Roberto Cicchetti

Outcomes after tongue–lip adhesion or mandibular distraction osteogenesis in infants with Pierre Robin sequence and severe airway obstruction

The objective was to review and compare outcomes after tongue-lip adhesion (TLA) and mandibular distraction osteogenesis (MDO) in infants with severe breathing difficulties related to Pierre Robin sequence (PRS). A single-centre retrospective (2002-2012) study was carried out; 18 infants with severe breathing difficulties related to PRS resistant to conservative treatment, who underwent TLA or MDO to correct airway obstruction, were enrolled. The primary outcome measures were successful weaning from respiratory support and resumption of full oral feeding. Nine underwent TLA and nine MDO. Eight of the nine infants who underwent MDO and all those treated with TLA were successfully weaned from respiratory support. After discharge, residual respiratory distress was diagnosed more commonly after TLA than after MDO (6/9 vs 1/9, P=0.050). Infants resumed oral feeding sooner after MDO than after TLA (mean days after surgery to full oral feeds 44±24 vs 217±134, P<0.003). The length of hospital stay was longer for infants treated with MDO than for those treated with TLA. The rate of complications was similar. Infants with severe airway obstruction related to PRS can benefit safely from either TLA or MDO. Although MDO lengthens the time to discharge, this option stabilizes airway patency of infants with PRS more efficiently and achieves full oral feeding more rapidly than TLA.

Mandibular distraction osteogenesis for neonates with Pierre Robin sequence and airway obstruction

Neonates with Pierre Robin Sequence (PRS) usually present with varying degrees of upper airway obstruction and difficulty feeding. Early treatment is important for such children in order to prevent impaired cognitive development resulting from hypoxemic episodes. Various procedures aimed at widening the pharyngeal space have been proposed, including prone position, tongue-lip adhesion, mandibular traction, non-invasive ventilation and palatal plates. Mandibular distraction osteogenesis (MDO) using external or internal devices has become increasingly popular as an alternative treatment option when other medical or surgical techniques do not prove to be satisfactory. This review summarizes current evidence on the effectiveness of MDO in infants with PRS. Because of a lack of studies comparing this treatment with other procedures, general recommendations cannot be drawn and treatment of infants with PRS still requires individualization.

What's new in the treatment of neonatal shock

Shock is a clinical disorder that challenges caregivers in the neonatal intensive care unit. The predominant cause of shock in neonates is sepsis. This article provides an overview of the current treatment of septic shock with particular emphasis on newer vasoactive drugs (milrinone, levosimendan and vasopressin) to support cardiovascular dysfunction.

Pharyngeal and esophageal pressure measurements to evaluate respiratory mechanics in infants on high flow nasal cannula: A feasibility study

High-flow humidified nasal cannula (HFNC) is often used to relieve respiratory distress in children with acute pulmonary disease, although its effects on respiratory mechanics have not been objectively studied. The purpose of this study was to test the feasibility of measuring pharyngeal (PP) and esophageal (Pes) pressures of young children on HFNC oxygen therapy through a specifically designed new monitoring, acquisition, and elaboration system (MAES). Through MAES we recorded and elaborated Pes and PP tracings obtained through esophageal and pharyngeal catheters in a group of young children hospitalized in a Pediatric Intensive Care Unit because of respiratory distress. All traces were recorded during spontaneous breathing and on HFNC 1 and 2 L/kg/min. To determine the onset and the end of inspiration, the Pes and PP signals were synchronized with the inspiratory flow obtained by a flow transducer placed in the HFNC circuit. Direct measurement of inspiratory flow by a face mask pneumotachograph also allowed for inspiratory tidal volume (TV) measurement which was used together with Pes curve to build Campbells diagram as well as the static lung and chest wall recoil curves required for pressure time product (PTP) evaluation. Using MAES we were able to obtain: time interval between the beginning of inspiratory effort and inspiration (Tdelay), TV, intrinsic positive end expiratory pressure (PEEPi), total inspiratory Pes variation (ΔPes), transpulmonary pressure at end of inspiration (Ptpei), dynamic lung compliance (CLdyn), total lung resistance (RLtot) along with all the relevant components of the inspiratory work of breathing (WOB) and PTP. We believe that this new system will allow clinicians for a bedside monitoring of respiratory distress in infants treated with HFNC and to modify flow rates accordingly.

High-Flow Nasal Cannula to Prevent Desaturation in Endotracheal Intubation: A Word of Caution.

Critical Care Medicine www.ccmjournal.org e327 The second point supporting our assertion comes from our preliminary experience in using HFNC to oxygenate infants undergoing endotracheal intubation, despite a high alveolar ventilation/functional residual lung capacity ratio and a high oxygen uptake with a consequently short desaturation time. We used HFNC in 20 infants younger than 3 months old undergoing endotracheal intubation and found that the benefit differed remarkably between those with healthy or injured lungs. Our study protocol consisted in giving 1–2 L/kg/min HFNC oxygen therapy 2 minutes before patients received sedation with fentanyl and propofol and then continuing HFNC during laryngoscopy and between attempts at intubation. If desaturation episodes less than 96% developed at any time, the mouth was gently closed to increase pharyngeal pressure, and when Sao 2 reached 100%, the procedure was resumed. If Sao 2 dropped to less than 86%, HFNC was suspended and the infant was bag ventilated. The results are shown in Table 1. We believe that despite physiologic differences between children and adults, these conflicting data underscore the need for randomized controlled trials to test the effect of HFNC before and during endotracheal intubation in patients stratified according to lung disease. The authors have disclosed that they do not have any potential conflicts of interest.