scholarly journals Extubation generates lung volume inhomogeneity in preterm infants

2021 ◽  
Author(s):  
R Bhatia ◽  
HR Carlisle ◽  
RK Armstrong ◽  
COF Kamlin ◽  
PG Davis ◽  
...  
Keyword(s):  
Preterm Infants ◽  
Lung Volume ◽  
Neonatal Intensive Care ◽  
Electrical Impedance ◽  
Prospective Observational Study ◽  
Positive Pressure Ventilation ◽  
Positive Pressure ◽  
Impedance Tomography ◽  
Non Invasive ◽  
Volume Inhomogeneity

AbstractObjectiveTo evaluate the feasibility of EIT to describe the regional tidal ventilation (VT) and change in end-expiratory lung volume (EELV) patterns in preterm infants during the process of extubation from invasive to non-invasive respiratory support.DesignProspective observational studySettingSingle-centre tertiary neonatal intensive care unitPatientsPreterm infants born <32 weeks gestation who were being extubated to nasal continuous positive airway pressure (nCPAP) as per clinician discretion.InterventionsElectrical Impedance Tomography measurements were taken in supine infants during elective extubation from synchronised positive pressure ventilation (SIPPV) before extubation, during and then at 2 and 20 minutes after commencing nCPAP. Extubation and pressure settings were determined by clinicians.Main outcome measuresGlobal and regional ΔEELV and ΔVT were measured. Heart rate, respiratory rate and oxygen saturation were measured throughout.ResultsThirty infants of median (range) 2 (1, 21) days were extubated to a median (range) CPAP 7 (6, 8) cmH2O. SpO2/FiO2 ratio was mean (95% CI) 50 (35, 65) lower 20 minutes after nCPAP compared with SIPPV. EELV was lower at all points after extubation compared to SIPPV, and EELV loss was primarily in the ventral lung (p=0.04). VT was increased immediately after extubation, especially in the central and ventral regions of the lung, but the application of nCPAP returned VT to pre-extubation patterns.ConclusionsLung behaviour during the transition from invasive positive pressure ventilation to CPAP at moderate distending pressures is variable and associated with lung volume loss in the ventral lung.

scholarly journals Extubation generates lung volume inhomogeneity in preterm infants

2021 ◽  
pp. fetalneonatal-2021-321788
Author(s):  
Risha Bhatia ◽  
Hazel R Carlisle ◽  
Ruth K Armstrong ◽  
C Omar Farouk Kamlin ◽  
Peter G Davis ◽  
...  
Keyword(s):  
Preterm Infants ◽  
Lung Volume ◽  
Neonatal Intensive Care ◽  
Prospective Observational Study ◽  
Applied Pressure ◽  
Respiratory Support ◽  
Positive Pressure ◽  
Impedance Tomography ◽  
Non Invasive ◽  
Volume Inhomogeneity

ObjectiveTo evaluate the feasibility of electrical impedance tomography (EIT) to describe the regional tidal ventilation (VT) and change in end-expiratory lung volume (EELV) patterns in preterm infants during the process of extubation from invasive to non-invasive respiratory support.DesignProspective observational study.SettingSingle-centre tertiary neonatal intensive care unit.PatientsPreterm infants born <32 weeks’ gestation who were being extubated to nasal continuous positive airway pressure as per clinician discretion.InterventionsEIT measurements were taken in supine infants during elective extubation from synchronised positive pressure ventilation (SIPPV) before extubation, during and then at 2 and 20 min after commencing nasal continuous positive applied pressure (nCPAP). Extubation and pressure settings were determined by clinicians.Main outcome measuresGlobal and regional ΔEELV and ΔVT, heart rate, respiratory rate and oxygen saturation were measured throughout.ResultsThirty infants of median (range) 2 (1, 21) days were extubated to a median (range) CPAP 7 (6, 8) cm H2O. SpO2/FiO2 ratio was a mean (95% CI) 50 (35, 65) lower 20 min after nCPAP compared with SIPPV. EELV was lower at all points after extubation compared with SIPPV, and EELV loss was primarily in the ventral lung (p=0.04). VT was increased immediately after extubation, especially in the central and ventral regions of the lung, but the application of nCPAP returned VT to pre-extubation patterns.ConclusionsEIT was able to describe the complex lung conditions occurring during extubation to nCPAP, specifically lung volume loss and greater use of the dorsal lung. EIT may have a role in guiding peri-extubation respiratory support.

