Providing one-lung ventilation in posttracheostomic tracheal stenosis for thoracoscopic plastic of the right diaphragm dome

The article is devoted to the consideration of a clinical case of providing artifcial one-lung ventilation for performing thoracoscopic plastic of the right dome of the diaphragm in a patient with grade 3 posttracheostomy cicatricial tracheal stenosis. The patient is presented after a new coronavirus infection COVID-19 from 2020, prolonged mechanical ventilation through a tracheostomy tube (74 days), the development of medium thoracic cicatricial tracheal stenosis of grade 3 (the lumen of the narrowest part of the trachea is 4 mm) after decannulation and the development of relaxation of the right dome of the diaphragm (according to CT data, the dome is located at the level of the IV intercostal space). The frst stage under conditions of combined general anesthesia and high-frequency ventilation of the lungs was performed to restore the lumen of the trachea by bougienage of the stenosis area with tubes of a rigid endoscope under the control of a fberoptic bronchoscope with further nasotracheal intubation with a thermoplastic single-lumen endotracheal tube with a diameter of 8.0 with a cuff. At the second stage, during thoracoscopic plastic of the right dome of the diaphragm, to provide artifcial one-lung ventilation, a bronchial blocker was used, introduced through the same endotracheal tube into the right main bronchus under the control of a fberoptic bronchoscope.

14 Diaphragmatic Electrical Activity in Preterm Infants on Non-Invasive High Frequency Oscillatory Ventilation (DEAP-NHFO Study)

Primary Subject area Neonatal-Perinatal Medicine Background Continuous Positive Airway Pressure (CPAP) is a common form of non-invasive respiratory support for preterm infants. Non-invasive high frequency ventilation (NHFOV) is a relatively new method of non-invasive respiratory support. NHFOV is being increasingly utilized in clinical practice in an attempt to prevent intubation and minimize ventilator-induced lung injury in preterm infants. Preliminary studies suggest superiority of NHFOV over CPAP, but little is known about its mechanism of action and its effect on respiratory control in the newborn. We hypothesize that NHFOV reduces respiratory drive and improves ventilation, resulting in decreased patient diaphragm energy expenditure, which can be assessed by measuring the electrical activity of the diaphragm (Edi). Objectives The objective of this study is to compare the effects of non-invasive respiratory support delivered by nasal CPAP versus NHFOV on respiratory pattern, as assessed by the Edi in very low birth weight (VLBW) preterm infants. Design/Methods In a prospective, randomized, crossover study, 20 preterm infants with birth weights ≤1500 g requiring CPAP were randomized to either NHFOV or CPAP for 105 min, followed by crossover to the other method for the same duration. Edi was continuously measured by a feeding catheter with miniaturized sensors embedded in its wall (Maquet, Solna). The general sequence was 15 minutes for acclimation to the mode, 75 minutes for a feed to be completed, followed by 15 minutes for breath-by-breath analyses of neural breathing pattern. Primary outcome was difference in the peak Edi between CPAP and NHFOV. Secondary outcomes included difference in other measures of respiratory drive: neural respiratory rate, neural inspiratory time, diaphragm energy expenditure, transcutaneous pCO2, number of apnea episodes on the Edi, and episodes of clinically significant apnea. Results No significant differences in Edi timing, Edi min, Edi peak, apnea, or CO2 were observed between the two modes of respiratory support. Conclusion In this cohort of VLBW preterm infants, neural respiratory pattern was not significantly different between NHFOV and CPAP. With this baseline information in stable preterm infants, it would now be important to assess whether these results hold true in infants with more severe lung disease, where NHFOV is often used as escalating support from CPAP.

Care practices and outcomes of extremely preterm neonates born at 22–24 weeks –A single centre experience

BACKGROUND: Wide variation in the care practices and survival rates of neonates born at peri-viable gestational ages of 22 +0 –24 +6 weeks exists. This study elucidates the postnatal risk factors for morbidity/mortality, contrasts the care practices and short-term outcomes of this vulnerable group of preterm neonates from a single center with others. METHODS: Retrospective study of neonates born at 22 +0 –24 +6 weeks in a level 3 neonatal intensive care unit in UK, over a period of 4 years (2016–2019). RESULTS: 94 neonates given active care studied. Survival until discharge was 51.1%(22–23 wks –44%, 24 wks –59.1%) and survival with no major brain injury (MBI) [grade III/IV IVH, cystic periventricular leukomalacia] was 38.3%(22–23 wks –32%, 24 wks –45.4%). Of those who survived until discharge, 75%had no MBI (22–23 wks –72.7%, 24 wks –76.9%). Neonates requiring significant respiratory support within first 72 hours as well as needing rescue high frequency ventilation had significantly high risk of mortality or MBI [aOR –7.17 (2.24–25.79), p = 0.00; 4.76 (1.43–20.00), p = 0.01]. CONCLUSIONS: Survival rate differed from other centres. MBI was low amongst survivors. Severe respiratory disease in the initial days was associated with a higher risk of death or MBI.

