/min, respectively. In this open valveless
breathing system, desynchronized spontaneous and artificial ventilation occurred quietly
without any marked variation in the airway pressures. This preliminary study on a new
pneumatic system shows its potential for simplifying and improving infant ventilation.
Chatwin, M., et al. (2011). "Outcome of goal-directed non-invasive ventilation and
mechanical insufflation/exsufflation in spinal muscular atrophy type I." Archives of Disease
in Childhood 96(5): 426-432.
There are widely discrepant views on the respiratory management of infants with
spinal muscular atrophy (SMA) type I. Typically, management is palliative.A descriptive
study of interventions and investigations is reported that were offered to a cohort of 13
children with SMA type I referred to our centre. Interventions and investigations included
sleep studies, provision of non-invasive positive pressure ventilation (NIPPV) for ventilatory
support/dependency and for physiotherapy and the use of mechanical
insufflation/exsufflation (MI-E).NIPPV was provided for the following indications:
continuous positive airways pressure flow driver dependency (n=3), nocturnal
hypoventilation (n=3), to enable successful extubation (n=2), in anticipation of respiratory
decompensation (n=3), and oxygen dependency/decompensation (n=2). NIPPV and MI-E
were used for successful protocol-led extubations (n=9) but not non protocol-led successes
(n=3). NIPPV was essential for discharge home in patients with ventilatory dependency (n=7)
and was used for palliation of respiratory symptoms (n=4). Chest wall shape improved with
NIPPV. The parents of children who died (n=5) were positive about the use of these
techniques.NIPPV can be used to facilitate discharge home, and MI-E is helpful in this group.
This symptom and goal-directed approach can be used to inform medical decision making
and to help parents make informed choices about the appropriateness of respiratory
interventions in SMA type I.
Chau, S.-K. and S.-L. Lee (2013). "Successful use of BiPAP in infants with congenital
myotonic dystrophy." Pediatrics International 55(2): 243-245.
Reported herein are two cases of severe phenotype of congenital myotonic dystrophy
(CDM) with presentation of respiratory insufficiency at birth. The infants were successfully
managed with bi-level positive airway pressure (BiPAP) via nasal mask. The use of BiPAP in
infants with CDM has not been reported before. The rationale for using BiPAP is discussed.
BiPAP may be more effective than continuous positive airway pressure in managing
respiratory insufficiency, especially in infants with the more severe phenotype of CDM.
Pediatrics International (copyright) 2013 Japan Pediatric Society.
Cheema, I. U. and J. S. Ahluwalia (2001). "Feasibility of tidal volume-guided ventilation in
newborn infants: a randomized, crossover trial using the volume guarantee modality."
Pediatrics 107(6): 1323-1328.
Volume guarantee (VG) is a new composite mode of pressure-limited ventilation,
available on the Dr?ger Babylog 8000 ventilator, which allows the clinician to set a target
mean tidal volume to be delivered while still maintaining control over peak airway pressures.
This study aimed to investigate the feasibility and efficacy of this mode of ventilation in
premature newborn infants with respiratory distress syndrome (RDS).Two groups of infants
were studied: those receiving synchronized intermittent positive pressure ventilation (SIPPV)
in early phase of RDS (group 1) and those in recovery phase of RDS being weaned from
artificial ventilation through synchronized intermittent mandatory ventilation (SIMV; group
2). Both groups of infants were studied over a 4-hour period. Before the start of the study, the
infants were either receiving SIPPV (group 1) or SIMV (group 2). Infants in group 1 were
randomized to either continue on SIPPV for the first hour of the study or to receive SIPPV
plus VG for the first hour. Subsequently, the 2 modes were used alternately for the remaining
three 1-hour periods. Similarly, infants in group 2 were randomized to either continue on
SIMV for the first hour of the study or to receive SIMV plus VG for the first hour. Data on
ventilation parameters and transcutaneous carbon dioxide and oxygen were collected
continuously.Forty infants were studied, 20 in each group. The mean (standard error)
gestational age was 27.9 (0.3) weeks; birth weight was 1064 (60) g. No adverse events were
observed during the study. Fractional inspired oxygen during SIMV plus VG was 0.31 (0.3);
during SIMV, 0.31 (0.3); during SIPPV plus VG, 0.41 (0.4); and during SIPPV, 0.40 (0.4).
Transcutaneous carbon dioxide pressure during SIMV plus VG was 6.0 (2.2) kPa; during
SIMV, 5.9 (2.2) kPa; during SIPPV plus VG, 6.4 (2.9) kPa; and during SIPPV, 6.4 (2.8) kPa.
Transcutaneous partial pressure of oxygen during SIMV plus VG was 8.4 (8.7) kPa; during
SIMV, 8.6 (8.8) kPa; during SIPPV plus VG, 7.6 (4.0) kPa; and during SIPPV, 7.7 (4.2) kPa.
None of these differences was statistically significant. The mean (standard error) peak
inspiratory pressure used during SIMV was 17.1 (3.4) cm of water; during SIMV plus VG,
15.0 (7.5) cm of water; during SIPPV plus VG, 17.1 (9.3) cm of water; and during SIPPV,
18.7 (8.3) cm of water. The mean airway pressure during SIMV plus VG was 6.5 (3.1) cm of
water; during SIMV, 6.9 (2.8) cm of water; during SIPPV plus VG, 9.6 (4.5) cm of water;
and during SIPPV, 9.8 (4.6) cm of water.VG seems to be a stable and feasible ventilation
mode for neonatal patients and can achieve equivalent gas exchange using statistically
significant lower peak airway pressures both during early and recovery stages of
RDS.ventilation, airway pressure, volume guarantee, tidal volume.
Chernick, V. (1973). "Continuous negative chest wall pressure therapy for hyaline membrane
disease." Pediatric clinics of North America 20(2): 407-417.
Chernick, V. (1973). "Hyaline-membrane disease: therapy with constant lung-distending
pressure." The New England journal of medicine 289(6): 302-304.
Chidini, G., et al. (2010). "Noninvasive continuous positive airway pressure in acute
respiratory failure: helmet versus facial mask." Pediatrics 126(2): e330-336.
Noninvasive continuous positive airway pressure (nCPAP) is applied through
different interfaces to treat mild acute respiratory failure (ARF) in infants. Recently a new
pediatric helmet was introduced in clinical practice to deliver nCPAP. The objective of this
study was to compare the feasibility of the delivery of nCPAP by the pediatric helmet with
delivery by a conventional facial mask in infants with ARF.We conducted a single-center
physiologic, randomized, controlled study with a crossover design on 20 consecutive infants
with ARF. All patients received nCPAP by helmet and facial mask in random order for 90
minutes. In infants in both trials, nCPAP treatment was preceded by periods of unassisted
spontaneous breathing through a Venturi mask. The primary end point was the feasibility of
nCPAP administered with the 2 interfaces (helmet and facial mask). Feasibility was evaluated
by the number of trial failures defined as the occurrence of 1 of the following: intolerance to
the interface; persistent air leak; gas-exchange derangement; or major adverse events. nCPAP
application time, number of patients who required sedation, and the type of complications
with each interface were also recorded. The secondary end point was gas-exchange
improvement.Feasibility of nCPAP delivery was enhanced by the helmet compared with the
mask, as indicated by a lower number of trial failures (P < .001), less patient intolerance (P
< .001), longer application time (P < .001), and reduced need for patient sedation (P < .001).
For both delivery methods, no major patient complications occurred.The results of this
current study revealed that the helmet is a feasible alternative to the facial mask for delivery
of nCPAP to infants with mild ARF.
Chidini, G., et al. (2010). "Treatment of acute hypoxemic respiratory failure with continuous
positive airway pressure delivered by a new pediatric helmet in comparison with a standard
full face mask: a prospective pilot study." Pediatric critical care medicine : a journal of the
Society of Critical Care Medicine and the World Federation of Pediatric Intensive and
Critical Care Societies 11(4): 502-508.
To evaluate the feasibility and efficacy of continuous positive airway pressure
delivered by a new pediatric helmet in comparison with a standard facial mask in infants with
acute hypoxemic respiratory failure.A single-center prospective case-control study.Pediatric
intensive care unit in a tertiary children hospital.Twenty consecutive infants treated with
continuous positive airway pressure by a helmet matched with a control patient treated with
continuous positive airway pressure by facial mask and selected by age, weight, PaO2:Fio2,
and PaCO2 on pediatric intensive care unit admission.Feasibility was defined as the
incidence of continuous positive airway pressure protocol failure secondary to 1) failure to
administer continuous positive airway pressure because of intolerance to the interface; 2)
deterioration in gas exchange soon after continuous positive airway pressure institution; and 3)
major clinical adverse events such as pneumothorax or any hemodynamic instability related
to the continuous positive airway pressure safety system device's failure. Evaluation of
feasibility included also the total application time of respiratory treatment, the number of
continuous positive airway pressure discontinuations/first 24 hrs. Interface-related
complications included air leaks, cutaneous pressure sores, eye irritation, inhalation, and
gastric distension. The 20 patients and control subjects had similar matching characteristics.
Continuous positive airway pressure delivered by a helmet compared with a facial mask
reduced continuous positive airway pressure trial failure rate (p = .02), increased application
time (p = .001) with less discontinuations (p = .001), and was not associated with an
increased rate of major adverse events, resulting in decreased air leaks (p = .04) and pressure
sores (p = .002). Both continuous positive airway pressure systems resulted in early and
sustained improvement in oxygenation.The helmet might be considered a viable and safe
alternative to a standard facial mask to deliver continuous positive airway pressure in
hypoxemic infants in the pediatric intensive care unit setting. In our study, the helmet allowed
more prolonged application of continuous positive airway pressure compared with a facial
mask, ensuring similar improvement in oxygenation without any adverse events and clinical
intolerance.
Chowdhury, M. M., et al. (2013). "Heliox therapy in bronchiolitis: phase III multicenter
double-blind randomized controlled trial." Pediatrics 131(4): 661-669.
Supportive care remains the mainstay of therapy in bronchiolitis. Earlier studies
suggest that helium-oxygen therapy may be beneficial, but evidence is limited. We aimed to
compare efficacy of 2 treatment gases, Heliox and Airox (21% oxygen + 79% helium or
nitrogen, respectively), on length of hospital treatment for bronchiolitis.This was a
multicenter randomized blinded controlled trial of 319 bronchiolitic infant subjects randomly
assigned to either gas; 281 subjects completed the study (140 Heliox, 141 Airox), whose data
was analyzed. Treatment was delivered via facemask (nasal cannula, if the facemask
intolerant) �� continuous positive airway pressure (CPAP). Severe bronchiolitics received
CPAP from the start. Primary end point was length of treatment (LoT) required to alleviate
hypoxia and respiratory distress. Secondary end-points were proportion of subjects needing
CPAP; CPAP (LoT); and change in respiratory distress score.Analysis by intention to treat
(all subjects); median LoT (inter-quartile range, days): Heliox 1.90 (1.08-3.17), Airox 1.87
(1.11-3.34), P = .41. Facemask tolerant subgroup: Heliox 1.46 (0.85-1.95), Airox 2.01 (0.932.86), P = .03. Nasal cannula subgroup: Heliox 2.51 (1.21-4.32), Airox 2.81 (1.45-4.78), P
= .53. Subgroup started on CPAP: Heliox 1.55 (1.38-2.01), Airox 2.26 (1.84-2.73), P = .02.
Proportion of subjects needing CPAP: Heliox 17%, Airox 19%, O.R. 0.87 (0.47-1.60), P
= .76. Heliox reduced respiratory distress score after 8 hours (mixed models estimate, -0.1298;
P < .001). The effect was greater for facemask compared with nasal cannula (mixed models
estimate, 0.093; P = .04).Heliox therapy does not reduce LoT unless given via a tight-fitting
facemask or CPAP. Nasal cannula heliox therapy is ineffective.
Claure, N., et al. (2003). "Elimination of ventilator dead space during synchronized
ventilation in premature infants." The Journal of pediatrics 143(3): 315-320.
Mainstream airflow sensors used in neonatal ventilators to synchronize mechanical
breaths with spontaneous inspiration and measure ventilation increase dead space and may
impair carbon dioxide (CO(2)) elimination.To evaluate a technique consisting of a continuous
gas leakage at the endotracheal tube (ETT) adapter to wash out the airflow sensor for
synchronization and ventilation monitoring without CO(2) rebreathing in preterm
infants.Minute ventilation (V'(E)) by respiratory inductance plethysmography, endinspiratory and end-expiratory CO(2) by side-stream microcapnography, and transcutaneous
CO(2) tension (TcPCO(2)) were measured in 10 infants (body weight, 835+/-244 g;
gestational age, 26+/-2 weeks; age, 19+/-9 days; weight, 856+/-206 g; ventilator rate, 21+/-6
beats/min; PIP, 16+/-1 centimeters of water (cmH(2)O); PEEP, 4.2+/-0.4 cmH(2)O; fraction
of inspired oxygen (FIo(2)), 0.26+/-0.6). The measurements were made during four 30minute periods in random order: IMV (without airflow sensor), IMV+Sensor, SIMV (with
airflow sensor), and SIMV+Leak (ETT adapter continuous leakage).Airflow sensor presence
during SIMV and IMV+Sensor periods resulted in higher end-inspiratory and end-expiratory
CO(2), Tcpco(2), and spontaneous V'(E) compared with IMV. These effects were not
observed during SIMV+Leak.The significant physiologic effects of airflow sensor dead space
during synchronized ventilation in preterm infants can be effectively prevented by the ETT
adapter continuous leakage technique.
Constantinidis, J., et al. (2000). "[Morphological and functional changes in nasal mucosa
after nCPAP therapy]." HNO 48(10): 747-752.
The treatment success of nCPAP therapy (nasal continuous positive airway pressure)
depends partly on the relief of symptoms and partly on long-term patient acceptance and the
related avoidance of complications. Nasal complaints constitute the most frequently reported
side effects and, together with problems of mask application, are among the primary factors
causing an nCPAP-therapy to be prematurely discontinued.To assess the morphological
changes of the nasal mucosa during nCPAP-therapy, we excised specimens of nasal mucosa
tissue in twelve patients with obstructive sleep apnea syndrome (OSAS) both before and 3-10
months after establishing nCPAP-mask acceptance. The specimens were examined by
electron microscopy.In all these patients, acceptance of the CPAP mask marked the initial
part of therapy. In addition, mucociliary clearance was assessed by the saccharin test before
and after therapy. In all patients, the nasal epithelium underwent fundamental changes upon
CPAP therapy, which became manifest as modifications in the shape of epithelial cells,
conglutination and clumping of the microvilli, and the appearance of immunocompetent cells.
Once patients were nCPAP mask compliant, mucociliary clearance was distinctly prolonged
in all cases.A successful therapeutic concept should provide normalization of room
temperature and air humidity once nCPAP mask compliance has been achieved, and include
regular assessment of the condition of the mucosa in the upper respiratory tract. Only by
these measures can nasal complications be countered or therapy be applied at an early stage.
Constantinidis, J., et al. (2000). "Fine-structural investigations of the effect of nCPAP-mask
application on the nasal mucosa." Acta Oto-Laryngologica 120(3): 432-437.
The treatment success of nasal continuous positive airway pressure (nCPAP)-therapy
is dependent, on the one hand, on the achieved relief of complaints and, on the other hand, on
long-term patient compliance and avoidance of compliance-related complaints. Next to the
problem of mask application, nasal complaints comprise the most frequently reported sideeffects and are among the primary factors causing nCPAP-therapy to be discontinued
prematurely. To assess the morphological changes in the nasal mucosa during nCPAPtherapy, we excised specimens of nasal mucosa tissue from 10 patients with obstructive sleep
apnoea syndrome (OSAS) before and 3-10 months after establishing nCPAP-mask
compliance. The specimens were examined by electron microscopy. In all these patients
compliance with the CPAP-mask marked the initial part of therapy. In addition, mucociliary
clearance was assessed by the saccharin test before and after therapy. In all patients the nasal
epithelium underwent fundamental changes upon CPAP-therapy, which became manifest as
modifications in the shape of epithelial cells, conglutination and clumping of the microvilli,
and the appearance of immunocompetent cells. Once patients were nCPAP-mask compliant,
mucociliary clearance was distinctly prolonged in all cases. A successful therapeutic concept
should provide normalization of room temperature and air humidity once nCPAP-mask
compliance has been achieved and include regular assessment of the condition of the mucosa
in the upper respiratory tract. Only by these measures can nasal complications be countered
or given therapy at an early stage.
Cook, S. E., et al. (2010). "Effects of imposed resistance on tidal volume with 5 neonatal
nasal continuous positive airway pressure systems." Respiratory Care 55(5): 544-548.
Neonates with respiratory distress syndrome are often treated with nasal continuous
positive airway pressure (CPAP). Nasal CPAP methods include electronic feedback control,
underwater seal, flow opposition, and flow opposition with fluidic flow reversal on expiration.
Few studies have compared those modes, and the results have been contradictory.We
compared the effect of resistive load on simulated tidal volume (V(T)) with 5 neonatal nasal
CPAP systems: Fisher and Paykel nasal CPAP tubing with Maquet Servo-i ventilator in NIV
CPAP mode; Cardinal Health AirLife nasal CPAP system; Fisher and Paykel nasal CPAP
tubing with water-seal pressure generator; AirLife infant nasal CPAP generator kit; and
Hamilton Medical Arabella fluidic nasal CPAP generator. The lung simulator settings were:
compliance 0.5 mL/cm H2O, resistance 125 H2O/L/s, sinusoidal patient-effort range 6.5-26
cm H2O, rise 25%, hold 0%, release 25%, respiratory rate 65 breaths/min. We compared the
mean values from 10 breaths.The mean inspiratory pressure drop and V(T) difference
(compared to the simulator alone, unloaded) increased with V(T), respectively, from 0.32 cm
H2O to 1.73 cm H2O, and from -0.04 mL to -0.40 mL. Flow opposition had the smallest
pressure drop (from 0.10 cm H2O to 0.64 cm H2O, P < .001). At V(T) of < or = 6 mL, the
bubble nasal CPAP's pressure drop was largest (P < .001), whereas at V(T) of > or = 9 mL
the electronic nasal CPAP's pressure drop was largest (P < .001). All systems except the
ventilator did not have an average end-expiratory pressure of the targeted 5 cm H2O.The
differences in these nasal CPAP systems correlate with the differences in unassisted V(T) due
to loading effects. The ventilator imposed the least load, and the AirLife nasal CPAP system
imposed the most.
Courtney, S. E., et al. (2011). "Bubble and ventilator-derived nasal continuous positive
airway pressure in premature infants: work of breathing and gas exchange." Journal of
perinatology : official journal of the California Perinatal Association 31(1): 44-50.
During bubble nasal continuous positive airway pressure (B-NCPAP), gas flows
through the expiratory limb of CPAP tubing submerged underwater to a depth in centimeters
considered equal to the desired end expiratory pressure. Ventilator-derived NCPAP (VNCPAP) controls the delivered pressure at the expiratory orifice. Limited data exist
comparing the two forms of NCPAP on work of breathing (WOB) and other short-term
respiratory outcomes. We compared WOB and gas exchange between B-NCPAP and VNCPAP at equivalent delivered nasal prong pressures among a cohort of preterm infants on
NCPAP.We performed a randomized crossover study in 18 premature infants <1500?g (BW
1101��254 g, GA 28��2 weeks, study age 13��8 days (means��s.d.)), who were
already on NCPAP for mild respiratory distress, comparing B-NCPAP to V-NCPAP. Each
infant was studied at a constant flow rate and varying pressures of 3, 5, 7, 4 and 2 cm H(2)O
in that order. Tidal volumes were obtained by calibrated respiratory inductance
plethysmography. Intrapleural pressure was estimated by an esophageal catheter. WOB
(inspiratory, elastic and resistive) was calculated from pressure volume data. Breathing
asynchrony was assessed with phase angle. Comparisons of respiratory rate, heart rate, tidal
volume, minute ventilation, breathing asynchrony, lung compliance, oxygen saturation and
transcutaneous (Tc) O(2) and CO(2) were also made.WOB and most respiratory parameters
were not different between B-NCPAP and V-NCPAP. TcO(2) was higher with B-NCPAP
compared to V-NCPAP (P=0.01). TcCO(2) was not different. None of the other measured
parameters was significantly different between the two devices.WOB and ventilation with BNCPAP and V-NCPAP are similar when equivalent delivered prong pressures are assured.
Improved oxygenation with B-NCPAP is intriguing and requires further investigation.
Cox, J. M. (1974). "Techniques in neonatal ventilation." International anesthesiology clinics
12(4): 111-140.
Cox, J. M., et al. (1974). "Individual nasal masks and intranasal tubes. A non-invasive
neonatal technique for the delivery of continuous positive airway pressure (CPAP)."
Anaesthesia 29(5): 597-600.
Cumarasamy, N., et al. (1973). "Artificial ventilation in hyaline membrane disease: the use of
positive end-expiratory pressure and continuous positive airway pressure." Pediatrics 51(4):
629-640.
Cuvelier, A. and J.-F. Muir (2003). "Indications of NPPV during chronic respiratory failure."
Medecine et Hygiene 61(2430): 650-655.
Noninvasive positive pressure ventilation (NPPV) is defined by a diurnal and/or
nocturnal (< 3 h/24) mechanical ventilation via a nasal mask, a facial mask or a mouth piece.
Hypercapnic chronic respiratory failure (HCRF) of restrictive etiology is the best indication
for home NPPV, especially thoracic deformations, post-tuberculosis sequels, neuromuscular
disorders and the obesity-hypoventilation syndrome. By means of a specialized and expert
home care network, NPPV is now performed till very advanced stage of HCRF disease in
order to improve prognosis, to improve quality of life and to delay (or eliminate) the
indication of tracheotomy-mediated ventilation. Benefits of home NPPV in hypercapnic
chronic obstructive pulmonary disorders are still under evaluation and may be valuable in
some patients with severe bronchiectasis, when waiting on a transplant list. In patients with
either restrictive or obstructive HCRF, tolerance and clinical benefits of long-term NPPV
should be regularly reassessed.
Cuvelier, A., et al. (2009). "Cephalic versus oronasal mask for noninvasive ventilation in
acute hypercapnic respiratory failure." Intensive Care Medicine 35(3): 519-526.
Compared to oronasal interfaces, a cephalic mask has a larger inner volume, covers
the entire anterior surface of the face and limits the risk of deleterious cutaneous side effects
during noninvasive ventilation (NIV). The present clinical study aimed to compare the
clinical efficacy of a cephalic mask versus an oronasal mask in patients with acute
hypercapnic respiratory failure (AHRF).Randomized controlled study in a Respiratory
Intermediate Care Unit.All consecutive patients admitted for AHRF were randomly assigned
to receive bilevel NIV either with a cephalic mask (n = 17) or an oronasal mask (n = 17)
during the first 48 h.The main outcome criterion was the improvement of arterial pH, 24 h
after NIV initiation. Secondary criteria included PaCO(2) and physiological
parameters.Compared to values at inclusion, pH, PaCO(2), encephalopathy score, respiratory
distress score and respiratory frequency improved significantly and similarly with both masks.
None of these parameters showed statistically significant differences between the masks at
each time point throughout the study period. Mean delivered inspiratory and expiratory
pressures were similar in both patient groups. Tolerance of the oronasal mask was improved
at 24 h and further. One patient with the cephalic mask suffered from claustrophobia that did
not lead to premature study interruption.In spite of its larger inner volume, the cephalic mask
has the same clinical efficacy and requires the same ventilatory settings as the oronasal mask
during AHRF.
Cvetnic, W. G., et al. (1989). "Continuous negative pressure and intermittent mandatory
ventilation in the management of pulmonary interstitial emphysema: a preliminary study."
Journal of perinatology : official journal of the California Perinatal Association 9(1): 26-32.
We reviewed the clinical courses of 12 prematurely born newborns who were placed
in continuous negative pressure (CNP) in an Isolette negative pressure ventilator for
refractory hypoxemia while receiving intermittent positive pressure mandatory ventilation.
All patients had severe lung disease as documented by an increased oxygenation index and
bilateral pulmonary interstitial emphysema on x-ray examination. Patients were separated
into two groups--survivors and nonsurvivors, with six patients in each group. Initiation of
CNP resulted in a significant initial improvement in oxygenation in both groups seen as a 52%
decrease in the oxygenation index in survivors and a 57% decrease in the oxygenation index
in nonsurvivors (P less than .05). The survivors characterized themselves by showing a
further sustained improvement in the oxygenation index--31.4 +/- 9.1 to 6.9 +/- 5.0 (P less
than .01)--and a significant decrease in the mean airway pressure--11.6 +/- 4.6 cm H2O to 5.0
+/- 1.9 cm H2O (P less than .05). Four of the six survivors showed radiographic resolution of
pulmonary interstitial emphysema. CNP was initiated at a mean age of 68.3 hours in the
survivors. Nonsurvivors were initiated in CNP at a mean age of 134.3 hours, but went on to
clinically deteriorate owing to irreversible hypoxemia and acidosis. Both oxygenation index
and mean airway pressures were virtually unchanged compared with their initial values. The
exact mechanisms by which CNP improves pulmonary function in this group of infants is
unknown.(ABSTRACT TRUNCATED AT 250 WORDS)
Daily, W. J. and P. C. Smith (1971). "Mechanical ventilation of the newborn infant. I."
Current problems in pediatrics 1(8): Jan-37.
Dalar, L., et al. (2013). "Early tracheal stenosis causing extubation failure and prolonged
ventilator dependency." Anaesthesia and Intensive Care 41(1): 108-112.
Postintubation stenosis is the most frequent cause of benign tracheal stenosis and
may cause reintubation and delay in weaning of intensive care unit patients. This case study
describes typical patients with tracheal stenosis and the management of these patients. Five
patients requiring reintubation and mechanical ventilation due to early intubation-related
stenosis are discussed. Stridor developed in three cases after extubation. In these cases,
bronchoscopy revealed tracheal stenosis. Dilatation and silicone stent placement were
performed using rigid bronchoscopy. The other two patients were on ventilators when they
were admitted to the intensive care unit and their stenoses were also treated by rigid
bronchoscopy. Hypercapnia and hypoxia resolved after intervention in three cases. Of the
remaining two patients, one had the tracheostomy closed and in the other patient ventilation
was stopped but the tracheostomy was maintained. Tracheal stenosis developing in the
subglottic region after extubation, especially after exposure to cuff pressure, may lead to
reintubation. A tracheostomy may hinder the diagnosis of progressive stenosis and may lead
to unnecessary maintenance of ventilator treatment. Early intubation-related tracheal stenosis
should therefore be considered in cases of weaning or extubation failure and prompt
appropriate investigation and treatment. (copyright) 2011 Anaesthesia and Intensive Care.
D'Amelio, et al. (2012). "Resuscitation at the limits of viability." Journal of Maternal-Fetal
and Neonatal Medicine 25: 102-.
Introduction: Management of neonatal reanimation in Italy, as in the others
developed countries, follows the International Guidelines that have been enacted by the
American Heart Association (AHA.) and the American Academy of Pediatrics (AAP.),
updated in 2005 and 2010, and the Country Legislation. In Italy there is the Law 194/22 of
May 1978: Regulations for the social protection of maternity and about the voluntary
termination of pregnancy. Methods: In the Gynecological Sciences and Human Reproduction
Department of Padua University, all the clinical records of mothers who gave birth there
prematurely, before 25 weeks + 6 days, and those of their babies (a total of 70 babies), have
been evaluated, in order to evaluate their need and reanimation modalities, according to the
Guidelines to neonatal reanimation of the AHA and the AAP of 2005. Moreover, babies'
conditions during the hospitalization in the Neonatal Intensive Care have been evaluated,
giving special attention to the incidence of intraventricular hemorrhage (IVH) and of
retinopathy of prematurity (ROP) in their different levels of manifestation, of necrotizing
enterocolitis, of perviety of the arterial duct and of pulmonary bronchodysplasia (BPD).
Results: Between 2005 and 2010, the 0.58% of births was <25 + 6 weeks of pregnancy. The
most used reanimation technique has been the orotracheal intubation (88.57%). Babies that
have not been intubated but reanimated with face mask and continuous positive airway
pressure were the 10.01%. Among the intubated babies, the 32.26% of them received an
administration of surfactant. The 50% of them will develop a BPD; those who have only been
intubated represent the 23.81%. -The FiO2 administered and the incidence of developing a
BDP and of a ROP (I-II-III): there is a higher incidence of ROP III in the group treated with
FiO2 = 100% (26.7%). FiO2 < 100% (18.19% of ROP III). After applying the Fisher test, the
result was a pi-value <0.04%, so we can affirm that there is a statistical significance. The
highest peak of IVH in the 22-22 + 6 weeks (80%), and a gradual decrease as the gestational
weeks increase up until the 25 + 6 week (27.7%). The 4.29% of the total of intubated babies
received an administration of adrenaline and the 2.9% of them received a cardiac massage.
Mortality rate is the 22.86%. The mortality rate noticed was: the 100% at 22-22 + 6 weeks;
the 5.9% at 23-23 + 6 weeks; the 10% at 24-24 + 6 weeks and the 38.8% at 25-25 + 6 weeks.
Conclusion: Guidelines of 2005 had been respected; O2 had been fractionated. For babies
born <23 weeks of pregnancy, Guidelines had not been respected, but the chosen protocol
announced the Guidelines of 2010. The most used reanimation technique has been the IOT.
Among the intubated babies, the 32.26% of them received an administration of surfactant. The 4.29% of the total of intubated babies received an administration of adrenaline and the
2.9% of them received a cardiac massage. The overall mortality rate is the 22.86%. The
mortality rate noticed was: the 100% at 22-22 + 6 weeks; the 5.9% at 23-23 + 6 weeks; the 10%
at 24-24 + 6 weeks and the 38.8% at 25-25 + 6 weeks.
Danan, C., et al. (1996). "Efficacy of dead-space washout in mechanically ventilated
premature newborns." American Journal of Respiratory and Critical Care Medicine 153(5):
1571-1576.
The prosthetic dead space makes a significant contribution to the total dead space in
low-birth-weight premature newborns receiving artificial ventilation in response to
respiratory distress. Use of an endotracheal tube with capillaries molded into the tube wall
enables washout of the dead space without insertion of a tracheal catheter. In 10 premature
newborns (mean gestational age, 27.5 +/- 2.2 wk; mean weight, 890 +/- 260 g) receiving
continuous positive-pressure ventilation (Paw = 12.7 +/- 1.8 cm H2O; FIO2 = 39 +/- 17%),
tracheal gas insufflation (TGI) for CO2 washout was conducted using this technique. The
flow of tracheal insufflation (0.5 L/min) was derived from the inspiratory line of the
ventilator circuit and blown into the trachea. Intratracheal pressures showed little or no TGIrelated modification ( < 1 cm H2O). A control system enabled TGI discontinuation in the
event of a pressure rise. At constant ventilation pressure, PaCO2 decreased by 12.1 +/- 5.9
mm Hg (delta PaCO2 = -26 +/- 12%) under TGI, whereas PaO2 remained unchanged. While
maintaining PaCO2 constant, peak inspiratory pressure (PIP) was decreased by 5.4 +/- 1.7 cm
H2O (delta PIP = -22.0 +/- 8.3%). TGI showed immediate efficacy (PCO2 reduction of at
least 5 mm Hg) in nine of the 10 newborns who then received chronic TGI (14 to 138 h). TGI
appears to be an effective method, suitable for long-term clinical application, enabling a
reduction in the aggressive nature of conventional ventilation.
Dassieu, G., et al. (1998). "Continuous tracheal gas insufflation enables a volume reduction
strategy in hyaline membrane disease: technical aspects and clinical results." Intensive Care
Medicine 24(10): 1076-1082.
Instrumental dead space wash-out can be used to improve carbon dioxide clearance.
The aim of this study was to define, using a bench test, an optimal protocol for long-term use,
and to assess the efficacy of this technique in neonates.A bench test with an artificial lung
model, and an observational prospective study. Dead space wash-out was performed by
continuous tracheal gas insufflation (CTGI), via six capillaries molded in the wall of a
specially designed endotracheal tube, in 30 preterm neonates with hyaline membrane
disease.Neonatal intensive care unit of a regional hospital.The bench test study showed that a
CTGI flow of 0.5 l/ min had the optimal efficacy-to-side-effect ratio, resulting in a maximal
or submaximal efficacy (93 to 100%) without a marked increase in tracheal and CTGI circuit
pressures. In the 30 newborns, 15 min of CTGI induced a significant fall in arterial carbon
dioxide tension (PaCO2), from 45 +/- 7 to 35 +/- 5 mmHg (p = 0.0001), and in 14 patients
allowed a reduction in the gradient between Peack inspirating pressure and positive endexpiratory pressure from 20.8 +/- 4.6 to 14.4 +/- 3.7 cmH2O (p < 0.0001) while keeping the
transcutaneous partial pressure of carbon dioxide constant. As predicted by the bench test, the
decrease in PaCO2 induced by CTGI correlated well with PaCO2 values before CTGI (r =
0.58, p < 0.002) and with instrumental dead space-to-tidal volume ratio (r = 0.54, p <
0.005).CTGI may be a useful adjunct to conventional ventilation in preterm neonates with
respiratory disease, enabling an increase in CO2 clearance or a reduction in ventilatory
pressure.
Dassieu, G., et al. (2000). "Continuous tracheal gas insufflation in preterm infants with
hyaline membrane disease. A prospective randomized trial." American Journal of Respiratory
and Critical Care Medicine 162(3 Pt 1): 826-831.
In mechanically ventilated neonates, the instrumental dead space is a major
determinant of total minute ventilation. By flushing this dead space, continuous tracheal gas
insufflation (CTGI) may allow reduction of the risk of overinflation. We conducted a
randomized trial to evaluate the efficacy of CTGI in reducing airway pressure over the entire
period of mechanical ventilation while maintaining oxygenation. A total of 34 preterm
newborns, ventilated in conventional pressure-limited mode, were enrolled in two study arms,
to receive or not receive CTGI. Transcutaneous Pa(CO(2)) (tcPa(CO(2))) was maintained at
40 to 46 mm Hg in both groups to ensure comparable alveolar ventilation. Respiratory data
were collected several times during the first day and daily until Day 28. Both groups were
similar at the time of inclusion. During the first 4 d of the study, the difference between peak
pressure and positive end-expiratory pressure was significantly lower in the CTGI group by
18% to 35%, with the same tcPa(CO(2)) level and with no difference in the ratio of tcPa(O(2))
to fraction of inspired oxygen (245 +/- 29 versus 261 +/- 46 mm Hg [mean +/- SD] over the
first 4 d). Extubation occurred sooner in the CTGI group (p < 0.05), and the duration of
mechanical ventilation was shorter (median: 3.6 d; 25th to 75th quartiles: 1.5 to 12.0 d;
versus median: 15.6 d; 25th to 75th quartiles: 7.9 to 22.2; p < 0.05) than in the non-CTGI
group. CTGI allows the use of low-volume ventilation over a prolonged period and reduces
the duration of mechanical ventilation.
Datta, J., et al. (2012). "Association of high ventilator pressures with the development of
chronic pulmonary hypertension in congenital diaphragmatic hernia patients requiring
ECMO." Pediatric surgery international 28(10): 977-982.
Congenital diaphragmatic hernia (CDH) patients requiring extracorporeal membrane
oxygenation (ECMO) were examined to determine, if aspects of their complex ventilatory
management were associated with the development of chronic pulmonary hypertension
(cPH).CDH patients requiring ECMO from 1992 to 2007 were retrospectively reviewed. cPH
was defined as pulmonary hypertension at 3 months of age. Demographic and clinical
variables including peak ventilatory pressures (PVP) and mean airway pressures (MAP) were
tabulated.10/31 (32 %) patients developed cPH. Gestational age, birth weight, inborn status,
CDH side and liver position were not different between cPH and non-cPH patients. PreECMO, both groups required statistically similar ventilatory support, though there was a
trend toward higher oxygenation index and higher PVP for cPH patients. While ECMO
duration was similar between groups, cPH patients required significantly higher PVP (30.0 vs.
25.0 cmH(2)O, p = 0.01) and MAP (11.5 vs. 9.0 cmH(2)O, p = 0.02) for ECMO
decannulation. Post-ECMO, maximum PVP (50.0 vs. 26.0 cmH(2)O, p < 0.001), MAP (18.1
vs. 12.0, p = 0.001), HFV requirement (90 vs. 10 %, p < 0.001), and ventilator time (35.7 vs.
20 days, p < 0.001) increased significantly for cPH patients.Not until after ECMO
decannulation do we see clinical differences separating patients who ultimately develop cPH.
Although the degree of pulmonary hypoplasia may ultimately dictate ECMO decannulation
criteria, perhaps greater physiologic optimization before decannulation could decrease the
incidence of cPH.
Davis, P. and D. Henderson-Smart (1999). "Post-extubation prophylactic nasal continuous
positive airway pressure in preterm infants: systematic review and meta-analysis." Journal of
Paediatrics and Child Health 35(4): 367-371.
To determine whether management with nasal continuous positive airway pressure
(NCPAP) in preterm infants having their endotracheal tube removed following a period of
intermittent positive pressure ventilation (IPPV), leads to an increased proportion remaining
free of additional ventilatory support, compared to extubation directly to headbox
oxygen.Search Strategy - Searches were made of the Oxford Database of Perinatal Trials,
Medline, abstracts of conferences and symposia proceedings, expert informants, journal hand
searching mainly in the English language and expert informant searches in the Japanese
language. Selection criteria - All trials utilising random or quasi-random patient allocation, in
which NCPAP (delivered by any method) was compared with headbox oxygen for
postextubation care were included. Methodological quality was assessed independently by
the two authors. Data collection and analysis - Data were extracted independently by the two
authors. Meta-analysis using event rate ratios (ERRs) and event rate differences (ERDs) was
performed using Revman 3.0 statistical software. Prespecified subgroup analysis to determine
the impact of different levels of NCPAP and use of aminophylline were also performed using
the same package. Similar analysis to investigate the effect of postnatal age on outcomes of
interest was also undertaken.Nasal CPAP, when applied to preterm infants being extubated
following IPPV, reduces the incidence of adverse clinical events (apnoea, respiratory acidosis
and increased oxygen requirements) indicating the need for additional ventilatory support.
This result is both statistically significant and clinically important; ERR, 0.62 (0.49, 0.79) and
ERD, - 0.175 (- 0.256, - 0.095). A trend towards reduction in the incidence of oxygen
dependency at 28 days of age is also seen in the group extubated to NCPAP; ERR, 0.86 (0.67,
1.10) and ERD, - 0.069 (- 0.177, 0.039).Nasal CPAP is effective in preventing failure of
extubation in preterm infants following a period of endotracheal intubation and IPPV. Further
definition of the patient gestational age and weight groups to whom these results apply is
required. Optimal levels of NCPAP as well as methods of administration remain to be
determined.
Davis, P. G. and J. A. Dawson (2012). "New concepts in neonatal resuscitation." Current
Opinion in Pediatrics 24(2): 147-153+277-278.
PURPOSE OF REVIEW: There has been a substantial increase in the number of
studies of neonatal resuscitation and it is timely to review the accumulating evidence.
RECENT FINDINGS: There have been major changes in the way that newly born infants are
managed in the delivery room. Colour is no longer recommended as a useful indicator of
oxygenation or effectiveness of resuscitation. Pulse oximetry provides rapid, continuous and
accurate information on both oxygenation and heart rate. Resuscitation of term infants should
begin with air, with the provision of blended oxygen to maintain oxygen saturations similar
to those of term infants requiring no resuscitation. Positive end-expiratory pressure during
initial ventilation aids lung aeration and establishment of functional residual capacity.
Respiratory function monitoring allows operators to identify factors adversely affecting
ventilation, including leak around the face mask and airway obstruction. Clamping of the
umbilical cord should be delayed for at least 1 min for infants not requiring resuscitation.
SUMMARY: The International Liaison Committee on Resuscitation guidelines on the
management of newborn infants were updated in 2010 and incorporate much of the newly
available evidence. The use of intensive care techniques in the delivery room is promising but
requires further evaluation. Monitoring techniques and interventions need to be adapted for
use in developing countries. (copyright) 2012 Lippincott Williams & Wilkins, Inc.
Davis, P. G., et al. (2009). "Non-invasive respiratory support of preterm neonates with
respiratory distress: Continuous positive airway pressure and nasal intermittent positive
pressure ventilation." Seminars in Fetal and Neonatal Medicine 14(1): 14-20.
Non-invasive techniques of respiratory support were developed in order to reduce the
adverse effects associated with ventilation via an endotracheal tube. Short bi-nasal prongs
provide the most effective nasal interface for delivery of nasal continuous positive airway
pressure (nCPAP). Devices used to generate CPAP include conventional ventilators, the
'bubbly bottle' system and the infant flow driver. NCPAP improves the rate of successful
extubation. It is useful for preterm infants with respiratory distress syndrome, reducing time
spent on an endotracheal tube and oxygen requirement at 28 d. However, nCPAP is
associated with an increased rate of pneumothorax. Nasal intermittent positive pressure
ventilation (NIPPV) is useful for augmenting the effectiveness of nCPAP. It further improves
rates of successful extubation and shows promise as an initial method of respiratory support.
Further research is required to determine the optimal settings for both nCPAP and NIPPV.
(copyright) 2008 Elsevier Ltd. All rights reserved.
Dawson, J. A., et al. (2007). "Free-flow oxygen delivery using a T-piece resuscitator [1]."
Archives of Disease in Childhood: Fetal and Neonatal Edition 92(5): F421-.
De Paoli, A. G., et al. (2003). "Nasal CPAP for neonates: what do we know in 2003?"
Archives of disease in childhood. Fetal and neonatal edition 88(3): F168-172.
Despite the acknowledged clinical usefulness of nasal CPAP, uncertainties regarding
aspects of its application remain. Clinical indications for the application of nasal CPAP vary
greatly between institutions. Furthermore, defining the optimal nasal CPAP system is
complicated by the multiplicity of nasal CPAP devices and techniques available to the
clinician. This review aims to identify what we know about nasal CPAP and what important
questions remain.
De Weerdt, S., et al. (2010). "Is there any relationship between nCPAP therapy and signs of
sinus hyperpneumatization?" B-ENT 6(3): 171-175.
Objectives: Both nasal continuous positive airway pressure (nCPAP) therapy and
nose blowing can generate high pressures in the nose and sinuses. Nose blowing generates
higher pressures than nCPAP therapy, but the duration of nCPAP therapy is considerably
longer than the duration of nose blowing. Therefore, nCPAP could cause bone deformation.
The aim of this study was to document the influence of the pressure generated by nCPAP
therapy on the structure and dimensions of the sinuses and on the nose-blowing patterns of
the patients. Methodology: The study included nine patients, who had recently been
diagnosed with obstructive sleep apnea syndrome (OSAS) and had not received any previous
treatment for OSAS. Before nCPAP therapy was started, they all underwent computer
tomography (CT) in the prone position with sequential coronal slices followed by pressure
measurements during nose blowing. After the initial measurements, nCPAP therapy
commenced. All of the patients were treated with a fixed-pressure device and nasal mask for
6 mo. nCPAP therapy compliance was checked after 6 mo. At the end of the 6 mo treatment
with nCPAP, coronal CT scans of the sinuses and pressure measurements during nose
blowing were repeated. Results and conclusion: Although CPAP therapy provides continuous
positive pressure for several hours at night, bone structure and sinus dimensions appeared to
be unchanged after 6 mo of therapy. However, CPAP therapy seemed to have an effect on the
nose-blowing pattern of the patients, with a significant decrease in nose blowing pressure
after 6 mo of CPAP treatment.
Deckardt, R. (1987). "[Advantages of early artificial respiration of the newborn infant using a
modified T-piece]." Geburtshilfe und Frauenheilkunde 47(2): 121-123.
Onset of sufficient respiration in the newborn may be delayed and require respiratory
assistance. Its early institution is mandatory and its mode guided by the respiratory
requirements of the newborn at risk. In our Department we use a simple respiratory
equipment consisting of a modified mask elbow and a pigtail bag. We have applied this
system in over thousand newborns without any complications. Sufficient respiratory care is
easily accomplished. The system offers advantages because of its simplicity. It is lightweight,
transparent, without valves and enables the user to applicate assisted or controlled ventilation
with or without CPAP or PEEP. Tidal volume and frequency of spontaneous respiration can
be gauged by watching the inflated bag's movements. If sufficient fresh gas flow is provided,
there is no hazardous rebreathing. An elevated orifice maintains a safe system pressure, while
still permitting high inspiratory pressures for resuscitation. Pressures applied are checked by
an attached manometer.
Deen, L. and J. G. Koppe (1973). "[Artificial respiration in the newborn by means of the
Amsterdam-Infant-Ventilator over a 5 year period]." Nederlands tijdschrift voor geneeskunde
117(35): 1305-1312.
Deindl, P., et al. (2014). "Influence of mask type and mask position on the effectiveness of
bag-mask ventilation in a neonatal manikin." European Journal of Pediatrics 173(1): 75-79.
Anatomical face mask with an air cushion rim might be placed accidentally in a false
orientation on the newborn's face or filled with various amounts of air during neonatal
resuscitation. Both false orientation as well as variable filling may reduce a tight seal and
therefore hamper effective positive pressure ventilation (PPV). We aimed to measure the
influence of mask type and mask position on the effectiveness of PPV. Twenty neonatal staff
members delivered PPV to a modified, leak-free manikin. Resuscitation parameters were
recorded using a self-inflatable bag PPV with an Intersurgical anatomical air cushion rim face
mask (IS) and a size 0/1 Laerdal round face mask. Three different positions of the IS were
tested: correct position, 90 and 180 rotation in reference to the midline of the face. IS masks
in each correct position on the face but with different inflation of the air cushion (empty, 10,
20 and 30 mL). Mask leak was similar with mask rotation to either 90 or 180 but significantly
increased from 27 (13-73) % with an adequate filled IS mask compared to 52 (16-83) % with
an emptied air cushion rim. Conclusion: Anatomical-shaped face mask had similar mask
leaks compared to round face mask. A wrongly positioned anatomical-shaped mask does not
influence mask leak. Mask leak significantly increased once the air cushion rim was empty,
which may cause failure in mask PPV. (copyright) 2013 Springer-Verlag Berlin Heidelberg.
Deis, J. N., et al. (2008). "Noninvasive respiratory support." Pediatric Emergency Care 24(5):
331-338.
Noninvasive ventilation (NIV) refers to the delivery of ventilatory support using
techniques that do not require an endotracheal airway. Noninvasive ventilation is being used
with increased frequency in a variety of clinical situations in the emergency department,
intensive care unit, and prehospital environment. This article reviews the history of NIV, the
rationale for its use, and the evidence of efficacy in both the adult and pediatric literature.
This article also describes equipment and techniques currently available for administration of
NIV as well as new trends in noninvasive respiratory support. (copyright) 2008 by Lippincott
Williams & Wilkins.
DeLemos, R. A. (1995). "Management of pediatric acute hypoxemic respiratory insufficiency
with bilevel positive pressure nasal mask ventilation." Chest 108(4): 894-895.
DeLemos, R. A., et al. "Continuous positive airway pressure as an adjunct to mechanical
ventilation in the newborn with respiratory distress syndrome." Anesthesia and Analgesia
52(3): 328-332.
Devlieger, H., et al. (1983). "Diagram for easy volume setting of an infant ventilator."
Critical care medicine 11(8): 657-659.
A pressure-volume diagram with isocompliance lines allows quick, accurate volume
setting of the piston-driven infant ventilator Bourns LS. A line parallel with the machine
compliance line and an intercept on the ordinate equal to the tidal volume, serves as a
guideline for initial volume setting and subsequent adaptation according to the patient's lung
compliance. This diagram is particularly useful when the lung compliance is low; changes
consistently during controlled ventilation.
Dhillon, J. S., et al. (1996). "A portable nitric oxide scavenging system designed for use on
neonatal transport." Critical care medicine 24(6): 1068-1071.
To evaluate a portable scavenging system for nitric oxide and its oxides, designed for
use on neonatal transport.A prospective evaluation of the nitric oxide scavenging system,
using a neonatal transport incubator ventilator and a test lung.Laboratory of a tertiary care
children's hospital.The scavenging system was tested, using a neonatal transport incubator
with attached ventilator, ventilator circuit, and a neonatal test lung. Nitric oxide was
administered on the inspiratory limb, and nitric oxide and its oxides were measured in the
expiratory gas after passing through the scavenger.A modified scrubber assembly was filled
with 50% activated charcoal and 50% aluminas potassium permanganate pellets (3). Three
wire meshes were placed before, in between, and after the two chemicals to facilitate gas
flow. Using the maximum FIO2, with a nitric oxide concentration of 120 parts per million
(ppm), the test lung continuous flow ventilation (FIO2 of 0.86, peak inspiratory pressure of
30 cm H2O, positive end-expiratory pressure of 6 cm H2O) and respiratory rate of 60
breaths/min) was performed for 4 hrs with each of four freshly prepared scavenging systems.
A fifth scavenging system was tested for a 12-hr period. The mean composition of the
exhaled gases for 4 hrs were: nitric oxide 0.01 +/- 0.03 (SD) ppm, nitric dioxide 0.06 +/- 0.06
ppm, and other oxides 0.05 +/- 0.09 ppm. After 12 hrs of 120 ppm of inhaled nitric oxide, the
fifth scavenger system had undetectable nitric oxide, nitric dioxide, and other oxides in the
exhaled gas. Normal room air contained between 0.0 and 0.03 ppm of nitric oxide, 0.0 and
0.02 ppm of nitric dioxide, and 0.0 and 0.02 ppm of other oxides.Nitric oxide, nitric dioxide,
and other dioxides can be safely scavenged by this portable scavenging system, allowing safe
administration of nitric oxide free from environmental contamination with nitric oxide and its
oxides.
DiBlasi, R. M., et al. (2008). "The impact of imposed expiratory resistance in neonatal
mechanical ventilation: a laboratory evaluation." Respiratory Care 53(11): 1450-1460.
Small endotracheal tubes (ETTs) and neonatal ventilators can impact gas exchange,
work of breathing, and lung-mechanics measurements in infants, by increasing the expiratory
resistance (R(E)) to gas flow.We tested two each of the Babylog 8000plus, Avea, Carestation,
and Servo-i ventilators. In the first phase of the study we evaluated (1) the imposed R(E) of
an ETT and ventilator system during simulated passive breathing at various tidal volume
(V(T)), positive end-expiratory pressure (PEEP), and frequency settings, and (2) the intrinsic
PEEP at various ventilator settings. In the second phase of this study we evaluated the
imposed expiratory work of breathing (WOB) of the ETT and ventilator system at various
PEEP levels during simulated spontaneous breathing using an infant lung model. Pressure
and flow were measured continuously, and we calculated the imposed R(E) of the ETT and
each ventilator, and the intrinsic PEEP with various PEEP, V(T), and frequency settings. We
measured the imposed expiratory WOB with several PEEP levels during a simulated
spontaneous breathing pattern.The ventilator's contribution to the imposed R(E) was greater
than that of the ETT with nearly all of the ventilators tested. There were significant
differences in ventilator-imposed R(E) between the ventilator brands at various PEEP, V(T),
and frequency settings. The Babylog 8000plus consistently had the lowest ventilator-imposed
R(E) in the majority of the test conditions. There was no intrinsic PEEP (>1 cm H(2)O) in
any of the test conditions with any ventilator brand. There were also no significant
differences in the imposed expiratory WOB between ventilator brands during simulated
spontaneous breathing.The major cause of R(E) appears to be the ventilator exhalation valve.
Neonatal ventilators that use a set constant flow during inhalation and exhalation appear to
have less R(E) than ventilators that use a variable bias flow during exhalation. Clinical
studies are needed to determine whether the imposed R(E) of these ventilator designs impacts
gas exchange, lung mechanics, or ventilator weaning.
Diblasi, R. M., et al. (2010). "Noninvasive respiratory support of juvenile rabbits by highamplitude bubble continuous positive airway pressure." Pediatric Research 67(6): 624-629.
Bubble continuous positive airway pressure (B-CPAP) applies small-amplitude,
high-frequency oscillations in airway pressure (DeltaPaw) that may improve gas exchange in
infants with respiratory disease. We developed a device, high-amplitude B-CPAP (HABCPAP), which provides greater DeltaPaw than B-CPAP provides. We studied the effects of
different operational parameters on DeltaPaw and volumes of gas delivered to a mechanical
infant lung model. In vivo studies tested the hypothesis that HAB-CPAP provides
noninvasive respiratory support greater than that provided by B-CPAP. Lavaged juvenile
rabbits were stabilized on ventilator nasal CPAP. The animals were then supported at the
same mean airway pressure, bias flow, and fraction of inspired oxygen (FiO2) required for
stabilization, whereas the bubbler angle was varied in a randomized crossover design at exit
angles, relative to vertical, of 0 (HAB-CPAP0; equivalent to conventional B-CPAP), 90
(HAB-CPAP90), and 135 degrees (HAB-CPAP135). Arterial blood gases and pressure-rate
product (PRP) were measured after 15 min at each bubbler angle. Pao2 levels were higher
(p<0.007) with HAB-CPAP135 than with conventional B-CPAP. PaCO2 levels did not differ
(p=0.073) among the three bubbler configurations. PRP with HAB-CPAP135 were half of the
PRP with HAB-CPAP0 or HAB-CPAP90 (p=0.001). These results indicate that HABCPAP135 provides greater respiratory support than conventional B-CPAP does.
Dick, W., et al. (1977). "[New PEEP device--application of PEEP and CPAP during
manually operated ventilation (author's transl)]." Der Anaesthesist 26(11): 631-632.
A new PEEP device has been developed for use with manually operated resuscitators.
The PEEP valve can be combined with adult resuscitators as well as with neonatal
resuscitators (40 g). The PEEP can be varied between 0 and +10 cm H2O. With this new
PEEP device it is now possible to apply PEEP during manually operated artificial ventilation,
e.g. during transportation etc.
Donn, S. M. and S. K. Sinha (2003). "Invasive and noninvasive neonatal mechanical
ventilation." Respiratory Care 48(4): 426-439; discussion 439-441.
Neonatal respiratory failure consists of several different disease entities, with
different pathophysiologies. During the past 30 years technological advances have drastically
altered both the diagnostic and therapeutic approaches to newborns requiring mechanical
assistance. Treatments have become both patient- and disease-specific. The clinician has
numerous choices among the noninvasive and invasive ventilatory treatments that are
currently in use. This article reviews the pathophysiology of respiratory failure in the
newborn and the available methods to treat it, including continuous positive airway pressure,
conventional and high-frequency mechanical ventilation, extracorporeal membrane
oxygenation, and styles of ventilation and monitoring.
Drevhammar, T., et al. (2013). "Comparison of nasal continuous positive airway pressure
delivered by seven ventilators using simulated neonatal breathing." Pediatric critical care
medicine : a journal of the Society of Critical Care Medicine and the World Federation of
Pediatric Intensive and Critical Care Societies 14(4): e196-201.
Nasal continuous positive airway pressure (NCPAP) is an established treatment for
respiratory distress in neonates. Most modern ventilators are able to provide NCPAP. There
have been no large studies examining the properties of NCPAP delivered by ventilators. The
aim of this study was to compare pressure stability and imposed work of breathing (iWOB)
for NCPAP delivered by ventilators using simulated neonatal breathing.Experimental in vitro
study.Research laboratory in Sweden.None.Neonatal breathing was simulated using a
mechanical lung simulator. Seven ventilators were tested at different CPAP levels using two
breath profiles. Pressure stability and iWOB were determined. Results from three ventilators
revealed that they provided a slight pressure support. For these ventilators, iWOB could not
be calculated. There were large differences in pressure stability and iWOB between the tested
ventilators. For simulations using the 3.4-kg breath profile, the pressure swings around the
mean pressure were more than five times greater, and iWOB more than four times higher, for
the system with the highest measured values compared with the system with the lowest.