scholarly journals Regional ventilation characteristics during non-invasive respiratory support in preterm infants

2020 ◽  
pp. fetalneonatal-2020-320449
Author(s):  
Jessica Thomson ◽  
Christoph M Rüegger ◽  
Elizabeth J Perkins ◽  
Prue M Pereira-Fantini ◽  
Olivia Farrell ◽  
...  
Keyword(s):  
Oxygen Saturation ◽  
Preterm Infants ◽  
Neonatal Intensive Care ◽  
Repeated Measure ◽  
Regional Ventilation ◽  
Quiet Breathing ◽  
Impedance Tomography ◽  
Non Invasive ◽  
Ventilation Inhomogeneity ◽  
The Right

ObjectivesTo determine the regional ventilation characteristics during non-invasive ventilation (NIV) in stable preterm infants. The secondary aim was to explore the relationship between indicators of ventilation homogeneity and other clinical measures of respiratory status.DesignProspective observational study.SettingTwo tertiary neonatal intensive care units.PatientsForty stable preterm infants born <30 weeks of gestation receiving either continuous positive airway pressure (n=32) or high-flow nasal cannulae (n=8) at least 24 hours after extubation at time of study.InterventionsContinuous electrical impedance tomography imaging of regional ventilation during 60 min of quiet breathing on clinician-determined non-invasive settings.Main outcome measuresGravity-dependent and right–left centre of ventilation (CoV), percentage of whole lung tidal volume (VT) by lung region and percentage of lung unventilated were determined for 120 artefact-free breaths/infant (4770 breaths included). Oxygen saturation, heart and respiratory rates were also measured.ResultsVentilation was greater in the right lung (mean 69.1 (SD 14.9)%) total VT and the gravity-non-dependent (ND) lung; ideal–actual CoV 1.4 (4.5)%. The central third of the lung received the most VT, followed by the non-dependent and dependent regions (p<0.0001 repeated-measure analysis of variance). Ventilation inhomogeneity was associated with worse peripheral capillary oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) (p=0.031, r2 0.12; linear regression). In those infants that later developed bronchopulmonary dysplasia (n=25), SpO2/FiO2 was worse and non-dependent ventilation inhomogeneity was greater than in those that did not (both p<0.05, t-test Welch correction).ConclusionsThere is high breath-by-breath variability in regional ventilation patterns during NIV in preterm infants. Ventilation favoured the ND lung, with ventilation inhomogeneity associated with worse oxygenation.

Continuous neurally adjusted ventilation: a feasibility study in preterm infants

2020 ◽  
Vol 105 (6) ◽  
pp. 640-645
Author(s):  
Marie-Eve Rochon ◽  
Gregory Lodygensky ◽  
Laurence Tabone ◽  
Sandrine Essouri ◽  
Sylvain Morneau ◽  
...  
Keyword(s):  
Electrical Activity ◽  
Preterm Infants ◽  
Feasibility Study ◽  
Neonatal Intensive Care ◽  
Positive Pressure ◽  
Non Invasive ◽  
Diaphragm Electrical Activity ◽  
Registration Number ◽  
Level 3 ◽  
The Impact

ObjectivesTo assess the feasibility and tolerance of NeuroPAP, a new non-invasive ventilation mode which continuously adjusts (during both inspiration and expiration) the pressure support proportionally to the diaphragm electrical activity (Edi), in preterm infants and to evaluate the impact on ventilation pressure and Edi.DesignProspective cross-over single-centre feasibility study.SettingOne level 3 neonatal intensive care unit in Canada.PatientsStable preterm infants ventilated with non-invasive positive pressure ventilation (NIPPV).InterventionsSubjects were successively ventilated in NIPPV with prestudy settings (30 min), in NeuroPAP with minimal pressure similar to NIPPV PEEP (positive end-expiratory pressure) (60 min), in NeuroPAP with minimal pressure reduced by 2 cmH20 (60 min), in continuous positive airway pressure (15 min) and again in NIPPV (30 min). Main outcome measures included tolerance, ventilation pressure, Edi and patient-ventilator synchrony.ResultsTwenty infants born at 28.0±1.0 weeks were included. NeuroPAP was well tolerated and could be delivered during 100% of planned period. During NeuroPAP, the PEEP was continuously adjusted proportionally to tonic diaphragm Edi, although the average PEEP value was similar to the set minimal pressure. During NeuroPAP, 83 (78–86)% breaths were well synchronised vs 9 (6–12)% breaths during NIPPV (p<0.001).ConclusionsNeuroPAP is feasible and well tolerated in stable preterm infants, and it allows transient adaptation in PEEP in response to tonic diaphragm electrical activity changes. Further studies are warranted to determine the impact of these findings on clinical outcomes.Trial registration numberNCT02480205.

