Transcutaneous monitoring of diaphragm activity as a measure of work of breathing in preterm infants

Abstract Background Non-invasive ventilation (NIV) has been recommended as the best respiratory support for preterm infants with respiratory distress syndrome (RDS). However, the best NIV technique to be used as first intention in RDS management has not yet been established. Nasal intermittent positive pressure ventilation (NIPPV) may be synchronized (SNIPPV) or non-synchronized to the infant’s breathing efforts. The aim of the study is to evaluate the short-term effects of SNIPPV vs. NIPPV on the cardiorespiratory events, trying to identify the best ventilation modality for preterm infants at their first approach to NIV ventilation support. Methods An unmasked randomized crossover study with three treatment phases was designed. All newborn infants < 32 weeks of gestational age with RDS needing NIV ventilation as first intention or after extubation will be consecutively enrolled in the study and randomized to the NIPPV or SNIPPV arm. After stabilization, enrolled patients will be alternatively ventilated with two different techniques for two time frames of 4 h each. NIPPV and SNIPPV will be administered with the same ventilator and the same interface, maintaining continuous assisted ventilation without patient discomfort. During the whole duration of the study, the patient’s cardiorespiratory data and data from the ventilator will be simultaneously recorded using a polygraph connected to a computer. The primary outcome is the frequency of episodes of oxygen desaturation. Secondary outcomes are the number of the cardiorespiratory events, FiO2 necessity, newborn pain score evaluation, synchronization index, and thoracoabdominal asynchrony. The calculated sample size was of 30 patients. Discussion It is known that NIPPV produces a percentage of ineffective acts due to asynchronies between the ventilator and the infant’s breaths. On the other hand, an ineffective synchronization could increase work of breathing. Our hypothesis is that an efficient synchronization could reduce the respiratory work and increase the volume per minute exchanged without interfering with the natural respiratory rhythm of the patient with RDS. The results of this study will allow us to evaluate the effectiveness of the synchronization, demonstrating whether SNIPPV is the most effective non-invasive ventilation mode in preterm infants with RDS at their first approach to NIV ventilation. Trial registration ClinicalTrials.gov NCT03289936. Registered on September 21, 2017.

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Diaphragmatic work of breathing in premature human infants

Journal of Applied Physiology ◽

10.1152/jappl.1987.62.4.1410 ◽

1987 ◽

Vol 62 (4) ◽

pp. 1410-1415 ◽

Cited By ~ 39

Author(s):

B. G. Guslits ◽

S. E. Gaston ◽

M. H. Bryan ◽

S. J. England ◽

A. C. Bryan

Keyword(s):

Lung Disease ◽

Preterm Infants ◽

Work Of Breathing ◽

Mechanical Efficiency ◽

Strongly Correlated ◽

Intercostal Muscle ◽

Human Infants ◽

Transdiaphragmatic Pressure ◽

Rib Cage ◽

Inspiratory Work

Present methods of assessing the work of breathing in human infants do not account for the added load when intercostal muscle activity is lost and rib cage distortion occurs. We have developed a technique for assessing diaphragmatic work in this circumstance utilizing measurements of transdiaphragmatic pressure and abdominal volume displacement. Eleven preterm infants without evidence of lung disease were studied. During periods of minimal rib cage distortion, inspiratory diaphragmatic work averaged 5.9 g X cm X ml-1, increasing to an average of 12.4 g X cm X ml-1 with periods of paradoxical rib cage motion (P less than 0.01). Inspiratory work was strongly correlated with the electrical activity of the diaphragm as measured from its moving time average (P less than 0.05). Assuming a mechanical efficiency of 4% in these infants, the caloric cost of diaphragmatic work may reach 10% of their basal metabolic rate in periods with rib cage distortion. When lung disease is superimposed, the increased metabolic demands of the diaphragm may predispose preterm infants to fatigue and may contribute to a failure to grow.

