Steven M. Donn

Multicenter controlled trial comparing high-frequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema

One hundred forty-four newborn infants with pulmonary interstitial emphysema were stratified by weight and severity of illness, and randomly assigned to receive treatment with high-frequency jet ventilation (HFJV) or rapid-rate conventional mechanical ventilation (CV) with short inspiratory time. If criteria for treatment failure were met, crossover to the alternate ventilatory mode was permitted. Overall, 45 (61%) of 74 infants met treatment success criteria with HFJV compared with 26 (37%) of 70 treated with CV (p less than 0.01). Eighty-four percent of patients who crossed over from CV to HFJV initially responded to the new treatment, and 45% ultimately met success criteria on HFJV. In contrast, only 9% of those who crossed over from HFJV to CV responded well to CV (p less than 0.01), and the same 9% ultimately met success criteria (p less than 0.05). Therapy with HFJV resulted in improved ventilation at lower peak and mean airway pressures, as well as more rapid radiographic improvement of pulmonary interstitial emphysema, in comparison with rapid-rate CV. Survival by original assignment was identical. When survival resulting from rescue by the alternate therapy in crossover patients was excluded, the survival rate was 64.9% for HFJV, compared with 47.1% for CV (p less than 0.05). The incidence of chronic lung disease, intraventricular hemorrhage, patent ductus arteriosus, airway obstruction, and new air leak was similar in both groups. We conclude that HFJV, as used in this study, is safe and is more effective than rapid-rate CV in the treatment of newborn infants with pulmonary interstitial emphysema.

Selective Serotonin Reuptake Inhibitor (SSRI) Use during Pregnancy and Effects on the Fetus and Newborn: A Meta-Analysis

Selective serotonin reuptake inhibitors (SSRIs) are frequently used to treat depression during pregnancy and the postpartum period. These drugs are capable of crossing the placenta and being transferred to the newborn during lactation. This report reviews the available information regarding the effects of SSRIs on the fetus and newborn; including long-term neurodevelopmental outcomes.

PREVENTION OF INTRAVENTRICULAR HAEMORRHAGE IN PRETERM INFANTS BY PHENOBARBITONE: A Controlled Trial

Sixty infants with birth-weights less than 1500 g and who were less than 6 h old were randomly assigned to a group given phenobarbitone or a control group. Intravenous phenobarbitone was given in doses sufficient to achieve anticonvulsant serum levels within 12-18 h. Maintenance therapy was continued for one week. Periventricular/intraventricular haemorrhage (IVH) occurred in 13.3% (4/30) of the phenobarbitone group and in 46.7% (14/30) of the control group. The occurrence of risk factors related to IVH was similar in the two groups. Phenobarbitone may reduce the incidence of IVH in small preterm infants.

Randomised trial of volume controlled versus time cycled, pressure limited ventilation in preterm infants with respiratory distress syndrome

Fifty preterm infants weighing 1200 g or more with clinical and radiographic evidence of respiratory distress syndrome, requiring both mechanical ventilation and exogenous surfactant replacement, were randomly allocated to receive either volume controlled ventilation or time cycled, pressure limited ventilation. Tidal volume delivery in each group was deliberately controlled at 5–8 ml/kg so that the only difference between the two groups was the ventilatory modality, the manner in which tidal volume was delivered. The rest of the ventilatory management and clinical care was done according to protocol. The two modes of ventilation were compared by determining the time required to achieve pre-determined success criteria, based on either the alveolar–arterial oxygen gradient or the mean airway pressure as a standard against which the speed of weaning could be objectively assessed. Infants randomised to volume controlled ventilation met success criteria sooner and had a shorter duration of mechanical ventilation. These babies also had a significantly lower incidence of intraventricular haemorrhages and abnormal periventricular echodensities on ultrasound scans.  Volume controlled ventilation seems to be both safe and effective in this group of patients.

Multicenter Crossover Study of Automated Control of Inspired Oxygen in Ventilated Preterm Infants

OBJECTIVE: To determine the efficacy and safety of automated adjustment of the fraction of inspired oxygen (Fio2) adjustment in maintaining arterial oxygen saturation (Spo2) within an intended range for mechanically ventilated preterm infants with frequent episodes of decreased Spo2. METHODS: Thirty-two infants (gestational age [median and interquartile range]: 25 weeks [24–27 weeks]; age: 27 days [17–36 days]) were studied during 2 consecutive 24-hour periods, one with Fio2 adjusted by clinical staff members (manual) and the other by an automated system (automated), in random sequence. RESULTS: Time with Spo2 within the intended range (87%–93%) increased significantly during the automated period, compared with the manual period (40% ± 14% vs 32% ± 13% [mean ± SD]). Times with Spo2 of >93% or >98% were significantly reduced during the automated period (21% ± 20% vs 37% ± 12% and 0.7% vs 5.6% [interquartile ranges: 0.1%–7.2% and 2.7%–11.2%], respectively). Time with Spo2 of <87% increased significantly during the automated period (32% ± 12% vs 23% ± 9%), with more-frequent episodes with Spo2 between 80% and 86%, whereas times with Spo2 of <80% or <75% did not differ between periods. Hourly median Fio2 values throughout the automated period were lower and there were substantially fewer manual Fio2 changes (10 ± 9 vs 112 ± 59 changes per 24 hours; P < .001), compared with the manual period. CONCLUSIONS: In infants with fluctuations in Spo2, automated Fio2 adjustment improved maintenance of the intended Spo2 range led to reduced time with high Spo2 and more-frequent episodes with Spo2 between 80% and 86%.