Overall, the Fabian ventilator was the most pressure stable system. Evita XL and SERVO-i
were found more pressure stable than Fabian in some simulations. The results for iWOB were
in accordance with pressure stability for systems that allowed determination of this
variable.Some of the tested ventilators unexpectedly provided a minor degree of pressure
support. In terms of pressure stability, we have not found any advantages of ventilators as a
group compared with Bubble CPAP, Neopuff, and variable flow generators that were tested
in our previous study. The variation between individual systems is great within both
categories. The clinical importance of these findings needs further investigation.
Duan, J., et al. (2012). "[Clinical application of proportional assist ventilation in very low
birth weight infants with ventilator dependence]." Zhongguo dang dai er ke za zhi = Chinese
journal of contemporary pediatrics 14(6): 401-405.
To study the effect of proportional assist ventilation (PAV) on physiology and
respiratory mechanics in very low birth weight (VLBW) infants with ventilator dependence
by comparison with conventional assist/control (A/C) ventilation.Forty-six infants with
ventilator dependence were randomly divided into two groups according to the ventilation
model: PAV (n=23) and A/C (n=23). The gain of resistive and elastic unloading was set
based on the runway method in the PAV group. Ventilation parameters were set based on the
conventional method in the A/C group. Infants were observed for 30 minutes three times per
day for three consecutive days. Arterial gas analysis results, transcutaneous saturation of
oxygen (SPO2), heart rate, blood pressure (BP), respiratory rate (RR), mean airway pressure
(MAP), peak inspiratory pressure (PIP), tide volume (VT), minute volume (MV) and
oxygenation index (OI), were compared between the two groups.Compared with the A/C
group, PaO2 and OI in the PAV group were significantly higher while PIP and MAP were
significantly lower. There were no significant differences in FiO2, SPO2, pH, PaCO2, PEEP,
VT, MV and RR between the two groups. Although mean arterial blood pressure and heart
rate in the PAV group were not different from the A/C group, beat-to-beat variabilities in
systolic and diastolic arterial blood pressure were significantly lower in the PAV group than
in the A/C group.PAV may safely maintain gas exchange at lower airway pressures compared
with A/C ventilation in VLBW infants. It can also improve oxygenation and infant-ventilator
synchronization.
Duncan, A. W., et al. (1986). "PEEP and CPAP." Anaesthesia and Intensive Care 14(3): 236250.
Positive end-expiratory pressure (PEEP) maintains airway pressure above
atmospheric at the end of expiration, and may be used with mechanical ventilation or
spontaneous breathing. CPAP, or continuous positive airway pressure, refers to spontaneous
ventilation with a positive airway pressure being maintained throughout the whole respiratory
cycle. PEEP/CPAP primarily improves oxygenation by increasing functional residual
capacity, and may increase lung compliance and decrease the work of breathing. PEEP/CPAP
may be applied using endotracheal tubes, nasal masks or prongs, or face masks or chambers
to treat a wide range of adult and paediatric respiratory disorders. Complications associated
with their use relate to the pressures applied and include pulmonary barotrauma, decreased
cardiac output and raised intracranial pressure.
Edwards, G., et al. (1997). "Ventilator management of infants before extracorporeal
membrane oxygenation." Southern medical journal 90(6): 627-632.
The aim of this project was to review the course of infants referred for consideration
of extracorporeal membrane oxygenation (ECMO) to identify maximal ventilator settings that,
when exceeded, did not provide clinical benefit to the patient. These settings might then be
used in defining failure of conventional mechanical ventilation. We reviewed referral records
and hospital charts of all infants treated for severe respiratory failure due to meconium
aspiration syndrome during the 52.5 month period from March 15, 1985, to August 1, 1989.
At an inspiratory pressure > 35 cm H2O, 75% (43/57) of patients eventually required ECMO,
and 28% (4/14) of the infants who did not receive ECMO died. When the inspiratory pressure
was > or = 40 cm H2O, 39/49 patients required ECMO, and 30% (3/10) of those not treated
with ECMO died. Once the inspiratory pressure was > 45 cm H2O, 91% (29/32) of patients
required ECMO, and only one third of those not treated with ECMO survived. Although the
limitations for conventional therapy suggested in this paper may be helpful to clinicians, each
center needs to establish guidelines for maximal conventional ventilator support. If these
guidelines are clearly defined, alternative methods of therapy can be used once these criteria
are achieved.
EH, K. (1989). "Successful extubation of newborn infants without preextubation trial of
continuous positive airway pressure." Journal of Perinatology 9(1): 72-76.
Sixty newborn infants who had been mechanically ventilated through 3.0- or 3.5-mm
endotracheal tubes were studied to examine the necessity of a preextubation trial of
continuous positive airway pressure (CPAP). Thirty randomly assigned study infants were
directly extubated from intermittent mandatory ventilation rates of six per minute; 30
randomly assigned control infants were extubated after a six-hour trial of continuous positive
airway pressure of 3 cm H2O. Changes in respiratory rate, in PCO2, and in PO2/FIO2 were
similar. All 30 study infants tolerated direct extubation without significant apnea or
respiratory acidosis. Two study and eight control infants developed apnea during six hours
after intermittent mandatory ventilation was discontinued (chi 2 = 4.3, P less than .05). Five
control and no study infants had apneic episodes greater than or equal to 0.5 per hour (chi 2 =
5.5, P less than .02). The results of this study suggest that newborn infants may tolerate direct
extubation from low intermittent mandatory ventilation rates without a preextubation trial of
CPAP. A preextubation trial of CPAP appears to be unnecessary and may cause more
frequent apnea in newborn infants if used for more than several hours.
el-Khatib, M. F., et al. (1994). "Mechanical ventilators optimized for pediatric use decrease
work of breathing and oxygen consumption during pressure-support ventilation." Critical care
medicine 22(12): 1942-1948.
a) To investigate whether the patient work of breathing needed to trigger inspiration
is affected by the type of ventilator delivering pressure-support ventilation for mechanically
ventilated pediatric patients. b) To determine whether changes in oxygen consumption (VO2)
trend with changes in work of breathing and would thus be helpful in tracking work of
breathing.Prospective study.Pediatric intensive care unit at a university hospital.Nine
mechanically ventilated patients (2 to 75 months of age).While maintaining a constant
pressure-support ventilation level, patients were alternately supported with the Siemens Servo
900C, the Bird VIP, and the Newport Wave E200 ventilators in random order.Work of
breathing, defined as the integral of the pressure-volume curve corresponding to negative
pressure, was calculated with a pulmonary monitoring system. VO2 was measured with a
metabolic cart. Patient distress levels were assessed using the COMFORT scale, a behavioral
scoring system. Mean values (20 breaths/patient) for measured variables with each ventilator
were compared using analysis of variance and Scheff? tests, with p < .05 indicating statistical
significance. The lowest VO2 (103 +/- 35 mL/min/m2) and work of breathing (24 +/- 15
g.cm/m2) were achieved with the Bird VIP ventilator and were significantly (p < .05) lower
than those values obtained with either the Siemens Servo 900C (VO2 147 +/- 33 mL/min/m2;
work of breathing 49 +/- 18 g.cm/m2) or the Newport Wave E200 (VO2 122 +/- 33
mL/min/m2; work of breathing 35 +/- 15 g.cm/m2). Also, the values of work of breathing
and VO2 obtained using the Newport Wave E200 were significantly (p < .05) lower than
those values obtained using the Servo 900C. No change in behavioral distress occurred when
the ventilators were changed. In all patients, there was a clear similarity in the trends of VO2
and work of breathing.We conclude that VO2 and work of breathing may be reduced
significantly using the latest generation of mechanical ventilators optimized for infant and
pediatric use. Because work of breathing is less with the Bird VIP than the other two
ventilators tested, leading to a corresponding decrease in VO2, we suggest that the Bird VIP
better adapts the patient to the ventilator and may facilitate weaning from ventilatory support.
We also suggest that changes in VO2 might be helpful in tracking changes in work of
breathing.
Elliott, R. D. (1994). "Neonatal resuscitation: the NRP guidelines." Canadian journal of
anaesthesia = Journal canadien d'anesth?sie 41(8): 742-752; quiz 752-743.
The Neonatal Resuscitation Programme, sponsored by the Canadian Heart and
Stroke Foundation and by the American Heart Association, is a structured learning package
and workshop for all individuals who provide resuscitation for newborns. The emphasis is on
rapid, decisive action using algorithms based on clearly stated criteria. This CME article
serves as an introduction to the NRP and discusses some of the new guidelines regarding
concurrent ventilation and chest compressions, tracheal suction for meconium and the use of
medications. The author encourages readers who find this article helpful to register in an
accredited NRP course to receive the extensive illustrated textbook and to benefit from the
hands-on nature of the workshop.
El-Orbany, M. and H. J. Woehlck (2009). "Difficult mask ventilation." Anesthesia and
Analgesia 109(6): 1870-1880.
Mask ventilation is the most fundamental skill in airway management. In this review,
we summarize the current knowledge about difficult mask ventilation (DMV) situations.
Various definitions for DMV have been used in the literature. The lack of a precise standard
definition creates a problem for studies on DMV and causes confusion in data
communication and comparisons. DMV develops because of multiple factors that are
technique related and/or airway related. Frequently, the pathogenesis involves a combination
of these factors interacting to cause the final clinical picture. The reported incidence of DMV
varies widely (from 0.08% to 15%) depending on the criteria used for its definition. Obesity,
age older than 55 yr, history of snoring, lack of teeth, the presence of a beard, Mallampati
Class III or IV, and abnormal mandibular protrusion test are all independent predictors of
DMV. These signs should, therefore, be recognized and documented during the preoperative
evaluation. DMV can be even more challenging in infants and children, because they develop
hypoxemia much faster than adults. Finally, difficult tracheal intubation is more frequent in
patients who experience DMV, and thus, clinicians should be familiar with the corrective
measures and management options when faced with a challenging, difficult, or impossible
mask ventilation situation. (copyright) 2009 International Anesthesia Research Society.
Emeriaud, G., et al. (2008). "Calibration of respiratory inductance plethysmograph in preterm
infants with different respiratory conditions." Pediatric Pulmonology 43(11): 1135-1141.
Respiratory inductance plethysmography (RIP) is a method for respiratory
measurements particularly attractive in infants because it is noninvasive and it does not
interfere with the airway. RIP calibration remains controversial in neonates, and is
particularly difficult in infants with thoraco-abdominal asynchrony or with ventilatory assist.
The objective of this study was to evaluate a new RIP calibration method in preterm infants
either without respiratory disease, with thoraco-abdominal asynchrony, or with ventilatory
support. This method is based on (i) a specifically adapted RIP jacket, (ii) the least squares
method to estimate the volume/motion ribcage and abdominal coefficients, and (iii) an
individualized filtering method that takes into account individual breathing pattern. The
reference flow was recorded with a pneumotachograph. The accuracy of flow reconstruction
using the new method was compared to the accuracy of three other calibration methods, with
arbitrary fixed RIP coefficients or with coefficients determined according to qualitative
diagnostic calibration method principle. Fifteen preterm neonates have been studied;
gestational age was (mean (plus or minus) SD) 31.7 (plus or minus) 0.8 weeks; birth weight
was 1,470 (plus or minus) 250 g. The respiratory flow determined with the new method had a
goodness of fit at least equivalent to the other three methods in the entire group. Moreover, in
unfavorable conditions - breathing asynchrony or ventilatory assist - the quality of fit was
significantly higher than with the three other methods (P < 0.05, repeated measures ANOVA).
Accuracy of tidal volume measurements was at least equivalent to the other methods, and the
breath-by-breath differences with reference volumes were lower, although not significantly,
than with the other methods. The goodness of fit of the reconstructed RIP flow with this new
method - even in unfavorable respiratory conditions - provides a prerequisite for the study of
flow pattern during the neonatal period. Pediatr Pulmonol. 2008; 43:1135-1141. (copyright)
2008 Wiley-Liss, Inc.
Erb, T., et al. (1999). "Fibreoptic bronchoscopy in sedated infants facilitated by an airway
endoscopy mask." Paediatric Anaesthesia 9(1): 47-52.
Fibreoptic bronchoscopy (FB) is frequently associated with a decline in PaO2, whose
degree and duration can be substantial especially in infants. The effect of a face mask, which
allows the administration of 100% oxygen and continuous positive airway pressure during FB,
on the incidence and severity of hypoxaemia was studied in thirty-one consecutive infants.
Sedation was provided by intravenous propofol titrated to allow patient comfort. A transient
fall in SpO2 <95% was recorded in 6/31 patients during endoscopy of the upper airway
(lasting 1.6+/-1.1 min) and in 11/31 patients during endoscopy of the lower airways (lasting
1.4+/-1.1 min). Capillary blood gas analysis before and after endoscopy of the lower airways
demonstrated an increase in the PCO2 6.4+/-1.3 to 7.3+/-1.4 kPa (49+/-10 to 56+/-11 mmHg).
The risk of hypoxaemia in sedated infants breathing spontaneously is low when 100%
oxygen and continuous positive airway pressure are administered during FB
Erler, T. and E. Paditz (2004). "Obstructive sleep apnea syndrome in children: A State-of-theArt review." Treatments in Respiratory Medicine 3(2): 107-122.
Snoring and obstructive sleep apnea are a frequent problem not only in adults, but
also in children and adolescents, as can be seen from current epidemiological data. The
epidemiology, etiology, diagnosis, and management of obstructive sleep apnea syndrome
(OSAS) in adults have been adequately established on the basis of evidential data. As a result
of this, both physicians and the public are increasingly aware of OSAS in adults. Although
there are numerous parallels between pediatric and adult OSAS, the situation in children
differs that in adults. There is a greater variety of symptoms in children with OSAS,
diagnosis is often more difficult with serious consequences for growth and development of
children. Treatment of OSAS in children is also different from that of the adult patient. There
are many possible causes for the development of obstructive sleep apnea in children. These
include hypertrophy of the tonsils and syndromes such as Down syndrome, Pickwickian
syndrome, Prader-Willi syndrome or Marfan syndrome. OSAS can, however, also be the
result of obesity, midfacial dysplasia, retro- or micrognathia, allergic rhinitis or muscular
dystrophy. Epidemiological data presented in the literature concerning the incidence of OSAS
in children is extremely varied. This wide range is probably due to the fact that snoring may
be misdiagnosed as OSAS. The diagnosis of OSAS in children may only be made by
considering clinical history (such as rate of growth, tendency to fall asleep during the day,
sleep disturbances, susceptibility to infection, etc.), polysomnography (if possible during
several nights) and accompanying instrumental diagnosis including cephalometry or
laryngoscopy. One of the problems of polysomnography in childhood is that performance and
interpretation of the results have not yet been standardized or evaluated for different age
groups. Treatment depends on the cause of OSAS and require multidisciplinary management
involving the pediatrician, pediatric or adolescent psychiatrist, ear, nose, and throat specialist,
maxillofacial surgeons, and neurosurgeons. Adenotonsillectomy (ATE) is the therapy
generally chosen if the child has adenoidal vegetations and/or tonsillar hypertrophy.
Corrective surgery is possible for rare malformation syndromes. Nocturnal masks for
continuous positive airway nasal pressure or procedures for mask respiration are effective in
children, but are only used in exceptional cases, such as when ATE is contraindicated or
when symptoms of OSAS remain after surgery. The success of pharmacological treatment of
OSAS in children has not been evaluated in controlled clinical trials. (copyright) 2004 Adis
Data Information BV. All rights reserved.
Fahey, D. (2009). "Failure of an infant Laerdal self-inflating resuscitator due to
misassembly." Anaesthesia and Intensive Care 37(3): 500-501.
Fanaroff, A. A., et al. (1973). "Controlled trial of continuous negative external pressure in the
treatment of severe respiratory distress syndrome." The Journal of pediatrics 82(6): 921-928.
Fauroux, B. and A. Clement (2007). "Requisite for stringent control of oxygen therapy in the
neonatal period." European Respiratory Journal 29(1): 05-Apr.
Finer, N. and W. Rich (2010). "Neonatal resuscitation for the preterm infant: Evidence versus
practice." Journal of Perinatology 30(SUPPL. 1): S57-S66.
In an effort to determine the actual conduct of neonatal resuscitation and the errors
that may be occurring during this process, we developed a method of video recording
neonatal resuscitations as an ongoing quality assurance project. We initiated video recordings
of resuscitations using simple video recorders attached to an overhead warmer and reviewed
the resultant tapes during biweekly quality improvement meetings. We also added the
continuous recording of analog information such as heart rate, oximeter values, fraction of
inspired oxygen and airway pressure. We subsequently developed a checklist that includes a
preresuscitation briefing and a postresuscitation debriefing, all of which are reviewed at the
same time as the video recording. We have examined the use of oxygen in the very preterm
infant, the effectiveness of bag and mask ventilation, including the detection of airway
obstruction during such ventilation, intubation in the delivery area and environment. In
addition, we have trained our teams and leaders using Crew Resource Management and
focused on improved communication. The availability of a dedicated room for resuscitation
allows an increased ambient environment and the ability to provide a user-friendly setting
similar to the neonatal intensive care unit to optimize performance. There are numerous
opportunities for improving team and leader performance and outcomes following neonatal
resuscitation. Further prospective studies are required to evaluate specific interventions.
(copyright) 2010 Nature America, Inc. All rights reserved.
Finer, N. N., et al. (2009). "Airway obstruction during mask ventilation of very low birth
weight infants during neonatal resuscitation." Pediatrics 123(3): 865-869.
The delivery of adequate but not excessive ventilation remains one of the most
common problems encountered during neonatal resuscitation, especially in the very low birth
weight infant. Our observations suggest that airway obstruction is a common occurrence after
delivery of such infants, and we use colorimetric carbon dioxide detectors during bag-andmask resuscitation to assist in determining whether the airway was patent. We reviewed our
experience to determine the frequency of the occurrence of recognizable airway obstruction
during resuscitation of very low birth weight infants.The previous prospective trial randomly
assigned preterm infants <32 weeks' gestation to resuscitation with either room air or 100%
oxygen using pulse oximetry. Colorimetric carbon dioxide detectors were used to assist with
bag-and-mask ventilation and to confirm intubation. From the video recordings, the number
of positive pressure breaths without a color change in the detector until the breaths were
associated with an unequivocal color change was counted as obstructed breaths. From the
analog tracings, the number of breaths that had a peak pressure plateau of >/=0.2 second and
were not associated with a color change was recorded as the number of obstructed
breaths.None of the studied infants required cardiopulmonary resuscitation or received
epinephrine, and all were judged to have an effective circulation during resuscitation. Six of
the 24 infants enrolled in the trial received only continuous positive airway pressure. The
remaining 18 infants received a median of 14 obstructed breaths (range: 4-37 breaths)
delivered over a mean and median interval of 56.7 and 45.0 seconds, respectively (range:
10.0-220.0 seconds). A subgroup of 11 infants was analyzed using airway-pressure data. The
target peak inspiratory pressure was 30 cm H(2)O. Ten of these 11 infants had obstructed
breaths as defined by no change in the PediCap despite reaching the target pressure for
>/=0.2 second.Airway obstruction occurs in the majority of the very low birth weight infants
who receive ventilation with a face mask during resuscitation and the use of a colorimetric
detector can facilitate its recognition and management.
Finer, N. N. and W. D. Rich (2004). "Neonatal resuscitation: Raising the bar." Current
Opinion in Pediatrics 16(2): 157-162.
Purpose of review: To provide an overview of neonatal resuscitation practices with
an emphasis on interventions that are not currently accepted or adapted into existing
resuscitation guidelines. Recent findings: Current resuscitation guidelines do not contain
specific guidelines for the approach to the extremely low birth weight infant. The differences
in environment and management between the neonatal ICU and delivery room are striking
and are magnified in the resuscitation of extremely low birth weight infants for whom
maintenance of a neutral thermal environment is essential. The use of a polyethylene wrap
applied at delivery has been shown to reduce the occurrence of hypothermia and decrease
mortality. There is substantial evidence that term and near-term newborn infants can be
effectively resuscitated with room air, and recent follow-up studies have demonstrated that
this approach is not associated with increased significant differences in neurologic handicap,
somatic growth, or developmental milestones when compared with the use of 100% oxygen.
The safety and potential benefits of this approach require prospective evaluation in the
premature and especially extremely low birth weight infant. There is preexisting evidence
that demonstrates that the use of prolonged inflations and t-piece resuscitators may be
advantageous during resuscitation, but not all guidelines support these interventions.
Although regulated continuous positive airway pressure, pulse oximeters, and blenders are
routinely used once an infant is admitted to the neonatal ICU, none of these interventions is
recommended in the delivery area. Although prospective studies have demonstrated that the
use of colorimetric CO2 detectors significantly decreases the time to recognize misplaced
endotracheal tubes placed during resuscitation, their use is not required by current guidelines.
The duration of an intubation attempt during resuscitation had never been prospectively
evaluated, and our recent findings suggest that a limit of 30 seconds is well tolerated and
provides adequate time for a successful attempt. Summary: There is significant potential for
improvement in current resuscitation environments and interventions that will only be
realised through further prospective research. @copy; 2004 Lippincott Williams & Wilkins.
Finer, N. N. and W. D. Rich (2011). "Unintentional variation in positive end expiratory
pressure during resuscitation with a T-piece resuscitator." Resuscitation 82(6): 717-719.
The ability of T-piece resuscitators to deliver consistent peak inspiratory pressure
(PIP) and positive end expiratory pressure (PEEP) during real and simulated neonatal
resuscitation has been well described. The Neopuff (Fisher & Paykel Healthcare, Auckland,
New Zealand) has been the device used for nearly all of these comparisons.All high risk
resuscitations were carried out in our dedicated resuscitation room, and were recorded on
video tape for quality assurance purposes.(1) In addition to the audio and video recording,
physiologic signals and resuscitation parameters, including oxygen saturation, pulse rate,
airway pressure, FiO(2), and others signals as appropriate were also captured. These
recordings were reviewed on a biweekly basis as part of a continuing quality review process.
Resuscitations were graded for standard of care and the resuscitation checklist was reviewed
to determine if the team had any unresolved issues that needed to be addressed.In the year
between April of 2009 and March 2010, a period when we fully reviewed approximately 120
videos, we recognized visually obvious PEEP changes on 8 different occasions in ELBW
infants. Our target PEEP was 5 cm H20. We observed rapid changes in the PEEP to as high
as 15 cm H20 during resuscitation.Based on our single-center experience, a T-piece
resuscitation device which has the adjustment for the PEEP level and the orifice which is
occluded to deliver a breath in the same location has the potential to cause an inadvertent and
potentially toxic increase of PEEP which might not be noticed by the operator.Copyright ?
2011 Elsevier Ireland Ltd. All rights reserved.
Fischer, H. S., et al. (2008). "Assessment of volume and leak measurements during CPAP
using a neonatal lung model." Physiological measurement 29(1): 95-107.
Although several commercial devices are available which allow tidal volume and air
leak monitoring during continuous positive airway pressure (CPAP) in neonates, little is
known about their measurement accuracy and about the influence of air leaks on volume
measurement. The aim of this in vitro study was the validation of volume and leak
measurement under CPAP using a commercial ventilatory device, taking into consideration
the clinical conditions in neonatology. The measurement accuracy of the Leoni ventilator
(Heinen & L?wenstein, Germany) was investigated both in a leak-free system and with leaks
simulated using calibration syringes (2-10 ml, 20-100 ml) and a mechanical lung model.
Open tubes of variable lengths were connected for leak simulation. Leak flow was measured
with the flow-through technique. In a leak-free system the mean relative volume error +/-SD
was 3.5 +/- 2.6% (2-10 ml) and 5.9 +/- 0.7% (20-60 ml), respectively. The influence of CPAP
level, driving flow, respiratory rate and humidification of the breathing gas on the volume
error was negligible. However, an increasing F(i)O(2) caused the measured tidal volume to
increase by up to 25% (F(i)O(2) = 1.0). The relative error +/- SD of the leak measurements
was -0.2 +/- 11.9%. For leaks > 19%, measured tidal volume was underestimated by more
than 10%. In conclusion, the present in vitro study showed that the Leoni allowed accurate
volume monitoring under CPAP conditions similar to neonates. Air leaks of up to 90% of
patient flow were reliably detected. For an F(i)O(2) > 0.4 and for leaks > 19%, a numerical
correction of the displayed volume should be performed.
Flavin, M., et al. "Aerosol delivery to the rabbit lung with an infant ventilator." Pediatric
Pulmonology 2(1): 35-39.
Little is known about delivery of aerosolized medications to infants undergoing
assisted positive pressure ventilation. To assess delivery of medications to the lung with an
infant ventilator (Bournes LS104), 27 experiments were performed on anesthetized adult
rabbits. Lung deposition was determined by using aerosol radiolabeled with 99m technetium
sulfur colloid. Initially a traditional nebulizer was studied and very inefficient delivery to the
lung was observed (0.19 +/- 0.10 SD% of the initial nebulizer dose). Subsequent experiments
using a nebulizer that generates submicronic aerosol particles, at equivalent aerosol output,
achieved a highly significant increase in delivery (1.96 +/- 1.19 SD%, P less than 0.001). Our
experiments demonstrated that modifications to to traditional nebulizer systems can enhance
delivery of aerosolized medication to the lungs of rabbits.
Fleck Jr., R. J., et al. (2013). "An adverse effect of positive airway pressure on the upper
airway documented with magnetic resonance imaging." JAMA Otolaryngology - Head and
Neck Surgery 139(6): 636-638.
Importance: Positive pressure air is used during basic life support to provide
respirations and applied as continuous positive airway pressure to maintain a patent airway
during sleep or anesthesia. These functions are more critical in children with obstructive sleep
apnea, who often have smaller airway dimensions and increased airway collapsibility.
Observations: We report 2 cases of boys with Down syndrome and a history of obstructive
sleep apnea in whom adverse narrowing of the retroglossal airway is caused by continuous
positive airway pressure applied via face mask as documented with magnetic resonance
imaging. Conclusions and Relevance: Administration of continuous positive airway pressure
by means of face mask to patients can result in adverse effects on the airway patency by
pushing the tongue posteriorly. Awareness of this effect on patients with open mouths and
large tongues, as present in Down syndrome, is important for sleep apnea treatment,
anesthesia, and emergency respiratory support. Generalization of our observation is not
possible at this time. Additional prospective studies of the effects of continuous positive
airway pressure on airway patency in sedated and/or anesthetized children are required to
confirm our anecdotal observations. (copyright)2013 American Medical Association. All
rights reserved.
Fleck, R., et al. (2012). "MRI of full face mask cpap causing narrowing of the retroglossal
airway." Pediatric Radiology 42: S271-.
Purpose or Case Report: To report the effect of applying positive pressure to an
airway during MR imaging of the nasopharyngeal airway in 2 children with Down syndrome
and sleep apnea. Methods & Materials: Patients with obstructive sleep apnea (OSA) and
Down syndrome (DS) were imaged as part of an ongoing study to dynamically model the
airway with a combination of computational fluid mechanics and flow structure interaction.
Subjects were sedated by anesthesia and moved into the MR scanner for static and dynamic
cine imaging of the nasopharyngeal airway under atmospheric pressure and continuous
positive airway pressure (CPAP) at 15 cm of water pressure by full facemask. Results: Down
syndrome patients with OSA typically sleep with the mouth open and have enlarged tongues
relative to their oral compartment. An open mouth and administration of CPAP resulted in
smaller AP diameter of the retroglossal airway compared to images without CPAP due to
CPAP pressure pushing the tongue posteriorly. In patient 1 volume of oral cavity anterior to
the tongue increased from 7.41 mL to 11.74 mL. Meanwhile, the AP diameter of the
retroglossal airway decreased from 4.8 to 1.4mm(71% decrease). In patient 2 the mouth was
initially closed but parted when the pressure of CPAP was added with the oral volume
increasing from 3.69 ml to 15.80 ml. The AP measure of the retroglossal airway decreased
from 8.3 mm to 2.8 mm (66% decrease). In patient 2 the mouth was then closed and CPAP
reapplied resulting in an AP measurement of 11.0 mm (33% increase). The AP diameter
difference between CPAP and no CPAP were tested with paired t-test, but were not
statistically significant (p=0.1475). Conclusions: Positive airway pressure on a patient by full
facemask and an open mouth can have an adverse effect on the retroglossal airway. This
adverse effect is an important consideration in the use of positive airway pressure to support
airways for OSA, or during emergency resuscitation when a full facemask is used.
Foitzik, B., et al. (1997). "[Dead space-free ventilation measurement in artificial respiration
of newborn infants]." Biomedizinische Technik. Biomedical engineering 42 Suppl: 502-503.
Frei, F. J., et al. (1995). "The airway endoscopy mask: useful device for fibreoptic evaluation
and intubation of the paediatric airway." Paediatric Anaesthesia 5(5): 319-324.
A mask is presented which allows the administration of 100% oxygen, inhalational
anaesthetics, continuous positive airway pressure and intermittent positive pressure
ventilation during diagnostic airway endoscopy and difficult intubation with a fibreoptic
bronchoscope in paediatric patients. The mask is particularly useful in small or critically ill
patients. It may also have its place in teaching situations.
Fricker, H. S., et al. (1980). "[Intermittent mandatory ventilation in the treatment of the
idiopathic respiratory distress syndrome of newborns]." Schweizerische medizinische
Wochenschrift 110(7): 251-255.
Intermittent mandatory ventilation (IMV) is a combination of CPAP and IPPV. In the
newborn period it offers the following advantages compared to IPPV alone: weaning is faster,
independent control of respiration is maintained and the effect on cardiac venous return is
minimized. 36 patients with idiopathic respiratory distress syndrome treated by IMV were
compared with 18 patients ventilated with IPPV: IMV reduced the total time on the respirator
by more than 50%. Exposure to increased FIO2 and hospital stay were markedly shortened,
and the incidence of complications was decreased. Intermittent mandatory ventilation
represents an optimal method for stress-free and safe ventilation of newborn infants.
Froese, A. B., et al. (1987). "High-frequency oscillatory ventilation in premature infants with
respiratory failure: a preliminary report." Anesthesia and Analgesia 66(9): 814-824.
High-frequency ventilation has been used successfully to manage life-threatening
complications in premature infants with lung disease. Here we report a preliminary
assessment of the efficacy and safety of high-frequency oscillatory ventilation-(HFO-A, A =
active expiratory phase) when used as a primary ventilator in 11 infants of 24-34 weeks
gestation who required ventilatory support. HFO-A was initiated after no more than 5.5 hr of
conventional mechanical ventilation (CMV). HFO-A at 15 Hz was used for 12-203 hr
following a protocol designed for rapid reduction of FI02 requirements. CO2 elimination was
easily achieved in all infants. Oxygenation was satisfactory, except in one infant with
congenital pneumonia. There were four deaths during HFO-A: two pulmonary (one
congenital pneumonia; one pulmonary hemorrhage) and two nonpulmonary. The HFO-A
protocol utilized lung volume recruitment maneuvers plus mean airway pressures (MAwP)
greater than those generally used early in the course of CMV. Therefore, in a subset of infants
less than or equal to 29 weeks' gestation with respiratory distress syndrome (RDS), ventilator
pressures and gas exchange were compared in infants treated with either HFO-A or CMV.
Maximum MAwP levels were reached earlier in six infants on HFO-A (5.2 +/- 2.5 hr; mean
+/- SD) than in a comparable group of 9 CMV-treated infants (36 +/- 1 hr). This earlier use of
high MAwP lowered the FI02 to less than 0.4 by 18.9 +/- 11 hr with HFO-A as compared
with 64 +/- 6 hr using CMV, without any evidence of an increase in pulmonary complications.
There were 17 complications in the nine CMV-treated infants; and four in the six HFO-A
treated ones. We conclude that HFO-A, instituted early and used with a protocol designed for
early reduction in FI02 requirements, demonstrates sufficient efficacy and safety to warrant
further clinical trials in the routine management of infant RDS.
Fuzaylov, G. and B. D. Cauley (2012). "Spontaneous ventilation via facemask and laryngeal
mask airway as bridge to extracorporeal membrane oxygenation during long-segment
tracheal stenosis repair." Paediatric Anaesthesia 22(12): 1226-1228.
G?mez, J., et al. (1975). "[Treatment of the idiopathic respiratory distress syndrome with
continuous positive airway pressure (author's transl)]." Anales espa?oles de pediatr?a 8 Suppl
1: 21-26.
Gerard, P., et al. (1975). "Early versus late introduction of continuous negative pressure in the
management of the idiopathic respiratory distress syndrome." The Journal of pediatrics 87(4):
591-595.
To evaluate the effectiveness of the early application of continuous negative pressure
about the thorax, 23 infants with the idiopathic respiratory distress syndrome who had
adequate alveolar ventilation were assigned to early or late application of CNP. There were
11 infants in the early CNP and 12 in the late CNP group. There were no differences between
the two groups with respect to birth weight, gestational age, age at admission to the study,
initial FIO2 requirements, or initial PaO2, PaCo2, and AaPO2. None of the ENCP patients
required mechanical ventilation, whereas four of the LCNP group did so. The FIO2
requirements were significantly less for the ECNP infants when compared to the LCNP ones.
The mean duration of FIO2 requirements greater than 0.6 was 28.3 hours for those receiving
ECNP and 60.7 hours for those in LCNP (P LESS THAN 0.05). This study suggests that the
course of RDS may be modified by the early application of CNP.
Gersony, W. M. and C. J. Hayes "Perioperative management of the infant with congenital
heart disease." Progress in cardiovascular diseases 15(3): 213-228.
Giacomini, M., et al. (2003). "Short-term noninvasive pressure support ventilation prevents
ICU admittance in patients with acute cardiogenic pulmonary edema." Chest 123(6): 20572061.
Study objectives: Noninvasive ventilation, although effective as treatment for
patients with acute cardiogenic pulmonary edema when prolonged for hours, is of limited use
in the emergency department (ED). The aim of the study was to determine whether a short
attempt at noninvasive pressure support ventilation avoids ICU admittance and to identify
lack of response prediction variables. Design: Prospective inception cohort study. Setting: ED
of a university hospital. Patients: Fifty-eight consecutive patients with cardiogenic pulmonary
edema who had been unresponsive to medical treatment and were admitted between January
1999 and December 2000. Interventions: Pressure support ventilation was instituted through a
full-face mask until the resolution of respiratory failure. A 15-min weaning test was
performed to evaluate clinical stability. Responder patients were transferred to a medical
ward. Nonresponding patients were intubated and were admitted to the ICU. Main outcome
measures: The included optimal length of intervention, the avoidance of ICU admittance, the
incidence of myocardial infarction, and predictive lack of response criteria. Results: Patients
completed the trial (mean [(plus or minus) SD] duration, 96 (plus or minus) 40 min). None of
the responders (43 patients; 74%) was subsequently ventilated or was admitted to the ICU.
Two new episodes of myocardial infarction were observed. Thirteen of 58 patients died. A
mean arterial pressure of < 95 mm Hg (odds ratio [OR], 10.6; 95% confidence interval [CI],
1.8 to 60.8; p < 0.01) and COPD (OR, 9.4; 95% CI, 1.6 to 54.0; p < 0.05) at baseline
predicted the lack of response to noninvasive ventilation. Conclusions: A short attempt at
noninvasive ventilation is effective in preventing invasive assistance. A 15-min weaning test
can identify patients who will not need further invasive ventilatory support. COPD and
hypotension at baseline are negative predictive criteria.
Gilgoff, I. S., et al. (1992). "Hypoventilation and apnea in children during mechanically
assisted ventilation." Chest 101(6): 1500-1506.
Uncuffed tracheostomy tubes are used for long-term mechanical ventilation in
children. However, upper airway mechanics differ between sleep and wakefulness; this may
affect air leak around tracheostomies. We studied 19 children with high cervical spinal cord
injury on portable positive pressure ventilators, age range birth to 19 years. Ventilator
settings were adjusted while awake to achieve PaCO2 less than 45 mm Hg and PO2 greater
than 90 mm Hg. Clinically several children with uncuffed tracheostomies became unstable at
night with seizures and sleep disruption. Nine of 11 children on volume controlled systems
were found to be inadequately ventilated during sleep. Substitution with a cuffed
tracheostomy allowed adequate ventilation both awake and asleep, suggesting that inadequate
ventilation during sleep was due to an uncompensated leak around the uncuffed tracheostomy.
To avoid cuffed tracheostomies, eight children received pressure controlled ventilation. Gas
exchange was adequate throughout the day and night. We conclude that children receiving
volume controlled mechanical ventilation via uncuffed tracheostomy tubes can exhibit
hypoventilation due to uncompensated air leak. Pressure controlled ventilation improves
adequacy of gas exchange during sleep and wakefulness.
Gobio Casali, L. and F. Fornasini (1974). "[Intermittent positive-pressure respiration in the
treatment of serious bronchiolitis in the infant. Clinical contribution]." Minerva Pediatrica
26(1): 25-36.
Goddard, P. J. and A. J. Becket (1971). "A simple safety valve for infant resuscitator and
ventilator gas circuits." Lancet 2(7724): 584.
Goldmann, K., et al. (2011). "[Clinical use of the ProSeal�� laryngeal mask in infants,
children and adolescents : prospective observational survey]." Der Anaesthesist 60(8): 729734.
In contrast to the adult population scientific data on ProSeal��-LMA (PLMA)
usage in infants, children, and adolescents are rather limited. Most data have been generated
by expert users in studies on small numbers of patients. The aim of this study was to gather
comprehensive data about the characteristics, efficacy and safety of its routine use in children
at a teaching institution.Using a standardized reporting form the following data were
collected in the course of a prospective survey on PLMA usage in patients aged up to 18
years: user characteristics, patient characteristics, type and duration of operation, details of
airway management and anesthetic technique, details of PLMA usage-related critical
incidents and postoperative status of the patient.Use of the PLMA was documented in 512
patients by 61 anesthesiologists (32% staff grade, 68% trainees). The average age, height and
weight of the patients was 8 years (range 0-17 years), 130?cm (range 54-193?cm) and
29?kgBW (range 5-130?kgBW), respectively. Anesthesia was induced intravenously in 458
patients (89.5%) and by inhalation in 54 patients. Maintenance of anesthesia was by total
intravenous anesthesia (propofol) in 184 patients (36.5%) and by an inhalational agent
(sevoflurane or desflurane) in 320 patients (63.7%). Neuromuscular blocking agents were
used in 7 patients (1.4%). The patients were anesthetized for an average of 80?min (range 15270?min) and insertion success rate was 99% with a maximum of 3 attempts. The average
initial airway leak pressure was 27cm?H(2)O (range 12-40?cm?H(2)O); however, lower
pressures were recorded for smaller size masks (size 1.5-2.5) without a dorsal cuff than for
larger size masks (size 3-5; p<0.01). Ventilation was controlled in 96% and combined with
PEEP in 39% of cases. Critical incidents associated with PLMA were documented in a total
of 8.4% of cases, the majority being minor trauma, evidenced by blood on the PLMA on
removal, followed by some form of airway obstruction. In 3.3% of cases these incidents were
judged as clinically relevant of which 0.6% were classified as serious. Twice as many
problems occurred during induction of anesthesia as in the maintenance phase and emergence
phase of anesthesia (p=0.037). In 1.6% the PLMA was abandoned in favor of the
endotracheal tube. In 7 patients the PLMA was exchanged in the induction room whereas in 1
patient this took place intraoperatively. Failure of ProSeal�� laryngeal mask use correlated
with the level of PLMA use experience with 75% of failures caused by users with an
experience of less than 50 uses and no failure in users with an experience of more than 100
uses. Failure did not correlate with the size of the mask. In 2 cases the PLMA was
successfully used after failed endotracheal intubation. In 6 patients drainage of regurgitated
gastric fluid through the drain tube was documented. No long-term adverse sequelae resulted
in any patient.This survey demonstrates that the PLMA can be used effectively in infants,
children and adolescents in the routine university clinical practice setting. However, this
study does not confirm the extremely high success and low complication rates reported in
controlled studies. The results support the assumption that with the PLMA regurgitated
gastric fluid can be drained away from the larynx through the drain tube.
Goodwin, A. W. (1972). "Continuous positive airway pressure in respiratory distress
syndrome." Lancet 1(7758): 1019-1020.
Graybar, G. B. and R. A. Smith (1980). "Apparatus and techniques for intermittent
mandatory ventilation." International anesthesiology clinics 18(2): 53-80.
Greenough, A. (2001). "Update on patient-triggered ventilation." Clinics in Perinatology
28(3): 533-546.
Physiologic studies have demonstrated short-term benefits of triggered ventilation
over conventional ventilation. The results of the randomized trials are disappointing. Metaanalysis has highlighted that the only significant difference in outcomes on PTV compared
with conventional ventilation is a shorter duration of weaning. A few of the trials included
infants with meconium aspiration syndrome and congenital pneumonia, but most infants
randomized had RDS. In addition, a high proportion of the infants included in the metaanalysis were from two trials in which the SLE 2000 and airway pressure triggering system
were mainly used. We cannot confidently conclude that in a population of infants with
another respiratory disorder or even in those with RDS supported by an alternative triggering
system, a different result might have been achieved. In addition, the benefits of PTV
demonstrated in physiologic studies are largely related to achieving synchronized ventilation.
In none of the randomized trials was any attempt made to determine if the infants were
breathing synchronously with their ventilators. Before dismissing PTV for use in the
management of infants with acute respiratory distress, an appropriately designed trial needs
to take place. Essential, before any such trial, is identification of optimum method of PTV
delivery, which may be disease specific.
Greenough, A. (2002). "Update on modalities of mechanical ventilators." Archives of disease
in childhood. Fetal and neonatal edition 87(1): F3-6.
Recent advances in ventilator technology have often not been confirmed by
randomised trials and instead serious shortcomings have been highlighted. Ventilation modes
should only be introduced into routine clinical practice when proved efficacious in
appropriately designed studies and no adverse outcomes identified by long term follow up.
Greenough, A. and F. Greenall "Performance of respirators at fast rates commonly used in
neonatal intensive care units." Pediatric Pulmonology 3(5): 357-361.
The effect on tidal volume and airway pressure of increasing ventilator rate (30, 60,
and 120/min) was tested in six commonly used neonatal ventilators. In all six ventilators
increased flow was necessary to maintain mean airway pressure at the higher rates. Tidal
volume decreased at rates of both 60 and 120/min in all six ventilators, associated with a
change in pressure waveform. The most marked reduction in tidal volume, however, was
associated with increased positive end-expiratory pressure (PEEP). This was only
demonstrated in four ventilators, all incorporating nonassisted expiratory valves. These
results stress the necessity for appropriately designed ventilators if fast rates are to be used
routinely in clinical practice.
Greenough, A., et al. (1991). "Airway pressure triggered ventilation for preterm neonates."
Journal of Perinatal Medicine 19(6): 471-476.
The usefulness of airway pressure triggered ventilation for the preterm newborn has
been assessed using a new patient triggered valveless ventilator, the SLE 2000 infant
ventilator (SLE 2000). This ventilator performs well at fast rates with no inadvertent positive
end expiratory pressure (PEEP) even at rates of 150 breaths per minute (bpm). The ventilator
is triggered by a change in airway pressure equal to or exceeding 0.5 cmH2O. If the infant
fails to achieve the change in airway pressure which will trigger the ventilator the infant is
ventilated at the back-up rate which is predetermined in conventional mode prior to
commencing PTV. Infants were ventilated for one hour on a conventional neonatal ventilator,
then for one hour on the SLE 2000 in conventional mode without changing the ventilator
settings and finally for one hour on the SLE 2000 in patient triggered mode. Arterial blood
gases were checked at the end of each hour. During patient triggered ventilation (PTV) the
peak pressure, inspiratory time and inspired oxygen concentration were the same as those
used during conventional mode. Simultaneous recordings were made of flow, volume,
ventilator and oesophageal pressure change, from this recording the trigger delay during PTV
was calculated. The trigger delay, being the time lag from the start of spontaneous inspiration,
indicated by the negative deflection in the oesophageal pressure trace, and the onset of the
ventilator breath. Thirteen infants were included in the study, median gestational age 32
weeks (range 25-35) and birthweight 1640 g (range 838-3038). All were being ventilated for
respiratory distress syndrome (RDS) and were 4 days of age.(ABSTRACT TRUNCATED
AT 250 WORDS)
Greenough, A. and A. D. Milner (1992). "Respiratory support using patient triggered
ventilation in the neonatal period." Archives of Disease in Childhood 67(1 Spec No): 69-71.
There are now a number of purpose built patient triggered ventilators for use in the
newborn. These ventilators are triggered either by air flow or airway pressure changes, their
triggering devices all have very high sensitivity and short systems delay. They all have the
advantage that they perform well without inadvertent positive end expiratory pressure at the
fast ventilator rates frequently triggered by immature infants. Despite all these improvements
in both ventilator and trigger performance, PTV is still frequently unsuccessful in the most
immature infants. We must conclude that the nature of the extremely preterm infant's
respiratory efforts in the acute stage of respiratory illness may mean that PTV is unlikely to
provide the optimal mode of respiratory support for this group of patients. Short term studies
have suggested that those infants with relatively mild respiratory distress syndrome showed
the greatest improvement in blood gases. These results suggest that PTV may have its most
efficacious role during weaning and in the larger, more mature baby who is 'fighting the
ventilator'.
Greenough, A. and N. R. Roberton (1986). "Neonatal ventilation." Early Human
Development 13(2): 127-136.
Gregoretti, C., et al. (2010). "Non-invasive ventilation in pediatric intensive care." Minerva
Pediatrica 62(5): 437-458.
The aims of this paper are: to examine the physiological rationale for noninvasive
respiratory support (NRS) in children with acute respiratory failure (ARF); to review clinical
available data and to give some practical recommendations to its safe application. NRS is the
delivery of ventilatory support without the need of an invasive airway. Two types of NRS are
commonly used in the pediatric population: non-invasive continuous positive airway pressure
(nCPAP) and non-invasive positive pressureventilation (nPPV). In general, the evidence to
promote the use of NRS in children with ARF is scarce. However, two randomized studies
have been recendy published suggesting that nPPV ameliorates clinical signs and gas
exchange while reducing the need for endotracheal intubation. Moreover, nCPAP and heliox
may improve clinical scores and CO2 washout in infants with severe bronchiolitis, without
major complications. Data from non controlled studies show that NRS unloads the respiratory
muscles and that the helmet can be a valid alternative to facial and/or nasal mask when
nCPAP is administered to children in the early stage of ARF.
Gupta, S. (2011). "Laryngeal mask airway for babies: Uncharted waters." Resuscitation
82(11): 1373-1374.
Guthrie, S. O., et al. (2005). "A crossover analysis of mandatory minute ventilation compared
to synchronized intermittent mandatory ventilation in neonates." Journal of perinatology :
official journal of the California Perinatal Association 25(10): 643-646.
Mandatory minute ventilation (MMV) is a novel ventilator mode that combines
synchronized intermittent mandatory ventilation (SIMV) breaths with pressure-supported
spontaneous breaths to maintain a desired minute volume. The SIMV rate is automatically
adjusted to maintain minute ventilation.To evaluate MMV in a cohort of infants without
parenchymal lung disease alternately ventilated by MMV and SIMV.Neonates >33 weeks'
gestational age and electively intubated for medical or surgical procedures were enrolled.
Exclusionary criteria included: nonintact respiratory drive or active pulmonary disease.
Infants were randomized to receive 2 hours of either SIMV or MMV and then crossed over to
the other mode for 2 hours. Ventilator parameters and end-tidal CO(2) (etCO(2)) were
measured via inline, mainstream monitoring and recorded every minute.In total, 20 infants
were evaluated. No statistically significant differences were found for overall means between
etCO(2), minute volumes, peak inspiratory pressure (PIP), or positive end expiratory pressure
(PEEP). However, there was a significant difference in the type of ventilator breaths given
and in the mean airway pressure. Additionally, there was a statistically significant negative
trend in MMV over time compared to SIMV, although this was subtle and could have been
due to extreme cases.Neonates with an intact respiratory drive can be successfully managed
with MMV without an increase in etCO(2). While this mode generates similar PIP and PEEP,
the decrease in mechanical breaths and the mean airway pressure generated with MMV may
reduce the risk of some of the long-term complications associated with mechanical
ventilation.
Haas, C. F., et al. (1993). "Effects of dense, high-volume, artificial surfactant aerosol on a
heated exhalation filter system." Critical care medicine 21(1): 125-130.
To evaluate a supplemental heated filter system during mechanical ventilation with
continuous nebulization of an artificial surfactant by a new, high-volume nebulizer.A new
nebulizer system, containing artificial surfactant, provided half of a 20-L minute ventilation
and the remainder of this minute ventilation was provided by a commonly used mechanical
ventilator. Ventilation sources were joined in the inspiratory limb of the breathing circuit,
which was connected to a test lung system. A supplemental filter system was placed upstream
of the ventilator's heated filter in the expiratory limb of the circuit. Circuit pressures at the
inlet of the supplemental filter (P1), between the filters (P2), and after the ventilator
expiratory filter (P3) were monitored and recorded. Nebulizer canisters containing artificial
surfactant were replaced every 4 hrs. The performance of four supplemental filters in
continuous use was examined. Another four filters were each used over 4 hrs, steam
autoclaved, and reused.The ventilator was set at a rate of 20 breaths/min, with a tidal volume
of 0.5 L, a flow rate of 40 L/min, and positive end-expiratory pressure of 10 cm H2O. The
nebulizer provided an equal volume and flow rate so that the delivered tidal volume was 1.0
L with a flow rate of 80 L/min.Ventilator failure and/or excessive airway pressure caused by
increased filter resistance occurred at a mean of 7.3 +/- 1.3 (SD) hrs of continuous ventilation.
Mean P1-peak increased from 67.5 +/- 8.2 to 94.0 +/- 10.7 cm H2O (p < .001) and P1baseline increased from 9.3 +/- 1.0 to 53.5 +/- 17.1 cm H2O (p = .014). Filters that were
autoclaved after 4 hrs of ventilation and reused lasted a total of 7.0 +/- 1.3 hrs. Mean P1-peak
increased from 68.9 +/- 4.9 to 84.8 +/- 19.1 cm H2O and P1-baseline increased from 9.5 +/1.7 to 30.8 +/- 14.2 cm H2O (p < .05).The supplemental filter system was able to protect the
ventilatory exhalation sensors for approximately 7 hrs at a minute ventilation of 20 L/min.
Steam sterilization did not extend the supplemental filter life.
Hakanson, D. O. and L. Stern (1975). "Respiratory distress sydnrome of the newborn.
Current status of ventilatory assistance." Postgraduate medicine 58(3): 200-206.
Halamek, L. P. and C. Morley (2006). "Continuous positive airway pressure during neonatal
resuscitation." Clinics in Perinatology 33(1): 83-98.
Numerous animal and human trials have investigated the effects of CPAP on
pulmonary function and other outcome variables. Although CPAP improves pulmonary
function in sick neonates, it may adversely affect lung function in some infants with mild
disease. To date, there are no prospective, randomized, sufficiently powered clinical trials
comparing CPAP with positive-pressure ventilation (via bag and mask or ETT) in
spontaneously breathing neonates (full term or preterm) manifesting respiratory distress and
requiring resuscitation. At this time, data are insufficient to support or refute the routine use
of CPAP during or immediately after neonatal resuscitation. (copyright) 2006 Elsevier Inc.
All rights reserved.
Hammer, J. (2001). "Nasal CPAP in preterm infants - Does it work and how?" Intensive Care
Medicine 27(11): 1689-1691.
Hartung, J. C., et al. (2012). "Leak during manual neonatal ventilation and its effect on the
delivered pressures and volumes: an in vitro study." Neonatology 102(3): 190-195.
Mask leak is a frequent problem during manual ventilation. Our aim was to
investigate the effect of predefined leaks on delivered peak inflation pressure (PIP), positive
end-expiratory pressure (PEEP) and tidal volume (V(t)) when using different neonatal
manual ventilation devices.A neonatal-lung model was ventilated at different respiratory rates
(RRs, 40, 60, 80/min) using a mechanically operated self-inflating bag (SIB) and a manually
operated T-piece resuscitator (PIP = 20 cm H(2)O, PEEP = 5 cm H(2)O). Four open tubes of
different lengths, which produced up to 90% leak, were consecutively attached between the
ventilation device and the lung model. A pneumotachograph was used to measure pressures,
flow and volume.With increasing leak (0-90%) PIP and PEEP decreased significantly (p <
0.001) for both devices. Using the SIB, the mean �� SD PIP fell from 20.1 �� 0.3 to 15.9
�� 7 cm H(2)O and PEEP fell from 5.0 �� 0 to 0.3 �� 0.5 cm H(2)O, leading to an
increased pressure difference (��p); V(t) increased from 8.8 �� 0.7 to 11.1 �� 0.8 ml
(p < 0.001). With increasing RRs, the leak-dependent changes were significantly lower (p <
0.001). Using the T-piece resuscitator, PIP dropped independent of RRs from 20.3 �� 0.5
to 18.5 �� 0.6 cm H(2)O and PEEP from 5.1 �� 0.4 to 4.0 �� 0 cm H(2)O, while
��p and V(t) did not differ significantly.The decrease in PIP and PEEP with increasing
leak is RR dependent and distinctly higher when using an SIB compared to a T-piece device.
In contrast to V(t) delivered with the SIB, V(t) delivered by the T-piece resuscitator was
nearly constant even for leaks up to 90%.Copyright ? 2012 S. Karger AG, Basel.
Hathorn, C., et al. (2013). "Bronchial balloon occlusion in children with complex pulmonary
air leaks." Archives of Disease in Childhood 98(2): 136-140.
Pulmonary air leaks in children are most commonly due to infection or barotrauma.
While cases of severe barotrauma are falling because of advances in neonatal care, the
incidence of necrotising pneumonia is rising. The majority of air leaks can be managed
conservatively, but more severe cases pose a significant challenge to the clinician. The use of
occlusive endobronchial balloons is an established anaesthetic technique for a number of
indications, but is not widely used in children. We conducted a review over a 12-year period,
and report six cases of complex air leaks in which balloon occlusion was used. Balloon
occlusion was successful in both cases of bronchopleural fistulae (secondary to severe
necrotising pneumonia) and half of the cases of intrapulmonary air leak (due to barotrauma).
In the other two cases (due to barotrauma and filamin A deficiency), it was transiently
effective. No serious adverse effects or complications were encountered. In selected cases,
endobronchial balloons are a useful adjunct in the management of life-threatening
bronchopleural fistulae and cystic lung disease. The procedure is non-operative, minimally
invasive and reversible. With the increasing incidence of bronchopleural fistulae, this may
become an increasingly important therapy.
Hauschild, M., et al. "[Measuring accuracy of commercial respiratory function equipment and
ventilation monitors for newborn infants]." Klinische P?diatrie 206(3): 167-174.