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The Effect of Initial Oxygen Exposure on Diaphragm Activity in Preterm Infants at Birth

Frontiers in Pediatrics ◽

10.3389/fped.2021.640491 ◽

2021 ◽

Vol 9 ◽

Author(s):

Ruud W. van Leuteren ◽

Anouk W. J. Scholten ◽

Janneke Dekker ◽

Tessa Martherus ◽

Frans H. de Jongh ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Preterm Infants ◽

Controlled Trial ◽

Statistical Significance ◽

Area Under The Curve ◽

Low Oxygen ◽

Randomized Controlled ◽

Oxygen Group ◽

Breathing Effort ◽

Diaphragm Activity

Background: The initial FiO2 that should be used for the stabilization of preterm infants in the delivery room (DR) is still a matter of debate as both hypoxia and hyperoxia should be prevented. A recent randomized controlled trial showed that preterm infants [gestational age (GA) < 30 weeks] stabilized with an initial high FiO2 (1.0) had a significantly higher breathing effort than infants stabilized with a low FiO2 (0.3). As the diaphragm is the main respiratory muscle in these infants, we aimed to describe the effects of the initial FiO2 on diaphragm activity.Methods: In a subgroup of infants from the original bi-center randomized controlled trial diaphragm activity was measured with transcutaneous electromyography of the diaphragm (dEMG), using three skin electrodes that were placed directly after birth. Diaphragm activity was compared in the first 5 min after birth. From the dEMG respiratory waveform several outcome measures were determined for comparison of the groups: average peak- and tonic inspiratory activity (dEMGpeak and dEMGton, respectively), inspiratory amplitude (dEMGamp), area under the curve (dEMGAUC) and the respiratory rate (RR).Results: Thirty-one infants were included in this subgroup, of which 29 could be analyzed [n = 15 (median GA 28.4 weeks) and n = 14 (median GA 27.9 weeks) for the 100 and 30% oxygen group, respectively]. Tonic diaphragm activity was significantly higher in the high FiO2-group (4.3 ± 2.1 μV vs. 2.9 ± 1.1 μV; p = 0.047). The other dEMG-parameters (dEMGpeak, dEMGamp, dEMGAUC) showed consistently higher values in the high FiO2 group, but did not reach statistical significance. Average RR showed similar values in both groups (34 ± 9 vs. 32 ± 10 breaths/min for the high and low oxygen group, respectively).Conclusion: Preterm infants stabilized with an initial high FiO2 showed significantly more tonic diaphragm activity and an overall trend toward a higher level of diaphragm activity than those stabilized with an initial low FiO2. These results confirm that a high initial FiO2 after birth stimulates breathing effort, which can be objectified with dEMG.

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Outcome of premature babies with RDS using bubble CPAP

International Journal of Contemporary Pediatrics ◽

10.18203/2349-3291.ijcp20171702 ◽

2017 ◽

Vol 4 (3) ◽

pp. 939

Author(s):

Vivek Arora ◽

Sandip G Gediya ◽

Rupali Jain

Keyword(s):

Mechanical Ventilation ◽

Preterm Infants ◽

Work Of Breathing ◽

Mortality And Morbidity ◽

X Ray ◽

Antenatal Steroids ◽

Chest X Ray ◽

Bubble Cpap ◽

Ventilation Rates ◽

Spontaneously Breathing

Background: Respiratory distress syndrome (RDS) contributes significantly to mortality and morbidity. Continuous positive airway pressure (CPAP), when applied to premature infants with RDS, re-expands collapsed alveoli, splints the airway, reduces work of breathing and improves the respiration. Objectives: To ascertain the immediate outcome of preterm infants with RDS on Bubble CPAP and identify risk factors associated with its failure.Methods: This was a prospective analytical study and inborn preterm infants (gestation 28 to 34 weeks) admitted to the NICU with RDS were included in the study. All the spontaneously breathing infants were stared on bubble CPAP and different variables were recorded. Those in whom CPAP failed were given surfactant and mechanical ventilation.Results: 170 neonates were enrolled in the study. 52 (30.5%) babies failed CPAP. The predictors of failure were; partial or no response to Antenatal Steroids (ANS), white-out on the chest X-ray, Silverman Anderson scoring >6 or FiO2 > 0.4 after 15-20 minutes of CPAP, extreme prematurity. Other maternal and neonatal variables did not influence the need for ventilation. Rates of mortality and duration of oxygen requirement was significantly higher in babies who failed CPAP. No baby had chronic lung disease.Conclusions: Infants with no or partial exposure to antenatal steroids, white-out chest X-ray and those with higher FiO2 requirement after initial stabilization on CPAP are at high risk of CPAP failure (needing mechanical ventilation). Bubble CPAP is safe for preterm infants with RDS; it decreases need of surfactant and mechanical ventilation.