The pediatrician and disaster preparedness

For decades, emergency planning for natural disasters, public health emergencies, workplace accidents, and other calamities has been the responsibility of government agencies on all levels and certain nongovernment organizations such as the American Red Cross. In the case of terrorism, however, entirely new approaches to emergency planning are under development for a variety of reasons. Terrorism preparedness is a highly specific component of general emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, terrorism preparedness must consider several additional issues, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if they are not monitored carefully. This article is designed to provide an overview of key issues for the pediatrician with respect to disaster, terrorism, and public health emergency preparedness. It is not intended to be a complete compendium of didactic content but rather offers an approach to what pediatricians need to know and how pediatricians must lend their expertise to enhance preparedness in every community. To become fully and optimally prepared, pediatricians need to become familiar with these key areas of emergency preparedness: unique aspects of children related to terrorism and other disasters; terrorism preparedness; mental health vulnerabilities and development of resiliency; managing family concerns about terrorism and disaster preparedness; office-based preparedness; hospital preparedness; community, government, and public health preparedness; and advocating for children and families in preparedness planning.

Minimising ventilator induced lung injury in preterm infants

Ventilator induced lung injury continues to occur at an unacceptably high rate, which is inversely related to gestational age. Although the “new BPD” may not be entirely avoidable in the extremely premature infant, recognition of risk factors and adoption of an appropriate ventilatory strategy, along with continuous real time monitoring, may help to minimise lung damage. This paper will review the pathogenesis of ventilator induced lung injury and strategies that may mitigate it.

Mechanism of endotracheal tube movement with change of head position in the neonate

The mechanism of alteration of endotracheal tube position with movement of the head and neck in the neonate was studied in a term newborn cadaver. The infant was intubated and serial radiographs were obtained with the head and neck in different positions. We propose that the skull acts as a lever arm from the anterior end of the maxilla to the first cervical vertebra. The fulcrum for movement of this lever arm is the upper cervical spine. Movement of the endotracheal tube in the trachea is directed by the maxillocervical lever arm when the skull and upper cervical spine are flexed, extended, or rotated.

Randomized trial of normal saline versus 5% albumin for the treatment of neonatal hypotension

OBJECTIVES: This study was designed to assess the comparative efficacy of normal saline (NS) and 5% albumin (ALB) for treatment of hypotension in the acutely ill newborn.STUDY DESIGN: Newborn infants who were <24 hours old and were admitted to the Holden Neonatal Intensive Care Unit at the University of Michigan were randomized to receive one of the two solutions for volume expansion. Hypotension was defined as a sustained (≥30 minutes) mean arterial pressure (MAP) of <30 mmHg for infants weighing ≤2500 g, or a MAP of <40 mmHg for those weighing >2500 g. The short-term outcome measure was the resolution of hypotension defined as a MAP over the minimum limits set for birthweight sustained for ≥30 minutes.RESULTS: In total 41 infants met criteria and were entered. Of these, 21 infants received ALB and 20 received NS. Successful treatment was seen in 17/21 (81%) of infants in the ALB group and 17/20 (85%) of infants in the NS group. There was no statistically significant difference in response to treatment (p=0.30). In addition, there was no statistically significant difference in the magnitude of change in MAP between the two (p=0.41).CONCLUSIONS: NS was shown to be as effective as ALB for the correction of acute hypotension in the newborn infant. Given comparable efficacy of NS, along with its relatively low cost and availability, it should be considered the initial treatment of choice in this setting.

Can mechanical ventilation strategies reduce chronic lung disease

Chronic lung disease (CLD) continues to be a significant complication in newborn infants undergoing mechanical ventilation for respiratory failure. Although the aetiology of CLD is multifactorial, specific factors related to mechanical ventilation, including barotrauma, volutrauma and atelectrauma, have been implicated as important aetiologic mechanisms. This article discusses the ways in which these factors might be manipulated by various mechanical ventilatory strategies to reduce ventilator-induced lung injury. These include continuous positive airway pressure, permissive hypercapnia, patient-triggered ventilation, volume-targeted ventilation, proportional assist ventilation, high-frequency ventilation and real-time monitoring.