Reliability and accuracy of the measured ventilatory and lung mechanical parameters
of different diagnostic systems (SensorMedics 2600, Med-Science RDS 4500) and
respiratory monitoring systems (BI-CORE CP-100, monitor of Babylog 8000) were
investigated using a mechanical lung model. The accuracy of pressure and volume signals
was measured statically over 6h. The errors of estimated lung mechanic parameters
(compliance C, resistance R, time constant T = R.C) were determined for the model
parameters Ci = 3.9; 6.4; 10.0; 13.0 ml/kPa and Ri = 4.0; 10.0 kPa/l/s without and with
endotracheal tubes (12 Ch, 16 Ch). Altogether 27 parameter combinations were used. The
lung mechanic parameters were measured by single occlusion tests. The Babylog 8000
permits only the measurement of the endinspiratory quasistatic compliance C = VT/(Pmax PEEP). The investigations have shown that -excepted the CP-100 (volume measuring error >
14%)-the accuracy of static measurements was sufficient and in conformity with the allowed
tolerances. No significant changes were found over 6h. The mean errors of measured lung
mechanic parameters differed extremely in relationship to the time constant of the model.
They are for T < 80 ms/T > or = 80 ms 7.4%/-3.5% (SM 2600), -8.4%/-5.8% (CP-100) and 22.0%/-17.3% (Babylog 8000) for compliance, 4.6%/-3.8% (SM 2600) and 189.0%/43.4%
(CP-100) for resistance. No reliable measurements of lung mechanics were possible with the
RDS 4500 due to software problems. We found, the smaller the time constant the higher the
measuring errors of lung mechanic parameters. There are big differences between the
investigated devices. Up to now for exact measurements expensive diagnostic systems can
not be replaced by respiratory monitors.
Hawkes, C. P., et al. (2010). "Should the Neopuff T-piece resuscitator be restricted to
frequent users?" Acta paediatrica (Oslo, Norway : 1992) 99(3): 452-453.
Hawkes, G. A., et al. (2013). "Efficacy and user preference of two CO2 detectors in an infant
mannequin randomized crossover trial." European Journal of Pediatrics 172(10): 1393-1399.
Assessment of effective ventilation in neonatal mask ventilation can be difficult. This
study aims to determine whether manual ventilation with a T-piece resuscitator containing an
inline CO2 detector (either a Pedi-Cap�� CO2 detector or a Neo-StatCO2 <Kg�� CO2
detector connected to a facemask) facilitates effective positive pressure ventilation compared
to no device in a mannequin study. Paediatric and neonatal trainees were randomly assigned
to determine which method they began with (no device, Pedi-Cap or a Neo-Stat). The
participants used each method for a period of 3 min. They were video-recorded to determine
the amount of effective ventilations delivered and the overall percentage efficiency of each
method. Efficacy of ventilation was determined by comparing the number of manual
ventilations delivered with the number of times chest rise was observed in the video
recording. There were 19 paediatric trainees who provided a total of 7,790 ventilations, and
93% were deemed effective. The percentage of effective ventilations with the T-piece
resuscitator alone, the PediCap and the NeoStat were 90, 94 and 96%, respectively. The
difference was greatest in the first minute (T-piece resuscitator alone 87.5%, PediCap 94%,
NeoStat 96%). Two thirds preferred the Neo-Stat. The use of a CO2 detector improves
positive pressure ventilation in a mannequin model, especially in the first minute of positive
pressure ventilation. The Neo-Stat CO2 detector was the preferred device by the majority of
the participants.
Hayes, B. "Ventilation and ventilators." Journal of medical engineering & technology 6(5):
177-192.
The history of ventilation is reviewed briefly and recent developments in techniques
of ventilation are discussed. Operating features of ventilators have changed in the past few
years, partly as the result of clinical progress; yet, technology appears to have outstripped the
clinician's ability to harness it most effectively. Clinical discipline and training of medical
staff in the use of ventilators could be improved. The future is promising if clinician and
designer can work together closely. Ergonomics of ventilators and their controls and the
provision of alarms need special attention. Microprocessors are likely to feature prominently
in the next generation of designs.
Healy, F. and H. B. Panitch (2010). "Pulmonary complications of pediatric neurological
diseases." Pediatric Annals 39(4): 216-224.
Heese, H. d. V., et al. (1970). "Intermittent positive pressure ventilation in hyaline membrane
disease." The Journal of pediatrics 76(2): 183-193.
Heller, K., et al. (1985). "[2-frequency artificial respiration--a new therapeutic concept]."
Monatsschrift Kinderheilkunde : Organ der Deutschen Gesellschaft f?r Kinderheilkunde
133(5): 309-310.
A new respiration system is described. The system has been developed for the
therapy of very ill newborn and premature infants (RDS stage IV, gestation age less than 28
weeks, severe pneumonia etc.). The special feature of the new respiratory device is an
alternating between cycles with low frequencies and relatively high amplitudes, and breathes
with low amplitudes and relatively high frequencies.
Helmrath, T. A., et al. (1970). "Positive pressure ventilation in the newborn infant: the use of
a face mask." The Journal of pediatrics 76(2): 202-207.
Helms, P. J. (1977). "Apnoea of prematurity." Lancet 1(8022): 1157.
Helou, S., et al. (2011). "The velcro mustache: a potential barrier to effective bag-and-mask
ventilation in neonates on nasal cpap: two case reports." Respiratory Care 56(7): 1040-1042.
Hudson prongs (Hudson RCI, Teleflex Medical, Research Triangle Park, North
Carolina) (a device to deliver nasal continuous positive airway pressure) are often secured
with a Velcro mustache in neonatal intensive care units. We report 2 premature infants who
required bag-and-mask ventilation while on Hudson prongs secured with a Velcro mustache.
Effective ventilation was achieved only after removing the Velcro mustache.
Hentschel, R., et al. (2011). "Endotracheal tube resistance and inertance in a model of
mechanical ventilation of newborns and small infants-the impact of ventilator settings on
tracheal pressure swings." Physiological measurement 32(9): 1439-1451.
Resistive properties of endotracheal tubes (ETTs) are particularly relevant in
newborns and small infants who are generally ventilated through ETTs with a small inner
diameter. The ventilation rate is also high and the inspiratory time (ti) is short. These
conditions effectuate high airway flows with excessive flow acceleration, so airway
resistance and inertance play an important role. We carried out a model study to investigate
the impact of varying ETT size, lung compliance and ventilator settings, such as peak
inspiratory pressure (PIP), positive end expiratory pressure (PEEP) and inspiratory time (ti)
on the pressure-flow characteristics with respect to the resistive and inertive properties of the
ETT. Pressure at the Y piece was compared to direct measurement of intratracheal pressure
(P(trach)) at the tip of the ETT, and pressure drop (��P(ETT)) was calculated. Applying
published tube coefficients (Rohrer's constants and inertance), P(trach) was calculated from
ventilator readings and compared to measured P(trach) using the root-mean-square error. The
most relevant for ��P(ETT) was the ETT size, followed by (in descending order) PIP,
compliance, ti and PEEP, with gas flow velocity being the principle in common for all these
parameters. Depending on the ventilator settings ��P(ETT) exceeded 8 mbar in the
smallest 2.0 mm ETT. Consideration of inertance as an additional effect in this setting
yielded a better agreement of calculated versus measured P(trach) than Rohrer's constants
alone. We speculate that exact tracheal pressure tracings calculated from ventilator readings
by applying Rohrer's equation and the inertance determination to small size ETTs would be
helpful. As an integral part of ventilator software this would (1) allow an estimate of work of
breathing and implementation of an automatic tube compensation, and (2) be important for
gentle ventilation in respiratory care, especially of small infants, since it enables the
physician to estimate consequences of altered ventilator settings at the tracheal level.
Hey, E. and J. Kelly (1968). "Gaseous exchange during endotracheal ventilation for asphyxia
at birth." The Journal of obstetrics and gynaecology of the British Commonwealth 75(4):
414-424.
Hey, E. and W. Lenney (1973). "Safe resuscitation at birth." Lancet 2(7820): 103-104.
Hird, M. F. and A. Greenough (1990). "Gestational age: an important influence on the
success of patient triggered ventilation." Clinical physics and physiological measurement : an
official journal of the Hospital Physicists' Association, Deutsche Gesellschaft f?r
Medizinische Physik and the European Federation of Organisations for Medical Physics
11(4): 307-312.
We have evaluated a new patient triggered (PT) ventilator which has been produced
as suitable for neonatal use. This ventilator, the Draeger Babylog 8000, is triggered by
airflow changes detected by a hot wire anemometer. Laboratory assessment demonstrated
maintenance of tidal volume and absence of inadvertent PEEP at flow rates up to 20 l min-1
and rates of 120 breaths min-1. The ventilator was then used in both conventional and trigger
mode in 14 pre-term infants. The results were compared with PT ventilation delivered by the
SLE ventilator. At all inflation times studied, using the Draeger ventilator 100% of
respiratory efforts were detected in the majority of infants. The trigger delay varied from a
median of 80-100 ms and was significantly shorter than the trigger delay of the SLE system
(P less than 0.05). Oxygenation improved on Draeger PT compared with conventional
ventilation, however, only in infants more mature than 27 weeks gestation. We conclude the
Draeger Babylog 8000 is an important advance in patient triggered ventilation, particularly at
fast frequencies, but PT ventilation should still be restricted to relatively mature infants.
Hogeling, M., et al. "Forehead pressure necrosis in neonates following continuous positive
airway pressure." Pediatric dermatology 29(1): 45-48.
After treatment with continuous positive airway pressure (CPAP) via nasal masks
and a face mask, three neonates developed pressure necrosis involving their central forehead
and left eyebrow. The pressure necrosis resulted in permanent scarring in all three infants.
We describe a case series of a new cutaneous iatrogenic complication of CPAP.? 2011 Wiley
Periodicals, Inc.
Hughes-Davies, T. (2008). "Nasal CPAP for very preterm infants." The New England journal
of medicine 358(23): 2521; author reply 2521.
Hussey, S. G., et al. (2004). "Comparison of three manual ventilation devices using an
intubated mannequin." Archives of disease in childhood. Fetal and neonatal edition 89(6):
F490-493.
To compare three devices for manual neonatal ventilation.Participants performed a
two minute period of ventilation using a self inflating device, an anaesthesia bag with
attached manometer, and a Neopuff device. An intubated neonatal mannequin, approximating
a 1 kg infant with functional lungs, was used for the study. Target ventilation variables
included a rate of 40 breaths per minute, peak inspiratory pressure (PIP) of 20 cm H2O, and
positive end expiratory pressure (PEEP) of 4 cm H2O. The circuit was attached to a laptop
computer for data recording.Thirty five participants were enrolled, including consultant
neonatologists, paediatricians, and anaesthetists, paediatric and anaesthetic registrars, and
neonatal nurses. The maximum PIP recorded using the self inflating bag, anaesthetic bag, and
Neopuff device were 75.9, 35.5, and 22.4 cm H2O respectively. There were significant
differences between the devices for mean PIP (30.7, 18.1, and 20.1 cm H2O), mean PEEP
(0.2, 2.8, and 4.4 cm H2O), mean airway pressure (7.6, 8.5, and 10.9 cm H2O), % total
breaths < or = 21 cm H2O PIP (39%, 92%, and 98%), and % total breaths > or = 30 cm H2O
PIP (45%, 0, and 0). There was no difference between doctors and allied health professionals
for the variables examined.The anaesthetic bag with manometer and Neopuff device both
facilitate accurate and reproducible manual ventilation. Self inflating devices without
modifications are not as consistent by comparison and should incorporate a manometer and a
PEEP device, particularly when used for resuscitation of very low birthweight infants.
Ian, S. and L. T. J (2009). "Pressure modification for improving usage of continuous positive
airway pressure machines in adults with obstructive sleep apnoea." Cochrane Database of
Systematic Reviews(4).
Background: Continuous Positive Airways Pressure (CPAP) is considered to be the
cornerstone of therapy for obstructive sleep apnoea (OSA). However, compliance with this
treatment is frequently poor, which may lead to ongoing symptoms of sleep disruption,
daytime sleepiness and poor waking cognitive function. Mechanical interventions which
involve changing the way that positive pressure is delivered, and the addition of
humidification, might improve compliance.Objectives: To determine the efficacy of pressure
level modifications and additional humidification in increasing CPAP machine usage.Search
methods: We searched the Cochrane Airways Group Specialised Register (September
2008).Selection criteria: Randomised controlled trials (RCTs) assessing interventions to
improve compliance with CPAP usage. Control groups received fixed pressure CPAP.Data
collection and analysis: Two authors assessed articles for inclusion in the review and
extracted data. We made attempts to obtain additional unpublished data from the
trialists.Main results: Forty-five studies met the inclusion criteria (1874 participants). AutoCPAP (30 studies, 1136 participants): a statistically significant difference in machine usage
of 0.21 hours/night (0.08 to 0.35) was observed in favour of auto-CPAP from cross-over
studies. This difference is of questionable clinical significance. Pooled effect estimates from
parallel group trials detected a similar sized difference for average nightly machine usage, but
this was not statistically significant. Evidence from parallel group studies did not identify a
statistically significant difference between pressure modes in Epworth Sleepiness Scores, but
there was an overall reduction of 0.64 units with cross-over studies (-0.12 to -1.16) in favour
of auto-CPAP. Parallel group studies did not identify a significant difference. More
participants preferred auto-CPAP to fixed CPAP where this was measured. Bi-level PAP (six
studies, 285 participants): no significant differences were observed in machine usage. One
small study found no difference in preference. C-Flex (six studies, 318 participants): no
significant difference was observed in machine usage. Humidification (three studies, 135
participants): there were conflicting findings between the studies. Two parallel group trials
found no significant difference in machine usage, whereas a cross-over study found a
significant difference.Authors' conclusions: Improvement in average machine use of autoCPAP was superior in studies with a cross-over design; the point estimate in parallel group
trials was similar, but did not reach statistical significance. It is uncertain how use of
machines in study settings relates to 'real world' use. Where preference was measured
participants preferred auto-CPAP to fixed pressure CPAP. Further studies are required to
assess the evidence for Bi-PAP, C-FlexTM and humidification. The studies assembled were
characterised by high machine usage in the control groups, and low withdrawal rates. Future
studies need to consider the effects of treatment in participants with more mild disease, and
those who struggle to accept therapy despite persistent symptoms.
Iankov, A. (1977). "[Continuous respiratory resuscitation of a newborn infant with
respiratory insufficiency]." Akusherstvo i ginekologii?a 16(4): 298-306.
Ioana Cristea, A., et al. (2013). "Outcomes of children with severe bronchopulmonary
dysplasia who were ventilator dependent at home." Pediatrics 132(3): e727-e734.
OBJECTIVE: To describe the incidence and outcomes of children with chronic
respiratory failure secondary to severe bronchopulmonary dysplasia (BPD) on chronic
positive pressure ventilation (PPV) via tracheostomy at home. METHODS: We
retrospectively reviewed medical charts of patients with severe BPD who were PPV
dependent at home and who were enrolled in a university-affiliated home ventilator program
between 1984 and 2010. We excluded patients with other comorbidities that could contribute
to the development of chronic respiratory failure. We reported the incidence of these children
in Indiana and cumulative incidences of survival, liberation from PPV, and decannulation.
RESULTS: Over 27 years, 628 children were cared for in our home ventilator program. Of
these, 102 patients met inclusion criteria: 83 (81.4%) were alive and 19 (18.6%) were
deceased. Sixty-nine patients (67.6%) were liberated from PPV, and 97.1% of them were
weaned before their fifth birthday, with a median age at liberation of 24 months (interquartile
range, 19-33). Similarly, 60 patients (58.8%) were decannulated, of which 96.7% completed
this process before their sixth birthday, with a median age at decannulation of 37.5 months
(interquartile range, 31.5-45). The incidence of children with chronic respiratory failure
secondary to BPD who were PPVdependent at home in Indiana was 1.23 per 100 000 live
births in 1984 and increased to 4.77 per 100 000 live births in 2010. CONCLUSIONS:
Although extreme prematurity associated with severe BPD necessitating PPV at home carries
significant risks of morbidity and mortality, successful liberation from mechanical ventilation
and decannulation are likely to occur. Copyright (copyright) 2013 by the American Academy
of Pediatrics.
J, R. s. n. and L. M (1991). "Breathing circuit respiratory work in infants recovering from
respiratory failure." Critical care medicine 19(1): 31-35.
OBJECTIVE: To compare cardiopulmonary function during spontaneous breathing
with three continuous-flow breathing circuits. The major difference between these circuits
was the degree of flow resistance offered by the exhalation valve. DESIGN: Randomized
crossover trial. PATIENTS: Twelve infants less than 12 months of age recovering from
respiratory failure of variable etiology. Only patients weighing 3 to 10 kg were studied.
INTERVENTIONS: The patients were connected to each respiratory circuit in a random
sequence, with 15 min allowed for equilibration before assessment of cardiopulmonary
function. Airway pressure (Paw) and FIO2 were maintained unchanged. MEASUREMENTS
AND MAIN RESULTS: Ventilation, gas exchange, or circulatory function were not altered
significantly by changing the breathing circuit. However, Paw and esophageal pressure
fluctuations were altered and were largest during breathing with the circuit that had an
exhalation valve with high-flow resistance. The Paw fluctuation recorded while the patient
was breathing with the flow-resistor circuit increased with weight and exceeded 2 cm H2O in
all patients weighing greater than 4.5 kg. Paw fluctuation could be decreased by greater than
2 cm H2O in ten of 12 patients by using the threshold-resistor circuit. CONCLUSIONS: The
results indicate a need for evaluating the characteristics of respiratory circuits used for
spontaneous breathing in infants and children, to avoid unnecessary equipment-related
increase in respiratory work.
Jackson, E., et al. (1994). "Increasing the length of the expiratory limb of the Ayre's T-piece:
implications for remote mechanical ventilation in infants and young children." British journal
of anaesthesia 73(2): 154-156.
We have assessed the effect of lengthening the expiratory limb of an Ayre's T-piece
from 0.5 to 10 m for ventilation with a Nuffield series 200 ventilator and Newton valve, as
this equipment is potentially suitable for infants and young children during anaesthesia for
magnetic resonance imaging (MRI). We used lung models with compliances and resistances
representative of the respiratory system with intubated trachea of a neonate, infant and child
weighing 15-20 kg. The effects on ventilation were small, being greatest with the largest lung
model where the longer T-piece resulted in a reduction in tidal volume from 261 to 236 ml
and an increase in intrinsic and extrinsic positive end-expiratory pressure from 0.20 to 0.32
kPa and from 0.14 to 0.25 kPa, respectively. Such changes are unlikely to be clinically
important and can be obviated by using the ventilator with the standard valve in children
weighing 15-20 kg.
Jacobsen, H.-C., et al. (2009). "Combined Internal and External Distraction of the Midface
for the Treatment of Crouzon Syndrome and Critical Obstructive Sleep Apnea: A Case
Report." Journal of Oral and Maxillofacial Surgery 67(9): 2004-2009.
Jahromi, G. S., et al. (2010). "Acute respiratory distress syndrome associated with H1N1
influenza during pregnancy." International Journal of Obstetric Anesthesia 19(4): 465-466.
Jardine, E., et al. (1999). "Current status of long term ventilation of children in the United
Kingdom: Questionnaire survey." British Medical Journal 318(7179): 295-299.
Objectives. To identify the number and current location of children, aged 0 to 16
years, requiring long term ventilation in the United Kingdom, and to establish their
underlying diagnoses and ventilatory needs. Design. Postal questionnaires sent to consultant
respiratory paediatricians and all lead clinicians of intensive care and special care baby units
in the United Kingdom. Subjects. All children in the United Kingdom who, when medically
stable, continued to need a mechanical aid for breathing. Results. 141 children requiring long
term ventilation were identified from the initial questionnaire. Detailed information was then
obtained on 136 children from 30 units. Thirty three children (24%) required continuous
positive pressure ventilation by tracheostomy over 24 hours, and 103 received ventilation
when asleep by a non-invasive mask (n = 62; 46%), tracheostomy (n = 32; 24%), or negative
pressure ventilation (n = 9; 7%). Underlying conditions included neuromuscular disease (n =
62; 46%), congenital central hypoventilation syndrome (n = 18; 13%), spinal injury (n = 16;
12%), craniofacial syndromes (n = 9; 7%), bronchopulmonary dysplasia (n = 6; 4%), and
others (n = 25; 18%). 93 children were cared for at home. 43 children remained in hospital
because of home circumstances, inadequate funding, or lack of provision of home carers. 96
children were of school age and 43 were attending mainstream school. Conclusions. A
significant increase in the number of children requiring long term ventilation in the United
Kingdom has occurred over the past decade, contributing factors include improvement
technology, developments in paediatric non-invasive ventilatory support, and a change in
attitude towards home care. Successful discharge home and return to school is occurring even
for severely disabled patients. Funding and home carers are common obstacles to discharge.
Jobe, A. (2011). "Respiratory support in the NICU-CPAP vs. ventilation strategies." Journal
of Perinatal Medicine 39: -.
The major intervention that improves the survival of sick term infants and preterm
infants is the provision of oxygen, and assisted ventilatory support that can include CPAP,
other forms of noninvasive ventilation, and mechanical ventilation. From a historical
perspective, CPAP was in introduced in 1971 for infants with severe RDS. However, CPAP
was quickly supplanted with mechanical ventilators designed for infants. As survival of very
low birth-weight infants improved, BPD became a more frequent and severe problem. Over
the past 10 years, the interest in CPAP has increased in order to avoid the complications of
intubation and mechanical ventilation that are so closely associated with BPD.
Simultaneously, the lung disease in many preterm infants has become less severe because of
the almost uniform use of antenatal corticosteroids, better obstetric management of preterm
deliveries, surfactant treatments, and changes in the goals of ventilatory management to
decrease lung injury in the delivery room and the NICU. More recently, noninvasive
ventilation strategies are being tested and more widely used. These include variable level
CPAP, different generators for CPAP, nonsynchronized or synchronized assisted ventilation
with CPAP in un-intubated infants, and high frequency augmentation of CPAP. Each
technique requires different equipment and skills for successful use, and the amount of
innovation is remarkable. Some conclusions can be drawn from recent clinical series and
randomized controlled trials. Even very preterm infants will breathe and can be transitioned
from the delivery room with CPAP. The combined use of CPAP and aggressive extubation
strategies can minimize days of mechanical ventilation. CPAP will not prevent BPD however,
CPAP can decrease the severity of BPD and can keep some infants off ventilators. The added
benefits of other noninvasive ventilation strategies remain to be demonstrated. Further,
patient selection for the various support strategies and the timing of surfactant treatments
remains controversial.
Johnston, K. L. and K. Aziz (2009). "The self-inflating resuscitation bag delivers high
oxygen concentrations when used without a reservoir: implications for neonatal
resuscitation." Respiratory Care 54(12): 1665-1670.
To measure the delivered fractional oxygen concentration (F(DO(2))) from pretermsize Laerdal silicone resuscitators (PLSR) without a reservoir.The North American Neonatal
Resuscitation Program manual states that self-inflating bags without a reservoir deliver
approximately 40% oxygen, differing from the PLSR manufacturer's specifications.A
neonatal test lung was manually ventilated using PLSRs without a reservoir. A 50 psi 100%
oxygen source and an oxygen flow meter were used to provide desired oxygen inlet flows.
F(DO(2)) was measured using 3 different PLSRs after 4 min of manual ventilation of a
neonatal test lung, at differing inspired tidal volumes (5 mL or 20 mL), respiratory rates (40
breaths/min or 60 breaths/min), and oxygen inlet flows (1 to 4, 5, and 10 L/min).In all tests
using 5 or 10 L/min, exceeded 0.95. The lowest F(DO(2)) was 0.59, at 1 L/min.The F(DO(2))
measured during this study did not differ from PLSR specifications. The F(DO(2)) did,
however, differ from information contained in the North American Neonatal Resuscitation
Program manual regarding use of a self-inflating bag without a reservoir. Care should be
taken when selecting a self-inflating resuscitation device to provide blended air and oxygen,
as high concentrations of oxygen may be delivered by these devices even when the reservoir
is removed. American and Canadian recommendations for the provision of supplemental
oxygen with self-inflating bags require reevaluation.
Jones, R. A. K. (1982). "Apnoea of immaturity. 1. A controlled trial of theophylline and face
mask continuous positive airways pressure." Archives of Disease in Childhood 57(10): 761765.
A randomised controlled trial of theophylline versus face-mask continuous positive
airways pressure (CPAP) treatment for recurrent apnoea of immaturity was carried out in 32
infants of 25 to 32 weeks' gestation. Continuous recording of electrocardiogram and
impedence pneumogram added objective assessment to the nurses' observations for 11
courses of treatment. The CPAP group had more adverse perinatal factors but the frequency
of apnoeic attacks before treatment was comparable. Infants given theopylline had a greater
reduction in the incidence of prolonged apnoeic attacks, and this difference persisted after
allowing for the effect of perinatal complications. Continuous recordings showed a greater
reduction in episodes of bradycardia of (less-than or equal to)80/minute with theophylline.
Five of 18 infants given theophylline needed intermittent positive pressure ventilation for
apnoea compared with 12 of 14 given CPAP. The poor response in 17 of 32 infants suggests
a need for a more effective method of preventing or treating apnoea in very immature babies,
in whom adverse perinatal factors often coexist.
Jonson, B., et al. (1980). "Continuous positive airway pressure: modes of action in relation to
clinical applications." Pediatric clinics of North America 27(3): 687-699.
Some physical effects of CPAP are discussed, as are the various devices used for
CPAP in infants. Some of the controversies about CPAP may be related to the unsuitability of
certain techniques. Use in hyaline membrane disease, extrathoracic and intrathoracic airway
obstruction, congestion of overperfusion of the lungs in diseases of the heart and great vessels,
apnea repetens of immaturity, and phrenic nerve palsy is presented.
Josten, K. (1977). "[The laerdal ventilation bag for newborns and infants (author's transl)]."
Praktische An?sthesie, Wiederbelebung und Intensivtherapie 12(2): 145-147.
The Laerdal resuscitator for neonates and infants is a ventilation bag designed for
resuscitation, anaesthesia and intensive care (CPAP PEEP). As the apparatus allows CPAP
therapy and PEEP ventilation is particularly useful in the labour and neonate ward and in
paediatric intensive care units.
Jouvet, P., et al. (1995). "Assessment of neonatal ventilator performances." Intensive Care
Medicine 21(9): 753-758.
To analyze efficiency and reliability of 4 modern neonatal ventilators under difficult
test conditions. The ventilators tested were: Babylog 8000 (Dr?ger Medical), BP 2001 (Bear
Medical Systems), Sechrist IV 100 B (Sechrist Industries), Infant Star (Infrasonics INC).Gas
flow generation was tested by comparison of preset flow values with no resistance in the
circuit to flow values obtained during interposition of a resistance in the inspiratory circuit. A
decrease in gas flow was observed when interposition of a resistance in the inspiratory circuit
increased peak inspiratory pressure to 60 cmH2O (gas flow decreased by 8% to 24%
depending on the ventilator tested). The pressure limiting valve and the positive endexpiratory pressure valve were also evaluated in order to test their behaviour under different
flow conditions. Flow-dependence of the pressure was noted for all ventilators except
Babylog 8000. Assessment of the reliability of pressure monitoring revealed either 'under' or
'over' estimation of peak inspiratory pressure and positive end-expiratory pressure depending
on the ventilator tested.For the best clinical use of mechanical ventilators, neonatologists
should be aware of these limitations. Therefore a regular assessment of ventilator
performance and monitoring reliability is recommended.
K, M. L., et al. (2011). "Nasal airways (single or double prong, long or short) for neonatal
resuscitation." Cochrane Database of Systematic Reviews(5).
This is the protocol for a review and there is no abstract. The objectives are as
follows:In infants resuscitated at birth with positive pressure ventilation does resuscitation
with: a nasal airway (e.g. single or double, long or short nasal prongs) compared to a face
mask; a nasal airway compared to a laryngeal mask airway; any type of nasal airway (e.g.
single nasal prong) compared to another nasal airway (e.g. short binasal prongs). reduce
morbidity and mortality?We plan subgroup analysis to determine whether safety and efficacy
vary according to: gestational age: term (37 weeks' gestation and above), preterm infants
(between 29 and 36 weeks gestation), very preterm infants (< 29 weeks); ventilation device
for delivering PPV:? self-inflating bag, flow-inflating bag and T-piece device.
Kahn, D. J., et al. (2007). "Unpredictability of delivered bubble nasal continuous positive
airway pressure: role of bias flow magnitude and nares-prong air leaks." Pediatric Research
62(3): 343-347.
Nasal continuous-positive-airway-pressure (NCPAP) is popular for infant respiratory
support. We compared delivered to intended intra-prong, proximal-airway, and distal-airway
pressures using ventilator (V-NCPAP) and bubble (B-NCPAP) devices. Measurements were
repeated at five flows (4, 6, 8, 10, and 12 L/min) and three NCPAP (4, 6, and 8 cm H2O)
under no, small, and large nares-prong interface leak conditions. With no-leak, delivered BNCPAP was systematically greater than intended levels at all pressure sites. The
corresponding V-NCPAP flow-dependence was none-to-minimal. Prong and intra-airway BNCPAP overshoots were also observed with small-leak, while only prong B-NCPAP showed
a flow-dependent overshoot for large-leak. Leaks did not affect intra-prong V-NCPAP but
resulted in progressively lower than desired, flow-independent intra-airway V-NCPAP. We
conclude that the self-adjusting capability of ventilators allows closely matched actual versus
intended V-NCPAP. Alternatively, for the range of flows used clinically, intra-prong and
intra-airway B-NCPAP are systematically higher at increasing flows than operator-intended
levels, even when appreciable nares-prong leak is present. Additionally, the oscillations
(noise) characterizing B-NCPAP are substantially attenuated between the proximal and distal
airways; therefore, it is unlikely that B-NCPAP engenders ventilation or lung recruitment via
this phenomenon. Tubing submersion depth for setting the level of B-NCPAP is highly
inaccurate, and operators should instead rely on intra-prong pressure measurement.
Kameyama, Y., et al. (2012). "A case of congenital central hypoventilation syndrome."
Journal of Anesthesia 26(6): 922-924.
We encountered a 2-year-old female infant with congenital central hypoventilation
syndrome (CCHS) who underwent an abdominal operation for strangulated ileus. Prior to the
surgery, at home, the infant had been receiving non-invasive positive-pressure ventilation
(NPPV) support only during sleep. However, after postoperative extubation, the blood
oxygen saturation (SpO 2) decreased to approximately 90 % with NPPV during sleep alone,
necessitating the use of biphasic cuirass ventilation (BCV) along with NPPV for 2 days. The
infant was weaned from the BCV on hospital day 9, and was discharged from the intensive
care unit (ICU) on hospital day 13. Although it has been said that CCHS is not under the
control of the respiratory center, there are no reports of the true CO2 response curves in these
patients. Therefore, during respiratory management in the ICU post-surgery, we examined
(with the consent of the mother) the relationship of the end-tidal carbon dioxide (ETCO2) to
the tidal volume and respiratory rate, for a period of 6 min in the absence of sedation, using a
respiratory profile monitor. Electrocardiographic and SpO2 monitoring was also conducted at
the same time, to ensure the patient's safety. In this patient, while the ETCO 2 increased, the
tidal volume and respiratory rate remained unchanged. No relationship was found between
the tidal volume and the respiratory rate. Various modalities have been used for the treatment
of CCHS (tracheotomy, NPPV, and diaphragmatic pacing). Treatment of these patients in the
ICU should be tailored to the needs of individual patients and their families. (copyright) 2012
Japanese Society of Anesthesiologists.
Kamlin, C. O. F., et al. (2012). "Mask or nasal tube to provide positive pressure ventilation
(PPV) to preterm infants in the delivery room (DR)-the mont trial." Archives of Disease in
Childhood 97: A39-.
Background For initial PPV a face mask is used, but obstruction and leak often
occurs. A nasal tube is an alternative interface in the DR to provide PPV. Its safety and
efficacy have not been tested in a large RCT in extremely preterm infants. Objective To
determine whether a single nasal tube is more effective than face mask during the
stabilisation of infants born between 24 and 29 weeks. Design and methods An RCT
performed in Melbourne and Leiden. Infants were randomized immediately prior to birth to
receive PPV using a T-piece with either a nasal tube or round mask. Resuscitation guidelines
were standardised. Criteria for intubation: cardiac compressions, apnea, CPAP >7cmH2O and
FiO2 >0.4. Primary outcome: intubation in the first 24 hours from birth. Results In total 368
infants were randomized. Baseline variables, primary and secondary outcomes were similar
(table). (Table presented) Conclusions In infants < 30 weeks gestation receiving PPV in the
DR, there were no differences in short term outcomes using the nasal tube compared to the
face mask.
Kamlin, C. O. F., et al. (2013). "Mask versus nasal tube for stabilization of preterm infants at
birth: a randomized controlled trial." Pediatrics 132(2): e381-388.
Positive-pressure ventilation (PPV) using a manual ventilation device and a face
mask is recommended for compromised newborn infants in the delivery room (DR). Mask
ventilation is associated with airway obstruction and leak. A nasal tube is an alternative
interface, but its safety and efficacy have not been tested in extremely preterm infants.An
unblinded randomized controlled trial was conducted in Australia, and the Netherlands.
Infants were stratified by gestational age (24-25/26-29 weeks) and center. Immediately before
birth infants were randomly assigned to receive PPV and/or continuous positive airway
pressure with either a nasal tube or a size 00 soft, round silicone mask. Resuscitation
protocols were standardized; respiratory support was provided using a T-piece device
commencing in room air. Criteria for intubation included need for cardiac compressions,
apnea, continuous positive airway pressure >7 cm H2O, and fraction of inspired oxygen >0.4.
Primary outcome was endotracheal intubation in the first 24 hours from birth.Three hundred
sixty-three infants were randomly assigned; the study terminated early on the grounds of
futility. Baseline variables were similar between groups. Intubation rates in the first 24 hours
were 54% and 55% in the nasal tube and face mask groups, respectively (odds ratio: 0.97; 95%
confidence interval: 0.63-1.50). There were no important differences in any of the secondary
outcomes within the whole cohort or between the 2 gestational age subgroups.In infants at
<30 weeks' gestation receiving PPV in the DR, there were no differences in short-term
outcomes using the nasal tube compared with the face mask.
Karam, O., et al. (2008). "Noise levels during nCPAP are flow-dependent but not devicedependent." Archives of disease in childhood. Fetal and neonatal edition 93(2): F132-134.
Nasal continuous positive airway pressure (nCPAP) has been shown to improve the
outcome of infants with respiratory distress syndrome. However, noise generation could be of
concern. Therefore, our study was designed to measure the noise levels of various CPAP
drivers.For infants admitted to our neonatal intensive care unit and paediatric critical care unit,
we measured the noise level in the oral cavity, using a microphonic probe with a flexible
capillary tube. Various CPAP drivers and interfaces have been tested.27 measurements were
made in eight infants. Mean noise level was 88.6 (SD 18.8) dB and was correlated with flow
(p<0.01) but not with pressure. A noise level above 90 dB was detected in 67% of the
measurements.nCPAP drivers are valuable devices for neonatal care that may prevent
primary mechanical ventilation or re-intubation, but generate a large amount of noise, often
higher than occupational limits accepted for adult workers. Therefore, new devices must be
designed to minimise this possible noxious exposure of premature infants to unacceptably
high noise levels.
Kawawaki, H., et al. (1998). "[Home mechanical ventilation with nasal intermittent positive
pressure ventilation for a boy with congenital central hypoventilation syndrome]." No to
hattatsu. Brain and development 30(3): 250-254.
We report a 4-year-old boy with congenital central hypoventilation syndrome (CCHS)
successfully treated with home mechanical ventilation with nasal intermittent positive
pressure ventilation (NIPPV) during sleep hours. He had had frequent severe apneic attacks
from the neonatal period. At 8 months, he was treated with positive pressure ventilation
following a tracheostomy. At 4 year and 2 months, NIPPV was attempted because of
recurrent respiratory tract infections and cor pulmonale. The tracheostomy was successfully
abandoned 6 months later. Adequate ventilation has been maintained for more than 3 years
without troubles. NIPPV is an effective and non-invasive treatment of CCHS that it
significantly improves the quality of life during daytime.
Keszler, M. and D. J. Durand (2001). "Neonatal high-frequency ventilation. Past, present, and
future." Clinics in Perinatology 28(3): 579-607.
High-frequency ventilation has become established as an effective treatment
modality in a variety of clinical situations. The laboratory and clinical investigations of these
techniques have contributed tremendously to our understanding of the pathophysiology of
respiratory failure and the important concept of maintaining adequate lung volume. Clinicians
have come to appreciate better the factors involved in lung injury and the potential for
damage to distant organs. The place of HFV in the therapeutic armamentarium will
undoubtedly continue to evolve in the years to come. Of particular interest is the advent of
advanced modes of fully synchronized and volume-targeted conventional mechanical
ventilatory modes, along with the trend to use smaller tidal volumes and higher levels of
PEEP with conventional ventilation. With these developments there seems to be a certain
convergence of HFV and tidal ventilation that is the logical result of our improved
understanding of respiratory pathophysiology. The available controlled trials of HFV versus
tidal ventilation do not clearly differentiate whether improved outcomes are the result of HFV
per se, or a reflection of the effects of optimizing lung volume, a benefit that may not be
unique to HFV.
Keszler, M., et al. (2009). "Evolution of tidal volume requirement during the first 3 weeks of
life in infants <800 g ventilated with Volume Guarantee." Archives of disease in childhood.
Fetal and neonatal edition 94(4): F279-282.
Volume-targeted ventilation is used in neonates to reduce volutrauma and inadvertent
hyperventilation. Little is known about appropriate tidal volume (V(T)) settings in extremely
low birthweight (ELBW) infants who remain intubated for extended periods. Hypothesis: The
V(T) required to maintain adequate partial pressure of carbon dioxide (P(CO2) levels changes
as the underlying disease evolves in infants ventilated for prolonged periods.To obtain
normative data for V(T) associated with normocapnia in ELBW infants ventilated with
Volume Guarantee over the first 3 weeks of life.Set and measured V(T), peak pressure,
respiratory rate and blood gas values were extracted from the records of babies <800 g born
January 2003 to August 2005 and ventilated with Volume Guarantee. Data were collected at
the time of each blood gas measurement during days 1-2, 5-7 and 14-21. Only the V(T)
corresponding to P(CO2) values within a defined normal range were included. Descriptive
statistics were used to define the patient cohort. Mean V(T) and P(CO2) for each patient
during each epoch was calculated, and these values were analysed by repeated-measures
analysis of variance.Twenty-six infants, mean (SD) birth weight 615 (104) g, were included.
A total of 828 paired blood gas and V(T) sets were analysed: days 1-2 = 251; days 5-7 = 185;
days 14-17 = 216; days 18-21 = 176. P(CO2) values (mean (SD)) rose from 44.0 (5.4) mm
Hg on days 1-2 to 46.3 (5.2) mm Hg on days 5-7 and remained stable during days 14-17 and
18-21 (53.9 (6.8) and 53.9 (6.2) mm Hg, respectively). Mean exhaled V(T) rose from 5.15
(0.62) ml/kg on day 1 to 5.24 (0.71) ml/kg on days 5-7, 5.63 (1.0) ml/kg on days 14-17, and
6.07 (1.4) ml/kg on days 18-21 (p<0.05).Despite permissive hypercapnia, V(T) requirement
rises with advancing postnatal age in ELBW infants. The increase is greatest during the third
week of life, which is probably due to distension of the upper airways (acquired
tracheomegaly) and increasing heterogeneity of lung inflation (increased alveolar dead space).
Keuskamp, D. H. (1974). "Ventilation of premature and newborn infants." International
anesthesiology clinics 12(4): 281-307.
Kirpalani, H., et al. (1988). "Some infant ventilators do not limit peak inspiratory pressure
reliably during active expiration." Critical care medicine 16(9): 880-883.
In order to minimize barotrauma in newborn infants with respiratory failure, peak
inspiratory pressures should not exceed those required for adequate gas exchange. We
examined whether four commonly used pressure-limited, constant flow ventilators limit
pressure reliably during simulated active expiration against the inspiratory stroke of the
ventilator. Three machines of each type were tested at 13 different expiratory flow rates (2 to
14 L/min). Flow-dependent pressure overshoot above a dialed pressure limit of 20 cm H2O
was observed in all machines. However, the magnitude differed significantly between
ventilators from different manufacturers (p = .0009). Pressure overshoot above 20 cm H2O
was consistently lowest in the Healthdyne (0.8 cm H2O at 2 L/min, 3.6 cm H2O at 14 L/min)
and highest in the Bourns BP200 (3.0 cm H2O at 2 L/min, 15.4 cm H2O at 14 L/min). We
conclude that peak inspiratory pressure overshoots on pressure-limited ventilators occur
during asynchronous expiration. This shortcoming may contribute to barotrauma in newborn
infants who fight positive-pressure ventilation.
Kitagawa, K. H., et al. (2006). "Retention of pediatric bag-mask ventilation efficacy skill by
inexperienced medical student resuscitators using standard bag-mask ventilation masks,
pocket masks, and blob masks." The American journal of emergency medicine 24(2): 223226.
To measure the ventilation efficacy with three single-sized mask types on infant and
child manikin models.Medical students were recruited as study subjects inasmuch as they are
inexperienced resuscitators. They were taught proper bag-mask ventilation (BMV) according
to the American Heart Association guidelines on an infant and a child manikin. Subjects
completed a BMV attempt successfully using the adult standard mask (to simulate the
uncertainty of mask selection), pocket mask, and blob mask. Each attempt consisted of 5
ventilations assessed by chest rise of the manikin. Study subjects were asked which mask was
easiest to use. Four to six weeks later, subjects repeated the procedure with no instructions (to
simulate an emergency BMV encounter without immediate pre-encounter teaching).Forty-six
volunteer subjects were studied. During the first attempt, subjects preferred the standard and
blob masks over the pocket mask. For the second attempt, the blob mask was preferred over
the standard mask, and few liked the pocket mask. Using the standard, blob, and pocket
masks on the child manikin, 39, 42, and 20 subjects, respectively, were able to achieve
adequate ventilation. Using the standard, blob, and pocket masks on the infant manikin, 45,
45, and 11 subjects, respectively, were able to achieve adequate ventilation.Both the standard
and blob masks are more effective than the pocket mask at achieving adequate ventilation on
infant and child manikins in this group of inexperienced medical student resuscitators, who
most often preferred the blob mask.
Kono, R., et al. (2010). "[A case report of successful treatment of a child with respiratory
distress using non-invasive continuous positive airway pressure via helmet]." Masui. The
Japanese journal of anesthesiology 59(10): 1284-1286.
Helmet is a new device of non-invasive continuous positive airway pressure (CPAP).
Few cases have been described about usage of the helmet in children. We describe successful
treatment of a child with respiratory distress using the helmet-delivered non-invasive CPAP.
A 2-month-old male infant (3.1 kg) with multiple anomalies (cardiovascular, facial, and
vertebral) developed respiratory distress after extubation. The helmet was well tolerated
regardless of facial anomaly. Helmet CPAP started at initial settings of CPAP 8 cm H2O and
FI(O2) 0.7, improved oxygenation. Pa(O2)/FI(O2) ratio increased from 106 to 316, and chest
X-rays showed a marked improvement (15 hour after NPPV initiation). The helmet offers
important advantage: the possibility of fitting to any children, regardless of any facial or
external anomalies.
Kopelman, A. E. and G. J. Myers (1978). "A new use for adult face masks." Pediatrics 61(1):
162.
Kopotic, R. J. and F. L. Mannino (1987). "Effects of infant ventilator design on spontaneous
breathing." Journal of perinatology : official journal of the California Perinatal Association
7(4): 298-300.
Study of the mechanical work of spontaneous breaths taken by eight infants attached
to infant ventilators. Work was estimated from the volume displacement and pressure
fluctuations of breathing during steady state mechanical ventilator conditions (i.e., stable
peak or PEEP pressures). A broad difference existed between manufacturers of infant
ventilators; a dramatic reduction was seen in work when attached to a demand as compared to
a continuous flow device. Additionally, some change in work occurred, depending on the
phase of the IMV cycle in which spontaneous breath was taken. Dynamic testing of
ventilators can reveal differences in function.
Krabbe, V. B., et al. (2014). "Accuracy of a disposable compared to a non-disposable infant
T-piece resuscitator." European Journal of Pediatrics.
Both disposable and non-disposable T-piece resuscitator (TPR) devices are used.
Accuracy of the disposable and non-disposable infant TPR was compared. Peak inspiratory
pressures (PIP) and positive end-expiratory pressures (PEEP) were measured during
ventilation of a test lung. Measured PIP ��1?cmH2O and PEEP ��0.5?cmH2O of the
desired pressures were considered acceptable. We tested the following: (A) Accuracy of
setting pressures using built-in manometers of three disposable TPRs, (B) Minimal and
maximal PIP and PEEP levels for the non-disposable and disposable TPR were measured
using different gas flow rates, and (C) Accuracy of 25 caregivers setting pressures (PIP
25?cmH2O and PEEP 5?cmH2O). The results of the tests performed were as follows: (A)
With pressures set: PIP 20, 25, 30, and 40?cmH2O and PEEP 5-8?cmH2O with 1?cmH2O
stepwise increment, measured PIPs and PEEPs were in acceptable range. (B) At gas flow
rates 5, 8, 10, and 15?L/min (disposable vs. non-disposable), min-max PIP were 4.0-43.2 vs.
2.9-77.1?cmH2O and min-max PEEP were 0.3-22.3 and 0.6-59.7?cmH2O. (C) Set PIP
(cmH2O) by participants using disposable vs. non-disposable TPR was 25.8 (0.8) vs. 25.9
(1.3) (ns). PEEP was 5.4(0.5) vs. 4.7(0.5); p?<?0.001. Conclusion: The accuracy of the
disposable TPR is comparable to that of the non-disposable TPR.
Krauel, J., et al. (1979). "Ventilator modifications for intermittent mandatory ventilation."
Critical care medicine 7(10): 471-472.
A Loosko MK2 ventilator has been modified to provide IMV in newborns. IMV rate
can be varied from 3-60/min. The minimum inspiration period can be theoretically as low as
0.1 sec. This modification in neonatal mechanical ventilation has been shown to be
economically feasible.
Kredba, V., et al. (1985). "[Experience with the Babylog I ventilator in the neonatal intensive
care unit]." Ceskoslovensk? pediatrie 40(8): 474-475.
Kurepa, D., et al. (2011). "Pleural effusion caused by nullcorrectlynull placed umbilical
venous catheter." Journal of Investigative Medicine 59(2): 454-.
Case Report: We describe very rare case of 28w infant with right pleural effusion
caused by UVC extravasation of TPN into pleural space. There is only one case in the
literature so far. Born by SVD. BW 1.190kg. Needed brief resuscitation with 30% O2 and Tpiece resuscitator due to mild grunting. Apgars 6 and 9. PE was normal. He was placed on
bubbleCPAP 27% O2, PEEP 6cm H2O. UAC and UVC were placed. Initial CXR: mild RDS,
UAC and UVC in correct position, UAC at level of T8, UVC at junction of IVC and RA.
Initial ABG: pH 7.25, PaCO2 66, PaO2 77, BD 1. CBC, RFP, blood Cx and CRP drawn.
Started on ampicillin, gentamicin and caffeine. TPN at 80ml/kg/day. Day 2, stable. All lab
results normal. Respiratory support down to 21%O2, bubbleCPAP 6cm H2O. ABG: pH7.30,
PaCO2 41, PaO2 91, BD 1. Remained NPO on TPN at 100ml/kg/day. Day 3, he became
tachypneic and tachycardic. Respiratory support up to 34% O2, bubbleCPAP 7cm H2O.
ABG: pH7.17, PaCO2 61, PaO2 64, BD -7.8. BP was normal but cap refill was 4-5s. Also,
had an episode of hypoglycemia, Dextrostix (Dxt) of 41. RFP showed increased BUN to 41
and Cr to 1.2. UO was 2ml/kg/h. TPN increased to 120ml/kg/day. ECHO was normal, no
PDA, UVC in IVC 1cm below junction with RA. CXR: large right pleural effusion. Chest
tube drained 78ml of pale yellow, clear fluid with clinical and radiographic resolution of
effusion. Since this was approximately 3/4 of daily IVF intake and accumulation was acute,
assumption was made that the UVC was infusing into the pleural space. Dxt on pleural fluid
was done at bedside while waiting for pleural fluid analysis from central lab. Dxt
measurement (ACCU-CHEK(registered trademark) Roche) displayed nulltoo high to readnull,
which appears when blood glucose exceeds 600mg/dL. UVC clamped. One hour later,
pleural fluid analysis showed glu of 944mg/dL, pH 7.55, LDH 24U/L, SG 1013g/ml, protein
of 0.2g/dL, RBC 2550/mm3, WBC 210/mm3 with 15% segs, 36% lymphs and 49% monos.
ABG 2h after the fluid drainage was pH 7.23, PaCO2 46, PaO2 68, BD -5. UVC removed.
No pleural fluid accumulation next 2 days and chest tube was removed. In VLBW infant,
acute deterioration in presence of UVC may be caused by pleural effusion due to proximity
of intrathoracic IVC and right pleura, relatively big size of the catheter for the blood vessel
and thin IVC wall.
L?pez-Gil, M., et al. (2012). "The Size 1 ProSeal�� laryngeal mask airway in infants: a
randomized, noncrossover study with the Classic�� laryngeal mask airway." Paediatric
Anaesthesia 22(4): 365-370.
In recent years, numerous scientific publications have endorsed the superiority of the
ProSeal�� laryngeal mask airway (PLMA) over the Classic�� laryngeal mask airway
(cLMA) in adults, children, and infants. The PLMA forms a better seal for both the
respiratory and gastrointestinal tracts, provides easier access to the gastrointestinal tract, and
exerts lower mucosal pressures for a given seal pressure. This study aims to determine
whether this superiority can also be observed for the size 1 PLMA used in anesthetized
neonates and infants with positive pressure ventilation.Sixty consecutive neonates and infants
undergoing elective surgical procedures were randomized to airway management with the
size 1 PLMA or cLMA. For all patients, we recorded ease of insertion, effective airway time,
number of placement attempts, oropharyngeal leak pressure, fiberoptic position, audible leaks,
mask displacement, number of reinsertions during maintenance, gastric insufflation, and
frequency of blood stain.Ease of insertion, successful insertion in <3 attempts, fiberoptic
position of the airway tube, and frequency of blood stain were similar in both groups.
Effective airway time was lower for the PLMA group (30.5 vs 35.6 s). Oropharyngeal leak
pressure was higher with the PLMA (32.9 vs 22.2 cm H(2)O, P < 0.001) and gastric
insufflation less common (0% vs 6%, P = 0.492). There were fewer mask displacements
during maintenance of anesthesia with the PLMA (0% vs 26.7%, P < 0.001). Mask
reinsertion was not necessary during maintenance of anesthesia with the PLMA, although it
was necessary in 14 cases in the cLMA group (0% vs 46%, P < 0.001). Audible leaks were
less common with the PLMA (0% vs 46%, P < 0.001).We conclude that the size 1 PLMA is a
stable, safe, and efficacious airway control device during neonatal and infant anesthesia,
allowing higher peak airway pressure during positive pressure ventilation, with fewer mask
displacements and gastric insufflations than the cLMA.? 2012 Blackwell Publishing Ltd.
L?pez-Herce, J. s., et al. (2009). "Hypoventilation due to reinhalation in infants with a
transport ventilator." Pediatric Emergency Care 25(9): 588-589.
An infant of 5 kg of body weight was being ventilated with a conventional ventilator
with a tidal volume of 40 mL and respiratory rate of 35 rpm, maintaining an expired CO2 of
37 mm Hg and a transcutaneous PCO2 of 43 mm Hg. For transfer, an Oxylog 3000 ventilator
(Dr?ger, L?beck, Germany) was set to intermittent positive-pressure ventilation mode with a
tidal volume of 50 mL and the same respiratory frequency. After connecting, the expired
CO2 increased rapidly to 75 mm Hg; the inspired CO2, to 27 mm Hg; and the transcutaneous
PCO2, to 82 mm Hg, despite good chest expansion. The respirator was checked and found to
be correct. On changing to the conventional ventilator, a rapid decrease was found in the
expired CO2 and transcutaneous PCO2 values and the inspired CO2 fell to 0. The Oxylog
3000 ventilator should not be used for the transport of small children because the dead space
rise to a significant reinhalation in these patients. Capnography and transcutaneous PCO2 are
useful for the early detection of hypercapnia and the dead space during the transfer of
pediatric patients.
Laass, K. and H. T. Abel (1979). "[Instrumental combination for formation of continuing
respiratory airway pressures]." Kinder?rztliche Praxis 47(3): 150-154.
Lal Sharma, M., et al. (2002). "Negative pressure pulmonary edema following thyroidectomy
[2]." Canadian Journal of Anesthesia 49(2): 215-.
Lang, M., et al. (1995). "[Practical experiences with home ventilation in childhood]."
Medizinische Klinik (Munich, Germany : 1983) 90(1 Suppl 1): 52-56.
The introduction of portable ventilators independent of compressed air as well as
non-invasive devices for assessment of blood gases, helped to facilitate a long-term
mechanical ventilation in family environment in the last decade. Home care is of particular
interest at the infant age, as the disruption of the mother-child relationship may induce severe
developmental disorders, known as syndrome of psychosocial deprivation.We investigated
retrospectively the tendency of the ventilator parameters, the support and the daily practice of
16 families with children of all ages with long-term ventilator assistance.The duration of the
ventilation ranged between 5 months and 14 years, on the average at 5.5 years. The average
portion of the ventilation at home care was 78%. The respiratory patterns, tidal volume and
positive inspiration pressure, exceeded occasionally the physiologic standard of the age group.
The common reason is, that the children prefer small sized tubes, having advantages in
comfort and speech abilities. Therefore results an increased tube-resistance and air leakage of
the tracheostomy tubes. The long-term tendency of the ventilator parameters is stable or
improving, excluding the patients with progredient primary diseases. Commonly the
motivation of the family members is high, therefore the psychosocial integration of the
patients satisfying. Two thirds of the families have no personal support for the domiciliary
care of the ventilator assisted child. Mothers tell about an enormous distress.The long-term
mechanical ventilation of children at home care is an adequate therapy for all ages. It
combines technical support of the underlying chronic respiratory failure with the chance of an
intact psychosocial development of the child. Specialized centres and a national organisation
may provide competent information and support for the increasing number of homeventilated children in Germany.
Lang, V. O. (1975). "[Additional gadget for new techniques of artifical respiration with the
Bennett repirator PR 2, particulary suitable for use in children (author's transl)]." Klinische
P?diatrie 187(1): 30-36.
A new gadget for the Bennett PR 2 repirator is described which in modified form can
also be used with other types of apparatus. It makes possible new techniques of artificial
respiration like IPPB with PEEP or compensated PEEP, the gasp respiration with CPAP or
CPAP by itself, in a simple way. In neonates one may do without the often problematical
assisted respiration when weaning from the respirator. Further it is now possible to achieve
sufficient warming and humidification of the gas mixture by using an auxiliary gas flow in
the expiratory phase.
Langeron, O., et al. (2000). "Prediction of difficult mask ventilation." Anesthesiology 92(5):
1229-1236.
