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Lung protective ventilatory strategies in very low birth weight infants

Abstract

Respiratory distress syndrome (RDS) is the most common respiratory diagnosis in preterm infants. Surfactant therapy and mechanical ventilation using conventional or high-frequency ventilation have been the standard of care in the management of RDS. Bronchopulmonary dysplasia (BPD) continues to remain as a major morbidity in very low birth weight infants despite these treatments. There is no significant difference in pulmonary outcome when an optimal lung volume strategy is used with conventional or high-frequency ventilation. Lung injury is directly related to the duration of invasive ventilation via the endotracheal tube. Studies using noninvasive ventilation, such as nasal continuous positive airway pressure and noninvasive positive pressure ventilation, have shown to decrease postextubation failures as well as a trend toward reduced risk of BPD. Lung protective ventilatory strategy may involve noninvasive ventilation as a primary therapy or following surfactant administration in very preterm infants with RDS. Initial steps in the management of preterm infants may also include sustained inflation to establish functional residual capacity, followed by noninvasive ventilation to minimize lung injury and subsequent development of BPD.

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References

  1. Walsh MC, Yao Q, Gettner P, Hale E, Collins M, Hensman A et al. Impact of a physiologic definition of bronchopulmonary dysplasia rates. Pediatrics 2004; 114: 1305–1311.

    Article  Google Scholar 

  2. Keszler M . High-frequency ventilation: evidence-based practice and special clinical indications. NeoReviews 2006; 7: e234–e249.

    Article  Google Scholar 

  3. Clark RH, Gerstmann DR, Null DM, deLemos RA . Prospective randomized comparison of high frequency oscillatory and conventional ventilation in respiratory distress syndrome. Pediatrics 1992; 89: 5–12.

    CAS  PubMed  Google Scholar 

  4. The HIFI Study Group. High-frequency oscillatory ventilation compared with conventional ventilation in the treatment of respiratory failure in preterm infants. N Engl J Med 1989; 320: 88–93.

    Article  Google Scholar 

  5. Gerstmann DR, Minton SD, Stoddard RA, Meredith KS, Monaco F, Bertrand JM et al. The Provo multicenter early high frequency oscillatory ventilation trial: improved pulmonary and clinical outcome in respiratory distress syndrome. Pediatrics 1996; 98: 1044–1057.

    CAS  PubMed  Google Scholar 

  6. Keszler M, Modanlou HD, Brudno DS, Clark FI, Cohen RS, Ryan RM et al. Multicenter controlled clinical trial of high frequency jet ventilation in preterm infants with uncomplicated respiratory distress syndrome. Pediatrics 1997; 100: 593–599.

    Article  CAS  Google Scholar 

  7. Wiswell TE, Graziani LJ, Kornhauser MS, Cullen J, Merton DA, McKee L et al. High-frequency jet ventilation in the early management of respiratory distress syndrome is associated with a greater risk for adverse outcomes. Pediatrics 1996; 98: 1035–1043.

    CAS  PubMed  Google Scholar 

  8. Plavka R, Kopecky P, Sebron V, Svihovec P, Zlatohlavkova B, Janus V . A prospective randomized comparison of conventional mechanical ventilation and very early high frequency oscillatory ventilation in extremely premature newborns with respiratory distress syndrome. Intensive Care Med 1999; 25: 68–75.

    Article  CAS  Google Scholar 

  9. Courtney SE, Durand DJ, Asselin JM, Hudak ML, Aschner JL, Shoemaker CT, The Neonatal Ventilation Study Group. High-frequency oscillatory ventilation versus conventional mechanical ventilation for very low birth weight infants. N Engl J Med 2002; 347: 643–652.

    Article  Google Scholar 

  10. Thome U, Kossel H, Lipowsky G, Porz F, Fürste HO, Genzel-Boroviczeny O et al. Randomized comparison of high-frequency ventilation with high-rate intermittent positive pressure ventilation in preterm infants with respiratory failure. J Pediatr 1999; 135: 39–46.

    Article  CAS  Google Scholar 

  11. Craft AP, Bhandari V, Finer NN . The sy-fi study: a randomized prospective trial of synchronized intermittent mandatory ventilation versus a high-frequency flow interrupter in infants less than 1000 g. J Perinatol 2003; 23: 14–19.