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Work of breathing using high-flow nasal cannula in preterm infants

Journal of Perinatology ◽

10.1038/sj.jp.7211530 ◽

2006 ◽

Vol 26 (8) ◽

pp. 476-480 ◽

Cited By ~ 123

Author(s):

J G Saslow ◽

Z H Aghai ◽

T A Nakhla ◽

J J Hart ◽

R Lawrysh ◽

...

Keyword(s):

Preterm Infants ◽

Work Of Breathing ◽

High Flow ◽

Nasal Cannula ◽

High Flow Nasal Cannula

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Does a brief trial of endotracheal CPAP before extubation increase the work of breathing in preterm infants?

Early Human Development ◽

10.1016/j.earlhumdev.2021.105368 ◽

2021 ◽

pp. 105368

Author(s):

Aggeliki Vervenioti ◽

Theodore Dassios ◽

Xenophon Sinopidis ◽

Gabriel Dimitriou

Keyword(s):

Preterm Infants ◽

Work Of Breathing

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AO-24. Effect of posture on work of breathing in preterm infants

Early Human Development ◽

10.1016/j.earlhumdev.2010.09.032 ◽

2010 ◽

Vol 86 ◽

pp. S10

Author(s):

Gabriel Dimitriou ◽

Aggeliki Vervenioti ◽

Despina Papakonstantinou ◽

Sotirios Tzifas ◽

Stefanos Mantagos

Keyword(s):

Preterm Infants ◽

Work Of Breathing

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Effect of prone and supine positioning on the diaphragmatic work of breathing in convalescent preterm infants

Pediatric Pulmonology ◽

10.1002/ppul.25594 ◽

2021 ◽

Author(s):

Gabriel Dimitriou ◽

Asimina Tsintoni ◽

Aggeliki Vervenioti ◽

Despina Papakonstantinou ◽

Theodore Dassios

Keyword(s):

Preterm Infants ◽

Work Of Breathing

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Effects of Early Respiratory Physiotherapy on Spontaneous Respiratory Activity of Preterm Infants: Study Protocol for a Randomized Controlled Trial

10.21203/rs.3.rs-452977/v1 ◽

2021 ◽

Author(s):

Alessia Di Polito ◽

Arianna Del Vecchio ◽

Milena Tana ◽

Patrizia Papacci ◽

Anna Laura Vento ◽

...

Keyword(s):

Mechanical Ventilation ◽

Preterm Infants ◽

Respiratory Activity ◽

Trigger Point ◽

Work Of Breathing ◽

Delivery Room ◽

Respiratory Support ◽

Control Group ◽

Non Invasive ◽

Digital Pressure

Abstract Background: Tactile maneuvers stimulating spontaneous respiratory activity in preterm infants are recommended since birth, but data on how and how often these maneuvers are applied in clinical practice are unknown. In the last years, most preterm newborns with respiratory failure are preferentially managed with non-invasive respiratory support and by stimulating spontaneous respiratory activity from the delivery room and in Neonatal Intensive Care Unit (NICU), in order to avoid the risks of intubation and prolonged mechanical ventilation.Methods: Preterm infants with gestational age ≤ 30 weeks not intubated in the delivery room and requiring non-invasive respiratory support at birth will be eligible for the study. They will be randomized and allocated to one of two treatment groups: 1) the Study Group infants will be subject to the technique of respiratory facilitation within the first 24 h of life, according to the reflex stimulations, by the physiotherapist. The newborn is placed in supine decubitus and a slight digital pressure is exerted on a hemithorax. The respiratory facilitation technique will be performed for about three minutes and repeated for a total of 4/6 times in sequence, three times a day until spontaneous respiratory activity is achieved, thus no respiratory support is required; 2) the Control Group Infants will take part exclusively in the Individualized Postural Care program. They will perform the technique of respiratory facilitation and autogenous drainage. The primary outcome of the study will be the incidence of intubation and mechanical ventilation in the first week of life. Discussion: The technique of respiratory facilitation is based on reflex stimulations, applied early to preterm infant. Slight digital pressure is exerted on a "trigger point” of each hemithorax, to stimulate the respiratory activity with subsequent increase of the ipsilateral pulmonary minute ventilation and to facilitate the contralateral pulmonary expansion. This mechanism will determine the concatenation of input to all anatomical structures in relation to the area being treated, to promote spontaneous respiratory activity and reducing work of breathing, avoiding or minimizing the use of invasive respiratory support.Trial registration: UMIN-CTR Clinical Trial, Identifier: UMIN000036066, Registered March 1, 2019. Protocol 1. https://www.umin.ac.jp/ctr

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