Background: Maintenance of airway patency and oxygenation are the main
objectives of face-mask ventilation. Because the incidence of difficult mask ventilation
(DMV) and the factors associated with it are not well known, we undertook this prospective
study. Methods: Difficult mask ventilation was defined as the inability of an unassisted
anesthesiologist to maintain the measured oxygen saturation as measured by pulse oximetry >
92% or to prevent or reverse signs of inadequate ventilation during positive-pressure mask
ventilation under general anesthesia. A univariate analysis was performed to identify
potential factors predicting DMV, followed by a multivariate analysis, and odds ratio and 95%
confidence interval were calculated. Results: A total of 1,502 patients were prospectively
included. DMV was reported in 75 patients (5%; 95% confidence interval, 3.9-6.1%), with
one case of impossible ventilation. DMV was anticipated by the anesthesiologist in only 13
patients (17% of the DMV cases). Body mass index, age, macroglossia, beard, lack of teeth,
history of snoring, increased Mallampati grade, and lower thyromental distance were
identified in the univariate analysis as potential DMV risk factors. Using a multivariate
analysis, five criteria were recognized as independent factors for a DMV (age older than 55
yr, body mass index > 26 kg/m2, beard, lack of teeth, history of snoring), the presence of two
indicating high likelihood of DMV (sensitivity, 0.72; specificity, 0.73). Conclusion: In a
general adult population, DMV was reported in 5% of the patients. A simple DMV risk score
was established. Being able to more accurately predict DMV may improve the safety of
airway management.
Leboulanger, N. and B. Fauroux (2013). "Non-invasive positive-pressure ventilation in
children in otolaryngology." European annals of otorhinolaryngology, head and neck diseases
130(2): 73-77.
Obstructive diseases of the upper airways are common in children and sometimes
difficult to manage. Non-invasive positive-pressure ventilation (NPPV) consists of delivering
continuous positive pressure during all or part of the respiratory cycle via a non-invasive
interface (face mask or nasal mask, or nasal prongs). NPPV is the treatment of choice for
severe obstructive sleep apnoea in children and should be considered prior to tracheotomy
and is also indicated in the case of persistent sleep-disordered breathing following surgical
treatment, a frequent situation in children with a malformation of the head and neck or upper
airways.A simple ventilator, able to deliver continuous positive airway pressure, is sufficient
is most cases in otolaryngology. The interface represents the major technical limitation of
NPPV, especially in infants for whom no appropriate commercial interface is available. A
sleep study before and after initiation of NPPV, followed by regular follow-up examinations,
is essential to confirm correction of gas exchanges and sleep quality in response to
NPPV.Finally, NPPV must be performed in a specialized paediatric centre with specific
expertise in this field.Copyright ? 2012 Elsevier Masson SAS. All rights reserved.
Lee, A., et al. (1994). "Computer determined compliance of the respiratory system (Crs) in
ventilated newborn infants." Wiener Klinische Wochenschrift 106(7): 193-196.
We describe a simple, low cost technique for computerized measurements of
compliance of the respiratory system (Crs) by airway occlusion technique in intubated
newborn infants. Tidal volumes of 5, 7.5, and 10 mL/kg were injected from a calibrated
syringe into the endotracheal tube via a three-way stop cock and a t-piece. Airway pressure
was measured by means of a differential pressure transducer. The analog pressure signal was
fed into an optically isolated signal conditioning termination panel and an analog input board
which was connected to the PC bus. The signal was amplified and A/D converted by the
input board and processed by the digital computer. Crs was determined as the ratio of the
injected tidal volume to the difference between the endexpiratory pressure and the pressure at
airway occlusion. The software is written in Turbo Pascal (Borland Int.) and includes a
patient data base and facilities for system configuration, calibration of transducers, data
acquisition, handling, calculation of Crs, reporting and archive storage. Data sampling
frequency may be individually set at 60 to 200 Hz. Synchronous measurements in 10
newborn infants using analog pressure amplification and polygraphic recording showed that
pressures were correctly determined by the computer and that amplitude and frequency
response of the pressure recordings were adequate.
Lee, E. Y. (2013). "Interstitial lung disease in infants: New classification system, imaging
technique, clinical presentation and imaging findings." Pediatric Radiology 43(1): 13-Mar.
Interstitial lung disease (ILD) is defined as a rare, heterogeneous group of
parenchymal lung conditions that develop primarily because of underlying developmental or
genetic disorders. Affected infants typically present with clinical syndromes characterized by
dyspnea, tachypnea, crackles and hypoxemia. Until recently, the understanding of ILD in
infants has been limited largely owing to a lack of evidence-based information of underlying
pathogenesis, natural history, imaging findings and histopathological features. However, ILD
in infants is now better understood and managed because of (1) advances in imaging methods
that result in rapid and accurate detection, (2) improved thoracoscopic techniques for lung
biopsy, (3) a consensus regarding the pathological criteria for these particular lung conditions
and (4) a new classification system based on the underlying etiology of ILD. This article
reviews the new classification system, imaging technique, clinical presentation and imaging
findings of ILD in infants. Specialized knowledge of this new classification system in
conjunction with recognition of characteristic imaging findings of ILD in infants has great
potential for early and accurate diagnosis, which in turn can lead to optimal patient
management. (copyright) 2012 Springer-Verlag Berlin Heidelberg.
Lee, J., et al. (2012). "Randomized crossover study of neurally adjusted ventilatory assist in
preterm infants." The Journal of pediatrics 161(5): 808-813.
To determine whether neurally adjusted ventilatory assist (NAVA), a new method of
mechanical ventilation that delivers pressure assistance that is proportional to the electrical
activity of the diaphragm (EAdi), could lower the inspiratory pressure and respiratory muscle
load in preterm infants supported with ventilators.Twenty-six mechanically ventilated
preterm infants were randomized to crossover ventilation with NAVA and synchronized
intermittent mandatory ventilation (SIMV) with pressure support (PS) for 4 hours each in a
randomized order. A 1-hour interval for washout was provided between the 2 modes of
ventilation. The ventilator settings were adjusted to maintain similar levels of end-tidal partial
pressure of CO(2). The ventilator parameters, vital signs, and gas exchange effects under the
2 ventilatory modes were compared.Nineteen infants completed the 9-hour crossover
comparison protocol. Peak inspiratory pressure (PIP), work of breathing, and peak EAdi with
NAVA were lower than those in SIMV with PS. Calculated tidal volume to peak EAdi ratio
and PIP to peak EAdi ratio were higher with NAVA. There were no significant differences in
mean airway pressure, inspiratory oxygen fraction, and blood gas values. The measurements
of vital signs did not differ significantly between the 2 modes.NAVA lowered PIP and
reduced respiratory muscle load in preterm infants at equivalent inspiratory oxygen fraction
and partial pressure of CO(2) of capillary blood in comparison with SIMV with
PS.Copyright ? 2012 Mosby, Inc. All rights reserved.
Lee, S.-Y. and V. Lopez (2002). "Physiological effects of two temperature settings in preterm
infants on nasal continuous airway pressure ventilation." Journal of clinical nursing 11(6):
845-847.
Lemley, K., et al. (2013). "Observed benefits of neurally adjusted ventilatory assist (NAVA)
in a child with hypoplastic left heart syndrome." Pediatric Critical Care Medicine 14(5):
S116-S117.
Background: Neurually Adjusted Ventilatory Assist (NAVA), a mode of ventilation
controlled by diaphragmatic electrical signals, demonstrates lower mean airway pressures and
improved ventilator synchrony in various patient populations. Case:We describe a 6-monthold with hypoplastic left heart syndrome (HLHS) and restrictive atrial septum that benefitted
from NAVA after his Norwood and bidirectional Glenn (BDG) procedures. After Norwood
procedure, the infant had myocardial insufficiency requiring ECMO, prolonged vasoactive
support and mechanical ventilation. After extubation on POD#29 from his Norwood, he
developed respiratory insufficiency with increased work of breathing and diminished cardiac
output with lower flank near infrared spectroscopy (NIRS) and SVO2. He was placed on noninvasive ventilation (NIV) pressure control via face mask. He had patient-ventilator
asynchrony initially and was transitioned to NIV NAVA. This resulted in improvements in
mixed-venous saturation (SVO2), NIRS, decreased average mean airway pressure (MAP)
(Table 1) and improved patient-ventilatory synchrony. After his BDG, he was extubated POD
#2, but reintubated POD #7 for repair of omental herniation. He remained intubated with
persistent atelectasis and failure to wean FiO2 and pressure support. NAVA was initiated
POD #11 with increase in SVO2 NIRS, and ventilator synchrony; decrease average MAP and
PEEP within 24 hours; (Table 1) and improved aeration on chest radiograph. Main Results:
Decreased MAP and PEEP. Improved SVO2 NIRS, patient-ventilatory synchrony, and lung
aeration Conclusion: NAVA may be beneficial in children with single ventricle physiology
and patient ventilator asynchrony. (Table Presented).
Leone, T. (2012). "Improving assisted ventilation immediately after birth." The Journal of
pediatrics 160(3): 359-360.
Leung, A., et al. (2012). "A prospective study to define pediatric pressure ulcers due to
facemasks: Assessment of novel metrics and interventions." Wound Repair and Regeneration
20(2): A29-.
Pressure ulcers (PUs) account for $11 billion of US health care costs. The incidence
and pathogenesis in the pediatric population is unknown. Our clinical experience has
identified noninvasive respiratory device-related pressure to be a significant culprit.
Therefore, we conducted a prospective study to evaluate the incidence and etiology of maskrelated PUs in a pediatric population. Further, we developed novel metrics to evaluate mask
fit and high-risk areas for PUs. With IRB approval, all patients in the neonatal and pediatric
intensive care units over 2 years were enrolled. Skin assessments were conducted every 2
weeks by designated staff. Stage, location and suspected cause of PUs were determined. Skin
hydration was evaluated at multiple areas beneath the mask immediately following mask
removal and compared to adjacent control skin for our standard CPAP-facemask and the
Sleepweaver mask, a novel cloth CPAP-facemask. Three-dimensional imaging of a
normocephalic child's face was compared to the three-dimensional surface scan of our most
commonly used pediatric CPAP-facemask. Two thousand eight hundred ninetyeight patient
evaluations were conducted with 155 PUs identified. 60.6% of these PUs were device-related
with the majority identified as stage II. Mask use caused 31.5% device-related PUs with a
higher incidence occurring in the PICU (NICU: 5.3% mask-PUs/device-PUs vs. PICU: 68.4%
mask-PUs/device-PUs, p = 0.02). 42% mask-related PUs were associated with craniofacial
abnormalities. Skin hydration beneath the mask was significantly elevated (254 capacitance
reactance unit (cru) (plus or minus) 55 vs. control 120 cru (plus or minus) 10, p = 0.04). The
Sleepweaver mask demonstrated no increase in hydration (Sleepweaver 107 cru (plus or
minus) 5 vs. control 126 cru (plus or minus) 15). Threedimensional scan demonstrated an
area of increased risk with 1 cm superimposed at the bridge of the nose in order to achieve
skin-mask contact on both cheeks. We have identified an underappreciated occurrence of
mask-related PUs in the pediatric population. In the effort to decrease PUs, the development
of novel metrics is critical not only in the evaluation of an intervention, but also in shifting
the paradigm from therapy to prevention.
Li, K. K., et al. (2000). "An unreported risk in the use of home nasal continuous positive
airway pressure and home nasal ventilation in children: Mid-face hypoplasia." Chest 117(3):
916-918.
We report the case of a 15-year-old boy with obstructive sleep apnea and obesity
who was treated since the age of 5 with nasal continuous positive airway pressure. Due to the
long-term use of a nasal mask, the child developed a mid-face hypoplasia. Chronic use of a
nasal mask for home ventilation in children should always be associated with regular
evaluations of maxillomandibular growth.
Liebler, J. M. (1998). "Noninvasive positive pressure mechanical ventilation." Western
Journal of Medicine 168(6): 529-.
Lim, K., et al. (2014). "Oxygen saturation targeting in preterm infants receiving continuous
positive airway pressure." Journal of Pediatrics 164(4): 730-736.e731.
Objective The precision of oxygen saturation (SpO2) targeting in preterm infants on
continuous positive airway pressure (CPAP) is incompletely characterized. We therefore
evaluated SpO2 targeting in infants solely receiving CPAP, aiming to describe their SpO2
profile, to document the frequency of prolonged hyperoxia and hypoxia episodes and of
fraction of inspired oxygen (FiO2) adjustments, and to explore the relationships with neonatal
intensive care unit operational factors. Study design Preterm infants <37 weeks' gestation in 2
neonatal intensive care units were studied if they were receiving CPAP and in supplemental
oxygen at the beginning of each 24-hour recording. SpO2, heart rate, and FiO 2 were
recorded (sampling interval 1-2 seconds). We measured the proportion of time spent in
predefined SpO2 ranges, the frequency of prolonged episodes ((greater-than or equal to)30
seconds) of SpO2 deviation, and the effect of operational factors including nurse-patient ratio.
Results A total of 4034 usable hours of data were recorded from 45 infants of gestation 30
(27-32) weeks (median [IQR]). When requiring supplemental oxygen, infants were in the
target SpO2 range (88%-92%) for only 31% (19%-39%) of total recording time, with 48 (6.990) episodes per 24 hours of severe hyperoxia (SpO2 (greater-than or equal to)98%), and 9.0
(1.6-21) episodes per 24 hours of hypoxia (SpO2 <80%). An increased frequency of
prolonged hyperoxia in supplemental oxygen was noted when nurses were each caring for
more patients. Adjustments to FiO2 were made 25 (16-41) times per day. Conclusion SpO2
targeting is challenging in preterm infants receiving CPAP support, with a high proportion of
time spent outside the target range and frequent prolonged hypoxic and hyperoxic episodes.
(copyright) 2014 Mosby Inc. All rights reserved.
Limeres, J., et al. "Individualized nasal mask fabrication for positive pressure ventilation
using dental methods." The International journal of prosthodontics 17(2): 247-250.
The aim of this study was to develop a simple technique to manufacture
individualized ventilatory nasal masks for pediatric patients using materials and procedures
commonly applied in dentistry.Three cases of pediatric patients who met with severe
difficulties in their adaptation to commercially available nasal masks are described: one
premature infant, one child diagnosed with achondroplasia, and one child with congenital
central hypoventilation syndrome.In each case, a light nasal mask was designed with two
independent parts that become perfectly adapted to the patient's nose: one soft for the skin
contact, and another rigid for dimensional stability. In all patients, adequate levels of
ventilation were reached.This easy, inexpensive nasal mask fabrication technique can be used
in a great number of patients, increasing the efficacy of individualized masks.
Linton, R. C., et al. (1965). "Respirator care in a general hospital: a five-year survey."
Canadian Anaesthetists' Society journal 12(5): 451-457.
Lipowsky, G. (1976). "[Combination of CPPB with IPPV (author's transl)]." Monatsschrift
f?r Kinderheilkunde 124(7): 543-547.
A combination of CPPB and IPPV has been used successfully in our hospital for
therapy of children with IRDS, when their spontaneous breathing under CPAP was not
sufficient and to get children progressively used to spontaneous respiration after prolonged
periods of controlled ventilation. The Assistor 644 and Servoventilator 900 respirators are not
equipped for the combination of CPPB and IPPV. We describe the modifications of both
respirators which we introduced to be able to use them for CPPB alone as well as for the
combination of CPPB with CPPV.
Lomholt, N., et al. (1968). "A method of humidification in ventilator treatment of neonates."
British journal of anaesthesia 40(5): 335-340.
Long, F. R. (2001). "High-resolution CT of the lungs in infants and young children." Journal
of thoracic imaging 16(4): 251-258.
The effects of respiratory motion and imaging at low tidal volumes can easily
obscure normal anatomy as well as pathology on high-resolution computed tomography
(HRCT) images of the lungs in infants and young children. The benefits of motion-free
HRCT in children at full inflation and end exhalation compared with HRCT during quiet
breathing has remained largely unexplored. The authors describe the application and benefits
of a physiologic, noninvasive technique called controlled-ventilation to obtain high-quality
HRCT images of the lungs, similar to those obtained in adults, in uncooperative young
children. The availability of this method should result in greater application of HRCT as a
clinical and research tool in the evaluation of childhood respiratory disease.
Long, F. R. and R. G. Castile (2001). "Technique and clinical applications of full-inflation
and end-exhalation controlled-ventilation chest CT in infants and young children." Pediatric
Radiology 31(6): 413-422.
Background. The inability of young children to cooperate with breath holding limits
the use fulness of chest CT. Objective. To describe the technique and utility of a non-invasive
method called controlled-ventilation CT (CVCT) for obtaining motion-free full-inflation and
end-exhalation images of the lung in infants and young children. Materials and methods.
Eighty-seven children (ages 1 week to 5 years, mean 2 years) underwent CVCT of the chest
during suspended respiration at full-lung inflation and end-exhalation for a variety of clinical
indications. Respiratory pauses were produced using conscious sedation and positive-pressure
facemask ventilation. Forty-one of 87 children had recordings of respiratory motion during
CVCT. Results. Respiratory pause lengths increased with age (P < 0.003), were highly
reproducible (r = 0.85), and lasted sufficiently long to be practical for full-inflation (24 (plus
or minus) 9 s) and end-exhalation (12 (plus or minus) 5 s) CT scanning. Full-inflation CVCT
was useful in evaluating tracheal and bronchial stenosis, bronchial wall thickening, early
bronchiectasis, bronchial fistula, extent of interstitial fibrosis, and lung nodules. Endexhalation CVCT was useful in evaluating tracheomalacia and air trapping. Conclusion.
Controlled-ventilation chest CT is a practical and reliable technique that promises to be
clinically useful for a number of clinical indications in infants and young children.
Long, F. R., et al. (1999). "Lungs in infants and young children: improved thin-section CT
with a noninvasive controlled-ventilation technique--initial experience." Radiology 212(2):
588-593.
Three sedated young children underwent thin-section computed tomography (CT) of
the chest while breathing and during controlled respiratory pauses induced by means of a step
increase in positive-pressure ventilation applied via a face mask. Motion-free inspiratory and
expiratory thin-section CT images were successfully acquired during 8-12-second respiratory
pauses. This simple, reproducible technique produced thin-section CT images that were
clearer and more clinically useful than those obtained during quiet tidal breathing.
Macharia, E. W., et al. (2012). "Fundoplication in ventilator-dependent infants with gastrooesophageal reflux." European journal of pediatric surgery : official journal of Austrian
Association of Pediatric Surgery ... [et al] = Zeitschrift f?r Kinderchirurgie 22(1): 91-96.
In ventilator-dependent infants with complex comorbidities, severe gastrooesophageal reflux (GOR) may contribute to prolonging the period of ventilation. It is often
difficult to predict whether antireflux surgery will improve the respiratory status of an infant
and assist with weaning off the ventilator. The aim of this study was to review the outcomes
in a cohort of ventilator-dependent infants who underwent fundoplication to help wean them
off ventilation.Between January 2006 and December 2010, out of 596 infants who underwent
fundoplication for symptoms of GOR, 26 were ventilator dependent before surgery; 13
patients had an emergency fundoplication following an acute life-threatening event (n = 5,
19%) or an acute deterioration of respiratory status (n = 8, 31%). Fundoplication was planned
in the rest of the group (n = 13, 50%) with the aim of improving respiratory status and
weaning from ventilation. The median age at surgery was 5.8 months (range: 0.8 to 19.4
months). The median weight at surgery was 6.3 kg (range: 4 to 15.1 kg). Data were collected
for each infant on comorbidities, pre- and postoperative ventilation status, pre- and
postoperative GOR symptoms, and survival.All infants underwent a Nissen fundoplication
with no intraoperative morbidity or mortality. Of these, 12 infants had a laparoscopic
fundoplication; 14 infants had an open fundoplication. Postoperatively, all infants received
invasive positive pressure ventilation in the intensive care unit (ICU). All infants were
successfully weaned from ventilation. The median time to extubation was 4 days (range: 2 to
18 days). The median postoperative ICU stay was 9 days (range: 3 to 52 days). Of the
patients, 9 (34%) had a recurrence of symptoms following fundoplication; 5 (19%)
subsequently underwent revision of fundoplication and 1 (3.8%) underwent oesophagogastric dissociation; and 10 (38%) died within the study period.In infants with severe GOR,
ventilator dependence, and complex comorbidities, fundoplication may be a useful procedure
to assist weaning off ventilator dependence. Rates of symptom recurrence, of revision of
fundoplication, and of mortality within this cohort were higher than expected. These data
reflect the challenges of patient selection in high-risk groups.Thieme Medical Publishers 333
Seventh Avenue, New York, NY 10001, USA.
MacIntyre, N. R. (2005). "Respiratory mechanics in the patient who is weaning from the
ventilator." Respiratory Care 50(2): 275-286; discussion 284-276.
Ventilator management of the patient recovering from acute respiratory failure must
balance competing objectives. On the one hand, aggressive efforts to promptly discontinue
support and remove the artificial airway reduce the risk of ventilator-induced lung injury,
nosocomial pneumonia, airway trauma from the endotracheal tube, and unnecessary sedation.
On the other hand, overly aggressive, premature discontinuation of ventilatory support or
removal of the artificial airway can precipitate ventilatory muscle fatigue, gas-exchange
failure, and loss of airway protection. To help clinicians balance these concerns, 2 important
research projects were undertaken in 1999-2001. The first was a comprehensive evidencebased literature review of the ventilator-discontinuation process, performed by the McMaster
University research group on evidence-based medicine. The second was the development (by
the American Association for Respiratory Care, American College of Chest Physicians, and
Society of Critical Care Medicine) of a set of evidence-based guidelines based on the latter
literature review. From those 2 projects, several themes emerged. First, frequent patientassessment is required to determine whether the patient needs continued ventilatory support,
from both the ventilator and the artificial airway. Second, we should continuously re-evaluate
the overall medical management of patients who continue to require ventilatory support, to
assure that we address all factors contributing to ventilator-dependence. Third, ventilatory
support strategies should be aimed at maximizing patient comfort and unloading the
respiratory muscles. Fourth, patients who require prolonged ventilatory support beyond the
intensive care unit should go to specialized facilities that can provide gradual reduction of
support. Fifth, many of these management objectives can be effectively carried out with
protocols executed by nonphysicians.
Mackinnon, R. J. and N. K. Anders (2002). "Cracking loss of continuous positive airway
pressure." Paediatric Anaesthesia 12(2): 193.
Macpherson, R. I., et al. (1972). "The complications of respirator therapy in the newborn."
Journal of the Canadian Association of Radiologists 23(2): 91-102.
Mahmoud, R. A., et al. (2009). "Relationship between endotracheal tube leakage and underreading of tidal volume in neonatal ventilators." Acta paediatrica (Oslo, Norway : 1992)
98(7): 1116-1122.
Protective ventilation in neonates requires careful volume monitoring to prevent
ventilator-induced lung injury caused by baro/volutrauma and hence chronic lung disease.
This study investigated the effect of endotracheal tube (ET) leakage on the displayed tidal
volume using an in vitro model.A neonatal lung model was ventilated via a 3 mm ET using
three ventilators [Babylog 8000 (BL), Leoni (LE) and Stephanie (ST)]. Tidal volume was
measured by each ventilator at the Y-piece and by a pneumotach (CO(2)SMO(+)) in the
model. ET leaks were simulated by open tubes of different lengths. PIP (20 cmH(2)O) and
PEEP (5 cmH(2)O) were kept constant, and the respiratory rate (RR) was varied between
20/min and 70/min (Ti:Te = 1:1).Tidal volume displayed by a ventilator decreased
independently of RR with increasing leakage up to 21% (BL), 30% (LE) and 33% (ST).
However, the volume delivered to the lung was nearly constant. The displayed leakage varied
between 0 and 78% and was dependent on RR and leakage resistance. There were distinct
differences between the three ventilators in the relationship between displayed leakage and
volume error. Accepting a volume error <10% for RR between 20 and 70/min, ET leakage of
up to 20% for BL, 12% for LE, but only <5% for ST, was acceptable.Tidal volume
underestimation arising from ET leakage depends on ventilator pressures, timing parameters
and ventilator-specific algorithms for signal processing. Therefore, neonatologists should be
aware of these issues to prevent lung over-inflation when adjusting target volume in the
presence of ET leakage.
Manson, H. J., et al. (1979). "A paediatric ventilator with a fluidic control system." British
journal of anaesthesia 51(3): 247-251.
A paediatric ventilator has been designed basically as a fluidic-logic controlled Tpiece occluder. Inspiratory and expiratory time, inflation pressure limit, positive endexpiratory pressure (PEEP), continuous positive airway pressure (CPAP) and inspiratory
flow-rate are controlled independently and intermittent mandatory ventilation (IMV) is
available. Warning systems are provided for failure of the driving as, low airway pressure and
inspiratory pressure limit. The breathing circuit is isolated from the control and warning
systems for ease of sterilization.
Manzano, J. J., et al. "[Intermittent mandatory ventilation (author's transl)]." Anales espa?oles
de pediatr?a 9(2): 150-157.
Intermittent mechanical ventilation is a frequent form of therapy for respiratory
failure in children. Due to its difficult application in patients with high respiratory rate and
difficult synchronization with the respirator, intermittent mandatory ventilation (I.M.V.) was
tried on these patients, introducing a unidirectional valve, connected to a continuous flow of
gases, on the inspiratory side of the respirator. With I.M.V. the patient is able to breath
spontaneously the gases coming from the unidirectional valve and at the same time the
respirator provides periodical insuflations at a frequency previously determined by us. The
pressure generated by the respirator in the respiratory circuit, closes the unidirectional valve
sending gases to patient. This technique not only reduced time of application of mechanical
ventilation but made weaning shorter, easier and safer.
Manzar, S., et al. (2004). "Use of nasal intermittent positive pressure ventilation to avoid
intubation in neonates." Saudi medical journal 25(10): 1464-1467.
Nasal intermittent positive pressure ventilation (NIPPV) has widely been used in
neonates to prevent extubation failure and apnea. This pilot study was carried out to look at
the early use of NIPPV to avoid intubation.The study was carried out over a period of 3
months from August 2003 to October 2003 at the Royal Hospital, Muscat, Sultanate of Oman.
The neonates with clinical signs of moderate to severe respiratory distress were given a trial
of early NIPPV based on the avoid-intubation protocol. Inclusion, exclusion and failure
criteria with general procedure were made clear to all medical and nursing staff and the
protocol was posted in the unit for further time to time referral.A total of 16 neonates met the
inclusion criteria for early NIPPV trial. Out of these, 13 (81%) had a successful NIPPV. The
mean age of entry was 0.95 hours; however, the mean duration of NIPPV was 23 hours. No
NIPPV related complications were noted in the study group.We concluded that NIPPV is an
appropriate mode of ventilation in neonates requiring respiratory support. The major
advantage of NIPPV is the non-invasive mechanics. It is also less expensive and less labor
intensive. Further randomized controlled trials with larger sample size are warranted to
confirm our findings.
Marchal, C., et al. (1972). "Continuous positive airway pressure in hyaline membrane
disease." Pediatrics 49(1): 142.
Markstr?m, A., et al. (2008). "Long-term non-invasive positive airway pressure ventilation in
infants." Acta paediatrica (Oslo, Norway : 1992) 97(12): 1658-1662.
To evaluate the clinical application of long-term non-invasive ventilation (NIV) in
infants with life-threatening ventilatory failure with regard to: diagnosis, age at initiation,
indication for and duration of treatment, clinical outcome and mortality and adverse
effects.The medical records of 18 infants treated in a home setting during a 7-year period
were reviewed. The criteria for ventilatory support were: (a) transcutaneous partial pressures
of carbon dioxide (TcPCO(2)) >6.5 kPa and oxygen (TcPO(2)) < 8.5 kPa and (b) decreased
cough ability and/or recurrent chest infections.The median age at initiation was 4 months
(range 1-12). NIV was initiated because of hypoventilation in 12 infants and because of
reduced cough ability and/or recurrent infections in six infants. Tracheotomy was eventually
needed in two infants. The median duration of treatment was 24 months (range 1-84). NIV
produced significant improvements, with median TcPCO(2) falling from 9.9 to 6.1 kPa, and
median TcPO(2) rising from 9.8 to 11.1 kPa.NIV can be successfully and safely used in
infants with prolonged life-threatening ventilatory failure, potentially avoiding intubation and
tracheotomy.
Marshall, R. E., et al. (1974). "Letter: Intracranial haemorrhage and hyaline-membrane
disease." Lancet 1(7862): 880.
Martin-Bouyer, G. (1970). "Positive-pressure respirators, and description of the French
machine RPR." Biology of the Neonate 16(1): 16-23.
Martin-Bouyer, G., et al. (1970). "Artificial ventilation in hyaline membrane disease.
Analysis of a series (130 cases)." Biology of the Neonate 16(1): 164-183.
Martin-Bouyer, G., et al. (1972). "[Constant positive pressure and residual positive pressure.
New technic for treatment of neonatal respiratory distress (hyaline membranes syndrome)]."
La Nouvelle presse m?dicale 1(33): 2181-2182.
Mattila, M. A. (1974). "The role of the physical characteristics of the respirator in artificial
ventilation of the newborn." Acta anaesthesiologica Scandinavica. Supplementum 56: 1-107.
McCallion, N., et al. (2008). "Neonatal volume guarantee ventilation: effects of spontaneous
breathing, triggered and untriggered inflations." Archives of disease in childhood. Fetal and
neonatal edition 93(1): F36-39.
During volume guarantee (VG) ventilation the peak inflating pressure (PIP) for each
ventilator inflation is adjusted to ensure the expired tidal volume (V(Te)) is close to the set
V(Te). Differences in the PIP between inflations triggered by the infant's inspirations and
untriggered inflations are seen.To investigate the effects of triggered and untriggered
inflations on PIP and V(Te).Neonates were ventilated with the Dr?ger Babylog 8000 using
assist control (synchronous intermittent positive pressure ventilation) and VG modes.
Continuous recordings of ventilator pressures and tidal volumes were made at 200 Hz for 10
minutes.In 10 infants, 6540 inflations were analysed, of which 4052 (62%) were triggered.
Triggered inflations had a significantly lower mean (SD) PIP than untriggered inflations: 12.9
(4.9) vs 17.0 (3.3) cm H2O, (p<0.001). Despite this, there was no significant difference in the
V(Te) of each type of inflation (103% and 101% of the set V(Te), respectively). When a
triggered inflation was immediately preceded or followed by an untriggered inflation the PIP
changed by about 5 cm H2O. Between adjacent inflations of the same type, the change in PIP
was less than 3 cm H2O: for triggered inflations it was 0.11 (1.50) cm H2O and for
untriggered inflations 0.06 (1.53) cm H2O.During VG ventilation with the Dr?ger Babylog
8000 the PIP was 4 cm H2O lower during triggered inflations than untriggered inflations,
although the expired tidal volumes were similar.
McCarthy, L. K., et al. (2013). "A randomized trial of nasal prong or face mask for
respiratory support for preterm newborns." Pediatrics 132(2): e389-395.
Resuscitation guidelines recommend that respiratory support should be given to
newborns via a face mask (FM) in the delivery room (DR). Respiratory support given to
preterm newborns via a single nasal prong (SNP; ie, short nasal tube, nasopharyngeal tube)
may be more effective. We wished to determine whether giving respiratory support to
preterm newborns with a SNP rather than a FM reduces the rate of intubation in the
DR.Infants <31 weeks' gestation were randomized just before delivery to SNP (endotracheal
tube shortened to 5 cm) or FM. Randomization was stratified by gestation (<28 weeks, 2830(+6)). Infants with apnea, respiratory distress, and/or heart rate <100 received positive
pressure ventilation with a T-piece. The primary outcome was intubation and mechanical
ventilation in the DR. Infants in both groups were intubated for heart rate <100 and/or apnea
despite PPV and not solely for surfactant administration. All other aspects of treatment in the
DR and NICU were the same. Relevant secondary outcomes were recorded and data were
analyzed by using the intention-to-treat principle.One hundred forty-four infants were
enrolled. The rate of intubation in the DR was the same in both groups (11/72 [15%] vs 11/72
[15%], P = 1.000]. Infants assigned to SNP had lower SpO2 at 5 minutes and received a
higher maximum concentration of oxygen in the DR. There were no significant differences in
other secondary outcomes.Giving respiratory support to newborn infants <31 weeks'
gestation via a SNP, compared with a FM, did not result in less intubation and ventilation in
the DR.
McDougall, R. J. (2013). "Paediatric emergencies." Anaesthesia 68(SUPPL. 1): 61-71.
The care of sick children can be challenging for the anaesthetist who is only involved
in the occasional care of paediatric patients. This paper outlines the care of medical and
surgical paediatric emergencies for which an anaesthetist working at a district general
hospital or equivalent may encounter. Conditions discussed include paediatric respiratory
emergencies, sepsis, status epilepticus, the acute abdomen in the newborn, intussusception,
the bleeding tonsil, trauma and the child with burns. (copyright) 2012 The Association of
Anaesthetists of Great Britain and Ireland.
McMahon, R. M., et al. (2006). "Use of mask continuous positive airway pressure in a
preterm infant presenting with bilateral cleft lip and palate." Journal of Laryngology and
Otology 120(3): 228-229.
This report highlights innovative ways of overcoming difficulties in delivering
effective continuous positive airway pressure in an extremely preterm baby with bilateral
cleft lip and cleft palate. (copyright) 2006 JLO (1984) Limited.
McNamara, F. and C. E. Sullivan (1997). "Nasal CPAP treatment in an infant with
respiratory syncytial virus-associated apnea." Pediatric Pulmonology 24(3): 218-221.
McNamara, F. and C. E. Sullivan (1999). "Obstructive sleep apnea in infants and its
management with nasal continuous positive airway pressure." Chest 116(1): 16-Oct.
Study objectives: Nasal continuous positive airway pressure (nCPAP) is the most
common treatment for obstructive sleep apnea (OSA) in adults, and it has been effective in
the treatment of OSA in children. We wanted to determine the effectiveness of long-term
nCPAP therapy for OSA in infants. Patients: Twenty-four infants who had OSA were treated
with nCPAP via nose mask. These infants had clinical histories that included a family history
of sudden infant death syndrome, an apparent life-threatening event, or facial and upper
airway anatomic abnormalities. Interventions: Overnight polysomnographic studies were
performed to assess the severity of OSA in each infant and to determine the appropriate level
of continuous positive airway pressure (CPAP). Studies were repeated to determine the
progress of OSA and the continuing need for CPAP in each infant. Results: nCPAP pressures
between 4 and 6 cm H2O prevented obstruction and reversed sleep disturbances that were
associated with OSA. Eighteen of the infants continued treatment at home from 1 month to >
4 years. CPAP therapy was discontinued in 13 infants after their OSA resolved. Five infants
who have upper airway anatomize abnormalities remain on CPAP, and the pressure level
required to prevent obstructive events during sleep has needed to be increased to as high as
10 cm H2O. Conclusions: nCPAP is an effective therapy for the management of OSA in
infants, and it can be used effectively in the home environment. Regular follow-up is
necessary, because the requirements for CPAP and pressure levels change with the infant's
growth and development.
Migliori, C., et al. (2003). "Early use of Nasal-BiPAP in two infants with Congenital Central
Hypoventilation syndrome." Acta Paediatrica, International Journal of Paediatrics 92(7): 823826.
Aim: To reduce the problems caused by prolonged artificial ventilation in babies
with Congenital Central Hypoventilation syndrome (CCHS). Methods: Two term infants with
CCHS, weighing 4030 g and 3100 g, respectively, at the beginning of treatment and aged 53
and 31 d, respectively, were successfully ventilated with a Nasal Bilevel Positive Airway
Pressure (N-BiPAP) device. Results: In the first patient the tcPO2 recordings (mean (plus or
minus) SD) during sleep were 46 (plus or minus) 12 mmHg before using N-BiPAP and 58
(plus or minus) 13 mmHg after using the device, while those for tcPCO2 were 75 (plus or
minus) 9 mmHg and 49 (plus or minus) 11 mmHg, respectively. In the second patient tcPO 2
during sleep was 42 (plus or minus) 3 mmHg before, and 55 (plus or minus) 5 after N-BiPAP,
and for tcPCO2 the recordings were 119 (plus or minus) 24 mmHg and 55 (plus or minus) 6
mmHg, respectively, showing a significant improvement. One infant had persistent gastrooesophageal reflux, and frontal skin abrasion caused by the face mask. Nevertheless, these
complications did not necessitate the discontinuation of N-BiPAP ventilation, thus precluding
prolonged use of intubation and tracheotomy. Conclusion: In infants with CCHS, early use of
non-invasive, positive-pressure ventilation with N-BiPAP, in association with careful
monitoring, can decrease problems caused by prolonged intubation and tracheotomy.
Mil?si, C., et al. (2010). "Continuous positive airway pressure ventilation with helmet in
infants under 1 year." Intensive Care Medicine 36(9): 1592-1596.
To report the feasibility of helmet use in infants between 1 and 12 months old with
acute respiratory failure.Observations were made before and 2 h after helmet CPAP of 6 cm
H(2)O. Failure was defined as recourse to intratracheal ventilation. Patient stabilization or
improvement was defined as a variation <10% or a decrease >10% in one of the following:
respiratory rate, inspired oxygen fraction, or capillary partial pressure of CO(2). Tolerance
was assessed by the pain and discomfort score, the systematic search for pressure sores, and
the measurement of helmet humidity and noise level.Twenty-three infants with a median age
of 5 (2-8) months were included. Helmet CPAP failed in two (9%) patients. Stability or
improvement occurred in 16 (70%) patients. The pain and discomfort score was stable or
improved in 22 (96%). Pressure sores were found in three (13%) infants. Humidity was 98%
(98-99%) and fell to 40% (39-43%) after the humidifier was stopped. The noise level in the
helmet was 81 (77-94) dB-SPL.The helmet was a satisfactory interface for CPAP delivery in
young infants in more than two-thirds of the cases. Pressure sores can be prevented by
placing a cushion in the helmet. Caregivers need to take into account the high humidity and
noise levels of this interface.
Miller, T. L., et al. (2004). "Tracheal gas insufflation-augmented continuous positive airway
pressure in a spontaneously breathing model of neonatal respiratory distress." Pediatric
Pulmonology 38(5): 386-395.
Respiratory distress syndrome (RDS) in neonates is characterized by labored
breathing and poor gas exchange, often requiring ventilatory support. Continuous positive
airway pressure (CPAP) is a preferred intervention to support spontaneous ventilatory efforts
by sustaining lung volume recruitment, while it prevents derecruitment during exhalation by
maintaining end-expiratory pressure. However, CO2 retention during CPAP often results in
the need for mechanical ventilation. Since tracheal gas insufflation (TGI) promotes CO2
elimination by reducing prosthetic dead space, we hypothesized that TGI used with CPAP
may reduce the need for more invasive therapies. The objective of this study was to evaluate
the physiologic effect of TGI with CPAP in a spontaneously breathing model of acute lung
injury with respect to gas exchange and pulmonary mechanics. Nineteen spontaneously
breathing neonatal pigs (2.4 +/- 0.4 kg) were anesthetized, sedated, instrumented, and placed
on CPAP at 5 cmH2O. All piglets were injured with intravenous oleic acid (0.08 ml/kg), and
then randomized to receive CPAP with TGI (TGI; n = 9) or CPAP alone (control; n = 10).
FiO2 was titrated at 0.05 every 15 min during the protocol to maintain SaO2 > 93%. Vital
signs, arterial blood gases, pulmonary mechanics, and thoracoabdominal motion (TAM) were
evaluated 30 min after injury and at 1-hr intervals for 4 hr. Following the 4-hr measurement,
the piglets were sacrificed and the lungs were grossly examined. After initiation of treatment,
we found that the PaCO2 was lower (33.1 +/- 5.0 vs. 47.0 +/- 10.3 mmHg; P < 0.01), while
the oxygenation indices were greater (PaO2, SaO2, a/A ratio; P < 0.01) in the TGI group than
with control animals. Subsequently, the pH was greater (7.45 +/- 0.08 vs. 7.36 +/- 0.08; P <
0.01) and closer to baseline values with TGI. By 4 hr, the FiO2 was titrated lower (0.37 +/0.06 vs. 0.49 +/- 0.15; P < 0.05) and ventilation was accomplished with a lower minute
ventilation (MV) in the TGI group than in the control group (445 +/- 113 vs. 581 +/- 223
ml/kg/min; P < 0.01). Respiratory compliance was greater with TGI than control (0.76 +/0.13 vs. 0.63 +/- 0.11 ml/cmH2O/kg; P < 0.01), whereas resistance and TAM were similar
between groups. We conclude that the use of TGI with CPAP in the treatment of RDS results
in improved gas exchange and pulmonary mechanics. As such, TGI-augmented CPAP may
prevent infants from requiring more invasive ventilation by reducing CO2 retention.(c) 2004
Wiley-Liss, Inc.
Milner, A. D. (1998). "Resuscitation at birth." European Journal of Pediatrics 157(7): 524527.
It is only in recent years that the techniques used for resuscitation at birth have come
under critical review and there have been very few controlled trials to assess their efficacy.
Recent studies have indicated that the large majority of asphyxiated term babies can be
resuscitated using air rather than 100% oxygen, possibly reducing damage from oxygen free
radicals during re-perfusion. Physiological studies have shown that inflation pressures of 25-
30 cm H2O maintained for up to 1 s, only result in approximately 40% of the mean
inspiratory volume achieved by babies who breathed spontaneously at birth. These
spontaneous inflation volumes can be matched either by maintaining the first inflation for 3 s,
or by using pressures of up to 50 cm H2O for 300 ms, a pattern adopted by spontaneously
breathing babies. Bag and mask systems are even less effective, often depending on the Head
paradoxical reflex to stimulate respiration rather than producing adequate tidal exchange.
Face mask T-piece devices provide more effective ventilatory exchange and are easier to
use.Although the pattern of ventilatory support in current use often leads to successful
resuscitation of asphyxiated babies at birth, more physiological and randomised controlled
studies are needed to refine techniques in order to limit babies' exposure to potentially
damaging hypoxia to the minimum.
Minocchieri, S., et al. (2011). "There's a hole in my facemask - Improving aerosol delivery to
preterm infants." Journal of Aerosol Medicine and Pulmonary Drug Delivery 24(3): 21-22.
Aerosol delivery to preterm infants under Continuous Positive Airway Pressure
(CPAP) is challenging. Investigating different patient interfaces, we found facemasks to be
more effective in increasing inhaled mass (IM). However, when adding additional dead space,
CO2 re-breathing is of concern. Purpose: We investigated the effect of facemask size and the
effect of introducing a vent in to the facemask on IM. Methods: Filter mass experiments
using the Premature Infant Nose Throat Model with two facemasks (Laerdal Infant, size 0/0
(S), 0/1 (L)) were performed. We simulated two breathing patterns (tidal volume (VT) of 9
and 18 mL, 40 breaths/min, I:E ratio of 1:2, minute ventilation (MV) of 360 and 720
mL/min). Salbutamol was aerosolized with an investigational eFlow Neonatal Nebulizer
System (PARI Pharma GmbH) under bubble CPAP (flow 6 L/min, pressure 5 cm H2O)
conditions. Different facemask vent sizes were investigated. Results are shown in Table 1. IM
was highest with the small facemask. Introducing a vent of 2.5 mm reduced IM significantly
in all conditions. For vented facemasks, VT of 9 and 18 mL with a vent diameter of 1.5 and
2.0 mm, respectively, yielded the highest IM. Conclusions: A vented facemask maintained
high IM given the vent diameter was adapted to the patients' MV. In addition, this benchmark
study endorsed the importance of the dead space (face mask) to tidal volume ratio.
Mintz, A. A., et al. (1973). "Pediatric grand rounds: Pulmonary sequelae of respiratory
distress syndrome." Texas medicine 69(12): 98-104.
Miske, L. J., et al. (2004). "Use of the mechanical in-exsufflator in pediatric patients with
neuromuscular disease and impaired cough." Chest 125(4): 1406-1412.
Impaired cough secondary to weakness from neuromuscular disease (NMD) can
cause serious respiratory complications, including atelectasis, pneumonia, small airway
obstruction, and acidosis. The mechanical in-exsufflator (MI-E) delivers a positive-pressure
insufflation followed by an expulsive exsufflation, thereby simulating a normal cough. Use of
the MI-E in adults with impaired cough results in improved cough flows and enhanced
airway clearance. However, only limited reports of MI-E use in children exist.To determine
the safety, tolerance, and effectiveness of the MI-E in a pediatric population.Retrospective
medical record review.Sixty-two patients (34 male patients) observed in a pediatric
pulmonary program with NMD and impaired cough in whom MI-E therapy was initiated.
Median age at initiation of MI-E use was 11.3 years (range, 3 months to 28.6 years).
Diagnoses included the following: Duchenne muscular dystrophy (17 patients); spinal
muscular atrophy, types I and II (21 patients); myopathy (12 patients); other nonspecific
NMD (12 patients). Mechanical ventilation via tracheostomy was used in 29 patients, and 25
patients used noninvasive ventilation.The median duration of use was 13.4 months (range, 0.5
to 45.5 months). One infant died before using MI-E at home. Five patients chose not to
continue MI-E therapy. Complications were reported in two patients, but ultimately they used
the MI-E device. Chronic atelectasis resolved in four patients after beginning MI-E therapy,
and five patients experienced a reduction in the frequency of pneumonias.In 90% of our study
population, the use of an MI-E was safe, well-tolerated, and effective in preventing
pulmonary complications.
Mitchell, J. P. and M. W. Nagel (2013). "Improved laboratory test methods for orally inhaled
products." Therapeutic Delivery 4(8): 1003-1026.
Existing pharmacopeial methods for the in vitro testing of orally inhaled products
(OIPs) are simplified representations of clinical reality, as their objective is to provide metrics
that are discriminating of product quality. Attempts to correlate measures such as fine particle
fraction <5 (mu)m aerodynamic diameter with in vivo measures of lung deposition have
therefore been notoriously difficult to achieve. Although particle imaging-based techniques
may be helpful to link in vitro to in vivo data as surrogates for clinical responses, a
reappraisal of the purposes for laboratory-based testing of OIPs is required. This article
provides guidance on approaches that may be helpful to develop clinically appropriate
methods to assess OIP performance in the laboratory, with the ultimate goal of developing
robust in vitro-in vivo relationships for the major inhaled drug classes. (copyright) 2013
Future Science Ltd.
Mockrin, L. D. and E. H. Bancalari (1975). "Early versus delayed initiation of continuous
negative pressure in infants with hyaline membrane disease." The Journal of pediatrics 87(4):
596-600.
Twenty-three infants with HMD of similar severity, who were less than 24 hours of
age and who were breathing spontaneously, were divided by random numbers into early and
delayed CNP groups. The infants who were treated with CNP before their PaO2 was less than
50 mm Hg while breathing 70% oxygen experienced a significantly greater increase in PaO2
in response to the initiation of CNP, required less time with O2 therapy, required no
mechanical ventilation, and had fewer complications. Based on these results, it is suggested
that CNP be initiated in infants with HMD, who are less than 24 hours of age and are
breathing spontaneously, before the PaO2 becomes less than 50 mm Hg on 70% O2.
Mondolfi, A. A., et al. (1997). "Comparison of self-inflating bags with anesthesia bags for
bag-mask ventilation in the pediatric emergency department." Pediatric Emergency Care
13(5): 312-316.
To compare bag-mask ventilation performed by emergency department (ED)
personnel using anesthesia bags (AB) and self-inflating bags (SIB).ED in a teaching
children's hospital where the AB is the device used during resuscitations.Experimental study.
Bag-mask ventilation was evaluated with an infant resuscitation mannequin equipped to
measure airway volumes and pressures. Pediatric residents, ED nurses, and pediatric
emergency medicine fellows performed bag-mask ventilation with AB and SIB and rated
their confidence using each device.Ventilation failure rates.Seventy subjects participated (17
interns, 16 junior residents, 13 senior residents, 10 fellows, and 14 nurses). There were 13
failures with the AB (18.6%) versus 1 (1.4%) with the SIB (P < 0.01) [95% confidence
interval: 5-29%], with a significant difference even after excluding the least experienced
subjects. There was no difference in high pressure breaths delivered (SIB 19% vs AB 15%, P
= 0.4) and a higher incidence of hyperventilation with the SIB (67 vs 25%, P < 0.01). While
using the SIB, 19 (27%) of the subjects did not turn on the O2 flow. There was no difference
in pretest confidence rating, but the posttest confidence rating was higher for the SIB (P <
0.05).Compared to SIB use for bag-mask ventilation in an ED, AB use resulted in more
ventilation failures, no advantage in preventing excessive airway pressures, and less
confidence among operators. The SIB should be the first choice for bag-mask ventilation in
the ED, with attention to maximize oxygen delivery.
Moore, F. A. and J. B. Haenel (1997). "Ventilatory strategies for acute respiratory failure."
American journal of surgery 173(1): 53-56; discussion 57-58.
Morley, C. and P. Davis (2004). "Continuous positive airway pressure: Current
controversies." Current Opinion in Pediatrics 16(2): 141-145.
Purpose of review: Continuous positive airway pressure is increasingly being used in
the care of premature infants. The purpose of this review is to highlight the current
controversies in the use of neonatal continuous positive airway pressure. Recent findings:
This review explores information about the devices available for delivering continuous
positive airway pressure and the pressures that can be used. It also investigates the
controversial issues of using continuous positive airway pressure during resuscitation of
premature infants and whether infants who are going to be managed on continuous positive
airway pressure should be intubated and given surfactant before continuous positive airway
pressure is started. It reviews the use of continuous positive airway pressure and the
prevention of chronic lung disease and the use of nasal intermittent positive pressure
ventilation and the difficult area of weaning from continuous positive airway pressure.
Summary: Existing evidence suggests that short binasal prongs are most effective, nasal
intermittent positive pressure ventilation is a useful way of augmenting neonatal continuous
positive airway pressure and that very premature infants can be managed with neonatal
continuous positive airway pressure in the delivery room as part of the resuscitation. Further
research is required to determine whether important outcomes are improved with the use of
nasal continuous positive airway pressure rather than endotracheal intubation and, if so,
whether surfactant should be given to infants so managed. Definition of optimal levels of
continuous positive airway pressure for infants at varying stages of their disease also requires
further research. (copyright) 2004 Lippincott Williams & Wilkins.
Morley, C. J. and P. G. Davis (2008). "Advances in neonatal resuscitation: Supporting
transition." Archives of Disease in Childhood: Fetal and Neonatal Edition 93(5): f334-f336.
Morrow, B., et al. (2007). "A recruitment manoeuvre performed after endotracheal suction
does not increase dynamic compliance in ventilated paediatric patients: a randomised
controlled trial." The Australian journal of physiotherapy 53(3): 163-169.
Does a recruitment manoeuvre after suctioning have any immediate or short-term
effect on ventilation and gas exchange in mechanically-ventilated paediatric
patients?Randomised controlled trial with concealed allocation, assessor blinding, and
intention-to-treat analysis.Forty-eight paediatric patients with heterogeneous lung pathology.
Fourteen patients were subsequently excluded from analysis due to large leaks around the
endotracheal tube.The experimental group received a single standardised suctioning
procedure followed five minutes later by a standardised recruitment manoeuvre. The control
group received only the single suctioning procedure.Measurements of ventilation (dynamic
lung compliance, expiratory airway resistance, mechanical and spontaneous expired tidal
volume, respiratory rate) and gas exchange (transcutaneous oxygen saturation) were recorded,
on three occasions before and on two occasions after the recruitment manoeuvre, using a
respiratory profile monitor.There was no difference between the experimental and the control
group in dynamic compliance, expired airway resistance, or oxygen saturation either
immediately after the recruitment manoeuvre, or after 25 minutes. The experimental group
decreased mechanical expired tidal volume by 0.3 ml/kg (95% CI 0.1 to 0.6), increased
spontaneous expired tidal volume by 0.3 ml/kg (95% CI 0.0 to 0.6), and increased total
respiratory rate by 3 bpm (95% CI 1 to 4) immediately after the recruitment manoeuvre
compared with the control group, but these differences disappeared after 25 minutes.There is
insufficient evidence to support performing recruitment manoeuvres after suctioning infants
and children.
Morton, C. M., et al. (2009). "Intrathecal Baclofen Administration During Pregnancy: A Case
Series and Focused Clinical Review." PM and R 1(11): 1025-1029.
Mu?oz-Bonet, J. I., et al. (2010). "Noninvasive ventilation in pediatric acute respiratory
failure by means of a conventional volumetric ventilator." World journal of pediatrics : WJP
6(4): 323-330.
Acute respiratory failure (ARF) is one of the main causes for admission to pediatric
intensive care unit (PICU). This study aimed to evaluate the feasibility and outcome of
noninvasive ventilation (NIV) by a volumetric ventilator with a specific mode in pediatric
acute respiratory failure.A three-year prospective non-controlled study was undertaken in
children with ARF who had received NIV delivered by Evita 2 Dura with NIV mode through
a nonvented oronasal mask.Thirty-two episodes of ARF were observed in 26 patients.
Pneumonia was observed in most of the children (46.8%). Pediatric logistic organ
dysfunction (PELOD) score was 12.4% �� 24% (range 0-84%). Peak inspiratory pressure
was 18.5 �� 2.7 cmH��O, positive end-expiratory pressure 5.7 �� 1.1 cmH��O,
pressure support 10.5 �� 2.7 cmH��O, and mean pressure 9.2 �� 2 cmH��O. The
clinical score was improved progressively within the first 6 hours. Before the initiation of
NIV, respiratory rate was 41.7 �� 16.3, heart rate 131.6 �� 25.8, systolic arterial pressure
108 �� 19.5, diastolic arterial pressure 58.2 �� 13.9, pH 7.33 �� 0.12, pCO�� 55.1
�� 20.2, SatO�� 87.8 �� 9.9 and FiO�� 0.55 �� 0.25. There was a significant
improvement in the respiratory rate, heart rate, pH, pCO�� and SatO�� at 2-4 hours.
This improvement was kept throughout the first 24 hours. The level of FiO�� was
significantly lower at 24 hours. Radiological improvement was observed after 24 hours in 17
out of 26 patients. The duration of NIV was 85.4 �� 62.8 hours. Complications were
defined as minor. Only 4 patients required intubation. All patients survived.NIV can be
successfully applied to infants and children with ARF using this volumetric ventilator with
specific NIV mode. It should be considered particularly in children whose underlying
condition warrants avoidance of intubation.
Mugford, M., et al. (1998). "Limited comparability of classifications of levels of neonatal
care in UK units." Archives of Disease in Childhood: Fetal and Neonatal Edition 78(3):
F179-F184.
Aim - To assess whether different classifications of neonatal care or dependency
scales are comparable when used in multicentre studies of cost effectiveness. Methods - A
survey of classifications was used in a nationally representative group of 57 units in 1990-1,
with a retrospective study of 10 354 cot days using patient records from a 5% random sample
of 1042 admissions. Local and national classifications were correlated with medical and
nursing procedures recorded for up to 26 days after each admission. Results - Classifications
varied substantially. Of the 57 units in our sample, 26 used one of two national classifications,
sometimes modified; 17 used the Northern Neonatal Network dependency scale; and the
other 14 did not record daily levels of care. In each classification, the highest level was
having respiratory support by ventilation or continuous distending pressure through an
endotracheal tube, nasal prongs, facemask or negative pressure device. This level of care was
consistently comparable between classifications; lower levels were not. Conclusions Retrospective comparisons between units with different classifications can only reliably
differentiate between days with and without respiratory support. There is a pressing need to
develop and validate more appropriate scales for prospective multicentre studies. These
should relate activity to costs and outcome.
Mukerji, A., et al. (2013). "Nasal high-frequency oscillation for lung carbon dioxide
clearance in the newborn." Neonatology 103(3): 161-165.
