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Mechanical ventilation in respiratory insufficiency in infants
INTERNATIONAL
lies of the
digestive
system,
urinary
tract,
diaphragm, and/or abdominal wall. The operative mortality of the entire group is 51.4 per cent as compared to 16.7 per cent operative mortality in 245 full-term infants subjected to similar procedures. The mortality among premature infants undergoing operation was found to be 30 per cent higher than among infants of the same weight not requiring surgery. The mortality in premature infants with more than one major anomaly was 71.4 per cent. Infection was the cause of death in approximately 75 per cent of the patients. It is noted that in this series, penicillin and streptomycin were after surgery.-Daniel
ANESTHESIA
given almost T. Clod
routinely
AND INHALATION THERAPY
TRACHEDSTOMY AND ITS CARE IN INFANTS.
E. Aberdeen. 900, 1965.
187
ABSTRACTS OF PEDIATRIC SURGERY
Proc.
Roy.
Sot.
Med.
58:
In the last 5% years at the Hospital for Sick Children, Great Ormond Street, London. 149 tracheostomies in I47 infants have indicated that most of the risks associated with this procedure can be avoided. Chief indications for it were improvement of respiratory efficiency and pulmonary drainage. Few were for upper obstructive lesions. Its avoidance was aided by full humidification of inspired material, nasopharyngeal aspiration and sedation, physiotherapy, intermittent tracheal aspiration. percutaneous tracheal catheter and nasotracheal intubation. One hundred and five out of 147 cases suffered from congenital heart disease and others in considerably lesser numbers suffered from esophageal atresia with or without congenital heart disease, diaphragmatic hernia, congenital emphysema, staphylococcal pneumonia, etc. One hundred and ten out of I49 were under 3 months of age. Fortv-six successful extubations were obtained indicating that many died from the severity of their disease or condition. Infection was the most common complicution affecting many cases in some degree. Bronchospasm was related to long and vigorous toilet maneuvers within the trachea.
There
were no instances
of tracheal
steno-
sis. Special P.V.C. tubes were developed and used, being pliable and nonirritant with a single lumen ranging up from 4.5mm. outer diameter and 24mm. intratracheal length. Other significant features were gentle curvature, oblique inner end, coned outer orifice for connector iftting. Tracheostomy was always done under general anesthesia with endotracheal inmidline incision through three tubation; tracheal rings without cartilage excision was practiced. was always present A special nurse throughout the intubated period. Tracheal aspiration was done at regular intervals and on requirement with a sterile catheter used gently-not an easy thing to do well. Fine humidification with nebulizer and tracheal saline instillation regularly as indicated, was essential. Mucolytics had their uses also on occasion. Avoidance of metabolic dehydration was found to be important. The head in the extended position was essential. Physiotherapy was used a great deal. Increasing use of ventilators increased the risk of tube displacement. The avoidance of abdominal distension by gastric aspiration, or rectal tube, was important. Urgent signs were restlessness and fa.t pulse and an estimation of the volume of air expired was judged audibly and palpably by placing the ear close to the stoma. Any vocal sound was considered of serious importance. Emergency resuscitation apparatus, spare tubes and inserting instruments were always available.-F. H. Robarts. MECHANICAL VENTILATION IN RESPIRATORY INSUFFICIENCY IN INFANTS. W.
Proc.
Roy. Sot.