    Article  Google Scholar 

  12. Moriette G, Paris-Llado J, Walti H, Escande B, Magny JF, Cambonie G et al. Prospective randomized multicenter comparison of high-frequency oscillatory ventilation and conventional ventilation in preterm infants of less than 30 weeks with respiratory distress syndrome. Pediatrics 2001; 107: 363–372.

    Article  CAS  Google Scholar 

  13. Bollen CW, Uiterwal CSPM, van Vught AJ . Cumulative meta analysis of high-frequency versus conventional ventilation in premature neonates. Am J Respir Crit Care Med 2003; 168: 1150–1155.

    Article  Google Scholar 

  14. Greenough A, Milner AD, Dimitriou G . Synchronized ventilation [Cochrane Review].In: The Cochrane Library, issue 1. Oxford update 2001.

    Google Scholar 

  15. Baumer JH . International randomized controlled trial of patient triggered ventilation in neonatal respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed 2000; 82: F5–F10.

    Article  CAS  Google Scholar 

  16. De Paoli AG, Morley C, Davis PG . Nasal CPAP for neonates: what do we know in 2003? Arch Dis Child Fetal Neonatal Ed 2003; 88: F168–F172.

    Article  CAS  Google Scholar 

  17. Lin CH, Wang ST, Lin YJ, Yeh TF . Efficacy of nasal intermittent positive pressure ventilation in treating apnea of prematurity. Pediatr Pulmonol 1998; 26: 349–353.

    Article  CAS  Google Scholar 

  18. Friedlich P, Lecart C, Posen R, Ramicone E, Chan L, Ramanathan R . A randomized trial of nasopharyngeal-synchronized intermittent mandatory ventilation versus nasopharyngeal continuous positive airway pressure in very low birth weight infants after extubation. J Perinatol 1999; 19: 413–418.

    Article  CAS  Google Scholar 

  19. Santin R, Brodsky N, Bhandari V . A prospective observational pilot study of synchronized nasal intermittent positive pressure ventilation (SNIPPV) as a primary mode of ventilation in infants ⩾28 weeks with respiratory distress syndrome (RDS). J Perinatol 2004; 24: 487–493.

    Article  Google Scholar 

  20. Courtney SE, Aghai ZH, Saslow JG, Pyon KH, Habib RH . Changes in lung volume and work of breathing: a comparison of two variable-flow nasal continuous positive airway pressure devices in very low birth weight infants. Pediatr Pulmonol 2003; 36: 248–252.

    Article  Google Scholar 

  21. Davis P, Davies M, Faber B . A randomized controlled trial of two methods of delivering nasal continuous positive airway pressure after extubation to infants weighing less than 1000 g: binasal (Hudson) versus single nasal prongs. Arch Dis Child Fetal Neonatal Ed 2001; 85: F82–F85.

    Article  CAS  Google Scholar 

  22. Lindner W, Vobbeck S, Hummler H, Pohlandt F . Delivery room management of extremely low birth weight infants: spontaneous breathing or intubation? Pediatrics 1999; 103: 961–967.

    Article  CAS  Google Scholar 

  23. Finer NN, Carlo WA, Duara S, Fanaroff AA, Donovan EF, Wright LL et al. Delivery room continuous positive airway pressure/positive end-expiratory pressure in extremely low birth weight infants: a feasibility trial. Pediatrics 2004; 114: 651–657.

    Article  Google Scholar 

  24. Meyer M, Mildenhall M, Wong M . Outcome for infants weighing less than 1000 g cared for with a nasal continuous positive airway pressure-based strategy. J Paediatr Child Health 2004; 40: 38–41.

    Article  CAS  Google Scholar 

  25. Sahni R, Ammari A, Suri MS, Milisavljevic V, Ohira-Kist K, Wung JT et al. Is the new definition of bronchopulmonary dysplasia more useful? J Perinatol 2005; 25: 41–46.

    Article  Google Scholar 

  26. Lee KS, Dunn MS, Fenwick M, Shennan AT . A comparison of underwater bubble continuous positive airway pressure with ventilator-derived continuous positive airway pressure in premature neonates ready for extubation. Biol Neonate 1998; 73: 69–75.