Noninvasive ventilation has been used increasingly in recent years to minimize the
duration of endotracheal mechanical ventilation in neonates due to its association with lung
injury. Nasal high-frequency oscillation (nHFO) is a relatively new noninvasive modality but
evidence for its use is limited.The goal of this study was to compare the CO2 clearance
efficacy of nHFO and noninvasive positive pressure ventilation (NIPPV) in a neonatal lung
model.A newborn mannequin with dimensions and anatomy similar to a term infant was
utilized. It was connected to a commercially available neonatal mechanical ventilator using a
manufacturer-provided nasal adaptor. Various modes of noninvasive ventilation were
compared as CO2 clearance was measured at the oropharynx by an end-tidal CO2 analyzer
following the addition of a known amount of CO2 into the lung. Measurements were
obtained at two different lung compliances using nHFO and compared with nCMV and nasal
continuous positive airway pressure (nCPAP) as a control. Pressures near the nasal adaptor
and the larynx were simultaneously measured with in-line pressure transducers. Results:
Whereas no CO2 elimination was observed under nCPAP, its clearance with nHFO was 3fold greater as compared to NIPPV. On nHFO, CO2 clearance was inversely proportional to
frequency and maximal at 6 and 8 Hz. At a lower lung compliance, CO2 clearance was
significantly higher at 6 Hz as compared to 10 Hz. During nHFO set to deliver a MAP of 10.0,
we documented pressures of 7.2 �� 0.3 at the nasal adaptor and only 2.3 �� 0.3 cm H2O
at the larynx.Nasal HFO is effective and superior to NIPPV at lung CO2 elimination in a
newborn mannequin model. The use of nHFO as the preferred mode of noninvasive
ventilation warrants further clinical studies.Copyright ? 2012 S. Karger AG, Basel.
Mulder, E. E. M., et al. (2012). "Changes in respiratory support of preterm infants in the last
decade: Are we improving?" Neonatology 101(4): 247-253.
Background: Ventilator-induced lung injury has been recognized as a major
contributing factor for bronchopulmonary dysplasia (BPD) in preterm infants. In the last
decade, focus has shifted towards a more gentle respiratory approach. Aim: To evaluate
whether guideline changes in respiratory management in the delivery room and the unit
improved the incidence of BPD in very preterm infants. Methods: Three cohorts of infants
<30 weeks of gestation, born at the Leiden University Medical Center in the Netherlands in
1996-1997 (cohort '96), 2003-2004 (cohort '03) and 2008-2009 (cohort '08), were compared
retrospectively. The major change was increasing use of continuous positive airway pressure
in time, and monitoring the tidal volume during mechanical ventilation in cohort '08. The
primary outcome was BPD at 36 weeks. Results: The incidence of BPD did not change from
47% in cohort '96 to 55% in cohort '03 (n.s.), but decreased significantly to 37% in cohort '08
(cohort '96 vs. '08 and cohort '03 vs. '08: p < 0.01). We observed the same effect when only
moderate and severe BPD were counted with 27% in cohort '96, 31% in cohort '03 and 14%
in '08 (cohort '96 vs. '03: p = n.s., cohort '96 vs. '08: p < 0.01, cohort '03 vs. '08: p < 0.05).
The mortality rate was not significantly different between the three cohorts. Conclusion: The
incidence of BPD in our cohort of preterm infants has decreased during the last decade and
could be due to the changes in respiratory management. Copyright (copyright) 2012 S.
Karger AG.
Murali, M. V., et al. (1988). "Continuous positive airway pressure with a face-mask in infants
with hyaline membrane disease." Indian pediatrics 25(7): 627-631.
Murdock, A. I., et al. (1970). "Mechanical ventilation in the respiratory distress syndrome: a
controlled trial." Archives of Disease in Childhood 45(243): 624-633.
Murphy, J. and W. A. Hodson (1974). "Neonatal intensive care. 2. Design and function of a
special unit." Postgraduate medicine 56(1): 65-70.
Murthy, V., et al. (2012). "The first five inflations during resuscitation of prematurely born
infants." Archives of disease in childhood. Fetal and neonatal edition 97(4): F249-253.
To study the first five inflations during the resuscitation of prematurely born infants
and whether the infant's inspiratory efforts influenced the expired tidal volume.Prospective
observational study.Two tertiary perinatal centres.Thirty infants, median gestational age 30
(23-34) weeks.The first five inflations delivered via a face mask and t-piece device were
examined using respiratory function monitoring.Inflation pressures, inflation times and
expiratory volumes were recorded and comparison made of inflations during which the infant
made an inspiratory effort (active inflation) or did not (passive inflation).Overall, the median
expired tidal volume was 2.5 (0-19.8) ml/kg and was lower for passive (median 2.1 ml/kg,
range 0-19.8 ml/kg) compared with active (median 5.6 ml/kg, range 1.2-12.2 ml/kg)
inflations (ratio of geometric means 1.85, 95% CI 1.18 to 28%) (p=0.007). Overall, the
median face mask leak was 54.5% and was lower for active (34.5%) compared with passive
(60.7%) inflations (mean difference in % leak: 12.4%, 95% CI 0.9 to 24%) (p=0.0354). There
was a significant positive correlation between the expiratory volumes and the inflation
pressures (R2 between subjects 0.19, p=0.04) and a negative correlation between the
expiratory tidal volumes and the face mask leaks (R2 between subjects=0.051, p<0.001), but
there was no significant correlation between the inflation times and the expiratory tidal
volumes.The expired tidal volume, inflation pressures and times during the first five
inflations during resuscitation were variable. The expired tidal volumes were significantly
greater if the infant inspired during the inflation.
Murthy, V., et al. (2012). "Comparison of the efficacy of face mask to endotracheal tube
resuscitation in prematurely born infants." Archives of Disease in Childhood 97: A133-.
Aims Prematurely born infants often need respiratory support immediately after birth.
International guidelines advise the initial use of a face mask to deliver positive pressure
ventilation, although endotracheal intubation is an alternative approach, particularly in the
very immature or asphyxiated infant. Our aim was to compare the efficacy of face mask to
endotracheal tube (ETT) resuscitation given as first line procedure; outcomes were the
expired tidal volume and end tidal carbon dioxide (ETCO2) levels before, during and after
the first active inflation in infants born prematurely. Methods Infants born at less than 29
weeks of gestation requiring resuscitation immediately at birth either by a face mask and tpiece resuscitation or via an endotracheal tube (ETT) were studied. A respiratory function
monitor (NM3 respiratory profile monitor) was used to record airway pressure, flow, tidal
volume and ETCO2 levels. Inflations were examined to identify the first active inflation (FB)
defined as the first inflation associated with a spontaneous breath by the infant. The FB, the
two passive breaths preceding (pre-FB), and first two passive breaths (post-FB) following the
first active inflation in each infant were analysed. Results Thirty five infants [median
gestational age 24 (23-28) weeks and birth weight of 670 (530-1346) grams] were studied.
Twenty infants were intubated with a size 2.5 endotracheal tube immediately after birth
(ETT), the remaining 15 infants received face mask resuscitation (face mask). The tidal
volumes and ETCO2 levels were significantly higher in infants resuscitated by ETT than face
mask prior to and during the FB (table 1). Conclusion Until the infant has made a
spontaneous inspiratory effort during resuscitation, face mask resuscitation is less effective in
achieving adequate ventilation than endotracheal intubation. (Table Presented).
Naef, A. P. (2003). "The mid-century revolution in thoracic and cardiovascular surgery: Part
1." Interactive Cardiovascular and Thoracic Surgery 2(3): 219-226.
Napiorkowski, T. N., et al. (2012). "Immediate reversal of clinically mute left-to-right shunt
into life-threatening right-to-left shunt during positive pressure ventilation of an ASA II
adult-a rare but possible cause of severe hypoxia during induction of anaesthesia." European
Journal of Anaesthesiology 29: 57-.
Background: ASD II is a congenital heart defect with a left-right shunt, found in 5%
of adults. Most pts with uncorrected ASD II have no clinical symptoms to adulthood; in 70%
of cases symptoms appear in the fifth decade. We present a pt in whom reversed intrathoracic
pressure during positive pressure ventilation caused sudden life-threatening symptoms of
nullacute Eisenmenger's syndromenull. Case report: A 48-year old man with mild HT and
type II diabetes was referred for elective neurosurgery. During induction of general
anaesthesia, at onset of positive pressure ventilation via face mask the patient suddenly
developed tachycardia of 150 bpm, central cyanosis, SpO2 fall to 82% and significantly
increased venous pressure (blood outflow from i.v. cannnulae). Arterial blood gas analysis
was identical with venous. Cyanosis and low SpO2 did not resolve during 100% oxygen
ventilation and exacerbated after intubation. Due to a life-threatening clinical condition
surgery was postponed and anaesthesia discontinued (anaesthetics pharmacologically
reversed). Chest X-ray in OR revealed significantly dilated mediastinum (absent on previous
scans). Due to suspicion of a severe right-left shunt (no improvement with 100% O2
ventilation) heart ultrasound was performed in the OR finding only symptoms of pulmonary
hypertension. The pt's status improved significantly with the return of spontaneous
ventilation - SpO2 98% (with falls to 74% on coughing), tachycardia subsided; he was
transferred to the ICU for further diagnostics. A more detailed heart ultrasound revealed a
left-to-right shunt through the foramen ovale, described as clinically insignificant. The patient
was transferred to a cardiology clinic, where an amplatzer was placed (intravascularly) to
block the ASD. Ten days later the neurosurgical procedure was re-attempted. The course of
anaesthesia and of the surgery was uneventful and the pt. was discharged in good overall
condition. Conclusion: In patients with a clinically mute and ultrasound-insignificant ASD II
left-to-right shunt any attempt at positive pressure ventilation may lead to an acute shunt
reversal with severe, life-threatening symptoms. Any form of cyanosis/fall in SpO2 which
shown no improvement on ventilation with 100% oxygen requires direct withdrawal of
positive pressure ventilation, reversal to spontaneous breathing and careful diagnostics. Even
an apparently negligible left-to-right shunt may prove dangerous during positive pressure
ventilation.
Narang, A. and A. Shenoi "Physiological principles of mechanical ventilation of the
newborn." Indian journal of pediatrics 59(1): 21-27.
Nardini, S. (1994). "Noninvasive mechanical ventilation in acute respiratory failure."
Monaldi archives for chest disease = Archivio Monaldi per le malattie del torace /
Fondazione clinica del lavoro, IRCCS [and] Istituto di clinica tisiologica e malattie apparato
respiratorio, Universit? di Napoli, Secondo ateneo 49(3): 271-272.
Narli, N. (2007). "Resuscitation of the newborn at birth." SENDROM 19(11): 16-Oct.
Approximately 10% of newborns require some degree of active resuscitation at birth.
All the equipment should be maintained before delivery as if the baby will be delivered in its
worst condition. The person caring the baby should be present in every delivery and should
be educated about newborn resuscitation. After delivery, determination of the need for
resuscitative efforts should begin immediately and proceed throughout the A, B, C and D
resuscitation blocks. With the developing perinatal care, the very extremely preterm babies
live more and these babies need different resuscitation management. Resuscitation of these
babies begin inutero. Neonatal T-piece resuscitator should be used to prevent valotrauma and
barotauma and time for surfactant installation should be managed properly.
Nasiroglu, O., et al. (2006). "Ventilator Y-piece pressure compared with intratracheal airway
pressure in healthy intubated children." Journal of clinical monitoring and computing 20(2):
95-100.
Compare airway pressure measurements at the ventilator Y-piece of the breathing
circuit (P( Y )) to intratracheal pressure measured at the distal end (P( T )) of the endotracheal
tube (ETT) during mechanical ventilation and spontaneous breathing of intubated
children.Thirty children (age range 29 days to 5 years) receiving general anesthesia were
intubated with an ETT incorporating a lumen embedded in its sidewall that opened at the
distal end to measure P( T ). Peak inflation pressure (PIP) was measured at P( Y ) and P( T )
during positive pressure ventilation. Just before extubation, all measurements were repeated
and imposed resistive work of breathing (WOBi) was calculated at both sites while breathing
spontaneously.Average PIP was approximately 25% greater at P( Y ) (19.7 +/- 3.4 cm H(2)O)
vs. P( T ) (15.0 +/- 2.9 cm H(2)O), p < 0.01. During spontaneous inhalation P( T ) was 59%
lower ({bond}8.5 +/- 4.0 cm H(2)O) vs. P( Y ) ({bond}3.5 +/- 2.0 cm H(2)O), p < 0.01.
WOBi measured at P( Y ) (0.10 +/- 0.02 Joule/L) was 86% less than WOBi measured at P( T )
(0.70 +/- 0.40 Joule/L), p < 0.01.In healthy children P( Y ) significantly overestimates PIP in
the trachea during positive pressure ventilation and underestimates the intratracheal airway
pressure during spontaneous inhalation. During positive pressure ventilation P( T ) better
assesses the pressure generated in the airways and lungs compared to P( Y ) because P( T )
also includes the difference in airway pressure across the ETT tube due to resistance. During
spontaneous inhalation, P( T ) reflects the series resistance of the ETT and ventilator circuit,
while P( Y ) reflects only the resistance of the ventilator circuit, accounting for the smaller
decreases in pressure. Additionally, P( Y ) underestimates the total WOBi load on the
respiratory muscles. Thus, P( T ) is a more accurate reflection of pulmonary airway pressures
than P( Y ) and suggests that it should be incorporated into ventilator systems to more
accurately trigger the ventilator and to reduce work of breathing.
Neeleman, C., et al. (1985). "Importance of pressure registration in positive pressure hand
ventilation." Tijdschrift voor Kindergeneeskunde 53(4): 145-147.
Neidhardt, M. and P. Emmrich (1973). "[Artificial respiration in pediatric intensive care]."
Monatsschrift f?r Kinderheilkunde 121(1): 27-35.
Neukirch, M., et al. (2004). "Non-invasive ventilation of children in an interdisciplinary
pediatric intensive care unit." Intensivmedizin und Notfallmedizin 41(3): 163-170.
Non-invasive ventilation (NIV) is defined as the use of a mask to provide ventilatory
support. Avoiding endotracheal intubation and reducing the rate of complications and
mortality secondary to intubation is the most important advantage. In a retrospective study we
analysed the number and indications for NIV in our pediatric intensive care unit (PICU) in
the last four years. We also examined the number of secondary intubations and deaths in
these patients. NIV was applied either with a constant flow device (Vital-Sign) with PEEP
valves from 5 to 12.5 cm H2O or Hamilton Galileo Gold using NIV or ASV (adaptive
support ventilation) mode. We used full face or nasal masks. NIV was applied in 25 patients
admitted to our PICU in the last four years. Underlying diseases were haematological
diseases, congenital cardiac abnormalities, cystic fibrosis, neuromuscular diseases, near
drowning, polytrauma and mechanical ileus. The most frequent indications for NIV were
pneumonias, the recruitment of atelectasis and pulmonary oedemas. Other indications were
the support of ventilation as a palliative treatment, status asthmaticus, respiratory failure
secondary to a spinal cord lesion and anticonvulsive treatment and in one patient with cystic
fibrosis as a bridge to lung transplantation. Secondary intubations had to be done in 7 patients.
Five of them had an underlying haematological disease with severe pneumonia and 3 of them
had also ALI or ARDS. All our patients survived, except one patient with lung aspergillosis,
who had to be intubated secondary and the 4 patients with end stage diseases obtaining NIV
as a palliative treatment. In our opinion the NIV offers an effective and successful alternative
to conventional mechanical ventilation, especially for the treatment and support of children
with pneumonias, atelectasis, pulmonary oedemas and weaning from ventilation. More
randomised controlled trails are required especially for patients with ALI and ARDS.
Nishimura, M., et al. (1995). "The response of flow-triggered infant ventilators." American
Journal of Respiratory and Critical Care Medicine 152(6 Pt 1): 1901-1909.
Patient-triggered ventilation (PTV) has not been feasible for infants because of large
trigger pressures and long delay times with pressure-triggered systems. Recently, four infant
ventilators with flow triggering have become available. We questioned if delay times, trigger
pressures, and trigger work with these ventilators would be acceptable for PTV in infants. All
ventilators were attached via 3-, 4-, and 5-mm endotracheal tubes to a spontaneously
breathing infant lung model. The lung simulator was set at an inspiratory time of 0.65 s, tidal
volume of 15, 30, and 45 ml, and 0 and 5 cm H2O positive end-expiratory pressure (PEEP).
Delay time, trigger pressure, and trigger work were determined from pressure measured at the
proximal airway, trachea, and alveolus. There were significant differences between the
endotracheal tube sizes, sites of measurement, ventilatory demand and ventilator brand at
each PEEP level for delay time, trigger pressure, and trigger work (p < 0.001). Delay time
was greatest with the 3-mm endotracheal tube at high ventilatory drive (maximum 138.2 +/2.1 ms). Both trigger pressure (minimum 0.23 +/- 0.02 cm H2O) and trigger work (minimum
0.05 +/- 0.01 g.ml) increased with decreasing endotracheal tube size, increasing ventilatory
demand, use of PEEP, and site of measurement: alveolus > trachea > airway (maximum:
trigger pressure 5.04 +/- 0.02 cm H2O; trigger work 114.48 +/- 0.88 g.ml). PTV may not be
appropriate under conditions of increased ventilatory drive and small endotracheal tube size
in infants.
Nyumura, I., et al. (2014). "A case of diabetes mellitus associated with severe sleep apnea
and Prader-Willi syndrome." Diabetology International 5(1): 69-73.
A 29-year-old woman with diabetes mellitus was admitted to our hospital for severe
congestive heart failure. She was suspected of having Prader-Willi syndrome (PWS) or
Angelman syndrome. On admission, a chest X-ray showed pneumonia and cardiomegaly
with massive pleural and pericardial effusion. Obstructive and central sleep apnea syndrome
was suggested, because of severe obesity and episodes of apnea without breathing and
movement of the rib cage. The causes of central sleep apnea syndrome include pneumonia,
hypoxia, and high metabolic production of an anticonvulsant drug because of epileptic
seizure, and she had an abnormal electroencephalogram. She went on to mechanical
ventilation (for example BiPAP, CPAP, and SIMV) and treatment with antibiotics. She
continued to receive pressure support ventilation and antiepileptic drug treatment, and her
systemic condition improved markedly after transfer to another hospital. She was finally
diagnosed as PWS by genetic testing. Unfortunately, she died suddenly after choking on a
sputum clog 5 months after discharge from the hospital. (copyright) 2013 The Japan Diabetes
Society.
O'Donnell, C. P. F., et al. (2005). "Neonatal resuscitation 2: an evaluation of manual
ventilation devices and face masks." Archives of disease in childhood. Fetal and neonatal
edition 90(5): F392-396.
The key to successful neonatal resuscitation is effective ventilation. Little evidence
exists to guide clinicians in their choice of manual ventilation device or face mask. The
expiratory tidal volume measured at the mask (V(TE(mask))) is a good estimate of the tidal
volume delivered during simulated neonatal resuscitation.To compare the efficacy of (a) the
Laerdal infant resuscitator and the Neopuff infant resuscitator, used with (b) round and
anatomically shaped masks in a model of neonatal resuscitation.Thirty four participants gave
positive pressure ventilation to a mannequin at specified pressures with each of the four
device-mask combinations. Flow, inspiratory tidal volume at the face mask (V(TI(mask))),
V(TE(mask)), and airway pressure were recorded. Leakage from the mask was calculated
from V(TI(mask)) and V(TE(mask)).A total of 10,780 inflations were recorded and analysed.
Peak inspiratory pressure targets were achieved equally with the Laerdal and Neopuff
resuscitators. Positive end expiratory pressure was delivered with the Neopuff but not the
Laerdal device. Despite similar peak pressures, V(TE(mask)) varied widely. Mask leakage
was large for each combination of device and mask. There were no differences between the
masks.During face mask ventilation of a neonatal resuscitation mannequin, there are large
leaks around the face mask. Airway pressure is a poor proxy for volume delivered during
positive pressure ventilation through a mask.
O'Donnell, C. P. F., et al. (2005). "Neonatal resuscitation 3: manometer use in a model of
face mask ventilation." Archives of disease in childhood. Fetal and neonatal edition 90(5):
F397-400.
Adequate ventilation is the key to successful neonatal resuscitation. Positive pressure
ventilation (PPV) is initiated with manual ventilation devices via face masks. These devices
may be used with a manometer to measure airway pressures delivered. The expiratory tidal
volume measured at the mask (V(TE(mask))) is a good estimate of the tidal volume delivered
during simulated neonatal resuscitation.To assess the effect of viewing a manometer on the
peak inspiratory pressures used, the volume delivered, and leakage from the face mask during
PPV with two manual ventilation devices in a model of neonatal resuscitation.Participants
gave PPV to a modified resuscitation mannequin using a Laerdal infant resuscitator and a
Neopuff infant resuscitator at specified pressures ensuring adequate chest wall excursion.
Each participant gave PPV to the mannequin with each device twice, viewing the manometer
on one occasion and unable to see the manometer on the other. Data from participants were
averaged for each device used with the manometer and without the manometer separately.A
total of 7767 inflations delivered by the 18 participants were recorded and analysed. Peak
inspiratory pressures delivered were lower with the Laerdal device. There were no
differences in leakage from the face mask or volumes delivered. Whether or not the
manometer was visible made no difference to any measured variable.Viewing a manometer
during PPV in this model of neonatal resuscitation does not affect the airway pressure or tidal
volumes delivered or the degree of leakage from the face mask.
O'Donnell, C. P. F., et al. (2003). "Resuscitation of premature infants: What are we doing
wrong and can we do better?" Biology of the Neonate 84(1): 76-82.
Neonatal resuscitation is based on experience with little evidence to support the
methods advocated. Current guidelines make no distinction between the techniques for term
and very premature infants. The guidelines support the use of 100%, cold, dry oxygen
delivered with devices that provide variable peak inspiratory pressures and tidal volumes with
no positive end-expiratory pressure (PEEP). It is possible that these techniques damage the
lungs. Self-inflating resuscitation bags give no indication about leaks, produce variable
inflating pressures, do not provide PEEP and cannot deliver prolonged inflations. Flowinflating bags will not work if there is leak at the facemask and also have variable inflating
pressures. Although they can provide PEEP and deliver prolonged inflations, they require
considerable skill to use. The Neopuff(registered trademark) is relatively easy to use,
provides PEEP and steady inflating pressure and does not achieve the set pressures if there is
a mask leak. Continuous positive airway pressure and PEEP are used in the neonatal
intensive care unit to maintain lung volume. It is surprising they are not routinely
recommended for resuscitation when establishing the lung volume is paramount. Volutrauma
is a potential problem in neonatal resuscitation and yet none of the devices give any
indication of the tidal volume delivered. There is considerable potential for improvement in
techniques of neonatal resuscitation through the application of evidence already available and
much scope for further research in this field. Copyright (copyright) 2003 S. Karger AG, Basel.
O'Donnell, C. P. F., et al. (2004). "Neonatal resuscitation: Review of ventilation equipment
and survey of practice in Australia and New Zealand." Journal of Paediatrics and Child
Health 40(4): 208-212.
Objective: The equipment used to provide positive pressure ventilation at neonatal
resuscitation varies between institutions. Available devices were reviewed and their use
surveyed in a geographically defined region. The aim of this study was to establish which
resuscitation equipment is used at neonatal intensive care units in Australia and New Zealand.
Methods: A questionnaire was sent to a neonatologist at each of the 29 neonatal intensive
care units in Australia and New Zealand, asking which resuscitation equipment they used. If
it was not returned, follow up was by email and telephone. Results: Data was obtained from
all units. Round face masks are used at all centres. Anatomically shaped masks are
infrequently used at two of the three centres (10%) that have them. Straight endotracheal
tubes are used exclusively at 23 (79%) centres. Shouldered tubes are used infrequently at
three of the six centres that have them. The Laerdal Infant Resuscitator self-inflating bag is
used at 22 (76%) centres. Flow-inflating bags are used at 12 (41%) centres. The Neopuff
Infant Resuscitator is used at 14 (48%) centres. Varying oxygen concentrations are provided
at delivery at 6/25 (24%) centres. Conclusions: There is a paucity of evidence for the efficacy
of the equipment used currently to resuscitate newborn infants. This complete survey of the
tertiary centres in a geographical region shows considerable variation in practice, reflecting
this lack of evidence and consequent uncertainty among clinicians. Further research is
necessary to determine which devices are preferable for this most important and common
intervention.
O'Donnell, C. P. F., et al. (2005). "Neonatal resuscitation 1: a model to measure inspired and
expired tidal volumes and assess leakage at the face mask." Archives of disease in childhood.
Fetal and neonatal edition 90(5): F388-391.
Neonatal resuscitation is a common and important intervention, and adequate
ventilation is the key to success. In the delivery room, positive pressure ventilation is given
with manual ventilation devices using face masks. Mannequins are widely used to teach and
practise this technique. During both simulated and real neonatal resuscitation, chest excursion
is used to assess tidal volume delivery, and leakage from the mask is not measured.To
describe a system that allows measurement of mask leakage and estimation of tidal volume
delivery.Respiratory function monitors, a modified resuscitation mannequin, and a computer
were used to measure leakage from the mask and to assess tidal volume delivery in a model
of neonatal resuscitation.The volume of gas passing through a flow sensor was measured at
the face mask. This was a good estimate of the tidal volume entering and leaving the lung in
this model. Gas leakage between the mask and mannequin was also measured. This occurred
principally during inflation, although gas leakage during deflation was seen when the total
leakage was large. A volume of gas that distended the mask but did not enter the lung was
also measured.This system can be used to assess the effectiveness of positive pressure
ventilation given using a face mask during simulated neonatal resuscitation. It could be useful
for teaching neonatal resuscitation and assessing ventilation through a face mask.
O'Donnell, C. P. F., et al. (2010). "Crying and Breathing by Extremely Preterm Infants
Immediately After Birth." Journal of Pediatrics 156(5): 846-847.
We reviewed videos of 61 extremely preterm infants taken immediately after birth.
The majority cried (69%) and breathed (80%) without intervention. Most preterm infants are
not apneic at birth. (copyright) 2010 Mosby, Inc. All rights reserved.
Okulu, E., et al. (2012). "The timing of surfactant prophylaxis in very-low-birth-weight
preterms: Is earlier better?" Early Human Development 88: S110-.
Objective: To determine whether the immediate bolus strategy combined with early
nasal CPAP (NCPAP) treatment could decrease the subsequent need for ventilation compared
to the administration of surfactant prophylaxis at 15-minutes after birth with early-NCPAP.
Design: Infants born before 28 weeks' and infants born at 29 to 30 weeks' who didn't receive
antenatal steroid (ANS) were randomised to groups 1 and 2. Infants in group 1 were intubated
as rapidly as possible after birth, and infants in group 2 received standard resuscitation
measures first, then were intubated electively at 15 minutes. Both groups received 100 mg/kg
surfactant. During resuscitation and surfactant administration infants were ventilated with Tpiece resuscitator (NeoPuff). After surfactant, infants were extubated to NCPAP (Infant
Flow(registered trademark)) in both groups if respiratory drive was present. Infants who
needed FiO2 > 0.4 on NCPAP to maintain an oxygen saturation 88-92% with clinical
deterioration, and had respiratory acidosis (pCO2 > 65mmHg, pH< 7.2) were intubated and
mechanical ventilation (MV) was initiated. The primary outcome was the need for MV within
the first 3 days of life. The secondary outcomes were neonatal morbidities, mortality and
duration of hospitalisation. Results: Total of 80 newborns were enrolled and randomised to
groups. Mean gestational age (GA), birth weight (BW), ANS use, presence of
chorioamnionitis, mode of delivery and Apgar scores at 5 minutes were not different between
the groups (p > 0.05). Ten infants in group 1, and 13 infants in group 2 couldn't be extubated
after surfactant. Mean GA and BW of these infants were similar in groups, but lower than the
infants who could extubated. Six infants in group 1 and four infants in group 2 needed MV
during the first 3 days (p > 0.05). The duration of NCPAP was similar in groups, where the
duration of total respiratory support was lower in group 1 (p = 0.05). There wasn't any case
with pneumothorax, and were no significant differences between the groups with a respect to
PDA, NEC, IVH, sepsis, ROP, BPD, mortality and duration of hospitalisation. Conclusion:
Our study didn't demonstrate a superiority of the immediate bolus strategy of surfactant
prophylaxis combined with early-NCPAP to the administration of surfactant at 15 minutes
after birth with early-NCPAP. Surfactant prophylaxis at 15 minutes with early-NCPAP seems
to be sufficiently effective to yield favourable outcomes in small preterm infants.
Oliveira, V. N., et al. (2011). "Audit of home CPAP/BPAP-how children access machines."
Journal of Sleep Research 20: 33-34.
Aim: An audit of the use of continuous positive airway pressure (CPAP) and bi-level
positive airway pressure (BPAP) support in infants and children, with particular attention to
sources of funding of the equipment, in a tertiary children's hospital. Introduction:
Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BPAP)
with nasal, full-face, nasal cushion interfaces are the most common and important forms of
pressure support for home use in children with sleep-disordered breathing. Methods: Review
of sleep medicine files, between March1999 and June 2011, as well as departmental
databases and hospital Home Equipment Lending Pool (HELP). Direct contact with state
health funding support agencies was also sought. Results: Home CPAP, BPAP was initiated
in 262 children (79 females). One hundred and seventy patients were identified, 82% (n =
144) were fitted with CPAP only. BPAP only was fitted in 3.5% (n = 6), and 14.5% (n = 18)
required both at some stage. Nasal mask, was used at least once in 91.7%. A full face mask
was tried at least once in 10% of patients, nasal cushions in 2.9% and 1.1% (n = 2) patients
have tracheostomies, 25.8% had obstructive sleep apnoea (OSA) and 4.7% had infantile OSA;
39.4% had OSA associated with a craniofacial malformation, cerebral palsy or other
syndrome, 13.5% had chronic respiratory disease, 8.8% neuromuscular disease. One child
was fitted with nasal CPAP as a trial for catathrenia. The majority of children, 71.7%, had
treatment exclusively with equipment loaned from the hospital. Twenty-four percent had their
equipment provided by state funding and only 3.5% had a privately funded machine.
Preliminary data showed from start of treatment, an application for state health support
services took an average of 15 months to be made. State health support services took an
average of 9 months to approve an application. Three weeks is the average time for rejection
of application. Sixteen percent of patients with application approved were still waiting for
funds to have their equipment delivered. Discussion: There is an increasing use of CPAP and
BPAP at home. There are disparate sources of funding for these machines and considerable
waiting times even if these machines are eventually approved.
ON, B. and S. CG (1999). "A comparison of halothane and isoflurane for gaseous induction
of anaesthesia in infants." Paediatric Anaesthesia 9(1): 25-29.
Sixty-four ASA 1 and 2 infants between the ages of 44 weeks postconceptual age and
one year presenting for routine, elective surgery were randomly anaesthetized with either 3%
halothane in oxygen (Group H) or 5% isoflurane in oxygen (Group I). Patients in Group I
took a mean (SD) time of 70.1(13.6) s to loss of eyelash reflex and 80.0 (13.5) s to tolerating
the face mask, compared with 80.2 (17.7) s and 93.4 (20.5) s in Group H (P=0.028 and
0.0072, respectively). There were no significant differences between the groups for
preinduction or induction state, lowest oxygen saturation, or the incidence of airway related
complications or interventions. This study demonstrates that 5% isoflurane in oxygen induces
anaesthesia in infants more quickly than 3% halothane in oxygen, without any increase in the
incidence or severity of airway-related complications.
Outerbridge, E. W., et al. (1972). "Continuous negative pressure in the management of severe
respiratory distress syndrome." The Journal of pediatrics 81(2): 384-391.
Outerbridge, E. W., et al. (1972). "Continuous positive airway pressure in hyaline membrane
disease." Pediatrics 49(1): 142-144.
P?rksen, C. (1975). "[Production of continuous positive airway pressure (CPAP) using a
nasal mask in the respiratory distress syndrome (RDS)]." Monatsschrift f?r Kinderheilkunde
123(5): 461-463.
Pablo Beca, J. and R. Filippa (1977). "[Continuous distending pressure in the treatment of
respiratory distress syndrome in the newborn (author's transl)]." Revista m?dica de Chile
105(2): 93-96.
Pape, K. E., et al. (1976). "Central nervous system patholgoy associated with mask
ventilation in the very low birthweight infant: a new etiology for intracerebellar
hemorrhages." Pediatrics 58(4): 473-483.
Mask-applied ventilatory support was noted to cause severe head molding in infants
with birthweights under 1,501 gm. To determine if this molding was detrimental to the infant,
the neonatal course and autopsy findings were reviewed for 106 infants. Twenty significant
intracerebellar hemorrhages were found. An association between these hemorrhages and
mask-applied positive pressure ventilation was demonstrated (P = .05). This relationship was
maintained when all cases of generalized bleeding dyscrasia were removed (P = .021). It is
proposed that the distortional forces produced by the mask attachment, together with the
buffeting effect of intermittent positive-pressure ventilation, are causally related to the
production of intracerebellar hemorrhages by direct contusion, by ischemic stasis, or by
altered venous drainage. The authors urge strong caution when dealing with the small
premature infant in using any attachment device that causes molding of the cranial vault,
particularly in the occipital area.
Patel, S. R. and R. Dhand (2011). "Current management of sleep-related breathing disorders."
Minerva Pneumologica 50(3): 217-236.
Breathing disorders occur very commonly during sleep, limit the ability to fall into
deep sleep, lead to daytime somnolence, and are associated with several comorbid conditions.
Sleep-related breathing disorders are classified into 3 categories, namely 1) obstructive sleep
apnea; 2) central sleep apnea; and 3) central hypoventilation syndromes. Although these
entities are described as discrete disorders there is significant overlap between them. This
article reviews the current management of sleep-related breathing disorders. Noninvasive
positive pressure ventilation remains the cornerstone of treatment for sleep-related breathing
disorders, and regular use of positive airway pressure has enormous benefits for patients with
sleep apnea. Adjunctive therapies include behavioral modification such as weight loss,
supplemental oxygen, oral appliances, surgical techniques, respiratory stimulants, and
measures to optimize cardiac function, among others. A multidisciplinary approach to
management which includes patient education, smoking cessation, behavioral modification,
and treatment of comorbidities is highly recommended. In addition, individual attention to
various occupational and social factors, the positive airway pressure requirement, a wellfitting interface that is acceptable to the patient, monitoring adherence to the treatment
regimen, frequent communication and patient education, and regular follow-up are required
to optimize outcomes in patients with sleep-related breathing disorders.
Paton, J. S., et al. (1976). "A comprehensive treatment unit for the respiratory distress
syndrome in the newborn." Biomedical engineering 11(6): 214-216, 219.
Various systems have been devised to improve the therapy of idiopathic respiratory
distress syndrome in newborn infants. This article describes a new ventilator which provides
alternating positive and negative pressure ventilation(APNPV) in addition to the more
conventional techniques. Safety aspects, technical performance and cleaning procedures are
described. A brief summary of the clinical performance of the machine is given.
Pavone, M., et al. (2013). "Non-invasive positive pressure ventilation in children." Early
Human Development 89(SUPPL3): S25-S31.
Non-invasive positive pressure ventilation is increasingly used in children both in
acute and in chronic setting. Clinical data supporting safety, efficacy and limitations in
children are growing. Technical problems related to the ventilators performance and
interfaces selection have not been fully resolved, especially for younger children. Noninvasive ventilation can be applied at home. Its use at home requires appropriate diagnostic
procedures, accurate titration of the ventilators, cooperative and educated families and careful,
well-organized follow-up programs. (copyright) 2013 Elsevier Ltd.
Paz, P. F., et al. (2013). "Primary neonatal resuscitation with nasal cannula: A prospective,
observational study." Journal of Investigative Medicine 61(1): 146-.
Purpose of Study: To evaluate whether a specially designed nasal cannula (NC) may
be an effective, alternative interface to face-mask, for ventilation of newborns requiring
resuscitation in the delivery room. Methods Used: All patients who were resuscitated with a
Neotech RAM NC in the delivery room were included in the study. Patients who received
any form of mask ventilation were excluded. An appropriate size NC was applied to the
newborn nares and attached to a T-piece resuscitator. PEEP was set at 5 cm H2O and PIP was
set at 20 cm H2O and adjusted based on the response of the patient. NCPAP was delivered
initially to patients requiring pressure support. For patients who did not respond to NCPAP
alone, sustained inflation for 5-10 seconds was considered for lung recruitment. Patients who
required further support were resuscitated with NC-IMV. Once stabilized, patients were
transported on either NCPAP or NC-IMV, unless intubated. Patients that were intubated in
the delivery room, were extubated to NC-IMV or NCPAP when deemed ready by the
attending neonatologist. Summary of Results: A total of 102 infants were resuscitated with
NC. Gestational age ranged from 23-41 weeks. Birth weights ranged from 270-4675g. 20
patients (19.6%) were <1000g, 29 (28.4%) were between 1000-2000g, 28 (27.4%) were
between 2001-3000g, 25 (24.5%) were >3000g. Eight (7.8%) patients were intubated in the
delivery room. Four of the eight (50%) patients intubated, were extubated within 24hrs to
NC-IMV. The other four patients (50%) that remained intubated were all <1000g. Five (4.9%)
patients required chest compressions in the delivery room, secondary to bradycardia from
unsuccessful intubation attempts, or from inadequate duration of positive pressure ventilation.
Five (4.9%) had pneumothorax noted on the first chest x-ray. Patients that developed
pneumothorax were 935 weeks gestational age. All of the pneumothoraces resolved
spontaneously without intervention. Conclusions: NC may be an effective, alternative
interface to face-mask for ventilation of newborns requiring resuscitation in the delivery
room. Prospective, randomized studies comparing NC versus mask in providing primary
resuscitation are needed to confirm our study findings.
Perlman, J. M., et al. (2010). "Part 11: Neonatal resuscitation: 2010 International Consensus
on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with
Treatment Recommendations." Circulation 122(16 SUPPL. 2): S516-S538.
PF, O. D. C., et al. (2004). "Manual ventilation devices for neonatal resuscitation." Cochrane
Database of Systematic Reviews(3).
This is the protocol for a review and there is no abstract. The objectives are as
follows:In newly born infants resuscitated with intermittent positive pressure ventilation,
does resuscitation with: any type of manual ventilation device (self-inflating bag, flowinflating bag or T-piece) as compared with another any model of a particular type of manual
ventilation device (eg. Laerdal vs. Ambu) as compared with another reduce mortality and
morbidity?Subgroup analysis will be performed to determine the safety and efficacy of types
or models of manual ventilation devices in term (37 weeks gestation and above) and preterm
(less than 37 weeks) infants
Piastra, M., et al. (2005). "Noninvasive ventilation options in pediatric myasthenia gravis."
Paediatric Anaesthesia 15(8): 699-702.
A 10-month-old female infant with congenital myasthenic syndrome suffering from
acute respiratory failure was supported using face mask positive pressure ventilation until
definitive diagnosis and specific treatment was achieved. A 12-year-old girl suffering from
seronegative myasthenia gravis was treated by helmet-delivered noninvasive ventilation
during recurrent myasthenic episodes. Noninvasive support was really beneficial in the
myasthenic crisis with respiratory muscle weakness, whereas a shift to tracheal intubation
was necessary when pulmonary infection and multiple atelectasis occurred. The new helmet
interface for noninvasive positive pressure ventilation can represent a valuable means of
respiratory support in the early phase of respiratory failure in older children.
Pocivalnik, M., et al. (2012). "Regional oxygen saturation during preterm neonatal
transition." Archives of Disease in Childhood 97: A309-.
Objective To evaluate arterial and regional tissue oxygen saturation during
immediate transition after birth in late preterm infants with and without respiratory support.
Methods Prospective observational study. Using nearinfrared spectroscopy, changes in
regional oxygen saturation of the brain (rSO2brain) and peripheral preductal tissue (rSO2pre)
were measured during the first 15 minutes of life after elective caesarean section. SpO2 and
heart rate were measured continuously. Fractional tissue oxygen extraction (FTOE) was
calculated for all regions. According to need for respiratory support two groups were formed,
respiratory support (RS) group and normal transition (NT) group (without need for
respiratory support). Positive pressure ventilation was applied with the T-piece resuscitator,
oxygen was applied according to SpO2 values. The Florian Respiratory Function Monitor
was used to monitor all ventilation parameter. All was recorded including videography.
Results 49 preterm infants fulfilled entry criteria, 7 had to be excluded because need for
intubation. Of the remaining infants, 21 formed NT group, and 21 RS group. Heartrate
showed comparable courses in both groups. SpO2, rSO2brain and rSO2pre values showed
significantly different courses in the two groups, always the NT group showing higher values.
FTOE course was significantly different, showing a delayed decrease in RS group.
Conclusion First systematic analysis of behaviour of regional and arterial oxygen saturation
in late preterm infants with and without need for respiratory support. Infants with respiratory
support showed significantly different oxygen saturation values, all were decreased compared
to a normal transition group.
Pomerance, J. J., et al. (1974). "Pneumopericardium complicating respiratory distress
syndrome: role of conservative management." The Journal of pediatrics 84(6): 883-886.
Racine, S. X., et al. (2010). "Face mask ventilation in edentulous patients: A comparison of
mandibular groove and lower lip placement." Anesthesiology 112(5): 1190-1193.
BACKGROUND: In edentulous patients, it may be difficult to perform face mask
ventilation because of inadequate seal with air leaks. Our aim was to ascertain whether the
lower lip face mask placement, as a new face mask ventilation method, is more effective at
reducing air leaks than the standard face mask placement. METHODS: Forty-nine edentulous
patients with inadequate seal and air leak during two-hand positive-pressure ventilation using
the ventilator circle system were prospectively evaluated. In the presence of air leaks, defined
as a difference of at least 33% between inspired and expired tidal volumes, the mask was
placed in a lower lip position by repositioning the caudal end of the mask above the lower lip
while maintaining the head in extension. The results are expressed as mean (plus or minus)
SD or median (25th-75th percentiles). RESULTS: Patient characteristics included age (71
(plus or minus) 11 yr) and body mass index (24 (plus or minus) 4 kg/m). By using the
standard method, the median inspired and expired tidal volumes were 450 ml (400-500 ml)
and 0 ml (0-50 ml), respectively, and the median air leak was 400 ml (365-485 ml). After
placing the mask in the lower lip position, the median expired tidal volume increased to 400
ml (380-490), and the median air leak decreased to 10 ml (0-20 ml) (P < 0.001 vs. standard
method). The lower lip face mask placement with two hands reduced the air leak by 95% (80100%). CONCLUSIONS: In edentulous patients with inadequate face mask ventilation, the
lower lip face mask placement with two hands markedly reduced the air leak and improved
ventilation. Copyright (copyright) 2010, the American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins.
Ramanathan, R. (2010). "Nasal respiratory support through the nares: its time has come."
Journal of perinatology : official journal of the California Perinatal Association 30 Suppl:
S67-72.
Respiratory distress syndrome (RDS) is the most common respiratory morbidity in
preterm infants. Surfactant therapy and invasive mechanical ventilation through the
endotracheal tube (ETT) have been the cornerstones in RDS management. Despite
improvements in the provision of mechanical ventilation, bronchopulmonary dysplasia (BPD),
a multifactorial disease in which invasive mechanical ventilation is a known contributory
factor, remains an important cause of morbidity among preterm infants. Barotrauma,
volutrauma or oxygen-induced lung inflammation (oxy-trauma) contributes significantly to
the development of BPD in neonates ventilated through an ETT. Recently, nasal respiratory
support has been increasingly used in preterm infants in an attempt to decrease postextubation failure and, perhaps, BPD, and for the treatment of apnea of prematurity in
nonventilated neonates. Observational studies using noninvasive respiratory support, such as
nasal continuous positive airway pressure (NCPAP), have shown a decrease in the incidence
of BPD when used to avoid intubation or minimize the duration of invasive mechanical
ventilation through the ETT. Moreover, synchronized as well as nonsynchronized nasal
intermittent positive-pressure ventilation (NIPPV) have been shown to significantly decrease
post-extubation failure compared with NCPAP and their use has been associated with a
reduced risk of BPD in small randomized controlled clinical trials. More recently, early
surfactant administration followed by extubation to NIPPV has been suggested to be
synergistic in decreasing BPD. Although these findings are promising, additional studies
evaluating different nasal interfaces, flow synchronization, synchronization using neurally
adjusted ventilatory assist mode, and closed loop control of oxygen during nasal ventilation
to minimize lung injury are needed in an attempt to further decrease the incidence of lung
injury in preterm neonates requiring respiratory support.
Rawlings, D. J., et al. (1980). "The Siemens-Elema Servo Ventilator 900 B for the
management of newborn infants with severe respiratory distress syndrome: a 22-month trial."
Critical care medicine 8(5): 307-311.
The Siemens-Elema Servo Ventilator 900 B is an electronically-controlled, volumelimited ventilator. To adapt this ventilator for use in newborns with respiratory failure,
minute volume control, PEEP valves, air-oxygen blenders, and respiratory tubing circuits
were modified. During a 22-month period, 161 newborn infants with severe respiratory
distress syndrome (RDS) were managed with this ventilator. The overall survival rate was
66%; the incidence of barotrauma was 20%; the survival rate was 53%. Of the infants studied,
12% developed bronchopulmonary dysplasia, and 79% of these survived. Of the 19% of
patients with a symptomatic intraventricular hemorrhage, 6% survived. The experience of the
authors with this ventilator modified to manage newborn infants with severe RDS has been
extremely encouraging. Furthermore, this ventilator is versatile because it can be readily
recalibrated for use in older patients and can be easily adapted for patients requiring surgery.
This ventilator has the extremely important advantage of being a volume ventilator which can
effectively provide positive pressure ventilatory support to patients of all age and weight
groups.
RB, B. and B. AJ (1984). "Positive nasal airway pressure eliminates snoring as well as
obstructive sleep apnea." Chest 85(1): 15-20.
Nine men who were habitual snorers were studied during a control and a treatment
night (in random order) to assess the effect of nasal continuous positive airway pressure
(CPAP) on snoring, sleep-disordered breathing, and nocturnal oxygen desaturation. Four
subjects had symptoms suggestive of the sleep apnea syndrome, but the other five were
asymptomatic. Polysomnography and recordings of snores were obtained on both nights. On
the treatment night, the subjects wore a customized infant anesthesia mask over their noses,
and CPAP was applied and adjusted upward from 4 cm H2O to a level that obliterated
snoring. Nasal CPAP (range 4 to 13 cm H2O) reduced the mean number of snores per night
from 1,015 per subject to 23 per subject (p less than 0.01). Mean numbers of episodes of
apnea, hypopnea, and desaturation were also significantly reduced. Analysis of sleep
structure showed no significant differences in sleep period time, total sleep time, or the
percentages of stages 3 and 4 sleep. The percentage of stages 1 and 2 was significantly
greater on control nights, and the percentage of REM sleep was greater on treatment nights.
On the control nights, snoring was common in stages 3 and 4 and least common during REM
sleep.
Rebello, C. M. (2010). "There is a need to review the concept of manual ventilation with selfinflating bags in newborn infants." Revista Paulista de Pediatria 28(1): 4-.
Rebello, C. M., et al. (2011). "Influence of the equipment used for manual ventilation over
the variability of respiratory mechanics in rabbits." Critical Care 15: 19-.
Introduction A self-inflating bag is used for newborns' manual ventilation, using an
oxygen concentration close to 100%, unknown peak inspiratory pressure (PIP), no end
positive expiratory pressure (PEEP) and high tidal-volume (Vt). Manual ventilation using a
T-piece device allows better control of PIP, use of PEEP and probably less variation in
pulmonary ventilation. Objective To compare using an experimental model with the adult
rabbit, the variability of PIP, PEEP, Vt, minute ventilation (VMin), respiratory rate (RR),
inspiratory time (Tins), expiratory time (Tex) and ratio Tins/Total time during manual
ventilation using a self-inflating bag or T-piece device. Methods Adult New Zealand White
rabbits were manually ventilated by 21 individuals using a self-inflating bag
(LIFESAVER(registered trademark) Neonate Manual Resuscitator; Teleflex Medical,
Research Triangle Park, NC, USA) or a T-piece device (Babypuff(registered trademark)
Fanem Ltd, Sao Paulo, Brazil). Before ventilation each animal was sedated with
intramuscular ketamine- acepromazine solution (10 mg/kg and 0.1 mg/kg, respectively) and
anesthetized (1% lidocaine, s.c.) at the site of incision for tracheostomy and carotid
cannulation. After curarization (pancuronium 1 mg/kg, i.v.) the ventilation was started and
ventilatory data (PIP, PEEP, Vt, minute volume, inspiratory and expiratory time) were
continuously recorded until sacrifice with sodium pentobarbital (100 mg/kg, i.v.), after 10minute ventilation. For each variable analyzed a variability index was calculated, defined as
the standard deviation of the mean values of each variable during the 10-minute ventilation.
Statistical analysis was by t test or Mann-Whitney test, significance was set at P = 0.05.
(Table presented) Results The variability indices for all variables analyzed during the 10minute ventilation are shown in Table 1. Conclusion The authors conclude that the use of a
T-piece device allows lower variability during manual ventilation, with the exception of
respiratory rate and expiratory time. We speculate that this lower variability could result in
lower lung injury during manual ventilation.
Reiterer, F., et al. (1993). "[Artificial respiration of premature infants]." Wiener Klinische
Wochenschrift 105(18): 511-515.
Better understanding of respiratory physiology and progress in ventilator technology
have contributed to improved mortality and morbidity of premature neonates. Yet, pulmonary
complications remain high and there is no consensus about the optimal regimen of
mechanical ventilation. We report our satisfactory 10-year experience with conventional
mechanical ventilation based on a relatively low incidence of pulmonary barotrauma. The
introduction of surfactant has facilitated the ventilatory management of premature neonates
since the usually rapid improvement of the acute lung disease after surfactant administration
allows for earlier weaning from mechanical ventilation. However, our own results and the
results from most surfactant studies show no significant reduction in the incidence of
intraventricular haemorrhage. Thus, though mechanical ventilation and surfactant
administration are milestones in neonatal therapeutic management, the problems encountered
in very low birth weight neonates both with respect to mortality and morbidity have not been
generally solved and underline the role of optimal perinatal management.
Relier, J. P. (1970). "Mechanical complications of artificial ventilation in the newborn."
Biology of the Neonate 16(1): 122-132.
Rhodes, P. G. and R. T. Hall (1973). "Continuous positive airway pressure delivered by face
mask in infants with the idiopathic respiratory distress syndrome: a controlled study."
Pediatrics 52(1): 05-Jan.
A controlled trial of the use of CPAP delivered by face mask was conducted in
infants with IRDS. A significant difference in survival (p < 0.05) was noted in treated (all of
13) compared with control patients (7 of 11) with birth weights greater than 1,500 g. Groups
were comparable according to birth weight, gestational age, initial blood gases, and age of
entry into the study. The mean duration of therapy was 32.4 hr. Complications were confined
to difficulties with mask fit and local skin care.
Richardson, P., et al. (1980). "A method of estimating the functional residual capacity of
infants with respiratory distress syndrome." Critical care medicine 8(11): 667-670.
This report describes and evaluates a new method of estimating the functional
residual capacity (FRC) of newborn infants receiving continuous positive airway pressure
(CPAP). Standard nitrogen washout methods of measuring lung volume are time consuming,
frequently interfere with patient care, and may be hazardous to prematurely born infants. The
authors are using a four-breath nitrogen washout technique to estimate the FRC of infants.
The method was evaluated using: (1) a mechanical lung model, and (2) results from 32
newborn infants with RDS. The actual volume of the mechanical lung model was 21.6 ml and
the estimated volume was 21.4 +/- 2.3 (SD) n = 13. Using different volumes in the
mechanical lung model and comparing with estimated FRCs yielded a correlation coefficient
of 0.96 (n = 15). Comparing the FRC of infants determined by standard nitrogen washout
with the estimated FRC yielded a correlation coefficient of 0.92, n = 145. Thus, the results of
the two methods are in good agreement. The new method reduces the period of breathing
pure oxygen from several minutes to just a few seconds, thus, decreasing the dangers of
absorption atelectasis and oxygen toxicity. The new system also lends itself well to microprocessor automation.
Riley, C. and J. Pilcher "Volume-guaranteed ventilation." Neonatal network : NN 22(2): 1722.
Pressure-limited, time-cycled ventilation has been the primary mode of ventilation
for neonates for several decades. But the realization that volume rather than pressure causes
ventilator-induced lung injury has led to the development of new strategies for ventilation.
Volume guarantee is a mode of ventilation that automatically adjusts the inspiratory pressure
to achieve a set tidal volume according to changes in lung compliance or resistance or the
patient's respiratory drive. Volume-guaranteed ventilation delivers a specific, preset volume
of gas, and inspiration ends when it has been delivered. This mode of ventilation requires
careful attention to the infant and to ventilator settings.
Robert, D. and L. Argaud (2007). "Non-invasive positive ventilation in the treatment of
sleep-related breathing disorders." Sleep Medicine 8(4): 441-452.
This chapter addresses the use of long-term non-invasive positive pressure
ventilation (NIPPV) (to the exclusion of continuous positive airway pressure) in the different
clinical settings in which it is currently proposed: principally in diseases responsible for
hypoventilation characterized by elevated PaCO2. Nasal masks are predominantly used,
followed by nasal pillow and facial masks. Mouthpieces are essentially indicated in case
daytime ventilation is needed. Many clinicians currently prefer pressure-preset ventilator in
assist mode as the first choice for the majority of the patients with the view of offering better
synchronization. Nevertheless, assist-control mode with volume-preset ventilator is also
efficient. The settings of the ventilator must insure adequate ventilation assessed by
continuous nocturnal records of at least oxygen saturation of haemoglobin-measured by pulse
oximetry. The main categories of relevant diseases include different types of neuromuscular
disorders, chest-wall deformities and even lung diseases. Depending on the underlying
diseases and on individual cases, two schematic situations may be individualized. Either
intermittent positive pressure ventilation (IPPV) is continuously mandatory to avoid death in
the case of complete or quasi-complete paralysis or is used every day for several hours,
typically during sleep, producing enough improvement to allow free time during the daylight
in spontaneous breathing while hypoventilation and related symptoms are improved. In case
of complete or quasi-complete need of mechanical assistance, a tracheostomy may become an
alternative to non-invasive access. In neuromuscular diseases, in kyphosis and in sequela of
tuberculosis patients, NIPPV always significantly increases survival. Conversely, no data
support a positive effect on survival in chronic obstructive pulmonary disease. (copyright)
2007 Elsevier B.V. All rights reserved.
Roberton, N. R. and M. Rosen (1982). "Safer resuscitation of the newborn." Clinics in
obstetrics and gynaecology 9(2): 415-435.
Rochow, N., et al. (2013). "Lung assist device for term and preterm newborns with severe
respiratory failure: nullArtificial placentanull-an update of development." Monatsschrift fur
Kinderheilkunde 161: 60-.
Background. Respiratory failure is a major cause of mortality and long term
morbidity in preterm infants. Based on the concept of the placenta we previously reported the
development of a lung assist device (LAD) which is connected via the umbilical vessel and is
pumpless as it is only driven by the heart. Previously we reported that our LAD provides
effective gas exchange in a newborn hypoxic piglet model comparable to 10% of a neonate's
oxygen consumption. Subsequent testing with different membrane types demonstrated that a
polydimethylsiloxane (PDMS) membrane could provide improved gas exchange in LAD.