High-Frequency Ventilation in the Treatment of Acute Respiratory Failure

The need for respiratory therapy can reach 90% depending on the category of the intensive care unit and intensive care unit (ICU). Currently is a wide selection of respiratory therapy methods, including fully controlled mechanical ventilation and assist ventilation. The widespread use of mechanical ventilation and its varieties significantly reduced the mortality of ICU patients. However, the mortality of patients from acute respiratory distress syndrome, nosocomial pneumonia, and newborns with respiratory disorders remains high. High-frequency mechanical ventilation (HFMV) is an alternative treatment for severe respiratory failure, but the frequency of use is not yet sufficient. Three main types of HF ventilation is currently available: high-frequency positive pressure ventilation (HFPPV), high-frequency jet ventilation (HFJV) and high-frequency oscillatory ventilation (HFOV). There is an opportunity to choose a specific mode which will be most applicable for a particular patient. The use of the HFOV method allows the successful treatment of newborns with severe respiratory failure due to primary surfactant deficiency, meconial aspiration or multiple organ failure. Recently high amount of publications appeared on the possibilities of non-invasive HFMV in both adult patients and in pediatrics. This mini-review is devoted to this problem.

Extracorporeal membrane oxygenation outcomes in children with Williams syndrome: a review of the ELSO registry

Introduction: Williams syndrome (WS) results from a microdeletion that usually involves the elastin gene, leading to generalized arteriopathy. Cardiovascular anomalies are seen in 80% of WS patients, including supravalvular aortic stenosis (SVAS), pulmonary artery stenosis (PAS), and pulmonary stenosis (PS). Sudden death associated with procedural sedation and in the perioperative period in WS children have been reported. This study aims to describe extracorporeal membrane oxygenation (ECMO) use in WS children, identify risk factors for hospital mortality of WS patients, and compare outcomes between WS children and non-WS children with SVAS, PAS, and PS. Methods: Children 0–18 years-old in the Extracorporeal Life Support Organization (ELSO) Registry with a primary or secondary diagnosis of WS, SVAS, PAS, or PAS were included. Results: Included were 50 WS children and 1222 non-WS children with similar cardiac diagnoses. ECMO use increased over time in both groups (p = 0.93), with most cases occurring in the current era. WS children were younger (p = 0.004), weighed less (p = 0.048), had a pulmonary indication for ECMO (50% vs 10%, p < 0.001), and were placed more on high frequency ventilation (p < 0.001) than non-WS patients. Despite reporting a respiratory indication, most (84%) WS patients were placed on VA-ECMO. There were no significant differences between the two groups in terms of pre-ECMO cardiac arrest, ECMO duration, or reason for ECMO discontinuation. Both groups had a mortality rate of 48% (p = 1.00). No risk factors for WS mortality were identified.

Management of Pulmonary Hypertension in Term Infants—A Review

Pulmonary hypertension (PH) in the term newborn is associated with roughly one-fifth higher mortality and morbidity. The diagnosis of PH is confirmed by echocardiogram based on established criteria, including assessment of cardiac function, size of the shunts, and presence of hypovolemia. The elementary steps in the management of PH are supportive measures followed by oxygenation, ventilation including possibly high frequency ventilation; lung recruitment and surfactant therapy. Ventilation strategies are based on the etiology of persistent pulmonary hypertension of the newborn (PPHN)-like lung parenchymal disease, or hypoplasia. Oxygenation index (OI) or oxygen saturation index (OSI) are the parameters used for monitoring the disease progression and treatment. Surfactant is given if OI >5 in PPHN due to underlying lung disease, and pulmonary vasodilators such as sildenafil are contemplated if OI <15 and inhaled nitric oxide (iNO) if OI >15. If iNO and sildenafil fail, the options available are milrinone, bosentan, adenosine, and prostaglandins. Extra corporeal membrane oxygenation is the final option available with OI >40. A structured algorithmic approach for the management of PH in term infants is discussed in this review. Novel therapies targeting specific pathways in the pulmonary vasculature are under investigation.