Med. 58:902,
J. Glooer. 1965.
Periods of ventilation in the preceding series varied from 24 hours to several weeks and were accomplished usually by the Engstrom ventilator or the Bird Mark VIII machine for patients with fairly normal lungs. The majority of infants requiring ventilation suffer from cardiopulmonary disease--cardiac failure, respiratory distress syndrome of the newborn, etc. The lungs have decreased compliance with high airway resistance which as the disease advances rises as the compliance continues to
188
INTERNATIONAL
fall. Ventilators are of two main types: flow or pressure generators. In the former the volume of flow is determined by the machine and continues to ventilate adequately even with low compliance or when airway resistance is high. Pressure generators, on the other hand, can vary in their delivery especially in severe cardiopulmonary disease and can fail to ventilate adequately. The Engstrom respirator incorporates a buffering device to control excessive variations in intratracheal and intrapulmonary pressures and is preferable in cases of severe cardiopulmonary disease. The rate of ventilation should not be fast and a brief static phase at the peak of inspiration is desirable to permit gas diffusion in the diseased lungs. The rate should be between 24 and 28 minute and the inspiratory:expiratory ratio should be fixed at 1:2. There are technical difficulties in the assessment of adequacy of ventilation by minute volume estimations. A comparison of minute volume requirements estimated by the recent E.H.N. nomogram and by the older Radford nomogram shows higher values with the former. Blood gas analysis by micro-Astrup estimations of PCO,, pH and standard bicarbonate is an important advance and requires only capillary blood except in situations where peripheral circulation is very poor, but a radial artery cannula maintained after pump-oxygenator use will permit better specimens for these estimations. Adequacy of humidification is essential either by drawover humidifiers which can be incorporated in volume-cycled machines or by compression nebulizers which can deliver aerosolforming drugs. The recent ultrasonic aerosol generator can be used with volume-controlled ventilation, but as relative humidity can be up to 300 per cent in infants, care to avoid overloading is essential and is indicated chiefly in the presence of severe crusting of secretions and tracheobronchitis and where bronchodilator aerosol drugs are desired. Mechanical ventilation is playing an increasing and important part in lowering the mortality from severe cardiopulmonary disease.--F. H. Rob&s.
ABSTRACTS OF PEDIATRIC SURGERY
SYMPOSIUM ON RESPIRATORY THERAPY. Clin.
Anes.
1:
1965.
This symposium, edited by Peter Safar, is devoted entirely to respiratory therapy. The entire volume contains interesting and informative papers on inhalation therapy and resuscitation. Chapter 12, dealing with “The Management of Newborn Resuscitation and the Respiratory Distress Syndrome” was written by Otto C. Phillips and Paul M. Taylor. This is an important article summarizing existing information on: (1) Evaluation of the newborn; (2) descriptions of available apparatus for resuscitation; (3) management of the depressed newborn; and, (4) the respiratory-distress syndrome-pathology, chemistry and physiology changes, etiology and treatmentMilton J. Marmer. THE
IMPORTANCE THE
OF TEMPERATURE
LATION
IN
INFANT
DURING
OPERATION
OPERATIVE PHASE.
Prax. 4:619-622,
AND
AND
IN
THE
Schweder.
N.
REGU-
NEWBORN POST-
Padiat.
1965.
In infants hypothermia may be harmful and can lead to postoperative disturbances of circulation, respiration and metabolism. Observation and regulation of temperature during and after operation are therefore of importance, more so the younger the child is. The author uses a heating mat which is kept at a temperature of 3840 C. All solutions for infusions including blood are used at room temperature. In this way the body temperature during operation ranges maximally up to 0.5 C. Stabilization of temperature has a beneficial effect on the general condition of the child.-W. Leuterer. VOLUME-PRESSURE SYSTEM
OF
Nightingale thesiology
OF
THE
RESPIRATORY
CURARIZED
INFANTS.
and
Richards.
C.
26:710-714,
C.
D. A. Anes-
1965.
Thirty-four infants under 6 months of age who had elective inguinal hernioplasty or pyloroplasty were selected for this study to determine the static compliance of the respiratory system when total paralyzation was produced with intravenous d-tubocurarine. Comparison of the data from this
lies of the
digestive
system,
urinary
tract,
diaphragm, and/or abdominal wall. The operative mortality of the entire group is 51.4 per cent as compared to 16.7 per cent operative mortality in 245 full-term infants subjected to similar procedures. The mortality among premature infants undergoing operation was found to be 30 per cent higher than among infants of the same weight not requiring surgery. The mortality in premature infants with more than one major anomaly was 71.4 per cent. Infection was the cause of death in approximately 75 per cent of the patients. It is noted that in this series, penicillin and streptomycin were after surgery.-Daniel
ANESTHESIA
given almost T. Clod
routinely
AND INHALATION THERAPY
TRACHEDSTOMY AND ITS CARE IN INFANTS.