Objective. To assess the feasibility of a LAD and the effects of extracorporeal bypass on
cardiovascular parameter in a piglet model. Method. The LAD is an array of parallel stacked
PDMS membrane single micro fluidic oxygenators (SOU) which was tested in a newborn
piglet model. The piglet was anaesthetized with Phenobarbital and mechanical ventilated
(FiO2: 0.21, PIP: 12 mbar, PEEP: 5 mbar, Freq.: 35/min). Both umbilical arteries and the
umbilical vein were cannulated with customized umbilical catheters (artery 5 Fr by 11 cm,
vein 6.5 Fr by 7 cm). Customized angio-catheters (14 G by 2.5 cm) were placed into the
carotid artery and jugular vein. Heparin was given for systemic anticoagulation.
Cardiovascular parameters were studied applying a short cut to create a bypass between: i)
umbilical artery and vein, and ii) carotid artery and jugular vein. Test flow rates ranged were i)
1-10 and ii) 1-30 mL/kg/min, respectively. The feasibility of the LAD was tested in a hypoxic
piglet model. Muscles were relaxed with Rocuronium and hypoxic conditions were applied
by mechanical ventilator (FiO2: 0.12, PIP: 6 mbar, PEEP: 0 mbar, Freq.: 30/min). Gas
exchange rate was measured. Results. Four newborn piglets with a weight of 1.5 to 2.3 kg
were studied. Heart rate remained stable by extracorporeal circulation up to 25 mL/kg/min
and increased by an average of 15 beats when blood flow was up to 30 mL/kg/min while
blood pressure remained stable. Via umbilical vessel flow rate up to 10 mL/kg/min could be
achieved. The average gas exchange for oxygen in the PDMS LAD was 1.5 (mu)l /cm2/min
and 6 (mu)l/cm2/min for carbon dioxide. Conclusion. The high gas exchange rates allow
lower residence time for the blood. High blood flows through our miniature device provide
appropriate gas exchange. The vascular access via umbilical vessels needs to be improved to
enhance performance of LAD.
Roloff, D. W., et al. (1973). "Combined positive and negative pressure ventilation in the
management of severe respiratory distress syndrome in newborn infants." Biology of the
Neonate 22(5): 325-337.
Rondio, Z., et al. (1984). "[Methods of intensive therapy in respiratory insufficiency in
newborn infants]." Pediatria polska 59(12): 991-997.
Rubecz, I. and M. Horv?th (1975). "[Oxygenation system in the treatment of respiratory
disorders in newborn infants]." Orvosi hetilap 116(11): 629-632.
Salem, M. R. (1994). "Cricoid pressure for preventing gastric insufflation in infants and
children." Anesthesiology 80(5): 1182-1183.
Salem, M. R. (1994). "Cricoid pressure for preventing gastric insufflation in infants and
children." Anesthesiology 80(3): 699.
Salyer, J. W. (2009). "Manual resuscitators: Some inconvenient truths." Respiratory Care
54(12): 1638-1643.
Samuels, M. and P. Boit (2007). "Non-invasive ventilation in children." Paediatrics and Child
Health 17(5): 167-173.
The use of non-invasive ventilation (NIV) within paediatrics has increased
significantly in recent years, probably due to improved understanding of its role and a rising
confidence in its ability to provide respiratory support to children. NIV is a valuable
treatment option for respiratory failure due to a variety of causes, both acute and chronic. Its
ease of use allows its application in both the hospital and community setting. This article
gives an overview of NIV use in the paediatric population, highlighting medical and nursing
considerations that are important. Appropriate assessment, well-managed initiation with
continued follow-up and support is vital for families and children embarking on NIV as a
long-term respiratory support. (copyright) 2007 Elsevier Ltd. All rights reserved.
Sanchez, A. M., et al. (2009). "Non-invasive mechanical ventilation: Continuous positive
airway pressure and nasal ventilation." Anales de Pediatria Continuada 7(1): 16-23.
Sandhar, B. K., et al. (1988). "Effects of positive end-expiratory pressure on hyaline
membrane formation in a rabbit model of the neonatal respiratory distress syndrome."
Intensive Care Medicine 14(5): 538-546.
Sixteen rabbits were anaesthetized and subjected to saline lavage of the lungs to
produce surfactant deficiency. This resulted in an arterial oxygen tension of less than 12 kPa
on 100% inspired oxygen and an inflection point on the pressure-volume curve at a pressure
of 8-12 mmHg. After lavage the animals were randomly assigned to receive either
conventional mechanical ventilation (CMV) with a positive end-expiratory pressure (PEEP)
of 1-2 mmHg (group I - low PEEP) or CMV with PEEP equal to the inflection point pressure
(group II - high PEEP). Mean airway pressures were kept at 14-16 mmHg in both groups by
increasing the inspiratory:expiratory time ratios in the low PEEP group. The 5-h protocol was
completed by 4 animals in group I and 6 animals in group II, early death usually being
associated with a metabolic acidosis. On 100% oxygen, the mean PaO2 at 2-h post-lavage
was 15.2 +/- 8.3 kPa in group I and 39.6 +/- 21.8 kPa in group II. Group I had much lower
end-expiratory lung volumes (3.0 +/- 1.5 ml above FRC) than group II (34.9 +/- 12.2 ml
above FRC). Histological examination of the lungs revealed significantly less hyaline
membrane formation in group II (p = 0.001). Thus, the prevention of alveolar collapse by the
use of high PEEP levels appears to reduce lung damage in this preparation.
Sarkar, S. and S. M. Donn (2007). "In support of pressure support." Clinics in Perinatology
34(1): 117-128, vii.
Present generation mechanical ventilators are available with advanced
microprocessor-based technology. Greater emphasis is being placed on the patient controlling
the ventilator, rather than the physician controlling it. Pressure support ventilation (PSV) is a
form of patient-triggered ventilation that supports spontaneous breathing during mechanical
ventilation. It is flow-cycled, allowing the patient to determine the inspiratory time and rate.
Each spontaneous breath is terminated when inspiratory flow decelerates to a predefined
percentage of peak flow. At present, strict comparisons of the usefulness of PSV with other
modalities of synchronized ventilation in newborns remain limited. This article reviews the
principles and clinical applications of PSV for newborns who have respiratory failure.
Saslow, J. G., et al. (2006). "Work of breathing using high-flow nasal cannula in preterm
infants." Journal of Perinatology 26(8): 476-480.
Objective: To compare the work of breathing (WOB) in premature neonates
supported with high-flow nasal cannula (HFNC) and nasal continuous positive airway
pressure (NCPAP). Study design: Eighteen preterm neonates <2.0 kg on HFNC or NCPAP
support were studied in a random order. A ventilator was used to deliver 6 cm H2O of
NCPAP with nasal prongs. High-flow nasal cannula delivered with Vapotherm (VAPO) at 3,
4 and 5l/min was used. Tidal ventilation was obtained using respiratory inductance
plethysmography calibrated with face-mask pneumotachography. An esophageal balloon
estimated pleural pressure from which changes in end distending pressure were calculated.
Inspiratory, elastic and resistive WOB and respiratory parameters were calculated. Results:
No differences were found in the WOB for all settings. Changes in end distending pressure
did not vary significantly over all device settings except VAPO at 5l/min. Conclusion: In
these preterm infants with mild respiratory illness, HFNC provided support comparable to
NCPAP.
Schachinger, H. and H. D. Frank (1974). "[A simple method for increasing endexpiratory
pressure in the Bird Mark 8 ventilator for infants (author's transl)]." Praktische An?sthesie,
Wiederbelebung und Intensivtherapie 9(1): 55-57.
Schaller, P., et al. (1983). "[Proposal for an improved CPAP system]." Kinder?rztliche Praxis
51(2): 77-82.
Schilleman, K., et al. (2010). "Leak and obstruction with mask ventilation during simulated
neonatal resuscitation." Archives of disease in childhood. Fetal and neonatal edition 95(6):
F398-402.
To evaluate mask technique during simulated neonatal resuscitation and test the
effectiveness of training in optimal mask handling.Seventy participants(consultants, registrars
and nurses) from neonatal units were asked to administer positive pressure ventilation at a
flow of 8 l/min and a frequency of 40-60/min to a modified leak free, term newborn manikin
(lung compliance 0.5 ml/cm H(2)O) using a Neopuff T-piece device. Recordings were made
(1) before training, (2) after training in mask handling and (3) 3 weeks later. Leak was
calculated. Obstruction (tidal volume <60% of optimal tidal volume) and severe obstruction
(<30% of optimal tidal volume) were calculated when leak was minimal.For the 70
participants, median (IQR) leak was 71% (32-95%) before training, 10% (5-37%) directly
after training and 15% (4-33%) 3 weeks later (p<0.001). When leak was minimal, gas flow
obstruction was observed before, directly after training and 3 weeks later in 46%, 42% and 37%
of inflations, respectively. Severe obstruction did not occur.Mask ventilation during
simulated neonatal resuscitation was often hampered by large leaks at the face mask.
Moderate airway obstruction occurred frequently when effort was taken to minimise leak.
Training in mask ventilation reduced mask leak but should also focus on preventing airway
obstruction.
Schirmer, U., et al. (1992). "[A study of the parameters of the delivered tidal volume.
Ventilation on a lung model using the CICERO anesthetic ventilator]." Der Anaesthesist
41(12): 785-789.
In many anaesthesia ventilators in common use, the tidal volume delivered is
different from the tidal volume preset on the respirator. Tidal volume delivered by
mechanical ventilation during anaesthesia may be influenced by fresh gas flow (FGF), the
respiratory rate (RR) or the inspiratory: expiratory ratio (I:E). This may cause inadequate
hypo- or hyperventilation in small children, especially in newborns and neonates. Using small
tidal volumes from 20 to 100 ml preset on the respirator, we investigated in a lung model the
tidal volumes delivered by the anaesthesia ventilator CICERO (Dr?ger, FRG) with variations
of FGF, RR and I:E. MATERIAL AND METHODS. The anaesthesia ventilator CICERO
(software version 4.16) was equipped with the low-compliance tubes of the Ulmer Kinder-Set
(R?sch Co.) and the regular CO2 canister (1500 ml) of the machine. The circuit was
connected to a lung model consisting of a glass clyinder filled with copper wool with a
compliance of 3.3 ml/mbar. To create a pressure-volume correlation of the entire system, i.e.
the lung model, the anaesthesia circuit and the ventilator, calibrated glass syringes were used
and the pressure increase in the test lung was measured. This pressure-volume correlation
was linear. The pressure increase in the lung model caused by the tidal volume during
ventilation therefore reflected the actual tidal volume delivered. The study was performed
with small tidal volumes from 20 to 100 ml that could be adjusted exactly on the ventilator.
Delivered tidal volumes were studied by varying the FGF from 1 to 6 l/min and the RR from
20 to 60/min (with I:E = 1:1.5) and by varying the RR from 20 to 60/min and the I:E from 2:1
to 1:3 (with FGF = 21/min). RESULTS. By varying FGF, RR and I:E no changes in delivered
tidal volumes were noted. In all settings of the ventilator studied, the delivered tidal volume
was similar to the desired tidal volume preset on the ventilator. The highest deviation from
the delivered tidal volume to the tidal volume preset was 17.5% with a tidal volume of 20 ml.
In preset tidal volumes 30-100 ml this deviation was lower than 10%. An intermittent autoPEEP up to 5 mbar was noted during high respiratory rates (50 and 60/min) combined with
an I:E at 2:1 and 1:1 or with a FGF at 4 or 6 l/min. The compliance of the ventilator equipped
with the circuit was 4.2 ml/mbar. CONCLUSION. The findings in this study prove that with
tidal volumes ranging from 20 to 100 ml the actual tidal volume delivered by the anaesthesia
ventilator CICERO is equivalent to the tidal volume set on the machine regardless of the
variation of FGF, RR and I:E. These findings are mainly based on two circumstances. Firstly,
fresh gas flow is fed into a reservoir and not added to the volume delivered by the bellow
during inspiration as in many other respirators. Secondly, the CICERO works with a
compliance correction function integrated into the machine. Computed compressible volume
from the circuit and the ventilator is added to the tidal volume preset on the ventilator;
therefore, the volume delivered by the bellow consists of the volume set on the ventilator plus
the compressible volume. With these characteristics the anaesthesia ventilator CICERO
meets important requirements for a ventilator in paediatric anaesthesia. However, for final
assessment further clinical studies are required.
Schm?lzer, G. M., et al. (2011). "Airway obstruction and gas leak during mask ventilation of
preterm infants in the delivery room." Archives of disease in childhood. Fetal and neonatal
edition 96(4): F254-257.
Preterm infants with inadequate breathing receive positive pressure ventilation (PPV)
by mask with variable success. The authors examined recordings of PPV given to preterm
infants in the delivery room for prevalence of mask leak and airway obstruction.The authors
reviewed recordings of infants at <32 weeks' gestation born between February 2006 and
March 2009. PPV was delivered with a T-piece or self-inflating bag and a round silicone face
mask. Airway pressures and gas flow were recorded with a respiratory function monitor
(RFM). Videos recorded from a web camera were used to review the resuscitation. The first 2
min of PPV were analysed for each infant. Obstruction was arbitrarily defined as a 75%
reduction in delivered expired tidal volume (V(Te)) and significant face-mask leak as
>75%.The authors analysed recordings of 56 preterm infants. Obstruction occurred in 14
(26%) recordings and leaks in 27 (51%). Both obstruction and mask leaks were seen in eight
(14%) recordings, and neither was seen in 15 (27%). Obstruction occurred at a median (IQR)
of 48 (24-60) s after the start of PPV. A median (range) of 22 (3-83) consecutive obstructed
inflations were delivered. Face-mask leaks occurred from the first inflation in 19/27 (70%)
and in the remaining eight at a median (IQR) of 30 (24-46) s after the start of PPV. A median
(range) of 10 (3-117) consecutive inflations with a leak >75% were delivered.Airway
obstruction and face-mask leak are common during the first 2 min of PPV. An RFM enables
detection of important airway obstruction and mask leak.
Schm?lzer, G. M., et al. (2011). "Tidal volume delivery during surfactant administration in
the delivery room." Intensive Care Medicine 37(11): 1833-1839.
Reduced mortality for infants born at less than 30 weeks�� gestation after
prophylactic surfactant administration has led many to advocate routine intubation and
administration of surfactant in all infants at risk of respiratory distress syndrome. However,
surfactant administration is associated with adverse events including bradycardia, changes in
cerebral blood flow and endotracheal tube obstruction. The aim of this study was to analyse
respiratory function immediately before and after surfactant administration in the delivery
room.We reviewed video recordings of the initial resuscitation in the delivery room of infants
born at less than 32 weeks�� gestation between February 2007 and March 2010. Positive
pressure ventilation was delivered with either a Neopuff T-piece or self-inflating bag.
Respiratory parameters were recorded with a respiratory function monitor (RFM). Each RFM
recording was analysed for 30 s before and 2 min after surfactant administration.Of 230
infants recorded during the study period 16 infants received surfactant in the delivery room.
Their mean (standard deviation, SD) gestation and birth weight were 25 (1) weeks and 757
(249) g, respectively. Complete airway obstruction was seen in 4/16 (25%) infants. The
median (interquartile range, IQR) duration of this obstruction was 16 (8?27) s. The median
(IQR) expired tidal volume before surfactant delivery was 8.0 (5.2?11.2) mL/kg compared to
4.6 (4.1?7.3) mL/kg (p = 0.03) after surfactant administration.Substantial tidal volume
changes occur before, during and after surfactant administration in the delivery room.
Complete airway obstruction is common. Monitoring respiratory function during this
procedure may help to assess the delivered tidal volume and airway pressures after surfactant
treatment.
Schm?lzer, G. M., et al. (2010). "Respiratory monitoring of neonatal resuscitation." Archives
of disease in childhood. Fetal and neonatal edition 95(4): F295-303.
Video observations and recordings of respiratory signals from mannequin studies and
delivery room (DR) resuscitations are described. This article discusses the uses of a
respiratory function monitor (RFM) during training and resuscitations along with potential
pitfalls and limitations. It adds objectivity to the clinical assessment. A respiratory function
monitor provides real-time quantitative information including tidal volume and leak. It may
be used to teach correct mask hold and positioning techniques during simulation-based
mannequin. Examples demonstrating its potential usefulness during resuscitations are
provided. However, further studies are needed to investigate whether it can help improve
short-term and long-term outcomes.
Schm?lzer, G. M., et al. (2010). "Assessment of tidal volume and gas leak during mask
ventilation of preterm infants in the delivery room." Archives of disease in childhood. Fetal
and neonatal edition 95(6): F393-397.
The aim was to compare resuscitators' estimates of tidal volume (V(T)) and face
mask leak with measured values during positive pressure ventilation (PPV) of newborn
infants in the delivery room.The authors measured inflating pressures and V(T) delivered
using a respiratory function monitor, and calculated face mask leak. After 60 s of PPV,
resuscitators were asked to estimate V(T) and face mask leak. These estimates were
compared with measurements taken during the previous 30 s.The authors studied 20 infants
who received a mean (SD) of 21 (6) inflations during the 30 s. The median (IQR) expired
tidal volume (V(Te)) delivered was 8.7 ml/kg (5.3-11.3). V(Te) varied widely during each
resuscitation and between resuscitators. Five resuscitators could not estimate V(Te), one
overestimated and 14 underestimated their median delivered V(Te). The median (IQR) face
mask leak was 29% (16-63%). Leak also varied widely during each resuscitation and between
resuscitators. One resuscitator could not estimate mask leak, four overestimated leak and 15
underestimated leak.During face mask ventilation in the delivery room, V(T) and face mask
leak were large and variable. The resuscitators were unable to accurately assess their face
mask leak or delivered V(T).
Schm?lzer, G. M., et al. (2010). "Respiratory function monitoring to reduce mortality and
morbidity in newborn infants receiving resuscitation." The Cochrane database of systematic
reviews(9): CD008437.
A respiratory function monitor is routinely used in neonatal intensive care units to
continuously measure and display airway pressures, tidal volume and leak during ventilation.
During positive pressure ventilation in the delivery room, clinical signs are used to monitor
the effectiveness of ventilation. The additional use of a respiratory function monitor during
positive pressure ventilation in the delivery room might help to improve the effectiveness of
ventilation.To determine whether the use of a respiratory function monitor in addition to
clinical assessment compared to clinical assessment alone in newborn infants resuscitated
with positive pressure ventilation reduces mortality and morbidity.We searched the Cochrane
Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2010),
MEDLINE (January 1996 to March 2010), EMBASE (January 1980 to March 2010) and
CINAHL (January 1982 to March 2010). Clinical trials registers and the abstracts of the
Society for Pediatric Research and the European Society for Pediatric Research were
searched from 2004 to 2009. No language restrictions were applied.We planned to include
randomised and quasi-randomised controlled trials and cluster trials that compared the use of
a respiratory function monitor in addition to clinical assessment, compared to clinical
assessment alone, in newborn infants resuscitated with positive pressure ventilation.Two
review authors independently evaluated the search results against the selection criteria. Data
extraction and risk of bias assessment were not performed because there were no studies that
met our inclusion criteria.No studies were found meeting the criteria for inclusion in this
reviewThere is insufficient evidence to determine the efficacy and safety of a respiratory
function monitor in addition to clinical assessment during positive pressure ventilation at
neonatal resuscitation. Randomised clinical trials comparing positive pressure ventilation
with and without a respiratory function monitor in addition to clinical assessment at neonatal
resuscitation are warranted.
Schm?lzer, G. M., et al. (2012). "Respiratory function monitor guidance of mask ventilation
in the delivery room: a feasibility study." The Journal of pediatrics 160(3): 377-381.e372.
To investigate whether using a respiratory function monitor (RFM) during mask
resuscitation of preterm infants reduces face mask leak and improves tidal volume
(V(T)).Infants receiving mask resuscitation were randomized to have the display of an RFM
(airway pressure, flow, and V(T) waves) either visible or masked.Twenty-six infants had the
RFM visible, and 23 had the RFM masked. The median mask leak was 37% (IQR, 21%-54%)
in the visible RFM group and 54% (IQR, 37%-82%) in the masked RFM group (P = .01).
Mask repositioning was done in 19 infants (73%) of the visible group and in 6 infants (26%)
of the masked group (P = .001). The median expired V(T) was similar in the 2 groups.
Oxygen was provided to 61% of the visible RFM group and 87% of the RFM masked group
(P = .044). Continuous positive airway pressure use was greater in the visible RFM group (73%
vs 43%; P = .035). Intubation in the delivery room was done in 21% of the visible group and
in 57% of the masked group (P = .035).Using an RFM was associated with significantly less
mask leak, more mask adjustments, and a lower rate of excessive V(T).Copyright ?? 2012
Mosby, Inc. All rights reserved.
Schm?lzer, G. M., et al. (2008). "Reducing lung injury during neonatal resuscitation of
preterm infants." The Journal of pediatrics 153(6): 741-745.
Schmidt-Nowara, W. W. (1984). "Continuous positive airway pressure for long-term
treatment of sleep apnea." American journal of diseases of children (1960) 138(1): 82-84.
Severe obstructive sleep apnea in a child with cleft palate and micrognathia
developed after soft-palate repair. Continuous positive airway pressure applied to the nose
during sleep corrected the abnormalities of sleep and breathing. Long-term treatment
produced a remission of all symptoms. Proper technique was important. Continuous positive
airway pressure was effective in treating obstructive sleep apnea in this child, and long-term
treatment was implemented in the home.
Schmolzer, G. M. (2012). "Techniques and devices for neonatal resuscitation." Archives of
Disease in Childhood 97: A18-.
Establishing breathing and oxygenation after birth is vital for survival and long-term
health of premature infants. However, approximately 10% of premature infants require
breathing support at birth. An international consensus and various national resuscitation
guidelines suggest techniques and equipment for neonatal resuscitation. They all agree
positive pressure ventilation is the cornerstone of breathing support in the delivery room. A
lung-protective strategy should start immediately after birth. To facilitate the early
development of functional residual capacity, and improve oxygenation during the transition
of preterm infants, sustained inflations, positive end expiratory pressure and continuous
positive airway pressure (CPAP) should be applied at the initiation of respiratory support.
Although sustained inflations (SI) are advocated as lung recruitment maneuvers and positive
end expiratory pressure helps to maintain end expiratory lung volume, neither of these has
been mandated in neonatal resuscitation guidelines. This presentation will provide an update
on current literature about techniques and devices used during neonatal resuscitation. Initial
respiratory support provided with either CPAP, SI, and positive pressure ventilation along
with available devices (e.g. face mask, nasal prong, Guedel airway, Laryngeal airway mask)
will be discussed. In addition, new insights about intubation and chest compressions will be
presented.
Schmolzer, G. M., et al. (2010). "Prevalence of airway obstruction and mask leak during face
mask ventilation of preterm infants in the delivery room." Journal of Paediatrics and Child
Health 46: 40-41.
Background: The effectiveness of positive pressure ventilation (PPV) in the delivery
room can be impaired by many factors. This study reviewed recordings of neonatal
resuscitations at The Royal Women's Hospital, Melbourne, Australia to assess the prevalence
of mask leak and airway obstruction. Methods and Patients: Recordings of infants <32 weeks
gestation born between February 2006 and March 2009 were reviewed. Mask PPV was
delivered with a T-piece or self-inflating bag. Airway pressure and gas flow were recorded. A
webcam showed the resuscitation. Obstruction was defined as a 75% reduction in expired
tidal volume compared to the 10 previous inflations. Face mask leak was defined as a leak
(greater-than or equal to)75% of delivered tidal volume. Results: Recordings from 53 preterm
infants were analysed. A median (IQR) of 76 (53-98) inflations were analysed for each infant.
Obstruction and leak were identified in 14 (26%) and 27 (51%) respectively. In eight infants
both obstruction and leak were present; in 17 neither occurred. Obstruction occurred at a
median (IQR) of 48 (24-60) s after start of PPV. A median (range) of 22 (3-83) consecutive
obstructed inflations were delivered during each resuscitation. Face mask leak occurred from
the first inflation in 19/27. A median (range) of 10 (3-117) consecutive inflations with a leak
(greater-than or equal to)75% were delivered. Conclusion: Face mask leak is more common
than airway obstruction during neonatal resuscitation. Both may cause a clinically important
reduction in the tidal volumes delivered.
Schmolzer, G. M., et al. (2010). "Delivery room resuscitation : Review of equipment and
survey of practice in Austria." Monatsschrift fur Kinderheilkunde 158(5): 471-476.
Approximately 3%-6% of all newborn infants require some form of resuscitation at
birth, making neonatal resuscitation one of the commonest medical interventions. An
internationally agreed consensus statement and various guidelines advise how newborn
infants should be resuscitated and suggest equipment to use. The aim of this study was to
compare the current standard of neonatal resuscitation in Austria with the neonatal
resuscitation guidelines published in 2005. A questionnaire was sent to Austrian neonatal
units with delivery rooms. The questionnaire evaluated the use of positive pressure
ventilation devices, pulse oximetry, laryngeal mask, oral (Guedel) airway, oxygen blenders,
use of supplementary oxygen in term infants, CO2 detectors and polyethylene wrapping for
infants (less-than or equal to) 28 weeks. All 20 neonatal units contacted answered the
questionnaire. The initial oxygen concentration during resuscitation of term infants ranged
between 21% and 100%. A total of 17 (85%) departments used oxygen blenders, the others a
flow meter. Pulse oximetry was used in 20 (100%) departments, nine (45%) used a selfinflating-bag and a T-piece device. Two departments used either the self-inflating or the Tpiece device and none used the flow-inflating bag. An oral airway (Guedel) was used in 10
(50%) and a laryngeal mask in eight (40%) departments. CO2 detectors were in use in six
(30%) and polyethylene wrapping in 11 (55%) departments. This survey shows that, in line
with the international trend, a wide-ranging variety of equipment is used also in Austria,
reflecting the lack of data on neonatal resuscitation. (copyright) 2010 Springer Medizin
Verlag.
Schulze, A. (2002). "Respiratory mechanical unloading and proportional assist ventilation in
infants." Acta paediatrica (Oslo, Norway : 1992). Supplement 91(437): 19-22.
Conventional patient-triggered ventilation attempts to synchronize the upstroke in
ventilator pressure with the onset of spontaneous inspiration. Other parameters of the
mechanical cycle such as the peak inspiratory pressure are preset by the clinician. They will
be imposed on the infant regardless of the actual spontaneous respiratory drive. Proportional
assist ventilation (PAV) and respiratory mechanical unloading of spontaneous breathing
(RMU, resistive and elastic unloading) are based on fundamentally different concepts. In
contrast to the conventional perception of the ventilator being a pump, RMU/PAV servocontrols the applied ventilator pressure continuously throughout each inspiration. These
modalities proportionally enhance the effect on ventilation of each respiratory effort. They
rely on rather than interfere with the subject's respiratory control system. The patient controls
all variables of the respiratory pattern while the ventilator works fully enslaved as a
proportional amplifier. Back-up conventional mechanical ventilation is initiated during
episodes of hypoventilation and apnoea. The clinician sets the degree of the assist during
RMU/PAV in terms of gains. Selecting specific gains for the elastic and resistive unloading
components allows the ventilator pressure waveform to be tailored to the individual degree of
restrictive and obstructive pulmonary disease. This results in a reduction in the
transpulmonary pressure cost of ventilation compared with conventional modes.Further
studies on RMU/PAV are required to evaluate clinically important long-term outcome
variables in infants and to determine whether the benefits outweigh potential drawbacks and
the complexity involved in these new modes of mechanical ventilation.
Scopesi, F., et al. (2010). "The proper tidal volume target using volume guarantee ventilation
in the course of neonatal respiratory distress syndrome: a crucial endpoint." The journal of
maternal-fetal & neonatal medicine : the official journal of the European Association of
Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International
Society of Perinatal Obstetricians 23(7): 692-694.
Volume guarantee ventilation (VGV) is an optional ventilation mode which has
become the most widely and extensively studied in the last 10 years in premature infants.
Nonetheless, theoretical expected endpoints are intriguing and even though VGV has not yet
become 'the' standard ventilation mode, a great deal of information has been acquired and
stored. In our experience, VGV during the course of respiratory distress syndrome is useful
and can be considered a standard ventilation mode. Weaning occurs in real time as described
earlier, and synchronized intermittent positive pressure ventilation and pressure support
ventilation (PSV) seem to be the preferred combined modes. Management during the acute
phase requires more care since several sudden changes take place in both the lung mechanics
and clinical behavior. The software is designed to protect the lung, and subsequently, sudden
changes in lung compliance following iatrogenic procedures such as surfactant administration
are powerfully counteracted. VGV has been extensively studied and the proposed algorithm
has been found to function as planned. Although the 'superiority' of one method over another
cannot be demonstrated, the use of new technologies require 'a staff learning curve' and
homogeneity of treatment, while at the same time other factors, such as patient heterogeneity
or illness phase, should be taken into due account.
Shaw, E. B. (1974). "Endotracheal intubation and tracheostomy--clinical concepts." Diseasea-month : DM: Jan-35.
Shepard, F. M., et al. (1971). "Hemodynamic effects of mechanical ventilation in normal and
distressed newborn lambs. A comparison of negative pressure and positive pressure
respirators." Biology of the Neonate 19(1): 83-100.
Shneerson, J. M. and A. K. Simonds (2002). "Noninvasive ventilation for chest wall and
neuromuscular disorders." European Respiratory Journal 20(2): 480-487.
Neuromuscular and chest wall disorders are individually uncommon but together
form an important group of conditions that can lead to chronic ventilatory failure. This is best
recognised in scoliosis, kyphosis, following a thoracoplasty, in muscular dystrophies, such as
Duchenne muscular dystrophy (DMD), and myotonic dystrophy, after poliomyelitis and with
motor neurone disease (amyotrophic lateral sclerosis). If bulbar function is impaired,
tracheostomy ventilation may be required, but in other situations, noninvasive ventilation is
preferable. Positive pressure techniques using nasal and face masks are usually the first
choice, but negative pressure ventilation is an alternative. There are no randomised-controlled
trials regarding the indications for initiating noninvasive ventilation, but this is usually
provided if there are symptoms due to nocturnal hypoventilation or right heart failure in the
presence of a raised carbon dioxide tension in arterial blood (Pa,CO2) either at night or, more
usually, in the daytime as well. There is no evidence that prophylactic ventilatory support is
of benefit if this is provided before ventilatory failure has appeared. Careful selection of
patients is required, especially in the presence of progressive neuromuscular disorders such as
DMD and motor neurone disease. There are no randomised-controlled trials concerning the
outcome of noninvasive ventilation in these conditions, but studies have shown an improved
quality of life, physical activity and haemodynamics, normalisation of blood gases and slight
improvement in other physiological measures, such as the vital capacity and maximal mouth
pressures. Survival in chest wall disorders is -90% at 1 yr and 80% at 5 yrs, and similar
figures have been obtained in nonprogressive neuromuscular conditions. If, however, the
underlying disorder is deteriorating, particularly if it involves the bulbar muscles, it may limit
survival despite the provision of adequate noninvasive ventilatory support.
Shuman, R. M. and T. K. Oliver (1976). "Face masks defended." Pediatrics 58(4): 621-623.
Sickles, E. A. and C. A. Gooding (1976). "Asymmetric lung involvement in
bronchopulmonary dysplasia." Radiology 118(2): 379-383.
The radiographic distribution of pulmonary abnormalities in bronchopulmonary
dysplasia (BPD) in all previously reported cases has been bilateral and generalized. The
authors studied 11 premature infants who had BPD that was primarily unilateral. The striking
feature in each of these patients was the occurrence of an episode of prolonged unilateral
atelectasis or tension pneumathorax. Few, if any, radiographic manifestations of BPD
developed. Results of a detailed analysis of oxygen exposure and respirator therapy during
the periods of unequal lung ventilation further characterizes the protective effect of atelectasis
and tension pneumothorax in the development of BPD.
Sills, J. H., et al. (1989). "Continuous negative pressure in the treatment of infants with
pulmonary hypertension and respiratory failure." Journal of perinatology : official journal of
the California Perinatal Association 9(1): 43-48.
We report the successful use of continuous negative pressure (CNP) with standard
intermittent mandatory ventilation (IMV) in five patients suffering from respiratory failure
and persistent pulmonary hypertension of the newborn (PPHN). These infants all fulfilled
criteria for use of extracorporeal membrane oxygenation (ECMO) with PaO2 less than 40 torr,
alveolar-arterial oxygen difference (AaDO2) greater than 620 mm Hg, and oxygenation index
(OI) greater than 50. Despite a considerable amount of conventional ventilation with mean
airway pressures (PAW) between 14 and 26 cm water, none of these patients were able to
improve oxygenation. All infants demonstrated significant improvement in ventilation
requirements after initiation of CNP as reflected by a decrease in PAW, proximal inspiratory
pressure (PIP), and IMV. Oxygenation dramatically improved in all infants. All five patients
survived without any pulmonary or neurological complications at discharge. Availability of
CNP may circumvent the need for ECMO in infants with severe lung disease and PPHN.
Silvestri, S. (2006). "The influence of flow rate on breathing circuit compliance and tidal
volume delivered to patients in mechanical ventilation." Physiological measurement 27(1):
23-33.
Assessment of the gas volume that actually reaches the airways during mechanical
ventilation appears to be a difficult task because of the presence of the breathing circuit. Most
ventilators measure tidal volume at ventilator level making the determination of circuit
compliance a critical factor in estimating the actual tidal volume. Tubing compliance can be
measured in several ways and its value, being strongly dependent on the compressibility of
the gas, may significantly differ depending on the measurement procedure. This paper
addresses the dependence of the circuit compliance on the flow rate, and a theoretical
hypothesis on the pneumatic behaviour of the breathing circuit is formulated and
experimentally validated, with several tests conducted in vitro on an infant analogue. The
dependence of the compliance on the inspiratory flow is experimentally assessed, and
differences of about 20% on the measured value in the common flow range utilized in infant
ventilation have been found, with consequent estimation errors of the volume delivered.
Experimental tests show that the correct value of the tidal volume actually delivered to the
patient can be reliably estimated from measurements performed at the ventilator level if the
circuit compliance is determined with the same flow rates that will be utilized in mechanical
ventilation.
Simbruner, G. and M. Baum (1976). "A fluidic-controlled, miniature respirator with a new
positive airway pressure device." Journal of Perinatal Medicine 4(3): 184-192.
A simple and miniature respirator was developed providing controlled ventilation
and application of a positive airway pressure. The positive airway pressure is achieved by an
airflow through a canula into the airways. During expiration the direction of this insufflated
air-flow is changed and the dynamic pressure necessary for it manifests itself as a positive
airway pressure. Mechanical ventilation functions according to the principle of the Ayre-TPiece: flow direction and, therefore ventilation, is controlled by occlusion of the expiratory
limb. Occlusion is brought about by inflating a balloon. The inflation of the balloon is
controlled by fluidic-circuits. They allow setting of frequency, duration of inspiration and
pressure limit. As the above mentioned system for creating a positive airway pressure is
integrated, mechanical ventilation with PEEP is achieved. Tests on a lung model were
performed to establish the variables which influence the amount of positive pressure
produced by an air-flow through a canula into a tube. Results indicate that the positive
pressure obtained is inversely correlated to the diameter of tube and canula and varies with
the angle of inflow (Tab. I, II, Fig. 4). The pressure-rise-velocity depicted in Fig. 5 suggests
that sighing is possible in an open system. On an anencephalic newborn pressure-flow-ratios
were established (Fig. 6). Pressure-time curves during spontaneous breathing, CPAP assisted
breathing and sighing combined with CPAP were recorded in a 3 month old baby (Fig. 7, 8,
9). The discussion states the technical performance of the respirator (frequency 100/min-1/3
min., tidal volume 5-100 ml, controlled ventilation with pressure limitation, application of
PEEP) and additional advantages (no apparatus deadspace, disposable i.e. sterile air supplysystem, the miniature dimensions 10 x 10 x 5 cm, versatility and simple therefore technically
reliable construction).
Simbruner, G. and G. A. Gregory (1981). "Performance of neonatal ventilators: the effects of
changes in resistance and compliance." Critical care medicine 9(7): 509-514.
The authors tested the ability of 6 neonatal ventilators (Baby bird, Bourns BP-200,
Veriflo, Bourns LS, ServoVent, SI-75) to deliver a preset tidal volume with minimal
pressures when the compliance and resistance of test lung were altered. The authors also
studied the effects of gas leaks from the system and the effects of PEEP. When the ventilator
cycling rates exceeded 28-43/min, gas trapping occurred despite compliances and resistance
appropriate for a healthy term infant. With a normal compliance and an elevated resistance,
gas trapping occurred above rates of 4-6/min. Under these same conditions (normal
compliance, elevated resistance), only 24-46% of the preset tidal volume was delivered. The
different ventilators caused the pressure within the test lung to exceed 5, 10, and 15 cm H2O
for differing amounts of time (sec)/min.
Simonds, A. K., et al. (2000). "Outcome of paediatric domiciliary mask ventilation in
neuromuscular and skeletal disease." European Respiratory Journal 16(3): 476-481.
Noninvasive positive pressure ventilation delivered by nasal mask or facemask has
been used widely in the last decade to manage chronic ventilatory failure in adults with
neuromuscular and chest wall disease. However, it has been thought that paediatric patients
would not be able to tolerate masks, and previous anecdotal reports on the paediatric
application of mask ventilation have not assessed the effects on nocturnal and arterial blood
gas control. Domiciliary mask ventilation has been used in 40 children with ventilatory
insufficiency due to congenital neuromuscular and skeletal disease aged 9 months-16 yrs.
Eighteen patients had symptomatic nocturnal hypoventilation, 17 had diurnal ventilatory
failure, three were referred for weaning and two had frequent chest infections associated with
sleep-disordered breathing. Thirty eight of the 40 patients tolerated mask ventilatory support
long-term. Diurnal mean(plus or minus)SD oxygen tension in arterial blood (Pa,O2)
increased from 8.5(plus or minus)1.8-10.9(plus or minus)1.7 kPa (p<0.001) and meansd
carbon dioxide tension in arterial blood (Pa,CO2) fell from 7.0(plus or minus)1.6-5.9(plus or
minus)0.8 kPa (p=0.01) following initiation of ventilatory support. Mean and minimum
nocturnal Pa,O2 and peak transcutaneous carbon dioxide tension (Ptc,CO2) (n=21) improved
significantly. Mask ventilation can be used successfully in young children and reverses
ventilatory insufficiency due to congenital neuromuscular and skeletal disease. (C) ERS
Journals Ltd 2000.
Sims, A. J., et al. (2012). "Remote measurement of the leak around the uncuffed tracheal tube:
objective measurement and physical characteristics." British journal of anaesthesia 108(1):
152-158.
We have developed a technique for measuring a characteristic of the tracheal tube
(TT)-trachea interface: the leak conductance (LC). This study aimed to validate the technique
in the laboratory and to compare LC with measurements of fractional volume loss (FVL) in
neonates undergoing mechanical ventilation.LC, expressed as leak flow at a lung pressure of
10 cm H(2)O, was derived remotely from ventilator pressure and flow signals. Validation
was by simulating breathing circuits for 10 models in which LC was measured directly. LC
was compared with FVL for different settings of PEEP, inspired pressure, and time at plateau
pressure. Clinically, LC was measured for 135 infants admitted to paediatric intensive care
after cardiac surgery and compared with FVL.No significant differences were found between
direct and remote laboratory measurements of LC (P>0.05). FVL varied with PEEP, plateau
pressure, and time at plateau (P<0.05) but LC did not (P>0.05). The between-patient standard
deviation (sd) of LC (0.4 litre min(-1)) exceeded the within-patient sd of lc (0.05 litre min(-1);
P<0.05); the between-patient sd of FVL (22.1%) exceeded the within-patient sd of FVL
(1.3%; P<0.05). The median LC was 0.38 (inter-quartile range 0.29-0.46) litre min(-1). LC
was correlated with FVL (r=0.82; 95% confidence interval 0.76-0.88) but wide ranges of
FVL were observed for patients with similar LC.LC can be derived remotely and was
correlated with FVL, a conventional proxy for tube fit. It may be a better measure of TT fit
than FVL.
Singh, J., et al. (2006). "Effects of a course in neonatal resuscitation--evaluation of an
educational intervention on the standard of neonatal resuscitation." Resuscitation 68(3): 385389.
Appropriate assessment and resuscitation is an important part of neonatal care
provided during the first minutes of life. Midwifery and junior medical staff are often in the
frontline of neonatal resuscitation. Appropriate education and training of midwifery staff is
therefore essential if the standard of care delivered to babies in the delivery suite is to be
improved and maintained. Evaluation of any such educational interventions is necessary to
assess their effectiveness.To assess the effect of a course in neonatal resuscitation introduced
in 1995 aimed at midwifery staff, on the standard of care provided to babies immediately
after birth. Prior to this, training in neonatal resuscitation was largely theoretical.Naturalistic
design observational study conducted in a maternity unit with a tertiary neonatal intensive
care unit in the North of England. We compared two groups of babies born before and after
the course was introduced. Use of naloxone in the delivery suite and appropriateness of its
use, and temperature on admission to neonatal intensive care unit were used as proxy markers
for standard of care and compared in the two groups. We also looked at the use of mask
intermittent positive pressure ventilation (IPPV) and tracheal intubation in the delivery
suite.Use of naloxone fell dramatically from 13.2% of all babies born in 1994 to 0.5% in
2003. Inappropriate use of naloxone before other resuscitation measures were initiated
declined from 75% of babies given naloxone in 1994 to 10% in 2003. The incidence of
hypothermia (<35 degrees C) on admission to neonatal unit declined from 9% of all
admissions to 2.3% in 2003. There was a trend towards increased use of mask ventilation in
the delivery suite with a corresponding trend towards less tracheal intubation.We have shown
that the intervention has been related temporally to an improvement in the quality of care
delivered by midwifery staff to newborn babies. Practical courses in neonatal resuscitation
can contribute to improvements in the quality of care provided to babies immediately after
birth. These courses are more effective than theoretical teaching alone.
Singh, R., et al. (2005). "Controlled trial to evaluate the use of LMA for neonatal
resuscitation." Journal of Anaesthesiology Clinical Pharmacology 21(3): 303-306.
One of every sixteen newborns require resuscitation in the delivery room. Most new
born infants who require positive-pressure ventilation are ventilated with a bag and mask or a
tracheal tube. The laryngeal mask airway, a relatively new general purpose airway, has been
used by some workers and they found it to be an effective alternative for establishing an
airway in resuscitation of the newly born infant, especially in case of ineffective bag-mask
ventilation or failed endotracheal intubation. Fifty neonates born surgically, who required
active resuscitation, were assigned randomly into two groups: a) Group-I :- 25 neonates who
were resuscitated with laryngeal mask airways, (b) Group-II :- 25 neonates who were
resuscitated with neonatal face mask. It was concluded that the use of laryngeal mask airway
was easy, safe and effective in the hands of personnel with expertise in airway management.
It can become an alternative to bag and mask ventilation for neonatal resuscitation.
Singh, Y. and S. Oddie (2012). "Stabilising preterm infants (< 32 weeks) in the delivery suite:
Current clinical practice in the uk." Archives of Disease in Childhood 97: A374-.
Background Resuscitation guideline for preterm infants has evolved over the last two
decades but this still lacks standardisation and clear recommendations. Clinical practice in
stabilising preterm infants in the delivery suite may vary from unit to unit. Aims and
objectives To find out the current clinical practice in the UK in stabilising the preterm infants
in the delivery suite. Study Design and methods Questionnaire based study carried out via
internet tool (SurveyMonkey) followed by telephone interview from non-responders.
Questionnaire completed by consultants, registrars or senior neonatal sisters (Band 6 and
above). Results 100% responses from all the 222 units providing neonatal care. 96% units
(113 of 222 units) use plastic bags for thermoregulation in preterm infants although clinical
practice varies from 27-32 weeks of gestation under what they use plastic bags. 56% units
(123 of 222 units) provide prophylactic CPAP in preterm infants to prevent or treat RDS.
Face mask with adjustable positive end expiratory pressure (PEEP) valve was the commonest
(50%; 111 of 222 units) means of providing prophylactic CPAP. But for ventilated babies 70%
units (154 of 222 units) provide PEEP routinely. 42% units (93 of 222 units) use start
resuscitation of preterm infants in bended oxygen, 33% in air, and 17% use 100% oxygen. 64%
units (143 of 222 units) use oxygen saturation monitor in the delivery suite while 28% don't
use it routinely. Conclusion Current clinical practice in stabilising preterm infants in the
delivery suite varies significantly from unit to unit in the UK.
Sinha, S. K. and S. M. Donn (1998). "Neonatal ventilation: present and future directions."
Indian pediatrics 35(7): 595-600.
Skare, C., et al. (2013). "Frequency of newborn resuscitation and stabilization in three
normal-risk delivery units in Norway." Circulation 128(22): -.
Introduction: Most newborn infants transition from intra- to extrauterine life without
interventions; yet neonatal morbidity remains a significant health problem in both resource
rich and resource poor health care systems. Although advanced resuscitation of newborn
infants with chest compressions, intravenous drugs, and fluids is relatively rare, there are
limited data on the frequency of neonatal stabilization and resuscitation measures in normalrisk delivery units. METHODS: Prospective, observational study conducted in the delivery
units in three hospitals in Norway. All newborn infants assessed for stabilization and/or
resuscitation during one month were included. After each incident, data on resuscitation
measures and outcome were registered and reviewed by study personnel at every on-call team
shift during the study period. Approval was obtained from department heads and institutional
review boards. Results: 1507 babies were live born during the study period, mean weight 3.3
kg and gestational age 39.4 weeks.: 113 (7 %) needed resuscitation interventions beyond
drying and stimulation. Suctioning of oropharynx was performed in 77 babies (5 %) and
tracheal suctioning in 10 (1%). Positive pressure ventilation (PPV) was provided by a T-piece
resuscitator and/or by a self-inflating bag to 58 (4 %) with 39 (3 %) receiving supplementary
oxygen. In addition CPAP (but no PPV) was provided to 17 (1 %). One needed chest
compressions. Tracheal intubation was accomplished in 4 infants of whom 3 were
prematurely born and treated with tracheal surfactant. Intravenous access was established in 8
infants, two received saline infusions and one received epinephrine. After initial resuscitation,
64 (4 %) were admitted to the neonatal intensive care unit and two died. Twenty-one events
were handled exclusively by midwifes, 244 by pediatric residents and 39 by attending
neonatologists. CONCLUSION: Most newborns do not need advanced resuscitation
procedures. However, even in low risk deliveries, more than 4 % of newborns required
assisted ventilation. Correct assessment of need for ventilatory support and correct execution
of positive pressure ventilation needs to be ensured.
Smith, R. B. (1982). "Ventilation at high respiratory frequencies. High frequency positive
pressure ventilation, high frequency jet ventilation and high frequency oscillation."
Anaesthesia 37(10): 1011-1018.
This paper reviews the development of different methods of ventilation at respiratory
rates higher than 60 per minute (1 Hz) along with data on experimental and clinical uses of
the techniques. The definitions and terms that have been used for these high rates at the
present time are confusing. An attempt to clarify the terms has been made. Whereas high
frequency positive pressure ventilation (HFPPV) refers to respiratory rates between 60-110
per minute (1-1.8 Hz), high frequency jet ventilation (HFJV) usually refers to rates between
110-400 per minute (1.8-6.7 Hz) and high frequency oscillation (HFO) refers to rates above
400 and up to 2400 per minute (40 Hz). It should be recognised that this differentiation in
terminology is rather arbitrary and does not necessarily represent a sudden switch to different
physiological methods of ventilation. In view of the various techniques which are involved in
ventilation methods utilising rates greater than 60 per minute (1 Hz), it is the purpose of the
present work to review the literature. In so doing, the contrasting rates, mechanical equipment,
and experimental and clinical uses of these different methods will be discussed in order to
clarify their potential contribution to clinical medicine.
Smith, Z. K. (2006). "Adapting a soft silicone dressing to enhance infant outcomes."
Ostomy/wound management 52(4): 30-32.
Smythe, P. M. (1966). "Treatment of tetanus neonatorum." International anesthesiology
clinics 4(2): 435-443.
Sola, A., et al. (1992). "Lack of relationship between the true airway pressure and the
pressure displayed with an infant ventilator." Critical care medicine 20(6): 778-781.
To establish if the pressure indicated in the manometer of an infant ventilator (IV
100B, Sechrist, Anaheim, CA) reflects the true pressure delivered to the proximal airway
during mechanical ventilation in the neonatal ICU.With approval of our Institutional
Research Board, data were collected prospectively. Peak inspiratory pressure and endexpiratory pressure were measured at the Y piece of the breathing tubing. Pressure readings
from the conventional ventilator's manometer were compared with simultaneously obtained
measurements using an electronic monitor.This study was conducted in a 45-bed neonatal
ICU, admitting 700 to 750 newborns per year.Twelve neonates who required mechanical
ventilation were included in the study.Specific interventions were not made by study design.
Measurements routinely obtained were compared.Two hundred seventy-five simultaneous
measurements of peak inspiratory pressure and positive end-expiratory pressure were
compared. Peak inspiratory pressure values were higher with the electronic monitor in 273
(99%) of 275 measurements and the mean of the differences between the electronic monitor
and ventilator's manometer was statistically significant (p less than .001). For positive endexpiratory pressure measurements, values indicated by the electronic monitor were lower in
152 (55%) of 275 determinations, equal in 65 (23%), and higher in 58 (21%) determinations.
Percent variations between methods ranged from 0% to 140% for peak inspiratory pressures
and from 0% to 500% for positive end-expiratory pressure.These data demonstrate that it is
impossible to know the true pressure delivered to the proximal airway of a neonate during
mechanical ventilation by observing the ventilator pressure manometer. The manometer
readings consistently underestimate the true peak inspiratory pressure values and are very
unpredictable regarding positive end-expiratory pressure values. These findings support the
use of other methods to monitor the proximal airway pressure besides the ventilator's
manometer in the neonatal ICU. Furthermore, mean airway pressure should not be calculated
from the pressure readings obtained from the tested ventilator's manometer.
Solberg, M. T., et al. (2013). "Adherence to oxygenation and ventilation targets in
mechanically ventilated premature and sick newborns: A retrospective study." BMC
Pediatrics 13(1): -.
Background: Ventilator treatment exposes newborns to both hyperoxemia and
hyperventilation. It is not known how common hyperoxemia and hyperventilation are in
neonatal intensive care units in Norway. The purpose of this study was to assess the quality
of current care by studying deviations from the target range of charted oxygenation and
ventilation parameters in newborns receiving mechanical ventilation.Methods: Single centre,
retrospective chart review that focused on oxygen and ventilator treatment practices.Results:
The bedside intensive care charts of 138 newborns reflected 4978 hours of ventilator time.
Arterial blood gases were charted in 1170 samples. In oxygen-supplemented newborns, high
arterial pressure of oxygen (PaO2) values were observed in 87/609 (14%) samples. In
extremely premature newborns only 5% of the recorded PaO2 values were high. Low arterial
pressure of CO2 (PaCO2) values were recorded in 187/1170 (16%) samples, and 64 (34%) of
these were < 4 kPa. Half of all low values were measured in extremely premature newborns.
Tidal volumes above the target range were noted in 22% of premature and 20% of full-term
newborns.Conclusions: There was a low prevalence of high PaO2 values in premature
newborns, which increased significantly with gestational age (GA). The prevalence of low
PaCO2 values was highest among extremely premature newborns and decreased with
increasing GA. Further studies are needed to identify whether adherence to oxygenation and
ventilation targets can be improved by clearer communication and allocation of
responsibilities between nurses and physicians. (copyright) 2013 Solberg et al.; licensee
BioMed Central Ltd.
Squires, K. A. G., et al. (2013). "High-frequency oscillatory ventilation with low oscillatory
frequency in pulmonary interstitial emphysema." Neonatology 104(4): 243-249.
Background: Pulmonary interstitial emphysema (PIE) is a common respiratory
illness in preterm infants associated with significant morbidity and mortality for which the
ventilatory management is imperfect. Objectives: To evaluate the impact of high-frequency
oscillatory ventilation (HFOV) with a low oscillatory frequency and thus prolonged
expiratory time in preterm infants with severe PIE. Methods: In a retrospective cohort study,
preterm infants (less-than or equal to)30 weeks' gestation with radiological findings of severe
PIE, and either high FiO2 or persistent respiratory acidosis were studied if managed on
HFOV with a low frequency (5-6 Hz, inspiratory time 30%) for >24 h. Trends in
physiological and ventilatory parameters were examined over the first 72 h, radiological
changes noted, and in-hospital outcomes ascertained. Results: 19 cases were identified and
analysed in two groups: 14 with bilateral and 5 with predominantly unilateral disease. After
transition to low-frequency HFOV, physiological responses were seen in both groups, in
particular a rapid and sustained improvement in oxygenation in the bilateral group (mean (SD)
alveolar-arterial oxygen difference at baseline: 404 (plus or minus) 206 mm Hg; 4 h posttransition: 262 (plus or minus) 181 mm Hg; 72 h: 155 (plus or minus) 74 mm Hg; p = 0.0003).
This occurred following a reduction in mean airway pressure (mean (SD) baseline: 14 (plus
or minus) 3.9 cm H2O; 72 h: 12 (plus or minus) 2.9 cm H2O; p = 0.011). In the unilateral
group, radiological resolution of PIE was observed on re-inflation following collapse of the
affected lung. Overall, 15 infants survived, including 10 of the bilateral cases (71%), and all
of the unilateral cases. Conclusion: HFOV with a low oscillatory frequency may afford
benefit in preterm babies with severe PIE. Copyright (copyright) 2013 S. Karger AG, Basel.
Stahlman, M. T. and R. B. Cotton (1975). "Letter: Early versus late initiation of continuous
negative pressure in infants with clinical hyaline membrane disease." The Journal of
pediatrics 87(4): 601.
Stayer, S. A., et al. (2001). "Volume ventilation of infants with congenital heart disease: a
comparison of Dr?ger, NAD 6000 and Siemens, Servo 900C ventilators." Anesthesia and
Analgesia 92(1): 76-79.
We compared the ventilation and pulmonary mechanics produced by a new
anesthesia ventilator (NAD 6000) using a circle system with that produced by a critical care
ventilator (Servo 900C) using a nonrebreathing circuit in infants with congenital heart disease.
Twenty patients, aged 1 day to 7 mo, weighing 2.1 to 4.6 kg, were studied. The NAD 6000
had improved alveolar ventilation: PaCO(2) 43 +/- 8 vs 47 +/- 5 mm Hg (P = 0.005), endtidal CO(2) 34 +/- 7 vs 37 +/- 5 mm Hg (P = 0.042); larger inspired tidal volumes 12.9 +/- 2.8
vs 11.3 +/- 2.2 mL/kg (P < 0.001), but with higher mean airway pressures 9.7 +/- 1.6 vs 8.6
+/- 1.3 cm H(2)O (P < 0.001). These differences in ventilation and airway pressures were not
clinically significant. Although there were differences in observed ventilatory variables, both
machines provided adequate ventilation when set in the volume control mode. Implications:
We compared two ventilators for use in infants. Twenty infants undergoing surgery for
congenital heart defects were randomized to receive ventilation first with one ventilator, then
with the other. Although there were differences in observed ventilatory variables, both
machines provided adequate ventilation when set in the volume control mode.