    Article  CAS  Google Scholar 

  27. Morley CJ, Lau R, De Paoli A, Davis PG . Nasal continuous positive airway pressure: does bubbling improve gas exchange? Arch Dis Child Fetal Neonatal Ed 2005; 90: F343–F344.

    Article  CAS  Google Scholar 

  28. Jobe AH, Kramer BW, Moss TJ, Newnham JP, Ikegami M . Decreased indicators of lung injury with continuous positive expiratory pressure in preterm lambs. Pediatr Res 2002; 52: 387–392.

    Article  Google Scholar 

  29. Pillow JJ, Travadi JN . Bubble CPAP: is the noise important? An in vitro study. Pediatr Res 2005; 57: 826–830.

    Article  Google Scholar 

  30. Stefanescu BM, Murphy WP, Hansell BJ, Fuloria M, Morgan TM, Aschner JL . A randomized, controlled trial comparing two different continuous positive airway pressure systems for the successful extubation of extremely low birth weight infants. Pediatrics 2003; 112: 1031–1038.

    Article  Google Scholar 

  31. Aly H, Massaro AN, Patel K, El-Mohandes AA . Is it safer to intubate premature infants in the delivery room. Pediatrics 2005; 115: 1660–1665.

    Article  Google Scholar 

  32. Sandri F, Ancora G, Lanzoni A, Tagliabue P, Colnaghi M, Ventura ML . Prophylactic nasal continuous positive airways pressure in newborns of 28–31 weeks gestation: multicenter randomized controlled clinical trial. Arch Dis Child Fetal Neonatal Ed 2004; 89: F394–F398.

    Article  CAS  Google Scholar 

  33. Kamlin COF, Davis PG, Morley CJ . Predicting successful extubation of very low birth weight infants. Arch Dis Child Fetal Neonatal Ed 2006; 91: F180–F183.

    Article  CAS  Google Scholar 

  34. Locke RG, Wolfson MR, Shaffer TH, Rubenstein SD, Greenspan JS . Inadvertent administration of positive end-expiratory pressure during nasal cannula flow. Pediatrics 1993; 91: 135–138.

    CAS  PubMed  Google Scholar 

  35. Finer NN, Rich W, Craft A, Henderson C . Comparison of methods of bag and mask ventilation for neonatal resuscitation. Resuscitation 2001; 49: 299–305.

    Article  CAS  Google Scholar 

  36. Barrington KJ, Bull D, Finer NN . Randomized trial of nasal synchronized intermittent mandatory ventilation compared with continuous positive airway pressure after extubation of very low birth weight infants. Pediatrics 2001; 107: 638–641.

    Article  CAS  Google Scholar 

  37. Kulkarni A, Ehrenkranz RA, Bhandari V . Effect of introduction of synchronized nasal intermittent positive-pressure ventilation in a neonatal intensive care unit on bronchopulmonary dysplasia and growth in preterm infants. Am J Perinatol 2006; 23: 1–8.

    Article  Google Scholar 

  38. Kugelman A, Feferkorn I, Riskin A, Chistyakov I, Kaufman B, Bader D . Nasal intermittent mandatory ventilation versus nasal continuous positive airway pressure for respiratory distress syndrome: a randomized, controlled, prospective study. J Pediatr 2007; 150: 521–526.

    Article  Google Scholar 

  39. te Pas AB, Walther FJ . A randomized, controlled trial of delivery-room respiratory management in very preterm infants. Pediatrics 2007; 120: 322–329.

    Article  Google Scholar 

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Correspondence to R Ramanathan or S Sardesai.

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Dr. Rangasamy Ramanathan has received grant support from Dey, L.P. and Chiesi Farmaceuti to conduct a multi-center study on non-invasive ventilation, and he is on the speakers bureau from Dey, L.P. Dr. Sardesai disclosed no competing interests.

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Ramanathan, R., Sardesai, S. Lung protective ventilatory strategies in very low birth weight infants. J Perinatol 28 (Suppl 1), S41–S46 (2008). https://doi.org/10.1038/jp.2008.49

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