Corrective steps to enhance ventilation in the delivery room

2020 ◽  
Vol 105 (6) ◽  
pp. 605-608 ◽  
Author(s):  
Kesi C Yang ◽  
Arjan B te Pas ◽  
Danielle D Weinberg ◽  
Elizabeth E Foglia
Keyword(s):  
Heart Rate ◽  
Tidal Volume ◽  
Preterm Infants ◽  
Prospective Observational Study ◽  
Positive Pressure Ventilation ◽  
Outcome Measure ◽  
Delivery Room ◽  
Positive Pressure ◽  
Mouth Pressure ◽  
Before And After

ObjectiveThe clinical impact of ventilation corrective steps for delivery room positive pressure ventilation (PPV) is not well studied. We aimed to characterise the performance and effect of ventilation corrective steps (MRSOPA (Mask adjustment, Reposition airway, Suction mouth and nose, Open mouth, Pressure increase and Alternative airway)) during delivery room resuscitation of preterm infants.DesignProspective observational study of delivery room PPV using video and respiratory function monitor recordings.SettingTertiary academic delivery hospital.PatientsPreterm infants <32 weeks gestation.Main outcome measureMean exhaled tidal volume (Vte) of PPV inflations before and after MRSOPA interventions, categorised as inadequate (<4 mL/kg); appropriate (4–8 mL/kg), or excessive (>8 mL/kg). Secondary outcomes were leak (>30%) and obstruction (Vte <1 mL/kg), and infant heart rate.ResultsThere were 41 corrective interventions in 30 infants, with a median duration of 15 (IQR 7–29) s. The most frequent intervention was a combination of Mask/Reposition and Suction/Open. Mean Vte was inadequate before 16/41 interventions and became adequate following 6/16. Mean Vte became excessive after 6/41 interventions. Mask leak, present before 13/41 interventions, was unchanged after 4 and resolved after 9. Obstruction was present before five interventions and was subsequently resolved only once. MRSOPA interventions introduced leak in two cases and led to obstruction in one case. The heart rate was <100 beats per minute before 31 interventions and rose to >100 beats per minute after 14/31 of these.ConclusionsVentilation correction interventions improve tidal volume delivery in some cases, but lead to ineffective or excessive tidal volumes in others. Mask leak and obstruction can be induced by MRSOPA manoeuvres.

scholarly journals Reintubation rates after extubation to different non-invasive ventilation modes in preterm infants

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Alaa Masry ◽  
Nuha A. M. A. Nimeri ◽  
Olfa Koobar ◽  
Samer Hammoudeh ◽  
Prem Chandra ◽  
...  
Keyword(s):  
Preterm Infants ◽  
Neonatal Intensive Care ◽  
Neonatal Morbidity ◽  
Intermittent Positive Pressure Ventilation ◽  
Nasal Cannula ◽  
Positive Pressure ◽  
Invasive Ventilation ◽  
Non Invasive ◽  
Non Invasive Ventilation ◽  
Increased Risk