Stayer, S. A., et al. (2000). "Comparison of NAD 6000 and servo 900C ventilators in an
infant lung model." Anesthesia and Analgesia 90(2): 315-321.
We compared the ability of the NAD 6000 (North American Dr?ger, Telford, PA)
and the Servo 900C (Siemens-Elema AB, Solna, Sweden) anesthesia ventilators to maintain
precise delivery of small tidal volumes (V(t)) and positive end-expiratory pressure using an
infant test lung model. A variety of ventilator and lung model settings were selected to test
clinical conditions simulating normal and extremely compromised lung function. Differences
in ventilator output were analyzed by using an independent t-test with P <0.05 considered
significant. With the ventilators set to deliver a V(t) of 30 mL, the actual delivered V(t) was
significantly better for the NAD 6000 (25 +/- 2 mL) compared with the Servo 900C (18 +/- 3
mL), P <0.001. When the ventilators were set to deliver 100 mL V(t), their delivered V(t)
were not significantly different, NAD 6000 (66 +/- 19 mL) and Servo 900C (60 +/- 12 mL), P
= 0.09. The exhaled V(t) read by the anesthesia machines was significantly closer to the
delivered V(t) for the NAD 6000 (11 +/- 9 mL) compared with the Servo 900C (37 +/- 11
mL), P < 0.001. Both ventilators maintained the end expiratory pressure delivered to the test
lung within 2 cm H(2)O of the set positive end-expiratory pressure on average. As the
conditions changed requiring the ventilator to develop a higher peak inflating pressure, both
ventilators showed a decrease in V(t) delivered, which was proportionate to the tubing
compression volume loss.The NAD 6000 (North American Dr?ger, Telford, PA) and Servo
900C (Siemens-Elema AB, Solna, Sweden) are able to precisely deliver small Tidal Volumes.
They both decreased in performance when tested under extreme conditions. Earlier studies of
traditional anesthesia ventilators suggest that the NAD 6000 and Servo 900C are superior
pediatric ventilators.
Steier, M., et al. (1974). "Pneumothorax complicating continuous ventilatory support." The
Journal of thoracic and cardiovascular surgery 67(1): 17-23.
Stern, L. (1970). "Results of artificial ventilation in the newborn." Biology of the Neonate
16(1): 155-163.
Stewart, A. R., et al. (1981). "Effects of alterations of inspiratory and expiratory pressures
and inspiratory/expiratory ratios on mean airway pressure, blood gases, and intracranial
pressure." Pediatrics 67(4): 474-481.
Twenty neonates requiring mechanical ventilation for respiratory failure, including
13 with hyaline membrane disease, were studied to assess the effects of alterations in
ventilator settings on mean airway pressure (MAP), blood gases, and intracranial pressure
(ICP). The study involved random alterations in peak inspiratory pressure (PIP), positive endexpiratory pressure (PEEP), and inspiratory/expiratory ratio while MAP, PaO2, ICP, and endtibal PCO2 were continuously monitored. The results showed a significant relationship
between MAP and PaO2 that was expressed as the change in PaO2 per millimeter of mercury
change in MAP (delta PaO2/delta MAP) with a mean delta PaO2/delta MAP of 4.92. The
delta PaO2/delta MAP was highest for changes in PEEP (6.08), followed by PIP (5.07), and
inspiratory/expiratory ratio (1.9). There was a significant relationship between alterations in
PEEP and PIP vs PaCO2 and pH. Increases in PEEP and decreases in PIP resulted in an
elevated PaCO2 and a lowered pH, and decreases in PEEP and increases in PIP resulted in a
decreased PaCO2 and an elevated pH. There was no significant relationship between MAP
and ICP, but there was a significant association between delta ICP and delta PaCO2 during
alterations in PIP (r = .64, P less than .001). Increases in PEEP will lead to the greatest
increase in PaO2 per change in MAP, followed by increase in PIP and inspiratory/expiratory
ratio using a pressure-limited ventilator.
Stock, M. C. and J. B. Downs "Administration of continuous positive airway pressure by
mask." Acute care 10(04-Mar): 184-188.
Stocks, J. G. (1973). "The management of respiratory failure in infancy." Anaesthesia and
Intensive Care 1(6): 486-506.
Surenthiran, S. S., et al. (2003). "Noise levels within the ear and post-nasal space in neonates
in intensive care." Archives of disease in childhood. Fetal and neonatal edition 88(4): F315318.
Noise exposure in neonatal units has long been suspected of being a cause of hearing
loss associated with such units. The noise intensity to which the neonate is exposed varies
with the type of ventilatory support used. Also, the post-nasal space is an enclosed cavity that
is close to the inner ear and an area of turbulent and hence potentially noisy airflow. Aim: To
determine noise intensities within the ear and post-nasal space in neonates on different modes
of ventilatory support using probe microphones, measures previously not undertaken.A
portable instrument with a probe microphone was used for the measurements. Three groups
of infants were included: (a) those receiving no respiratory support (NS); (b) those receiving
conventional ventilation (CV); (c) those receiving continuous positive airways pressure
(CPAP) support.The mean in-the-ear noise intensities (at 1 kHz) were 41.7 dB SPL (NS),
39.5 dB SPL (CV), and 55.1 dB SPL (CPAP). The noise intensities in the post-nasal space in
those receiving CPAP support were higher than in the other groups, reached mean levels of
up to 102 dB SPL at some frequencies, and increased with increasing flow rates.The most
important finding is the high noise intensities in the post-nasal space of those receiving CPAP
support. Given the proximity of the post-nasal space to the inner ear, enough noise could be
transmitted, especially in infants receiving the higher flow rates, to cause cochlear damage
and hence hearing loss. It would therefore be wise, wherever possible, to avoid using the
higher flow rates.
Suutarinen, T., et al. (1966). "Intubation in respiratory difficulty in children." Acta OtoLaryngologica: Suppl 224:417+.
Swyer, P. R. (1970). "Methods of artificial ventilation in the newborn (IPPV)." Biology of
the Neonate 16(1): 15-Mar.
Swyer, P. R. (1970). "Symposium on artificial ventilation. Summary of conference
proceedings." Biology of the Neonate 16(1): 191-195.
Szczapa, T., et al. (2013). "Monitoring diaphragm electrical activity and the detection of
congenital central hypoventilation syndrome in a newborn." Journal of Perinatology 33(11):
905-907.
A full-term newborn infant is described with recurrent episodes of oxygen
desaturation and apnea on the day of birth. The apnea did not improve with continuous
positive airway pressure (CPAP) and intermittent nasal ventilation, therefore intubation and
mechanical ventilation were required. A preliminary diagnosis of congenital central
hypoventilation syndrome (CCHS) was made with the use of simultaneous measurements of
end-tidal CO 2 (EtCO 2) and a diaphragm electrical activity waveform that was detected
using microsensors placed on the infant's feeding tube. It was observed that during deep sleep,
the diaphragm electrical activity waveform was close to 0 (mu)V (central apnea) and EtCO 2
levels rose accordingly (central hypoventilation). Genetic testing subsequently revealed a
Phox2b mutation, establishing the diagnosis of CCHS. Simultaneously measuring diaphragm
electrical activity and EtCO 2 is feasible and may be a valuable bedside diagnostic tool in
cases of suspected CCHS before the diagnosis is confirmed with genetic testing. (copyright)
2013 Nature America, Inc. All rights reserved.
Szyld, E. G., et al. (2012). "Newborn ventilation: Comparison between a T-piece resuscitator
and self-inflating bags in a neonatal preterm simulator." Archivos Argentinos de Pediatria
110(2): 106-112.
Introduction. Although the provision of effective assisted ventilation is the most
effective intervention in delivery room resuscitation of depressed newborn infants, there is
still limited evidence about which is the optimal device to deliver positive pressure
ventilation (PPV). Objective. To compare the accuracy of pressures and ventilation rate (VR)
delivered to a neonatal simulator with three devices: 240 ml and 450 ml self-inflating bags
(SIB) and a T-piece resuscitator, and to evaluate the variability in terms of providers'
experience. Material and methods. 76 health care providers divided in two groups according
to experience were asked to provide positive pressure ventilation to a neonatal simulator
through a facial mask or an endotracheal tube with three ventilating devices: a T-piece
resuscitator, a 240 ml and a 450 ml self-inflating bags. Participants used each combination of
device and interface randomly on 2 consecutive occasions. Mean and maximum PIP and
respiratory rate were recorded. Statistical analyses were performed using two-factor analysis
of variance for repeated measures. Result. SIB 240 and 450 were similar in the mean target
peak inspiratory pressure (PIP) but both were significantly different (p < 0.001) from T-piece,
although all values were close to the target. Mean VR was over the target for all the devices
(p < 0.001). The highest difference found was 7 (plus or minus) 1.7 breaths/minute with the
240 ml bag when compared with the T-piece using a mask. Experienced operators were
closer than novice operators to target VR, regardless of the device or interface. Conclusion.
The accuracy for the devices was comparable in the variables measured regardless operator's
experience. Overall, the T-piece provided lower PIP while both SIB, higher than the target.
The VR was over the target for all the devices. Both SIB and novice participants were
associated with higher VR. The intraoperator consistency was comparable in the variables
measured with all devices.
Szyld, E. G., et al. (2012). "[Newborn ventilation: comparison between a T-piece resuscitator
and self-infating bags in a neonatal preterm simulator]." Archivos argentinos de pediatr?a
110(2): 106-112.
Although the provision of effective assisted ventilation is the most effective
intervention in delivery room resuscitation of depressed newborn infants, there is still limited
evidence about which is the optimal device to deliver positive pressure ventilation (PPV).To
compare the accuracy of pressures and ventilation rate (VR) delivered to a neonatal simulator
with three devices: 240 ml and 450 ml self-infating bags (SIB) and a T-piece resuscitator, and
to evaluate the variability in terms of providers' experience.76 health care providers divided
in two groups according to experience were asked to provide positive pressure ventilation to a
neonatal simulator through a facial mask or an endotracheal tube with three ventilating
devices: a T-piece resuscitator, a 240 ml and a 450 ml self-infating bags. Participants used
each combination of device and interface randomly on 2 consecutive occasions. Mean and
maximum PIP and respiratory rate were recorded. Statistical analyses were performed using
two-factor analysis of variance for repeated measures.SIB 240 and 450 were similar in the
mean target peak inspiratory pressure (PIP) but both were significantly different (p < 0.001)
from T-piece, although all values were close to the target. Mean VR was over the target for
all the devices (p < 0.001). The highest difference found was 7 �� 1.7 breaths/minute with
the 240 ml bag when compared with the T-piece using a mask. Experienced operators were
closer than novice operators to target VR, regardless of the device or interface.The accuracy
for the devices was comparable in the variables measured regardless operator��s
experience. Overall, the T-piece provided lower PIP while both SIB, higher than the target.
The VR was over the target for all the devices. Both SIB and novice participants were
associated with higher VR. The intraoperator consistency was comparable in the variables
measured with all devices.
T?llner, U. and W. Steuer (1977). "[An efficient and simple installation for CPAP
treatment]." An?sthesiologische und intensivmedizinische Praxis 13(1): 139-142.
Tassaux, D., et al. (2002). "Comparative bench study of triggering, pressurization, and
cycling between the home ventilator VPAP II and three ICU ventilators." Intensive Care
Medicine 28(9): 1254-1261.
To compare triggering, pressurization, and cycling of the home ventilator VPAP II
with those of three ICU ventilators (Evita 4, Galileo, and Servo 300).Two-compartment lung
model study in a research laboratory, university hospital.One compartment was driven by an
ICU ventilator to mimic patient inspiratory effort, while the other was connected to the tested
ventilator. Pressure support of 10, 15, 20, and 25 cmH2O, and inspiratory efforts of 5, 10, 15,
20, and 25 cmH2O (inspiratory time 1 s) were used in normal, obstructive, and restrictive
conditions. Triggering delay (Td), triggering workload, pressurization at 300 and 500 ms, and
difference between the patient's inspiratory time and that of the ventilator were analyzed.No
difference was noted in triggering workload between VPAP II, Evita 4, and Galileo while
Servo 300 had a lower value. Pressurization at 300 ms on Evita 4 and Servo 300 reached 75%
of the ideal value, on Galileo 35%, and on VPAP II 45%. Pressurization at 500 ms on Evita 4
and Servo 300 reached 85% of the ideal value, on Galileo 50%, and on VPAP II 55%.
Cycling was delayed in obstructive conditions and premature in restrictive conditions with
each of the devices.The VPAP II performed as well as one ICU ventilator and less well than
two. Home devices for noninvasive ventilation in acute respiratory failure outside the ICU
could prove attractive as they are smaller, less costly, and easier to use than ICU machines.
Tatsuno, K., et al. (1976). "Therapeutic use of helium-oxygen mixture in continuous positive
airway pressure for early weaning from mechanical ventilation after cardiovascular surgery in
infants." The Journal of thoracic and cardiovascular surgery 72(1): 119-122.
Therapeutic use of helium-oxygen mixture in continuous positive airway pressure
(He-CPAP) was employed for early weaning from mechanical ventilation of 11 infants who
underwent cardiac surgery from August, 1974, to April, 1975. With the use of He-CPAP, a
20 to 30 mm. Hg elevation of PaO2 was usually observed and respiratory distress was
reduced, as compared to results obtained with nitrogen-oxygen CPAP. In all cases, He-CPAP
resulted in the possibility of relatively early removal of the endotracheal tube. Therefore, HeCPAP is recommendable for intermediate respiratory support between mechanical ventilation
and nitrogen-oxygen CPAP.
te Pas, A. B., et al. (2011). "Low versus high gas flow rate for respiratory support of infants
at birth: a manikin study." Neonatology 99(4): 266-271.
Neonatal resuscitation guidelines do not specify the gas flow rate during mask
ventilation. Aim: Investigating the effect of gas flow rates on pressures, volumes delivered
and mask leak.Flow 5 and 10 liters/min were tested. In study part 1, pressure ranges were
measured when ventilating an intubated manikin with a Neopuff��. In study part 2,
pediatric staff mask-ventilated a manikin (peak inflation pressure (PIP) 30 cm H(2)O,
positive end expiratory pressure (PEEP) 5 cm H(2)O). We measured pressures, expired tidal
volume (V(Te)) and mask leak.Study part 1:an intubated manikin was ventilated with flow 5
versus 10 liters/min: range in PEEP was 0.4-3.6 and 2-14 cm H(2)O, respectively, maximum
PIP was 73 cm H(2)O with both flow rates. Study part 2: when mask ventilation was given
with flow 5 versus 10 liters/min: leak decreased (24% (8-85) vs. 80% (34- 94); p < 0.0001),
V(Te) increased (6.7 (5.1-7.8) vs. 4.7 (2.4-7.0) ml; p < 0.001), PEEP decreased (3.1 (0.8) vs.
3.7 (0.7) cm H(2)O; p < 0.001), PIP was similar (28.1 (2.7) vs. 28.0 (2.3) cm H(2)O; NS).
Large leaks decreased V(Te) and PEEP during both flow rates, PIP only with flow 5
liters/min.A low flow rate during neonatal mask ventilation may be a good alternative
approach in reducing mask leak, provided that inflation time and flow rate warrants set
pressures. Only large leaks seem to influence delivered pressures and volumes. Before
resuscitation guidelines are advised, more studies on gas flow rates are needed.Copyright ?
2010 S. Karger AG, Basel.
te Pas, A. B. and F. J. Walther (2006). "Ventilation of very preterm infants in the delivery
room." Current Pediatric Reviews 2(3): 187-197.
Adequate functional residual capacity (FRC) is difficult to create with manual
ventilation in very preterm infants an carries a high risk for creating lung damage.
International guidelines for neonatal resuscitation do not provide ventilation guidelines for
very preterm infants despite evidence that a different approach may be warranted. Peak
inspiratory pressures (PIPs) generated with bag and mask ventilation are usually insufficient
to open up the lung or unintentionally excessive. The long time constant of the fluid-filled
immature lung can be overcome by delivering a prolonged inflation at a lower PIP, followed
by application of positive end-expiratory pressure (PEEP) to maintain FRC after lung
recruitment. To minimize the damage provoked by manual ventilation a consistent PIP,
adequate PEEP and prolonged inflation, have to be guaranteed. A mechanical pressurelimited T-piece resuscitator is the only device that meets these requirements. Leakage
between mask and face is prevented by using the nasopharyngeal route. After resuscitation,
FRC can be preserved by starting nasal continuous positive airway pressure (nCPAP) in the
delivery room, which will reduce the need for intubation and mechanical ventilation. This
review discusses the accumulated data supporting these recommendations. (copyright) 2006
Bentham Science Publishers Ltd.
Teague, W. G. (2003). "Noninvasive ventilation in the pediatric intensive care unit for
children with acute respiratory failure." Pediatric Pulmonology 35(6): 418-426.
Noninvasive ventilation, a novel treatment to increase alveolar ventilation, is
accomplished with either subatmospheric or positive pressure administered via an external
interface. In adults with acute respiratory failure, noninvasive positive pressure ventilation
(NPPV) is superior to standard therapy in preventing intubation and reducing mortality. The
role of NPPV in pediatric-age patients with acute respiratory distress is not as well
established. Early case reports showed that NPPV treatment does acutely improve both the
clinical manifestations of respiratory distress and respiratory gas exchange in children with
respiratory distress. However, it is not clear whether NPPV in this setting can prevent vs.
delay endotracheal intubation. Other uses of NPPV in the pediatric intensive care unit include
the treatment of upper airway obstruction, atelectasis, and exacerbations of neuromuscular
disorders, and to facilitate weaning from invasive mechanical ventilation. Successful use of
NPPV in young infants with respiratory distress is impeded by the lack of suitable size
interfaces, and the response characteristics of commercially available bilevel ventilators.
Despite these challenges, NPPV is a promising alternate to standard therapies in the treatment
of acute respiratory distress in the pediatric-age patient.Copyright 2003 Wiley-Liss, Inc.
Teague, W. G. and J. D. Fortenberry (1995). "Noninvasive ventilatory support in pediatric
respiratory failure." Respiratory Care 40(1): 86-96.
Thio, M., et al. (2014). "Self-inflating bags versus T-piece resuscitator to deliver sustained
inflations in a preterm lamb model." Archives of disease in childhood. Fetal and neonatal
edition.
In neonatal resuscitation, the use of a sustained inflation (SI) may facilitate lung
aeration. Previous studies comparing different resuscitation devices have shown that one
model of self-inflating bag (SIB) could not deliver an SI. We aimed to compare the delivery
of an SI using four SIBs with that of a T-piece.In intubated preterm lambs, we compared four
models of SIB fitted with a positive end expiratory pressure (PEEP) valve to a T-piece using
a gas flow of 8 L/min. Four operators aimed to deliver three SIs of 20 cm H2O for 30 s. The
study was repeated with the PEEP valve removed and again with no flow. We measured
duration of SI, average inflation pressure (IP) and analysed the shape of the pressure
curves.204 combinations were analysed. Mean (SD) duration of SI was Ambu 6(2)s, Laerdal
14(8)s, Parker Healthcare 5(1)s, Mayo Healthcare 33(2)s and T-piece 33(1)s. Mean (SD)
average IP was Ambu 17(3)cm H2O, Laerdal 17(3)cm H2O, Parker Healthcare 12(5)cm H2O,
Mayo Healthcare 21(2)cm H2O and T-piece 20(0)cm H2O. Duration of SI and average IP
was significantly different between SIBs (all p<0.001). The findings were substantially
unchanged when PEEP valve and flow were removed (all p>0.05). Only the Mayo system
delivered SIs with duration and average IP not significantly different from the T-piece
(p>0.05).The performance of the four SIBs tested varied considerably. Some are able to
deliver an SI even in the absence of gas flow. This may be useful in a resource-limited setting
with no gas supply.
Thio, M., et al. (2011). "Changing oxygen concentration in the delivery room; you may not
get what you expect." Journal of Paediatrics and Child Health 47: 111-.
Background: Supplemental oxygen is often given to infants in the delivery room.
Clinicians adjust oxygen concentration (FiO2) in order to prevent hypoxia and hyperoxia.
Using an animal model, we aimed to measure the delivered FiO2 when using a T-piece and a
self-inflating bag (SIB) and oxygen via a blender. Method: Preterm lambs were ventilated
using a T-piece (gas flow 8 L/min, PIP 30 cm H2O, PEEP 5 cm H2O) or a SIB (gas flow 8
L/min, targeted PIP 30 cm H2O, no PEEP) at a rate of 60 inflations/min. FiO2 was set at the
blender and measured close to the ETT. Delivered FiO2 was measured for both devices using
various combinations of rate and size of incremental changes. Results: 234 combinations
were analysed. Delivered FiO2 was always less than that set at the blender when increasing
FiO2. The T-piece took significantly less time than the SIB to deliver an increase of at least
80% of each desired change mean(SD) 12(5) versus 19(4) seconds (P < 0.001). When
decreasing FiO2, the set level was never reached using the SIB if changes were made every
15 seconds. It took a mean (SD) of 38 (8) seconds to reach 21% when oxygen was weaned
straight from 100% to 21%. Conclusions: There are important differences between set and
delivered FiO2 when using a blender in the delivery room. Clinicians should be aware of the
considerable time delay between making changes on a blender and the infant receiving the
desired oxygen concentrations.
Tobin, M. J., et al. (1995). "Using physiologic end points to assess innovations in mechanical
ventilation." Respiratory Care 40(9): 971-974.
It is our view that new ventilatory methods should be withheld from clinical practice
until there has been adequate evaluation of their effect on physiologic variables and the link
to long-term outcomes has been established. In the past, premature and over-enthusiastic
acceptance of ventilatory strategies may have resulted in patient discomfort and even harm,
and this can be minimized by a more careful evaluation of the physiologic effects of such
innovations before their acceptance into clinical practice.
Tognet, E., et al. (1994). "Treatment of acute respiratory failure with non-invasive intermitent
positive pressure ventilation in haematological patients." Clinical Intensive Care 5(6): 282288.
Objective: The aim of this study was to assess whether non-invasive positive
pressure ventilation delivered intermittently (Ni-IPPV) by means of a facial or nasal mask is
beneficial in haematological patients suffering from acute respiratory failure. Design:
Prospective, open, non-randomised study. Setting: University Hospital, medical intensive
care unit. Patients and method: Eighteen haematological patients with acute respiratory
failure which occurred before, during or just after therapeutic aplasia were ventilated with NiIPPV delivered via an individual nasal mask or a standard facial mask. Non-invasive
ventilation was achieved until weaning (success (S)) or intubation (failure (F)). Results:
Twelve patients were ultimately intubated and died (F group). Seven needed intubation
within 3 hours following admission because of the inability of Ni-IPPV to provide adequate
ventilation in six patients and after cardiac arrest, probably related to cardiac aspergillosis in
one patient. Six patients were not intubated and were discharged alive (S group). Of 11
patients who received Ni-IPPV for more than 3 hours, the respiratory rate decreased
significantly (p < 0.05) from 33 (plus or minus) 7 breaths/min to 24 (plus or minus) 5
breaths/min with NI-IPPV and the PaO2 increased significantly from 6.6 (plus or minus) 1.7
kPa upon admission to 17.7 (plus or minus) 5.5 kPa during Ni-IPPV. Mean daily ventilation
was 12 (plus or minus) 7 hours for a mean duration of 5.5 (plus or minus) 4.4 days. Pressure
support was used in nine patients and appeared the most efficient ventilation mode of noninvasive ventilation. The duration per day of Ni-IPPV was shorter and PaCO2 values during
Ni-IPPV were lower in the S group than in the F group. Conclusions: This technique is able
to provide adequate ventilatory support for many haematological patients and allows
avoidance of ventilation in some.
Tonnesen, P. and S. Stovring (1984). "Positive expiratory pressure (PEP) and lung
physiotherapy in cystic fibrosis: A pilot study." European Journal of Respiratory Diseases
65(6): 419-422.
Positive expiratory pressure (PEP) on a face mask was compared with conventional
lung physiotherapy in 12 patients with cystic fibrosis. Residual volume (p <0.02) and
functional residual capacity (NS) was reduced and vital capacity increased (NS) during 6-9
months of PEP treatment. The subjective sputum production was significantly greater during
the PEP period. PEP is easy to administer and is inexpensive.
Tracy, M., et al. (2011). "Mask leak in one-person mask ventilation compared to two-person
in newborn infant manikin study." Archives of Disease in Childhood: Fetal and Neonatal
Edition 96(3): F195-F200.
Aim: To compare a new two-person method (four hands) of delivering mask
ventilation with a standard one-person method using the Laerdal self-inflating bag (SIB) and
the Neopuff (NP) infant resuscitator in a manikin model. Background: Recent studies of
simulated neonatal resuscitation using bag and mask ventilation techniques have shown
facemask leak levels of 55-57% in expert hands. Methods: 48 participants were randomly
paired and instructed to give mask ventilation for a 2-min period as single-person
resuscitators, then as two-person paired resuscitators at set pressures for NP and set
parameters for SIB. Airway pressure, flow, inspiratory tidal volume, expiratory tidal volume
and mask leak were recorded. Results: A total of 21 578 inflations were recorded and
analysed. For SIB, mask leak was greater (11.5%) with single-person compared to twoperson (5.4%; mean difference 6.1%, 95% CI 1.5 to 10.7, p<0.01). For NP, mask leak was
greater for single-person (22.2%) compared to two-person (9.1%; mean difference 13.1% 95%
CI 3.6 to 22.6, p<0.01). For single-person mask ventilation, mask leak was greater with NP
(22.2%) compared to SIB (11.5%; mean difference 10.7%, 95% CI 1.4 to 19.7, p<0.01). For
two-person mask ventilation, mask leak was greater for NP (9.1%) compared to SIB (5.4%;
mean difference 3.7%, 95% CI 0.1 to 6.4, p<0.05). Conclusions: Two-person mask
ventilation technique reduces mask leak by approximately 50% compared to the standard
one-person mask ventilation method. NP mask ventilation has higher mask leak than Laerdal
SIB for both single- and two-person technique mask ventilation.
Tracy, M. B., et al. (2011). "Ventilator-delivered mask ventilation compared with three
standard methods of mask ventilation in a manikin model." Archives of disease in childhood.
Fetal and neonatal edition 96(3): F201-205.
Little is known regarding the variations in effective ventilation during bag and mask
resuscitation with standard methods compared with that delivered by ventilator-delivered
mask ventilation (VDMV).To measure the variations in delivered airway pressure, tidal
volume (TV), minute ventilation (MV) and inspiratory time during a 3-min period of mask
ventilation comparing VDMV with three commonly used hand-delivered methods of bag and
mask ventilation: Laerdal self-inflating bag (SIB); anaesthetic bag and T-piece Neopuff.A
modified resuscitation manikin was used to measure variation in mechanical ventilation
during 3-min periods of mask ventilation. Thirty-six experienced practitioners gave positive
pressure mask ventilation targeting acceptable chest wall movement with a rate of 60
inflations/min and when pressures could be targeted or set, a peak inspiratory pressure (PIP)
of 18 cm water, positive end-expiratory pressure (PEEP) of 5 cm water, for 3 min with each
of the four mask ventilation methods. Each mode was randomly sequenced.A total of 21 136
inflations were recorded and analysed. VDMV achieved PIP and PEEP closest to that
targeted and significantly lower variation in all measured parameters (p<0.001) other than
with PIP. SIB delivered TV and MV over twice that delivered by VDMV and
Neopuff.During 3-min periods of mask ventilation on a manikin, VDMV produced the least
variation in delivered ventilation. SIB produced wide variation and unacceptably high TV
and MV in experienced hands.
Tracy, M. B., et al. (2014). "Mask leak increases and minute ventilation decreases when chest
compressions are added to bag ventilation in a neonatal manikin model." Acta Paediatrica,
International Journal of Paediatrics 103(5): e182-e187.
Aim: To determine changes in respiratory mechanics when chest compressions are
added to mask ventilation, as recommended by the International Liaison Committee on
Resuscitation (ILCOR) guidelines for newborn infants. Methods: Using a Laerdal Advanced
Life Support leak-free baby manikin and a 240-mL self-inflating bag, 58 neonatal staff
members were randomly paired to provide mask ventilation, followed by mask ventilation
with chest compressions with a 1:3 ratio, for two minutes each. A Florian respiratory function
monitor was used to measure respiratory mechanics, including mask leak. Results: The
addition of chest compressions to mask ventilation led to a significant reduction in inflation
rate, from 63.9 to 32.9 breaths per minute (p < 0.0001), mean airway pressure reduced from
7.6 to 4.9 cm H2O (p < 0.001), minute ventilation reduced from 770 to 451 mL/kg/min (p <
0.0001), and there was a significant increase in paired mask leak of 6.8% (p < 0.0001).
Conclusion: Adding chest compressions to mask ventilation, in accordance with the ILCOR
guidelines, in a manikin model is associated with a significant reduction in delivered
ventilation and increase in mask leak. If similar findings occur in human infants needing an
escalation in resuscitation, there is a potential risk of either delay in recovery or inadequate
response to resuscitation. (copyright)2014 Foundation Acta Paediatrica. Published by John
Wiley & Sons Ltd.
Trevisanuto, D., et al. (2008). "Noise levels during neonatal helmet CPAP." Archives of
disease in childhood. Fetal and neonatal edition 93(5): F396-397.
Trevisanuto, D., et al. (2004). "The laryngeal mask airway: potential applications in
neonates." Archives of disease in childhood. Fetal and neonatal edition 89(6): F485-489.
The laryngeal mask airway is a safe and reliable airway management device. This
review describes the insertion techniques, advantages, limitations, and potential applications
of the laryngeal mask airway in neonates.
Trevisanuto, D., et al. (2004). "Laryngeal mask airway: is the management of neonates
requiring positive pressure ventilation at birth changing?" Resuscitation 62(2): 151-157.
To evaluate the impact of the laryngeal mask airway (LMA) on neonatal
resuscitation policy.We analyzed retrospectively the records of neonates requiring positive
pressure ventilation (PPV) at birth before (1996) and after (2000) the introduction of the
LMA into our delivery suites. In addition, the outcome of neonates treated with the LMA was
compared with that of neonates matched for gestational age and mode of delivery who were
resuscitated using a face mask.During the year 2000, 95 out of 380 (25%) resuscitated
neonates were treated with the LMA. The LMA was effective in 94 out of 95 (99%) of these
infants. Over the same period, the percentage of neonates receiving tracheal intubation (TI) at
birth (34%) was significantly reduced compared with the figure for 1996 (67%). There were
no reported complications associated with the use of the LMA. Seventy-four out of the 95
neonates treated with the LMA were considered suitable for matching for gestational age and
mode of delivery with 74 neonates treated with a face mask. No differences were found
between the two groups for birth weight, Apgar scores, need for tracheal intubation, need for
admission to the Neonatal Intensive Care Unit (NICU), primary diagnosis at discharge and
primary outcomes. The LMA provided effective ventilation in four neonates in whom the
face mask failed.The LMA is changing neonatal resuscitation practice in our Institution. Our
data suggest that it is a safe and useful alternative method for respiratory support in neonates
requiring PPV at birth, which merits further study.
Tuck, S. and L. R. Ment (1980). "A follow-up study of very low-birthweight infants receiving
ventilatory support by face mask." Developmental medicine and child neurology 22(5): 633641.
Recent evidence has suggested that face-mask ventilation of very low birthweight
(VLBW) infants may have serious neurological consequences. The 30 surviving VLBW
infants from the neonatal intensive care unit at Hammersmith Hospital who had received
ventilatory support via face masks over a 25-month period have been reviewed and compared
with a control group. Neuropathological findings in the VLBW infants who died during this
time have also been reviewed in relation to their ventilatory management. The findings
suggest that face-mask treament did not have a major deleterious effect on the surviving
infants. The factors which may determine the neurological sequelae of this form of
ventilatory support are discussed.
Tummons, J. L. (1973). "A positive end-expiratory pressure-nasal-assist device (PEEP-NAD)
for treatment of respiratory distress syndrome." Anesthesiology 38(6): 592-595.
Tunstall, M. E. (1973). "Ventilator circuits for infants and children." Anaesthesia 28(3): 309311.
Turner, K. M. S. and L. L. Basnight (2010). "Newborn ventilation." Pediatrics in Review
31(8): 347-348.
Urban, B. J. and S. W. Weitzner (1974). "The Amsterdam infant ventilator and the Ayre Tpiece in mechanical ventilation." Anesthesiology 40(5): 423-432.
Urbano, J., et al. (2012). "High-flow oxygen therapy: pressure analysis in a pediatric airway
model." Respiratory Care 57(5): 721-726.
The mechanism of high-flow oxygen therapy and the pressures reached in the airway
have not been defined. We hypothesized that the flow would generate a low continuous
positive pressure, and that elevated flow rates in this model could produce moderate pressures.
The objective of this study was to analyze the pressure generated by a high-flow oxygen
therapy system in an experimental model of the pediatric airway.An experimental in vitro
study was performed. A high-flow oxygen therapy system was connected to 3 types of
interface (nasal cannulae, nasal mask, and oronasal mask) and applied to 2 types of pediatric
manikin (infant and neonatal). The pressures generated in the circuit, in the airway, and in the
pharynx were measured at different flow rates (5, 10, 15, and 20 L/min). The experiment was
conducted with and without a leak (mouth sealed and unsealed). Linear regression analyses
were performed for each set of measurements.The pressures generated with the different
interfaces were very similar. The maximum pressure recorded was 4 cm H(2)O with a flow of
20 L/min via nasal cannulae or nasal mask. When the mouth of the manikin was held open,
the pressures reached in the airway and pharynxes were undetectable. Linear regression
analyses showed a similar linear relationship between flow and pressures measured in the
pharynx (pressure = -0.375 + 0.138 �� flow) and in the airway (pressure = -0.375 + 0.158
�� flow) with the closed mouth condition.According to our hypothesis, high-flow oxygen
therapy systems produced a low-level CPAP in an experimental pediatric model, even with
the use of very high flow rates. Linear regression analyses showed similar linear relationships
between flow and pressures measured in the pharynx and in the airway. This finding suggests
that, at least in part, the effects may be due to other mechanisms.
Urlesberger, B. (2006). "Primary respiratory care in neonatal resuscitation: Comment."
Monatsschrift fur Kinderheilkunde 154(8): 825-.
Urquhart, D. S. (2013). "Investigation and management of childhood sleep apnoea."
Hippokratia 17(3): 196-202.
Sleep-disordered breathing includes disorders of breathing that affect airway patency,
e.g. obstructive sleep apnoea syndrome, and also conditions that affect respiratory drive
(central sleep disorders) or cause hypoventilation, either as a direct central effect or due to
peripheral muscle weakness. Obstructive sleep apnoea syndrome (OSAS) is an increasinglyrecognised clinical entity affecting up to 5.7% of children, which, if left untreated, is
associated with adverse effects on growth and development including deleterious cognitive
and behavioural outcomes. Evidence exists also that untreated OSAS impacts on
cardiovascular risk. Close attention should be paid to assessment and investigation of this
relatively common condition, instigating early and appropriate treatment to children with
OSAS. First-line treatment in younger children is adenotonsillectomy, although other
treatment options available include continuous positive airways pressure (CPAP), antiinflammatory therapies (nasal corticosteroids and anti-leukotrienes), airway adjuncts and
orthodontic appliances. Central sleep-disordered breathing may be related to immaturity of
respiratory control and can be associated with prematurity as well as disorders such as
Prader-Willi syndrome. In some cases, central apnoeas occur as part of a central
hypoventilation disorder, which may be inherited, e.g. Congenital Central hypoventilation
Syndrome, or acquired, e.g. Arnold-Chiari malformation, brain tumour, or spinal injury. The
treatments of central breathing problems depend upon the underlying aetiology.
Vallurupalli, S., et al. (2013). "Platypnea-Orthodeoxia syndrome after repair of a
paraesophageal hernia." BMJ Case Reports: -.
The Platypnea-Orthodeoxia syndrome is characterised by dyspnoea and
deoxygenation accompanying a change from the recumbent to the upright position. An 81year-old woman had an elective paraesophageal hernia repair. She developed dyspnoea and
hypoxemia post-operatively that was worse when upright. An agitated saline echocardiogram
revealed a right-to-left shunt through a patent foramen ovale that increased when the patient
was upright. Over 3 weeks the patients' shunt, dyspnoea and hypoxemia improved and she
was discharged home. Copyright 2013 BMJ Publishing Group. All rights reserved.
van Vonderen, J. J., et al. (2012). "Compressive force applied to a manikin's head during
mask ventilation." Archives of disease in childhood. Fetal and neonatal edition 97(4): F254258.
To investigate the compressive force applied to the head during mask ventilation and
determine whether this force increases in response to an attempt to correct the mask leak.The
authors asked 24 participants (consultants, fellows and nurses) to administer positive pressure
ventilation to a modified leak-free, term newborn manikin using a self-inflating bag (SIB)
and a Neopuff T-piece device. Recordings were made before and after the participants were
informed about their percentage of mask leak and asked to correct this. Airway pressure and
flow were measured using a Florian monitor, and the force applied to the head was measured
using a concealed custom-made load cell weighing scale.There were no differences in the
mean (SD) force applied to the head between devices used and before or after the attempt to
correct the mask leak (SIB before 2215 (892) and after 2195 (989) g; Neopuff before 1949
(957) and after 2028 (909) g). There was a large variation in force with both devices before
and after the attempt (coefficient of variation: SIB before 40% and after 45%; Neopuff before
50% and after 45%). There was no correlation between mask leak and the difference in force
used before and after the attempt to correct the mask leak using both devices.During mask
ventilation of a manikin, the authors observed that large forces were exerted on the head with
either an SIB or a Neopuff, but these forces did not increase during the attempt to minimise
the mask leak.
Vega-Brice?o, L., et al. (2004). "[Early use of BiPAP in the management of respiratory
failure in an infant with osteogenesis imperfecta: case report]." Revista m?dica de Chile
132(7): 861-864.
Osteogenesis imperfecta (OI) is an heterogeneous group of genetic disorders that
affect connective tissue integrity. Severe forms cause chest deformities, sometimes associated
to alveolar hypoventilation. We report a 4 months old infant with OI type III, who developed
respiratory failure (RF) due to a bronchiolitis and required mechanical ventilation. Weaning
progressed successfully to a nasal bi-level Positive Airway Pressure (n-BiPAP) device.
Clinical follow up showed a normal cognitive development and growth. Respiratory
condition, blood gases and ventilation status were in normal ranges. Non invasive ventilation,
associated to careful monitoring may avoid tracheostomy and its complications in infants
with OI.
Vento, M., et al. (2012). "Oxygen saturation after birth in preterm infants treated with
continuous positive airway pressure and air: Assessment of gender differences and
comparison with a published nomogram." Archives of Disease in Childhood: Fetal and
Neonatal Edition: -.
Aims: The goal of the study was to compare preductal SpO2 in the first 10 min after
birth in preterm infants treated with non-invasive continuous positive airway pressure (CPAP)
and air with a published nomogram of preductal SpO2 in preterm infants who received no
medical intervention, and to examine gender differences. Design: Prospective observational
study. Patients: and methods We enrolled infants of 7gt;32 weeks gestation who were
spontaneously breathing with heart rate >100 bpm, and treated with face mask CPAP and air
during postnatal stabilisation. SpO2 limits were targeted at (greater-than or equal to)75% at 5
min and (greater-than or equal to)85% at 10 min and heart rate at >100 bpm. FIO2 was
titrated against SpO2. Preductal SpO2, airway pressure and FIO2 were recorded with a data
acquisition system from birth until stabilisation. Babies receiving supplemental oxygen
(>21%), positive pressure ventilation, were intubated and/or received chest compressions or
drugs were excluded. Results: Measurements were obtained in 102 babies with median
gestational age of 29 (range: 24-31) weeks. Median SpO2 was significantly higher in the
observational group than in the reference range at 3 min (82% (CI 71% to 85%) vs 76% (CI
67% to 83%); p<0.05), at 4 min (87% (CI 81% to 90%) vs 81% (CI 72% to 88%); p<0.05), at
5 min (92% (CI 88% to 95%) vs 86% (CI 80% to 92%); p<0.05), at 6 min (94% (CI 90% to
97%) vs 90% (CI 81% to 95%); p<0.05), at 7 min (95% (CI 92% to 97%) vs 92% (CI 85% to
95%); p<0.05), at 8 min (96% (CI 93% to 98%) vs 92% (CI 87% to 96%); p<0.05) and at 9
min (97% (CI 92% to 99%) vs 93% (CI 87% to 96%); p<0.05). Female babies achieved
targeted SpO2 significantly earlier than male babies. Conclusions: Preterm babies receiving
CPAP and air and especially female subjects achieve reference oxygen saturation more
rapidly than spontaneously breathing preterm babies without respiratory aid. Copyright
Article author (or their employer) 2012.
Versmold, H. T., et al. (1978). "In vivo vs in vitro response time of trancutaneous PO2
electrodes. A comparison of four devices in newborn infants." Acta anaesthesiologica
Scandinavica. Supplementum 68: 40-48.
Four devices for transcutaneous PO2 (tcPO2) monitoring have been applied
simultaneously in 16 infants. Both during a maximal change in PaO2 and during
physiological PO2 variations, the in vivo response time of the electrodes did not show the
differences observed in vitro. We compared A, a prototype of the electrode by Huck, L?bbers
and Huch (25 micrometer Telfon membrane) ; B, the commercial version of A by Hellige-Draeger (25 micrometer Telfon); C, the Radiometer TCM I oxygen monitor (25 micrometer
polypropylene); and D, the Roche macrocathode electrode (6 micrometer Mylar), at 44
degree C. In vitro the 50% response times were 2.9 (A), 4.4 (B), 3.7 (C), and 7.4 (D) sec. The
rates of tcPO2 changes at the midpoint of the response curves were 3.8(A) 2.0 (B), 3.0 (C),
and 1.7 (D) kPa/sec. In vivo during a sudden change from hyperoxemia (FIO2 1.0) to
normoxaemia the respective rates were 0.6 (A), 0.8 (B), 1.1 (C), and 1.0(D) kPa/sec. The in
vivo 50% response times were 53.3 (A), 51.1 (B), 46.2 (C) and 45.3 (d) kPa/sec. The in vivo
50% response time were 53.3 (A), 51.1 (B), 46.2 (C), and 45.3 (d) kPa/sec. The in vivo 50%
resonse time were 53.3 (A), 51.1 (B), 46.2 (C), and 45.3 (D) sec. The lag time between PaO2
and tcPO2 was about one third of this overall response time. The response to more
physiological variations of PaO2 (periodic breathing) was not different among the tested
electrodes in terms of damping and of delay of the tcPO2 deflections. In a steady state the
correlation of tcPO2 44 degree C vs PaO2 was close (r = 0.98) with all devices up to 6.1 kPa
(456 torr).
Vidyasagar, D. (1974). "Physiological basis and clinical implications of continuous negative
chestwall pressure in hyaline membrane disease." International anesthesiology clinics 12(4):
153-171.
Vidyasagar, D., et al. (1975). "Assisted ventilation in infants with meconium aspiration
syndrome." Pediatrics 56(2): 208-213.
In a retrospective analysis of infants born with meconium staining over an 18-month
period at Cook County Hospital, 32 infants met two of the three criteria for the diagnosis of
meconium aspiration syndrome: (1) history of meconium in the oropharynx or trachea; (2)
clinical evidence of respiratory distress; and (3) x-ray evidence of aspiration pneumonia.
Seventeen infants developed respiratory failure; nine of these infants died. One infant without
respiratory failure died of sepsis. Analysis of sequential arterial blood pH and gas tension
showed that nonsurviving infants had persistently high PCO2 and A-a gradient in spite of
initiation of assisted ventilation. These changes seem to be related to severe right-to-left
shunting and ventilation perfusion abnormalities. The data further suggest that asphyxia and
acidosis occur well before the infant is born and that intrapartum monitoring to recognize
fetal asphyxia may help in improving morbidity and mortality from meconium aspiration
syndrome.
Vidyasagar, D., et al. "Use of Amsterdam infant ventilator for continuous positive pressure
breathing." Critical care medicine 2(2): 89-90.
Vidyasagar, D. and W. Wai "Respirator weaning of the newborn: some practical
considerations." Critical care medicine 3(1): 16-22.
Weaning of neonates from assisted ventilation or continous positive pressure
breathing is a complex process. Unfortunately, at present we lack sensitive indices to measure
the infant's ability to sustain spontaneous breathing. In the absence of such criteria we should
rely heavily on clinical findings correlated with available biochemical data. Good clinical
acumen and experience is necessary for successful weaning.
Vignaux, L., et al. (2011). "Patient-ventilator asynchrony during mechanical non-invasive
assisted ventilation in children: Preliminary results." American Journal of Respiratory and
Critical Care Medicine 183(1): -.
Introduction Severe patient-ventilator asynchrony is very common (43%) in adults
receiving non-invasive ventilation (NIV) with pressure support (PS) mode via a face mask,
mainly due to leaks (1). Neurally Adjusted Ventilatory Assist (NAVA), which uses the
diaphragmatic electrical activity (Eadi) to pilot the ventilator improves triggering and cycling
compared to PS in infants (2). However there is insufficient data available on the incidence of
severe asynchrony in children during NIV with PS (NIV-PS) and it is unknown whether NIVNAVA reduces asynchrony in this patient group. Purpose To document the prevalence and
type of asynchrony in children receiving non-invasive mechanical ventilation with PS vs
NAVA. Methods Prospective interventional study. Children (0-5years) with NIV received
randomly NIV-PS and NIV-NAVA with subsequent cross-over. A 20 min NIV-NAVA
session was compared to three NIV-PS sessions, one with the PS settings chosen by the
clinician in charge (15 min) and two with an expiratory trigger setting (ETS)
increased/decreased by 15%, respectively (5 min each). The NAVA gain (proportionality
factor between the Eadi and the delivered airway pressure) was set to match the peak pressure
in PS before inclusion. FIO2 and PEEP remained unchanged. Continuous recording of airway
pressure, flow and Eadi was performed during all sessions allowing determination of Trigger
delay (Td), patient neural inspiratory time (Tin), duration of pressurization by the ventilator
(Tiv), excess duration of pressurization (Ti excess = Tiv-Tin / Tin X100) and number of
asynchrony events by minute. Asynchrony Index [AI= number of asynchrony events /
(Breath rate + Auto triggering)] was calculated and severe asynchrony defined as AI >10%.
Results The first 3 patients were analyzed, age (mean(plus or minus)SD) 2(plus or minus)0.8
years, weight 8(plus or minus)2 Kg, ventilatory cycles per patient 1654(plus or minus)83; 2
acute respiratory failures post-extubation, 1 cardiac decompensation. Initial settings: PS
8(plus or minus)2 cmH2O, PEEP 5(plus or minus)0.5 cmH2O, initial ETS 22(plus or
minus)14%, NAVA gain 1.5(plus or minus)0.8 cmH2O/mV, FiO2 0.31(plus or minus)0.13.
Measured and calculated parameters are shown in the Table below. There was a trend to
lower Td, PC, Eadi and AI and higher Pmean during NAVA as compared to NIV-PS.
Oxygenation, transcutaneous CO2 and minute ventilation remained unchanged during the
study. (Table Presented) Conclusion During NIV-PS in three small children, several types of
patient-ventilator asynchronies occured, predominantly premature cycling, resulting in severe
asynchrony. Our observation suggests that NIV- NAVA allows for better synchrony than
NIV-PS ventilation in children, and reduces Eadi markedly.
Villaa, M. P., et al. (2002). "Mid-face hypoplasia after long-term nasal ventilation [3]."
American Journal of Respiratory and Critical Care Medicine 166(8): 1142-1143.
Von Ungern-Sternberg, B. S. (2008). "Impact of anaesthesia on lung function in children."
European Respiratory Review 17(107): 26-29.
Waters, K. A., et al. (1995). "Obstructive sleep apnea: the use of nasal CPAP in 80 children."
American Journal of Respiratory and Critical Care Medicine 152(2): 780-785.
This is a retrospective review of children 15 years of age or younger, who underwent
overnight sleep studies between 1980 and 1993. All were diagnosed and treated for
obstructive sleep apnea (OSA). Overnight studies were performed for OSA in 413 children.
One hundred seventy-five (42.4%) children were treated with adenotonsillectomy and 80
(19.4%) with nasal mask continuous positive airway pressure (nCPAP). The proportion of
male children was greater than expected in both the entire study group (69%, p < 0.001) and
in those treated with nCPAP for OSA (71% p < 0.001). There was no significant difference
between the mean age of the children treated with nCPAP (5.7 +/- 0.5 yr) and the entire
group studied (5.04 +/- 0.21 yr). A greater proportion of the children who received nCPAP
therapy had a congenital syndrome or malformation than in the group with OSA as a whole;
27.7% of children assessed for OSA were affected, and 53% of those children with OSA who
received treatment with nCPAP (p < 0.001). Therapy with nCPAP (mean duration 15 +/- 3
mo, mean pressure 7.9 cm H2O) eliminated the signs of OSA in 72 children (90%).
Respiratory disturbance index fell from a mean of 27.3 +/- 20.2 to 2.55 +/- 2.74 (p < 0.001).
Eight of 32 children who underwent pressure determination studies could not tolerate nCPAP
above an upper limit because of hypoventilation or frequent central apneas. Nevertheless, we
conclude that nCPAP is an effective and generally well-tolerated therapy for treatment of
OSA in infants and children.
Weisman, I. M., et al. (1983). "Intermittent mandatory ventilation." The American review of
respiratory disease 127(5): 641-647.
Welte, T. (2003). "Noninvasive ventilation in the intensive care unit - Is it still negligible?"
Wiener Klinische Wochenschrift 115(04-Mar): 89-98.
Non-invasive positive pressure ventilation (NIPPV) has been discussed
comprehensively in the last years, but usage of non-invasive ventilation in Intensive Care
Units is rare. The reasons may be uncertainty in indications and difficulties in handling the
masks and ventilators. In the last years the introduction of full face masks and respiratory
helmets has made it possible to ventilate patients with unusal facial forms and to avoid
problems of pressure necrosis. Software components designed for NIPPV are available for
standard respirators. Indications for NIPPV (neuromuscular diseases, spinal abnormalities,
chest wall malformations, COPD, cardiogenic pulmonary edema) have been ensured in
clinical trials. No sufficient data are available for the application of NIPPV in weaning and
respiratory failure following extubation. Indication for NIPPV becomes apparent when
therapy starts in early stage with sufficient ventilation pressure. Compared to standard
therapy, no reliable advantage has been seen for NIPPV in hypoxic hypercapnia respiratory
failure except for malignant diseases. However, prophylactic use in patients with high risk
might be conceivable. For these patients strict criteria of termination are required to avoid
missing the time point for intubation. Gas exchange disturbances in advanced lung fibrosis,
pneumonia and ARDS are not amenable to NIPPV. Contraindications for NIPPV are noncompliant patients, absence of cough- and pharyngeal reflexes as well as retention of
secretions and malignant ventricular arrhythmia. Relative contraindications are
catecholamine-dependent circulatory collapse and acute myocardial infarction, since
sufficient data for NIPPV are missing.
Westerlind, A., et al. (1999). "The use of continuous positive airway pressure by face mask
and thoracic epidural analgesia after lung transplantation." Journal of Cardiothoracic and
Vascular Anesthesia 13(3): 249-252.
Objective: To evaluate the clinical use of continuous positive airway pressure (CPAP)
and thoracic epidural analgesia (TEA) after lung transplantation (LTx). Design: Retrospective
case series. Setting: Cardiothoracic intensive care unit (ICU) at a university hospital.
Participants: All heart-lung, bilateral, and single-lung transplant recipients between 1990 and
1996 at this institution (n = 102). Interventions: Postoperative pain was controlled by a
thoracic epidural infusion of bupivacaine, 1 mg/mL, and sufentanil, 1 (mu)g/mL. After
extubation, CPAP, 5 to 10 cm H2O by face mask, was used to prevent reperfusion edema.
Measurements and Main Results: In 99 patients, the length of ventilation (LOV) was a
median of 4.3 hours (range, 1.0 to 312.0 hours). The median LOV was 8.0 hours (range, 1.5
to 41.0 hours) in the heart-lung recipients, 4.5 hours (range, 2.0 to 47.0 hours) in the bilaterallung recipients, and 3.5 hours (range, 1.0 to 312.0 hours) in the single-lung recipients. Three
transplant recipients, all with primary pulmonary hypertension, were prematurely extubated
and reintubated because of pulmonary edema. Twelve hours after extubation, the median
oxygenation index (PaO2/F1O2, PaO2 in kilopascal units) was greater than 35. The median
ICU length of stay for all transplant recipients was 4 days (range, 2 to 270 days). Conclusion:
The postoperative use of CPAP and TEA is associated with early and safe tracheal extubation
after LTx and may shorten ICU stay.
Wetzel, R. C. and F. R. Gioia (1987). "High frequency ventilation." Pediatric clinics of North
America 34(1): 15-38.
High frequency ventilation (HFV) presents a new respiratory therapy modality that
has taught us much about the theories of gas transport in the lung. Both experimental and
clinical applications are summarized. Although the future clinical role of HFV remains
uncertain, pediatric applications and investigation continue at the forefront of this new
technology.
Willard, D., et al. (1972). "[Gas mixtures in positive pressure respirators]." Annales de
p?diatrie 19(3): 191-196.
Wille, L., et al. (1975). "[Mobile intensive-care-unit for transportation of premature and
newborn babies at risc (author's transl)]." Monatsschrift f?r Kinderheilkunde 123(2): 49-51.
This is a technical report on a specially equipped ambulance for transportation of
high-risk, seriously ill neonates. A mobile neonatal intensive-care-unit operating
independently of the car utilized an Ohio-transport-incubator with 12V-DC portable power
pak and collapsible stand, battery-operated ECG-monitor with optical and acoustical signal, a
ECG-monitor with optical and acoustical signal, a battery-operated infusion pump, a Birdrespirator mark 8 with oxygen-blender, nebulizer and infant circuit with modification for
PEEP as well as additional accessories. Ambulance-duty service is guaranteed by the German
Red Cross (DRK) to facilitate transfer at any time, while skilled personal (physician, nurse)
of the intensive care ward in on 24 hs call.
Williams, E. M., et al. (2011). "Estimation of tidal ventilation in preterm and term newborn
infants using electromagnetic inductance plethysmography." Physiological measurement
32(11): 1833-1845.
Tidal volume (VT) measurements in newborn infants remain largely a research tool.
Tidal ventilation and breathing pattern were measured using a new device, FloRight, which
uses electromagnetic inductive plethysmography,and compared simultaneously with
pneumotachography in 43 infants either receiving no respiratory support or continuous
positive airway pressure (CPAP).Twenty-three infants were receiving CPAP (gestational age
28 �� 2 weeks, mean �� SD) and 20 were breathing spontaneously (gestational age 34
�� 4 weeks). The two methods were in reasonable agreement, with VT (r2 = 0.69) ranging
from 5 to 23 ml (4?11 ml kg?1) with a mean difference of 0.4 ml and limit of agreement
of ?4.7 to + 5.5 ml. For respiratory rate, minute ventilation,peak flow and breathing pattern
indices, the mean difference between the two methods ranged between 0.7% and 5.8%. The
facemask increased the respiratory rate (P < 0.001) in both groups with the change in VT
being more pronounced in the infants receiving no respiratory support. Thus, FloRight
provides an easy to use technique to measure term and preterm infants in the clinical
environment without altering the infant's breathing pattern.
Wilson, E. V., et al. (2012). "Three different mask holds for positive pressure ventilation in a
neonatal mannequin." Archives of Disease in Childhood 97: A288-.
Background and Aim Mask ventilation is commonly used for neonatal resuscitation.
Variable leak and inconsistent tidal volumes are reported in mannequin and delivery room
studies. We compared the spider hold (SH) against the two-point top hold (TPTH), and twohanded hold (THH) for delivering positive pressure ventilation (PPV). Methods 53
participants from 5 professional groups provided PPV with each hold for 1 minute to a
mannequin, using a T-piece resuscitator (PIP/PEEP 30/5 cmH2O, 40-60 inflations/min).
Mask leak and expired tidal volume (TVE) were measured with a flow sensor. ANOVA was
used to compare the average median leak from each participant for each hold and by
professional group. Results 7324 inflations were analysed. The mean (SD) leak was 35(27)%,
38(34)% and 39(33)% for the TPTH, SH and THH respectively (p=0.003). The mean (SD)
TVE was not significantly different between the three holds (p=0.09). The lowest mean (SD)
leak was measured with the THH by registrars 13(14)% and highest by midwives with the
THH 48(36)% (p=0.001). Conclusion Each hold can be used to give PPV. The SH does not
appear to reduce leak when compared to the other holds. (Table presented).
Wilson, E. V., et al. (2014). "A comparison of different mask holds for positive pressure
ventilation in a neonatal manikin." Archives of disease in childhood. Fetal and neonatal
edition 99(2): F169-171.
Ventilation during neonatal resuscitation is typically initiated with a face mask, but
may be ineffective due to leak or obstruction.To compare leak using three methods of mask
hold.Medical and nursing staff regularly involved in neonatal resuscitation used the three
holds (two-point, two-handed, spider) on a manikin in a random order to apply positive
pressure ventilation (PPV) at standard settings each for 1 min while mask leak was
recorded.Participants (n=53) varied in experience (1-23 years) and hand size. Combined
median (IQR) leak was 14 (2-46)% and was not different among the holds.There was no
difference in the leak measured using the three different mask holds.
Wimmer, J. E. and D. G. Parsons (1976). "Respiratory therapy in the neonatal intensive care
unit." Clinics in Perinatology 3(2): 379-390.
Wollinsky, K. H., et al. (1995). "[Effectiveness of home ventilation of young children and
infants]." Medizinische Klinik (Munich, Germany : 1983) 90(1 Suppl 1): 57-59.
The home care ventilation of patients with chronic respiratory insufficiency is a wellestablished method. In treating infants and newborns a lot of problems arise that deal with
indication, prognosis and management.We investigated 7 newborns and infants with chronic
respiratory insufficiency after cervical spine trauma causing pentaplegia or due to inherited
neuromuscular disorders (spinal muscular atrophy, myopathy) during homecare ventilation.In
contrast to experience with adults the management of the children with pentaplegia was
relatively harmless. All were tracheostomized primarily, but 1 tracheostomy could be closed,
because the patient finally achieved to be ventilated only during night-time in the iron lung.
The 3 children with neuromuscular diseases were ventilated noninvasively by specially fitted
nasal masks. Despite coming to the frontiers of feasibility, and taking into account the
psychological stress for patients, relatives, doctors and nurses, satisfactory results were
obtained.
Wood, F. (2011). "Optimizing mask ventilation during resuscitation." Monatsschrift fur
Kinderheilkunde 159: 37-.
In many areas of neonatal resuscitation, recommendations for practice are based on
nullexpertnull opinion rather than robust evidence. Research in this field has increased in
recent years with the aim of refining our approach to this common intervention. As such,
seemingly simple procedures and practices are now under scrutiny. The ability to provide
positive pressure ventilation using a face mask is a mandatory skill for all those who may
encounter newborn infants and neonates. When providing positive pressure ventilation we are
aiming to deliver an appropriate tidal volume. Inadequate tidal volume as the result of mask
leak or airway obstruction may result in failure to resuscitate an infant and high tidal volumes
will cause lung injury. Currently, we judge efficacy of mask ventilation by observing chest
rise and an increase in heart rate. In this lecture we will review the evidence base regarding
face mask ventilation with a focus on key strategies for avoiding factors that may result in
failure to resuscitate an infant. We will also explore new and emerging evidence in this area.
There will be an opportunity to practice the techniques described later in the session.
Wood, F. E. and C. J. Morley (2013). "Face mask ventilation - the dos and don'ts." Seminars
in Fetal and Neonatal Medicine 18(6): 344-351.
Face mask ventilation provides respiratory support to newly born or sick infants. It is
a challenging technique and difficult to ensure that an appropriate tidal volume is delivered
because large and variable leaks occur between the mask and face; airway obstruction may
also occur. Technique is more important than the mask shape although the size must
appropriately fit the face. The essence of the technique is to roll the mask on to the face from
the chin while avoiding the eyes, with a finger and thumb apply a strong even downward
pressure to the top of the mask, away from the stem and sloped sides or skirt of the mask,
place the other fingers under the jaw and apply a similar upward pressure. Preterm infants
require continuous end-expiratory pressure to facilitate lung aeration and maintain lung
volume. This is best done with a T-piece device, not a self-inflating or flow-inflating bag.
(copyright) 2013 Elsevier Ltd.
Wood, F. E., et al. (2008). "A respiratory function monitor improves mask ventilation."
Archives of disease in childhood. Fetal and neonatal edition 93(5): F380-381.
This study investigated whether the use of a respiratory monitor during simulated
neonatal resuscitation reduced leak at the face mask. It showed the leak was more than halved,
being reduced from 27% to 11% when 25 participants used the monitor to identify and
correct the mask leak.
Wood, F. E., et al. (2008). "Assessing the effectiveness of two round neonatal resuscitation
masks: study 1." Archives of disease in childhood. Fetal and neonatal edition 93(3): F235237.
Positive pressure ventilation (PPV) via a face mask is an important skill taught using
manikins. There have been few attempts to assess the effectiveness of different face mask
designs.To determine whether leak at the face mask during simulated neonatal resuscitation
differed between a new round mask design and the current most widely used model.50
participants gave PPV to a modified manikin designed to measure leak at the face mask. Leak
was calculated from the difference between the inspired and expired tidal volumes.Mask leak
varied widely with no significant difference between devices; mean (SD) percentage leak for
the Laerdal round mask was 55% (31) and with the Fisher & Paykel mask it was 57%
(25).We compared a new neonatal face mask with an established design and found no
difference in leak. On average the mask leak was >50% irrespective of operator experience or
technique.
Wood, F. E., et al. (2008). "Improved techniques reduce face mask leak during simulated
neonatal resuscitation: study 2." Archives of disease in childhood. Fetal and neonatal edition
93(3): F230-234.
Techniques of positioning and holding neonatal face masks vary. Studies have shown
that leak at the face mask is common and often substantial irrespective of operator
experience.(1) To identify a technique for face mask placement and hold which will minimise
mask leak. (2) To investigate the effect of written instruction and demonstration of the
identified technique on mask leak for two round face masks.Three experienced neonatologists
compared methods of placing and holding face masks to minimise the leak for Fisher &
Paykel 60 mm and Laerdal size 0/1 masks. 50 clinical staff gave positive pressure ventilation
to a modified manikin designed to measure leak at the face mask. They were provided with
written instructions on how to position and hold each mask and then received a demonstration.
Face mask leak was measured after each teaching intervention.A technique of positioning and
holding the face masks was identified which minimised leak. The mean (SD) mask leaks
before instruction, after instruction and after demonstration were 55% (31), 49% (30), 33%
(26) for the Laerdal mask and 57% (25), 47% (28), 32% (30) for the Fisher & Paykel mask.
There was no significant difference in mask leak between the two masks. Written instruction
alone reduced leak by 8.8% (CI 1.4% to 16.2%) for either mask; when combined with a
demonstration mask leak was reduced by 24.1% (CI 16.4% to 31.8%).Written instruction and
demonstration of the identified optimal technique resulted in significantly reduced face mask
leak.
Xue, F. S., et al. (2009). "Anesthesia and airway management for children with
macroglossia." Paediatric Anaesthesia 19(3): 275-277.
Yen Ha, T. K., et al. (2007). "Atelectatic children treated with intrapulmonary percussive
ventilation via a face mask: clinical trial and literature overview." Pediatrics international :
official journal of the Japan Pediatric Society 49(4): 502-507.
Persistent atelectasis in children is lacking a gold standard treatment. Intrapulmonary
percussive ventilation (IPV) is presented as a promising chest physiotherapy technique in the
treatment of atelectasis. This study aimed to follow the evolution of atelectasis resolution
with noninvasive IPV in young children and to detect eventual adverse effects.Six children
were hospitalized for respiratory distress with suspicion of atelectasis. A 15 min IPV
treatment was immediately started at D1 twice a day for 5 days. Children were free of any
other treatment. Chest X-Ray (CXR) was performed on the second day (D2) and was
repeated 3 days later (D5). After the study, CXR were retrospectively reviewed by three
specialists who had no knowledge of the clinical observations of the patients. They were
asked to assess atelectasis by a score between 4 (complete collapse) and 0 (complete
resolution). A clinical score on a maximum of 4 points was assessed by appetite deterioration,
dyspnoea, mucus production and cough presence at D1 and D5 (1 point per symptom present).
Paired t-test compared D1 and D5 results.All patients returned home after 5 days IPV. SpO2
normalized (93.2 +/- 0.8 to 95.3 +/- 0.8; P = 0.002) and patients all improved clinically (score,
2.8 +/- 0.9 to 0.8 +/- 0.6; P < 0.05). Out of four patients with radiographic evidence of
atelectasis, three improved their atelectasis score.No side-effect or adverse effect was
observed during IPV treatments. IPV was safe and effective in atelectasis resolution in 3/4 of
the cases. Patients all recovered a stable clinical state. CXR improved in 4/5 children. They
were all discharged home after 5 days of IPV treatment.
Yogasakaran, B. S. (2009). "Use of the Oracle face mask postoperatively after nasal surgery
in a patient with severe obstructive sleep apnoea." Anaesthesia 64(7): 804-805.
Obstructive sleep apnoea (OSA) is the most common medical sleep disorder. Seen
more commonly in the obese (body mass index > 30) and those with craniofacial
abnormalities, patients with OSA are at high risk of developing complications under
anaesthesia or sedation [1]. Continuous positive airway pressure (CPAP) is the gold standard
treatment for medium and high risk OSA. Case report A 68-year-old female diagnosed with
severe OSA and using a nasal CPAP mask at home was awaiting nasal surgery. She had a
body mass index (BMI) of 34 and no other co-morbidities. Her sleep study displayed an
Apnoeic Hypopnoea Index (AHI) of 69 and a maximum oxygen desaturation (SpO2) to 66%
indicative of severe OSA. The pre-operative airway assessment gave us the suspicion of a
difficult intubation and a questionable airway when anaesthetised. Difficult Airway Society
guidelines were followed in the anaesthetic room. She underwent surgery and anaesthesia
uneventfully. She was extubated in the sitting up position. We used the Oracle ace mask
(Fisher and Paykel, Maidenhead, UK) in the high dependency unit (HDU) attached to the
CPAP machine with oxygen until the nasal pack was removed. There were no changes in her
saturation or electrocardiogram while in the HDU. Discussion The use of the Oracle face
mask did help us to overcome the period when the oral CPAP mask was uncomfortable over
the bridge of the nose with the nasal pack in place. The Oracle face mask with its flaps fitting
into the vestibule of the mouth was preferable for CPAP rather than the oral CPAP mask
which covers the face. Identification and assessment of OSA has been made easy and adverse
outcomes reduced by the help of the currently available Scottish Intercollegiate Guidelines
Network (SIGN-2003) and the American society of Anesthesiologists Taskforce Guidelines
(ASA-2005) [2]. About 80% of patients are undiagnosed when presenting for airway related
or unrelated surgery. Therefore good pre-operative evaluation and assessment of predisposing
factors such as difficult airways and systemic complications is essential. Close monitoring of
the cardio respiratory status extending into the postoperative period with a fully awake
patient in a HDU is the key to a safe practice.
Yong, S.-C., et al. (2005). "Incidence of nasal trauma associated with nasal prong versus
nasal mask during continuous positive airway pressure treatment in very low birthweight
infants: a randomised control study." Archives of disease in childhood. Fetal and neonatal
edition 90(6): F480-483.
To compare the incidence of nasal trauma associated with the use of prong or mask
during nasal continuous positive airway pressure (nCPAP) support in very low birthweight
(<1501 g) infants.Randomised controlled clinical trial.Tertiary care university hospital,
Department of Paediatrics, Kuala Lumpur, Malaysia.All very low birthweight infants
admitted to the neonatal intensive care unit between July 2001 and December 2003 who
received nCPAP through the Infant Flow Driver were randomised to the use of either nasal
prong or mask. The nasal cavity of these infants was inspected daily during the first week and
then weekly until they were weaned off nCPAP.Of the 89 infants recruited, 41 were
randomised to the mask group and 48 to the prong group. There was no significant difference
in the incidence of nasal trauma between the two groups (p = 0.5). The primary site of trauma
was at the junction between the nasal septum and the philtrum in infants in the mask group
and the walls of the nasal septum in the prong group. Logistic regression analysis showed that
duration of nCPAP was the only significant risk factor associated with development of nasal
injury, after birth weight, gestational age, and nasal device used had been controlled for
(adjusted odds ratio 1.04; 95% confidence interval 1.01 to 1.07; p = 0.003).Irrespective of the
type of nasal device used, nasal trauma is common during nCPAP treatment, which should
therefore be terminated as soon as possible.
Zanardo, V., et al. (2009). "Breastfeeding the 'healthy' near-term infants after laryngeal mask
airway or traditional resuscitation methods." Journal of Maternal-Fetal and Neonatal
Medicine 22(SUPPL. 3): 92-95.
Background. The influence of delivery room resuscitation practice on neonatal
breastfeeding pattern is largely not data driven, and clinical experience is insufficient to
indicate the impact of available management methods. Aim. This cohort observational study
investigated weather laryngeal mask airway LMA rather conventional positive pressure
resuscitation devices, face mask FM, or endotracheal-tube ETT would influence
breastfeeding pattern in the near-term infants triaged to regular newborn nursery. Methods.
We identified through 18,641 birth records from 2002 to 2006, 921 4.9 records of near-term
infants of 3436 67 weeks' gestation, 710 77.1 triaged to regular newborn nursery. Among
those, 52710 7.3 required positive pressure resuscitation at birth, inclusive of LMA 29, 55.7,
bag-face mask FM, 19, 36.5, and endo-tracheal tube ETT, 4, 7.6, respectively. Fifty nonresuscitated near-term infants were used as controls. Results. Anthropometrical and clinical
characteristics of resuscitated near-term study groups were comparable to controls. LMA was
more frequently employed at birth to resuscitate near-term infants triaged to regular newborn
nursery OR; 95 CI 17.16; 5.3455.14, whereas ETT was less frequently utilized OR; 95 CI
0.11; 0.020.55. Although LMA and ETT resuscitation methods did not influence
breastfeeding rate at discharge with respect to controls, FM resuscitation was associated with
both the lowest breastfeeding rate OR; 95 CI 3.20; 1.079.57 and the more frequently formulafeeding OR; 95 CI 7.23; 1.5832.92, and bottle-feeding use OR; 95 CI 4.20; 1.3013.49 at
discharge. Conclusion. LMA is an effective and safe alternative to more conventional forms
of airway management in near-term infants needing resuscitation at birth. Other studies are
needed to clarify the potential advantages of the LMA on breastfeeding. (copyright) 2009
Informa UK Ltd.
Zanardo, V. and M. Chiaranda "[High-frequency ventilation in the newborn infant]." La
Pediatria medica e chirurgica : Medical and surgical pediatrics 7(6): 801-807.
High-frequency ventilation (HFV), currently under investigation in three categories:
high-frequency positive pressure ventilation (HFPPV), high-frequency jet ventilation (HFJV),
and high-frequency oscillation (HFO), is a new form of mechanical ventilation that employs
small tidal volumes in relation to dead space and extremely rapid rates, ranging from 1 to 40
Hz. It has a number of theoretical advantages when compared with current methods of
conventional ventilation, and provides adequate gas exchange using minimal proximal airway
pressure with little circulatory interference. Reports of successful application of the principles
of the HFV in the treatment of infants with respiratory distress syndrome and particularly
those with severe interstitial emphysema have raised hopes that this technique might prevent
barotrauma to the lungs and have stimulated physicians and engineers to develop new
equipment that might be useful in ventilating small infants. Approximately 80 infants are
known to have been treated with HFV, mostly for short periods of time. In some with
pulmonary interstitial emphysema, the only means of ventilating the infant have been with
HFV. There is evidence that the technique can produce adequate gas exchange in infants,
primarily when employed for a short period of time. As more knowledge is gained about the
etiology of chronic neonatal lung disorders and as the questions of serious adverse effects of
HFV are answered, it seems likely that a controlled, randomized, clinical trial might be
needed in the future to determine whether HFV can decrease the incidence of complications
such as air leak, lessen the morbidity, shorten the duration of dependency on the ventilator,
and decrease the requirement for oxygen.
Zanardo, V., et al. (2010). "Delivery room resuscitation of near-term infants: role of the
laryngeal mask airway." Resuscitation 81(3): 327-330.
This observational study aims to describe: (1) the use of positive pressure ventilation
(PPV) for resuscitation in the delivery room among newly born near-term infants; (2) the
methods used for PPV resuscitation [e.g., bag-facial mask (BFM), laryngeal mask airway
(LMA), endotracheal tube (ETT)]; and (3) the association of each device with short-term
neonatal outcomes.We identified near-term (34 0/7-36 6/7 weeks) infants delivered at the
Padua University Hospital (Padua, Italy) during the years 2002-2006. The mode of delivery,
gestational age, birth weight, Apgar scores, methods of resuscitation and respiratory outcome
after NICU admission were analysed.During the 5-year study period, 921 (4.9%) near-term
infants were identified from a total of 18,641 live births. PPV was provided in the delivery
room to 86 (9.3%) of these infants. Among them, 36 (41.8%) were managed by LMA, 34
(39.5%) by BFM and 16 (18.6%) by ETT. Thirty-four (39.5%) resuscitated near-term infants
were admitted to the Neonatal Intensive Care Unit (NICU): 15 (44.1%) after BFM, 12 (75%)
after ETT and seven (19.4%) after LMA. Resuscitation with an ETT was associated with an
increased rate of respiratory distress syndrome when compared with either BFM or LMA.
Resuscitation with an LMA was associated with a lower rate of NICU admission and shorter
length of stay when compared with either BFM or ETT.The LMA is an effective device for
primary airway management of near-term infants and for secondary airway management
among near-term infants failing BFM or ETT resuscitation.Copyright 2009 Elsevier Ireland
Ltd. All rights reserved.
Zaramella, P., et al. (2006). "Does helmet CPAP reduce cerebral blood flow and volume by
comparison with Infant Flow driver CPAP in preterm neonates?" Intensive Care Medicine
32(10): 1613-1619.
We compared neonatal helmet continuous positive airway pressure (CPAP) and the
conventional nasal Infant Flow driver (IFD) CPAP in the noninvasive assessment of absolute
cerebral blood flow (CBF) and relative cerebral blood volume changes (DeltaCBV) by nearinfrared spectroscopy.A randomized crossover study in a tertiary referral NICU.Assessment
of CBF and DeltaCBV in 17 very low birth weight infants with respiratory distress (median
age 5 days) treated with two CPAP devices at a continuous distending pressure of 4
mbar.Neonates were studied for two consecutive 60-min periods with helmet CPAP and with
IFD CPAP. Basal chromophore traces enabled DeltaCBV changes to be calculated. CBF was
calculated in milliliters per 100 grams per minute from the saturation rise integral and rate of
rise O(2)Hb-HHb. Median (range) CBF with helmet CPAP was 27.37 (9.47-48.20) vs. IFD
CBF 34.74 (13.59-60.10)(p=0.049) and DeltaCBV 0.15 (0.09-0.28) with IFD and 0.13 (0.070.27) with helmet CPAP (NS). Using helmet and IFD CPAP, the neonates showed no
difference in mean physiological parameters (transcutaneous carbon dioxide and oxygen
tension, pulse oximetry saturation, heart rate, breathing rate, mean arterial blood pressure,
desaturation rate, axillary temperature).Assessing CBF and DeltaCBV measured by nearinfrared spectroscopy with two CPAP devices revealed no differences in relative blood
volume, but CBF was lower with helmet CPAP. Greater active vasoconstriction and/or
passive capillary and/or venous vessel compression seem the most likely reason, due to a
positive pressure around the head, neck, and shoulders by comparison with the airway
pressure.
Miller, R. D. and W. K. Hamilton (1969). "Pneumothorax during infant resuscitation."
JAMA : the journal of the American Medical Association 210(6): 1090-1091.
Okulu, E., et al. (2012). "Clinical outcomes of very-low-birth-weight infants who receive
non-invasive ventilator support." Early Human Development 88: S108-S109.
Objective: To evaluate the clinical outcomes of very-low-birth-weight infants who
receive non-invasive ventilation at delivery room (DR) and NICU. Design: The study was
designed prospectively from January-2009 for three years. Infants born before 28 weeks and
infants born at 29 to 30 weeks who didn't receive antenatal steroid (ANS) were included.
During resuscitation, stabilisation and transport infants were ventilated with a T-piece
resuscitator (NeoPuff). All received 100 mg/kg surfactant. If respiratory drive was present,
infants were extubated to nasal CPAP (NCPAP) through short binasal prong (Infant
Flow(registered trademark)). Any infant who needed FiO2 > 0.4 on NCPAP to maintain an
oxygen saturation at 88-92% with clinical deterioration or who had respiratory acidosis
defined as pCO2 > 65mmHg and pH< 7.2 on arterial blood gas sample was intubated and
mechanical ventilation (MV) was initiated. The need for MV within the first 3 days of life,
neonatal morbidities, mortality, and duration of hospitalisation were assessed. Results: Eighty
infants met the inclusion criteria during the study period. The mean gestational age (GA) and
the mean birth weight (BW) of infants were 27.0(plus or minus)2.1 weeks, and 936.5(plus or
minus)299.1 g, respectively. Half of them were male, 74% of infants were born by C/S, 55%
of infants were born from multiple pregnancies. ANS was given to 27.5% of the pregnancies.
The presence of premature rupture of membranes and chorioamnionitis were 57.5% and 34%,
respectively. Twenty-three (28.7%) infants could not be extubated at the DR, where 53
(71.3%) infants received NCPAP. Mean GA and BW were statistically lower in the infants
who couldn't be extubated (p < 0.001). Ten (17.5%) of 53 infants who were on NCPAP
initially needed MV during their first 3 days. There wasn't any case with air leak. The
incidence of pulmonary haemorrhage, PDA, NEC, IVH, BPD, ROP and mortality were 6.2%,
30%, 20%, 14%, 10%, 9% and 38.7%, respectively. The duration of respiratory support was
1-720 hours (median: 29 hours). Mean duration of hospitalisation was 34.9(plus or
minus)28.4 days. Mean GA and BW were lower, the incidence of pulmonary haemorrhage,
IVH, BPD and mortality were higher in infants who failed NCPAP than infants who never
intubated (p < 0.05). Conclusion: Our study demonstrated that NCPAP is an effective
noninvasive ventilatory strategy. It didn't increase the risk of air leak. The incidences of BPD
and ROP in our series were lower than reported in 'NICHD Neonatal Research Network' data
(10% vs 27%, and 9% vs 12%).
Shah, V., et al. (2010). "Use of T-piece resuscitator in the delivery ROM: Is it feasible, safe
and efective?" Paediatrics and Child Health 15: 25A-.
Background: Current NRP guidelines recommend the use of T-piece resuscitator to
provide effective ventilation in neonates. Advantages include provision of: 1) consistent and
reliable inflating and positive endexpiratory pressures; 2) free-flow oxygen; and 3)
continuous positive airway pressure. Disadvantages include: 1) occurrence of air leak
syndrome due to prolonged inspiratory time; 2) difficulty in feeling the compliance of the
lung; and 3) difficulty in making changes to the inflating pressure while performing
resuscitation. Objective: To determine the feasibility, safety and effectiveness of using Tpiece resuscitator in providing effective ventilation in the delivery room and for transport in
infants < 32 wks gestation. Design/Methods: Prospective observational study for the period
April-October 2009. T-piece resuscitator was introduced in our unit in April 2009. Practical
training in its use was provided to all medical and nursing staff and respiratory therapists
providing resuscitation. Guidelines for its use during initial resuscitation and for transport of
infants from the resuscitation room into the NICU were developed by the Neonatologists
using a consensus approach. Using a pre-specified data collection form, information
regarding its use during resuscitation and transport of infants < 32 wks was collected. Data
were analyzed and results are presented using descriptive statistics. Results: Of the 221
infants < 32 wks gestation born during the study period, 168 required resuscitation. Complete
data were available for 131/168 (78%) infants. The mean (SD) GA and BW of the study
population was 28.2 (2.4) wks and 1.1 (0.37) kg respectively. T-piece resuscitator was used
in 127/131 (97%) of infants during resuscitation. Reasons for non-use were: congenital
diaphragmatic hernia (N=1) and non-availability of resuscitator circuits (N=3). Bag-mask
ventilation (BMV) was provided in 18/131 (14%) infants. Reasons for use of BMV were:
non-responders to T-piece resuscitator (N=15) and personal preference (N=3). Compliance
with guidelines was reported in 82%. 76% of the infants required intubation and ventilation.
T-piece resuscitator was used to transfer infants to NICU in 68%.The operators were able to
generate the settings within 3 minutes in 79%. Pneumothorax was reported in 1 infant.
Conclusions: T-piece resuscitator can be used safely and effectively to provide ventilation
during resuscitation and transport in infants < 32 wks gestation.
(Duplicated; 23 articles)
Braima, O. and C. A. Ryan (2008). "Neonatal Resuscitation Program Guidelines 2006: Ready,
steady, can't go!" Irish Medical Journal 101(5): -.
New evidence-based guidelines have been launched with recommendations that may
impact how resuscitations, particularly of LBW infants, are enacted. Aim: to determine
current resuscitation practices in Maternity units in Ireland and benchmarked these results to
a recent study in the United States. Methods: A 20-question survey was developed and
mailed to a lead neonatologist/paediatrician in each of 19 maternity units in Ireland in May
2006. Results: There was 84% response rate to the surveys mailed which included 10 level II
and 6 level III units. NRP qualification was considered obligatory for all paediatrics doctors
in all units, with 14/ 16 units running at least one NRP course per year (range 1-9). Self
inflating bags were more commonly used (44%), followed by T-piece resuscitators (31%)
and flow inflating bags(25%). Pulse oximeters to alter the fraction of inspired oxygen were
used by (25%) of units during the management of very low birth weigh infants, with a useful
signal being achieved in one minute in most cases. Air/oxygen blenders were available for
(44%) of units; however, all units use 100% O2 for initial resuscitation. CO2-detectors for
ETT position were used in only 2 units (12%). A third of units (31%) used plastic wrap to
prevent heat loss in VLBW infants. CPAP/PEEP were used by 44% of the surveyed units,
generally with initiating pressure of 5 cm H2O Conclusions: NRP is now an obligatory
feature in all NICU's in Ireland compared to the 1990s when resuscitation training was
disorganized and inconsistent. Variations in resuscitation practices still exist among different
units. Many units may not be able to apply 2006 NRP guidelines especially for VLBW
infants unless there is a significant investment in air/oxygen blenders, pulse oximeters, CO2
detectors and resuscitators that control peak pressures and CPAP/PEEP.
DA, B., et al. (1976). "Is continuous transpulmonary pressure better than conventional
respiratory management of hyaline membrane disease? A controlled study." Pediatrics 58(6):
800-808.
The influence of continuous positive airway pressure (CPAP) and positive endexpiratory pressure (PEEP) on mortality and complication rates in severe hyaline membrane
disease (HMD) was evaluated in a randomized, prospective study. Patients were admitted to
the study if the Po2 was less than 50 mm Hg with FiO2 greater than 0.6. Twenty-four patients
in each of three weight groups were equally divided between treatment and control groups.
The treatment regimen included CPAP (6 to 14 cm H2O) for spontaneously breathing
patients and PEEP for patients requiring mechanical ventilation for apnea or hypercapnia
(Pco2 greater than 65 mm Hg). Control patients received oxygen and were mechanically
ventilated if they had apnea, hypercapnia, or Po2 less than 50 mm Hg with FiO2 greater than
0.8. Oxygenation improved after the start of CPAP or PEEP; however, Pco2 rose after CPAP
was initiated. There was no significant difference between treatment and control groups in
mortality, requirement for mechanical ventilation, or incidence of pulmonary sequelae. The
incidence of pulmonary air-leak was increased with Peep. the findings suggest that CPAP and
PEEP have not significantly altered the outcome of HMD.
Finer, N. N. and W. D. Rich (2004). "Neonatal resuscitation: raising the bar." Current
Opinion in Pediatrics 16(2): 157-162.
To provide an overview of neonatal resuscitation practices with an emphasis on
interventions that are not currently accepted or adapted into existing resuscitation
guidelines.Current resuscitation guidelines do not contain specific guidelines for the approach
to the extremely low birth weight infant. The differences in environment and management
between the neonatal ICU and delivery room are striking and are magnified in the
resuscitation of extremely low birth weight infants for whom maintenance of a neutral
thermal environment is essential. The use of a polyethylene wrap applied at delivery has been
shown to reduce the occurrence of hypothermia and decrease mortality. There is substantial
evidence that term and near-term newborn infants can be effectively resuscitated with room
air, and recent follow-up studies have demonstrated that this approach is not associated with
increased significant differences in neurologic handicap, somatic growth, or developmental
milestones when compared with the use of 100% oxygen. The safety and potential benefits of
this approach require prospective evaluation in the premature and especially extremely low
birth weight infant. There is preexisting evidence that demonstrates that the use of prolonged
inflations and t-piece resuscitators may be advantageous during resuscitation, but not all
guidelines support these interventions. Although regulated continuous positive airway
pressure, pulse oximeters, and blenders are routinely used once an infant is admitted to the
neonatal ICU, none of these interventions is recommended in the delivery area. Although
prospective studies have demonstrated that the use of colorimetric CO2 detectors
significantly decreases the time to recognize misplaced endotracheal tubes placed during
resuscitation, their use is not required by current guidelines. The duration of an intubation
attempt during resuscitation had never been prospectively evaluated, and our recent findings
suggest that a limit of 30 seconds is well tolerated and provides adequate time for a
successful attempt.There is significant potential for improvement in current resuscitation
environments and interventions that will only be realized through further prospective research.
HS, F., et al. (1980). "[Intermittent mandatory ventilation in the treatment of the idiopathic
respiratory distress syndrome of newborns]." Schweizerische medizinische Wochenschrift
110(7): 251-255.
Intermittent mandatory ventilation (IMV) is a combination of CPAP and IPPV. In the
newborn period it offers the following advantages compared to IPPV alone: weaning is faster,
independent control of respiration is maintained and the effect on cardiac venous return is
minimized. 36 patients with idiopathic respiratory distress syndrome treated by IMV were
compared with 18 patients ventilated with IPPV: IMV reduced the total time on the respirator
by more than 50%. Exposure to increased FIO2 and hospital stay were markedly shortened,
and the incidence of complications was decreased. Intermittent mandatory ventilation
represents an optimal method for stress-free and safe ventilation of newborn infants.
IU, C. and A. JS (2001). "Feasibility of tidal volume-guided ventilation in newborn infants: a
randomized, crossover trial using the volume guarantee modality." Pediatrics 107(6): 13231328.
BACKGROUND AND AIM: Volume guarantee (VG) is a new composite mode of
pressure-limited ventilation, available on the Dr?ger Babylog 8000 ventilator, which allows
the clinician to set a target mean tidal volume to be delivered while still maintaining control
over peak airway pressures. This study aimed to investigate the feasibility and efficacy of this
mode of ventilation in premature newborn infants with respiratory distress syndrome (RDS).
METHODS: Two groups of infants were studied: those receiving synchronized intermittent
positive pressure ventilation (SIPPV) in early phase of RDS (group 1) and those in recovery
phase of RDS being weaned from artificial ventilation through synchronized intermittent
mandatory ventilation (SIMV; group 2). Both groups of infants were studied over a 4-hour
period. Before the start of the study, the infants were either receiving SIPPV (group 1) or
SIMV (group 2). Infants in group 1 were randomized to either continue on SIPPV for the first
hour of the study or to receive SIPPV plus VG for the first hour. Subsequently, the 2 modes
were used alternately for the remaining three 1-hour periods. Similarly, infants in group 2
were randomized to either continue on SIMV for the first hour of the study or to receive
SIMV plus VG for the first hour. Data on ventilation parameters and transcutaneous carbon
dioxide and oxygen were collected continuously. RESULTS: Forty infants were studied, 20
in each group. The mean (standard error) gestational age was 27.9 (0.3) weeks; birth weight
was 1064 (60) g. No adverse events were observed during the study. Fractional inspired
oxygen during SIMV plus VG was 0.31 (0.3); during SIMV, 0.31 (0.3); during SIPPV plus
VG, 0.41 (0.4); and during SIPPV, 0.40 (0.4). Transcutaneous carbon dioxide pressure during
SIMV plus VG was 6.0 (2.2) kPa; during SIMV, 5.9 (2.2) kPa; during SIPPV plus VG, 6.4
(2.9) kPa; and during SIPPV, 6.4 (2.8) kPa. Transcutaneous partial pressure of oxygen during
SIMV plus VG was 8.4 (8.7) kPa; during SIMV, 8.6 (8.8) kPa; during SIPPV plus VG, 7.6
(4.0) kPa; and during SIPPV, 7.7 (4.2) kPa. None of these differences was statistically
significant. The mean (standard error) peak inspiratory pressure used during SIMV was 17.1
(3.4) cm of water; during SIMV plus VG, 15.0 (7.5) cm of water; during SIPPV plus VG,
17.1 (9.3) cm of water; and during SIPPV, 18.7 (8.3) cm of water. The mean airway pressure
during SIMV plus VG was 6.5 (3.1) cm of water; during SIMV, 6.9 (2.8) cm of water; during
SIPPV plus VG, 9.6 (4.5) cm of water; and during SIPPV, 9.8 (4.6) cm of water.
CONCLUSION: VG seems to be a stable and feasible ventilation mode for neonatal patients
and can achieve equivalent gas exchange using statistically significant lower peak airway
pressures both during early and recovery stages of RDS.ventilation, airway pressure, volume
guarantee, tidal volume.
J, D., et al. (2012). "[Clinical application of proportional assist ventilation in very low birth
weight infants with ventilator dependence]." Zhongguo dang dai er ke za zhi [Chinese journal
of contemporary pediatrics] 14(6): 401-405.
OBJECTIVE: To study the effect of proportional assist ventilation (PAV)
onphysiology and respiratory mechanics in very low birth weight (VLBW) infants
withventilator dependence by comparison with conventional assist/control (A/C)ventilation.
METHODS: Forty-six infants with ventilator dependence were randomlydivided into two
groups according to the ventilation model: PAV (n=23) and A/C(n=23). The gain of resistive
and elastic unloading was set based on the runwaymethod in the PAV group. Ventilation
parameters were set based on theconventional method in the A/C group. Infants were
observed for 30 minutes threetimes per day for three consecutive days. Arterial gas analysis
results,transcutaneous saturation of oxygen (SPO2), heart rate, blood pressure
(BP),respiratory rate (RR), mean airway pressure (MAP), peak inspiratory pressure(PIP), tide
volume (VT), minute volume (MV) and oxygenation index (OI), werecompared between the
two groups. RESULTS: Compared with the A/C group, PaO2 andOI in the PAV group were
significantly higher while PIP and MAP weresignificantly lower. There were no significant
differences in FiO2, SPO2, pH,PaCO2, PEEP, VT, MV and RR between the two groups.
Although mean arterial bloodpressure and heart rate in the PAV group were not different
from the A/C group,beat-to-beat variabilities in systolic and diastolic arterial blood pressure
weresignificantly lower in the PAV group than in the A/C group. CONCLUSIONS: PAV
maysafely maintain gas exchange at lower airway pressures compared with A/Cventilation in
VLBW infants. It can also improve oxygenation andinfant-ventilator synchronization
Johnston, K. L. and K. Aziz (2009). "The self-inflating resuscitation bag delivers high
oxygen concentrations when used without a reservoir: Implications for neonatal
resuscitation." Respiratory Care 54(12): 1665-1670.
OBJECTIVE: To measure the delivered fractional oxygen concentration (F DO2)
from preterm-size Laerdal silicone resuscitators (PLSR) without a reservoir.
BACKGROUND: The North American Neonatal Resuscitation Program manual states that
self-inflating bags without a reservoir deliver approximately 40% oxygen, differing from the
PLSR manufacturer's specifications. METHODS: A neonatal test lung was manually
ventilated using PLSRs without a reservoir. A 50 psi 100% oxygen source and an oxygen
flow meter were used to provide desired oxygen inlet flows. FDO2 was measured using 3
different PLSRs after 4 min of manual ventilation of a neonatal test lung, at differing inspired
tidal volumes (5 mL or 20 mL), respiratory rates (40 breaths/min or 60 breaths/min), and
oxygen inlet flows (1 to 4, 5, and 10 L/min). RESULTS: In all tests using 5 or 10 L/min,
FDO2 exceeded 0.95. The lowest FDO2 was 0.59, at 1 L/min. CONCLUSIONS: The FDO2
measured during this study did not differ from PLSR specifications. The FDO2 did, however,
differ from information contained in the North American Neonatal Resuscitation Program
manual regarding use of a self-inflating bag without a reservoir. Care should be taken when
selecting a self-inflating resuscitation device to provide blended air and oxygen, as high
concentrations of oxygen may be delivered by these devices even when the reservoir is
removed. American and Canadian recommendations for the provision of supplemental
oxygen with self-inflating bags require reevaluation. (copyright) 2009 Daedalus Enterprises.
JS, A., et al. (1998). "Infant Flow Driver or single prong nasal continuous positive airway
pressure: short-term physiological effects." Acta paediatrica 87(3): 325-327.
The effectiveness of single prong nasal continuous positive airway pressure (CPAP)
was compared with the Infant Flow Driver (IFD) in a crossover study in 20 neonates treated
with > or = 30% oxygen by nasal CPAP. They were randomized to the device used at the
start of the study. Each infant was studied for four consecutive 2-h periods alternating
between single prong nasal CPAP and the IFD. The FiO2 from the IFD read 0.02 higher than
the same setting on the ventilators used for single prong nasal CPAP. The IFD improved the
mean (95% CI) of the FiO2 by 0.05 (0.02-0.08), p = 0.008. Taking into account the
systematic error in the FiO2 between the devices the real mean improvement in FiO2
produced by the IFD was 0.03 (-0.005 to 0.06), p=0.09. There were no significant differences
in respiratory rate, heart rate, blood pressure or comfort score of infants during periods of
single nasal prong CPAP compared with periods on the IFD.
Kim, E. H. (1989). "Successful extubation of newborn infants without preextubation trial of
continuous positive airway pressure." Journal of perinatology : official journal of the
California Perinatal Association 9(1): 72-76.
Sixty newborn infants who had been mechanically ventilated through 3.0- or 3.5-mm
endotracheal tubes were studied to examine the necessity of a preextubation trial of
continuous positive airway pressure (CPAP). Thirty randomly assigned study infants were
directly extubated from intermittent mandatory ventilation rates of six per minute; 30
randomly assigned control infants were extubated after a six-hour trial of continuous positive
airway pressure of 3 cm H2O. Changes in respiratory rate, in PCO2, and in PO2/FIO2 were
similar. All 30 study infants tolerated direct extubation without significant apnea or
respiratory acidosis. Two study and eight control infants developed apnea during six hours
after intermittent mandatory ventilation was discontinued (chi 2 = 4.3, P less than .05). Five
control and no study infants had apneic episodes greater than or equal to 0.5 per hour (chi 2 =
5.5, P less than .02). The results of this study suggest that newborn infants may tolerate direct
extubation from low intermittent mandatory ventilation rates without a preextubation trial of
CPAP. A preextubation trial of CPAP appears to be unnecessary and may cause more
frequent apnea in newborn infants if used for more than several hours.
L, C., et al. (2005). "A randomized trial comparing oxygen delivery on intermittent positive
pressure with nasal cannulae versus facial mask in neonatal primary resuscitation." Acta
paediatrica 94(2): 197-200.
AIM: To compare, in a prospective clinical trial, oxygen delivery on intermittent
positive pressure with nasal cannulae versus facial mask in primary resuscitation of the
newborn with moderate asphyxia. METHODS: 617 neonates with moderate asphyxia at birth
were randomized: 303 were resuscitated by oxygen on intermittent positive pressure with
nasal cannuale and 314 neonates by mask. Resuscitation followed the Neonatal Resuscitation
Program guidelines of the American Academy of Pediatrics, 3rd edition. RESULTS:
Resuscitation through the nasal route less frequently requires chest compressions and
intubations (26 neonates needed chest compression and 20 needed intubation out of 314
resuscitated by mask; five neonates needed chest compression and two needed intubation out
of 303 resuscitated by nasal cannulae). Apgar scores, admission rates to neonatal intensive
care units, air-leak syndromes, birthweight, gestational age, use of prenatal steroids and
deaths did not differ between groups. CONCLUSION: Oxygen delivery on intermittent
positive pressure with nasal cannulae in primary resuscitation of the newborn with moderate
asphyxia is a less aggressive and potentially advantageous alternative to the traditional oral
route.
LD, M. and B. EH (1975). "Early versus delayed initiation of continuous negative pressure in
infants with hyaline membrane disease." Journal of Pediatrics 87(4): 596-600.
Twenty-three infants with HMD of similar severity, who were less than 24 hours of
age and who were breathing spontaneously, were divided by random numbers into early and
delayed CNP groups. The infants who were treated with CNP before their PaO2 was less than
50 mm Hg while breathing 70% oxygen experienced a significantly greater increase in PaO2
in response to the initiation of CNP, required less time with O2 therapy, required no
mechanical ventilation, and had fewer complications. Based on these results, it is suggested
that CNP be initiated in infants with HMD, who are less than 24 hours of age and are
breathing spontaneously, before the PaO2 becomes less than 50 mm Hg on 70% O2.
McNamara, F. and C. E. Sullivan (1999). "Obstructive sleep apnea in infants and its
management with nasal continuous positive airway pressure." Chest 116(1): 06-Oct.
Nasal continuous positive airway pressure (nCPAP) is the most common treatment
for obstructive sleep apnea (OSA) in adults, and it has been effective in the treatment of OSA
in children. We wanted to determine the effectiveness of long-term nCPAP therapy for OSA
in infants.Twenty-four infants who had OSA were treated with nCPAP via nose mask. These
infants had clinical histories that included a family history of sudden infant death syndrome,
an apparent life-threatening event, or facial and upper airway anatomic
abnormalities.Overnight polysomnographic studies were performed to assess the severity of
OSA in each infant and to determine the appropriate level of continuous positive airway
pressure (CPAP). Studies were repeated to determine the progress of OSA and the continuing
need for CPAP in each infant.nCPAP pressures between 4 and 6 cm H2O prevented
obstruction and reversed sleep disturbances that were associated with OSA. Eighteen of the
infants continued treatment at home from 1 month to > 4 years. CPAP therapy was
discontinued in 13 infants after their OSA resolved. Five infants who have upper airway
anatomic abnormalities remain on CPAP, and the pressure level required to prevent
obstructive events during sleep has needed to be increased to as high as 10 cm H2O.nCPAP
is an effective therapy for the management of OSA in infants, and it can be used effectively
in the home environment. Regular follow-up is necessary, because the requirements for
CPAP and pressure levels change with the infant's growth and development.
MF, e.-K., et al. (1994). "Mechanical ventilators optimized for pediatric use decrease work of
breathing and oxygen consumption during pressure-support ventilation." Critical care
medicine 22(12): 1942-1948.
OBJECTIVES: a) To investigate whether the patient work of breathing needed to
trigger inspiration is affected by the type of ventilator delivering pressure-support ventilation
for mechanically ventilated pediatric patients. b) To determine whether changes in oxygen
consumption (VO2) trend with changes in work of breathing and would thus be helpful in
tracking work of breathing. DESIGN: Prospective study. SETTING: Pediatric intensive care
unit at a university hospital. PATIENTS: Nine mechanically ventilated patients (2 to 75
months of age). INTERVENTIONS: While maintaining a constant pressure-support
ventilation level, patients were alternately supported with the Siemens Servo 900C, the Bird
VIP, and the Newport Wave E200 ventilators in random order. MEASUREMENTS AND
MAIN RESULTS: Work of breathing, defined as the integral of the pressure-volume curve
corresponding to negative pressure, was calculated with a pulmonary monitoring system.
VO2 was measured with a metabolic cart. Patient distress levels were assessed using the
COMFORT scale, a behavioral scoring system. Mean values (20 breaths/patient) for
measured variables with each ventilator were compared using analysis of variance and Scheff?
tests, with p < .05 indicating statistical significance. The lowest VO2 (103 +/- 35 mL/min/m2)
and work of breathing (24 +/- 15 g.cm/m2) were achieved with the Bird VIP ventilator and
were significantly (p < .05) lower than those values obtained with either the Siemens Servo
900C (VO2 147 +/- 33 mL/min/m2; work of breathing 49 +/- 18 g.cm/m2) or the Newport
Wave E200 (VO2 122 +/- 33 mL/min/m2; work of breathing 35 +/- 15 g.cm/m2). Also, the
values of work of breathing and VO2 obtained using the Newport Wave E200 were
significantly (p < .05) lower than those values obtained using the Servo 900C. No change in
behavioral distress occurred when the ventilators were changed. In all patients, there was a
clear similarity in the trends of VO2 and work of breathing. CONCLUSIONS: We conclude
that VO2 and work of breathing may be reduced significantly using the latest generation of
mechanical ventilators optimized for infant and pediatric use. Because work of breathing is
less with the Bird VIP than the other two ventilators tested, leading to a corresponding
decrease in VO2, we suggest that the Bird VIP better adapts the patient to the ventilator and
may facilitate weaning from ventilatory support. We also suggest that changes in VO2 might
be helpful in tracking changes in work of breathing.
O'Donnell, C. P. F., et al. (2004). "Neonatal resuscitation: review of ventilation equipment
and survey of practice in Australia and New Zealand." Journal of Paediatrics and Child
Health 40(4): 208-212.
The equipment used to provide positive pressure ventilation at neonatal resuscitation
varies between institutions. Available devices were reviewed and their use surveyed in a
geographically defined region. The aim of this study was to establish which resuscitation
equipment is used at neonatal intensive care units in Australia and New Zealand.A
questionnaire was sent to a neonatologist at each of the 29 neonatal intensive care units in
Australia and New Zealand, asking which resuscitation equipment they used. If it was not
returned, follow up was by email and telephone.Data was obtained from all units. Round face
masks are used at all centres. Anatomically shaped masks are infrequently used at two of the
three centres (10%) that have them. Straight endotracheal tubes are used exclusively at 23
(79%) centres. Shouldered tubes are used infrequently at three of the six centres that have
them. The Laerdal Infant Resuscitator self-inflating bag is used at 22 (76%) centres. Flowinflating bags are used at 12 (41%) centres. The Neopuff Infant Resuscitator is used at 14
(48%) centres. Varying oxygen concentrations are provided at delivery at 6/25 (24%)
centres.There is a paucity of evidence for the efficacy of the equipment used currently to
resuscitate newborn infants. This complete survey of the tertiary centres in a geographical
region shows considerable variation in practice, reflecting this lack of evidence and
consequent uncertainty among clinicians. Further research is necessary to determine which
devices are preferable for this most important and common intervention.
O'Donnell, C. P. F., et al. (2004). "Positive pressure ventilation at neonatal resuscitation:
review of equipment and international survey of practice." Acta paediatrica (Oslo, Norway :
1992) 93(5): 583-588.
The equipment used to provide positive pressure ventilation to newborns needing
resuscitation at delivery varies between institutions. Devices were reviewed and their use
surveyed in a sample of neonatal centres worldwide.To determine which equipment is used to
resuscitate newborns at delivery in a sample of teaching hospitals around the world.A
questionnaire was sent via e-mail to a neonatologist at each of 46 NICUs in 23 countries on
five continents, asking which resuscitation equipment they used. If it was not returned,
follow-up was by e-mail.Data were obtained from 40 (87%) centres representing 19 countries.
Round face masks are used at 34 (85%) centres, anatomically shaped masks are used
exclusively at six (15%) and a mixture of types are used at 11 (28%). Straight endotracheal
tubes are used exclusively at 36 (90%) centres: shouldered tubes are used infrequently at
three of the four centres that have them. The self-inflating bag is the most commonly used
manual ventilation device (used at 33 (83%) centres), the Laerdal Infant Resuscitator the
most popular model. Flow-inflating bags are used at 10 (25%) centres. The Neopuff Infant
Resuscitator is used at 12 (30%) centres. Varying oxygen concentrations are provided during
neonatal resuscitation at half of the centres, while 100% oxygen is routinely used at the other
half.This survey shows considerable variation in practice, reflecting this lack of evidence and
consequent uncertainty among clinicians. Comparison of the two most popular manual
ventilation devices, the Laerdal Infant Resuscitator and the Neopuff Infant Resuscitator, is
urgently required.
P, G., et al. (1975). "Early versus late introduction of continuous negative pressure in the
management of the idiopathic respiratory distress syndrome." Journal of Pediatrics 87(4):
591-595.
To evaluate the effectiveness of the early application of continuous negative pressure
about the thorax, 23 infants with the idiopathic respiratory distress syndrome who had
adequate alveolar ventilation were assigned to early or late application of CNP. There were
11 infants in the early CNP and 12 in the late CNP group. There were no differences between
the two groups with respect to birth weight, gestational age, age at admission to the study,
initial FIO2 requirements, or initial PaO2, PaCo2, and AaPO2. None of the ENCP patients
required mechanical ventilation, whereas four of the LCNP group did so. The FIO2
requirements were significantly less for the ECNP infants when compared to the LCNP ones.
The mean duration of FIO2 requirements greater than 0.6 was 28.3 hours for those receiving
ECNP and 60.7 hours for those in LCNP (P LESS THAN 0.05). This study suggests that the
course of RDS may be modified by the early application of CNP.
PG, D. and H.-S. DJ (1999). "Post-extubation prophylactic nasal continuous positive airway
pressure in preterm infants: systematic review and meta-analysis (Structured abstract)."
Journal of Paediatrics and Child Health 35(4): 367-371.
R?s?nen, J. and M. Leijala (1991). "Breathing circuit respiratory work in infants recovering
from respiratory failure." Critical care medicine 19(1): 31-35.
To compare cardiopulmonary function during spontaneous breathing with three
continuous-flow breathing circuits. The major difference between these circuits was the
degree of flow resistance offered by the exhalation valve.Randomized crossover trial.Twelve
infants less than 12 months of age recovering from respiratory failure of variable etiology.
Only patients weighing 3 to 10 kg were studied.The patients were connected to each
respiratory circuit in a random sequence, with 15 min allowed for equilibration before
assessment of cardiopulmonary function. Airway pressure (Paw) and FIO2 were maintained
unchanged.Ventilation, gas exchange, or circulatory function were not altered significantly
by changing the breathing circuit. However, Paw and esophageal pressure fluctuations were
altered and were largest during breathing with the circuit that had an exhalation valve with
high-flow resistance. The Paw fluctuation recorded while the patient was breathing with the
flow-resistor circuit increased with weight and exceeded 2 cm H2O in all patients weighing
greater than 4.5 kg. Paw fluctuation could be decreased by greater than 2 cm H2O in ten of
12 patients by using the threshold-resistor circuit.The results indicate a need for evaluating
the characteristics of respiratory circuits used for spontaneous breathing in infants and
children, to avoid unnecessary equipment-related increase in respiratory work.
Rhodes, P. G. and R. T. Hall (1973). "Continuous positive airway pressure delivered by face
mask in infants with the idiopathic respiratory distress syndrome: a controlled study."
Pediatrics 52(1): 05-Jan.
SA, S., et al. (2001). "Volume ventilation of infants with congenital heart disease: a
comparison of Dr?ger, NAD 6000 and Siemens, Servo 900C ventilators." Anesthesia and
Analgesia 92(1): 76-79.
We compared the ventilation and pulmonary mechanics produced by a new
anesthesia ventilator (NAD 6000) using a circle system with that produced by a critical care
ventilator (Servo 900C) using a nonrebreathing circuit in infants with congenital heart disease.
Twenty patients, aged 1 day to 7 mo, weighing 2.1 to 4.6 kg, were studied. The NAD 6000
had improved alveolar ventilation: PaCO(2) 43 +/- 8 vs 47 +/- 5 mm Hg (P = 0.005), endtidal CO(2) 34 +/- 7 vs 37 +/- 5 mm Hg (P = 0.042); larger inspired tidal volumes 12.9 +/- 2.8
vs 11.3 +/- 2.2 mL/kg (P < 0.001), but with higher mean airway pressures 9.7 +/- 1.6 vs 8.6
+/- 1.3 cm H(2)O (P < 0.001). These differences in ventilation and airway pressures were not
clinically significant. Although there were differences in observed ventilatory variables, both
machines provided adequate ventilation when set in the volume control mode. Implications:
We compared two ventilators for use in infants. Twenty infants undergoing surgery for
congenital heart defects were randomized to receive ventilation first with one ventilator, then
with the other. Although there were differences in observed ventilatory variables, both
machines provided adequate ventilation when set in the volume control mode.
Salyer, J. W. (2009). "Manual resuscitators: some inconvenient truths." Respiratory Care
54(12): 1638-1643.
SY, L. and L. V (2002). "Physiological effects of two temperature settings in preterm infants
on nasal continuous airway pressure ventilation." Journal of clinical nursing 11(6): 845-847.
Westerlind, A., et al. (1999). "The use of continuous positive airway pressure by face mask
and thoracic epidural analgesia after lung transplantation. Gothenburg Lung Transplant
Group." Journal of Cardiothoracic and Vascular Anesthesia 13(3): 249-252.
To evaluate the clinical use of continuous positive airway pressure (CPAP) and
thoracic epidural analgesia (TEA) after lung transplantation (LTx).Retrospective case
series.Cardiothoracic intensive care unit (ICU) at a university hospital.All heart-lung,
bilateral, and single-lung transplant recipients between 1990 and 1996 at this institution (n =
102).Postoperative pain was controlled by a thoracic epidural infusion of bupivacaine, 1
mg/mL, and sufentanil, 1 microg/mL. After extubation, CPAP, 5 to 10 cm H2O by face mask,
was used to prevent reperfusion edema.In 99 patients, the length of ventilation (LOV) was a
median of 4.3 hours (range, 1.0 to 312.0 hours). The median LOV was 8.0 hours (range, 1.5
to 41.0 hours) in the heart-lung recipients, 4.5 hours (range, 2.0 to 47.0 hours) in the bilaterallung recipients, and 3.5 hours (range, 1.0 to 312.0 hours) in the single-lung recipients. Three
transplant recipients, all with primary pulmonary hypertension, were prematurely extubated
and reintubated because of pulmonary edema. Twelve hours after extubation, the median
oxygenation index (PaO2/F(I)O2, PaO2 in kilopascal units) was greater than 35. The median
ICU length of stay for all transplant recipients was 4 days (range, 2 to 270 days).The
postoperative use of CPAP and TEA is associated with early and safe tracheal extubation
after LTx and may shorten ICU stay.