Abstract Introduction Respiratory Distress Syndrome (RDS) is a common cause of neonatal morbidity and mortality in premature newborns. In this study, we aim to compare the reintubation rate in preterm babies with RDS who were extubated to Nasal Continuous Positive Airway Pressure (NCPAP) versus those extubated to Nasal Intermittent Positive Pressure Ventilation (NIPPV). Methods This is a retrospective study conducted in the Neonatal Intensive Care Unit (NICU) of Women’s Wellness and Research Center (WWRC), Doha, Qatar. The medical files (n = 220) of ventilated preterm infants with gestational age ranging between 28 weeks 0 days and 36 weeks + 6 days gestation and extubated to non-invasive respiratory support (whether NCPAP, NIPPV, or Nasal Cannula) during the period from January 2016 to December 2017 were reviewed. Results From the study group of 220 babies, n = 97 (44%) babies were extubated to CPAP, n = 77 (35%) were extubated to NIPPV, and n = 46 (21%) babies were extubated to Nasal Cannula (NC). Out of the n = 220 babies, 18 (8.2%) were reintubated within 1 week after extubation. 14 of the 18 (77.8%) were reintubated within 48 h of extubation. Eleven babies needed reintubation after being extubated to NCPAP (11.2%) and seven were reintubated after extubation to NIPPV (9.2%), none of those who were extubated to NC required reintubation (P = 0.203). The reintubation rate was not affected by extubation to any form of non-invasive ventilation (P = 0.625). The mode of ventilation before extubation does not affect the reintubation rate (P = 0.877). The presence of PDA and NEC was strongly associated with reintubation which increased by two and four-folds respectively in those morbidities. There is an increased risk of reintubation with babies suffering from NEC and BPD and this was associated with an increased risk of hospital stay with a P-value ranging (from 0.02–0.003). Using multivariate logistic regression, NEC the NEC (OR = 5.52, 95% CI 1.26, 24.11, P = 0.023) and the vaginal delivery (OR = 0.23, 95% CI 0.07, 0.78, P = 0.018) remained significantly associated with reintubation. Conclusion Reintubation rates were less with NIPPV when compared with NCPAP, however, this difference was not statistically significant. This study highlights the need for further research studies with a larger number of neonates in different gestational ages birth weight categories. Ascertaining this information will provide valuable data for the factors that contribute to re-intubation rates and influence the decision-making and management of RDS patients in the future.

scholarly journals Time to desaturation in preterm infants undergoing endotracheal intubation

2021 ◽  
pp. fetalneonatal-2020-319509
Author(s):  
Radhika Kothari ◽  
Kate Alison Hodgson ◽  
Peter G Davis ◽  
Marta Thio ◽  
Brett James Manley ◽  
...  
Keyword(s):  
Endotracheal Intubation ◽  
Preterm Infants ◽  
Neonatal Intensive Care ◽  
Positive Pressure Ventilation ◽  
Secondary Analysis ◽  
Neonatal Resuscitation ◽  
Physiological Data ◽  
Positive Pressure ◽  
Postmenstrual Age ◽  
Registration Number

BackgroundNeonatal endotracheal intubation is often associated with physiological instability. The Neonatal Resuscitation Program recommends a time-based limit (30 s) for intubation attempts in the delivery room, but there are limited physiological data to support recommendations in the neonatal intensive care unit (NICU). We aimed to determine the time to desaturation after ceasing spontaneous or assisted breathing in preterm infants undergoing elective endotracheal intubation in the NICU.MethodsObservational study at The Royal Women’s Hospital, Melbourne. A secondary analysis was performed of video recordings of neonates ≤32 weeks’ postmenstrual age undergoing elective intubation. Infants received premedication including atropine, a sedative and muscle relaxant. Apnoeic oxygenation time (AOT) was defined as the time from the last positive pressure or spontaneous breath until desaturation (SpO2 <90%).ResultsSeventy-eight infants were included. The median (IQR) gestational age at birth was 27 (26–29) weeks and birth weight 946 (773–1216) g. All but five neonates desaturated to SpO2 <90% (73/78, 94%). The median (IQR) AOT was 22 (14–32) s. The median (IQR) time from ceasing positive pressure ventilation to desaturation <80% was 35 (24–44) s and to desaturation <60% was 56 (42–68) s. No episodes of bradycardia were seen.ConclusionsThis is the first study to report AOT in preterm infants. During intubation of preterm infants in the NICU, desaturation occurs quickly after cessation of positive pressure ventilation. These data are important for the development of clinical guidelines for neonatal intubation.Trial registration numberACTRN12614000709640

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