E. Aberdeen. 900, 1965.
187
ABSTRACTS OF PEDIATRIC SURGERY
Proc.
Roy.
Sot.
Med.
58:
In the last 5% years at the Hospital for Sick Children, Great Ormond Street, London. 149 tracheostomies in I47 infants have indicated that most of the risks associated with this procedure can be avoided. Chief indications for it were improvement of respiratory efficiency and pulmonary drainage. Few were for upper obstructive lesions. Its avoidance was aided by full humidification of inspired material, nasopharyngeal aspiration and sedation, physiotherapy, intermittent tracheal aspiration. percutaneous tracheal catheter and nasotracheal intubation. One hundred and five out of 147 cases suffered from congenital heart disease and others in considerably lesser numbers suffered from esophageal atresia with or without congenital heart disease, diaphragmatic hernia, congenital emphysema, staphylococcal pneumonia, etc. One hundred and ten out of I49 were under 3 months of age. Fortv-six successful extubations were obtained indicating that many died from the severity of their disease or condition. Infection was the most common complicution affecting many cases in some degree. Bronchospasm was related to long and vigorous toilet maneuvers within the trachea.
There
were no instances
of tracheal
steno-
sis. Special P.V.C. tubes were developed and used, being pliable and nonirritant with a single lumen ranging up from 4.5mm. outer diameter and 24mm. intratracheal length. Other significant features were gentle curvature, oblique inner end, coned outer orifice for connector iftting. Tracheostomy was always done under general anesthesia with endotracheal inmidline incision through three tubation; tracheal rings without cartilage excision was practiced. was always present A special nurse throughout the intubated period. Tracheal aspiration was done at regular intervals and on requirement with a sterile catheter used gently-not an easy thing to do well. Fine humidification with nebulizer and tracheal saline instillation regularly as indicated, was essential. Mucolytics had their uses also on occasion. Avoidance of metabolic dehydration was found to be important. The head in the extended position was essential. Physiotherapy was used a great deal. Increasing use of ventilators increased the risk of tube displacement. The avoidance of abdominal distension by gastric aspiration, or rectal tube, was important. Urgent signs were restlessness and fa.t pulse and an estimation of the volume of air expired was judged audibly and palpably by placing the ear close to the stoma. Any vocal sound was considered of serious importance. Emergency resuscitation apparatus, spare tubes and inserting instruments were always available.-F. H. Robarts. MECHANICAL VENTILATION IN RESPIRATORY INSUFFICIENCY IN INFANTS. W.
Proc.
Roy. Sot.
Med. 58:902,
J. Glooer. 1965.
Periods of ventilation in the preceding series varied from 24 hours to several weeks and were accomplished usually by the Engstrom ventilator or the Bird Mark VIII machine for patients with fairly normal lungs. The majority of infants requiring ventilation suffer from cardiopulmonary disease--cardiac failure, respiratory distress syndrome of the newborn, etc. The lungs have decreased compliance with high airway resistance which as the disease advances rises as the compliance continues to
188
INTERNATIONAL
fall. Ventilators are of two main types: flow or pressure generators. In the former the volume of flow is determined by the machine and continues to ventilate adequately even with low compliance or when airway resistance is high. Pressure generators, on the other hand, can vary in their delivery especially in severe cardiopulmonary disease and can fail to ventilate adequately. The Engstrom respirator incorporates a buffering device to control excessive variations in intratracheal and intrapulmonary pressures and is preferable in cases of severe cardiopulmonary disease. The rate of ventilation should not be fast and a brief static phase at the peak of inspiration is desirable to permit gas diffusion in the diseased lungs. The rate should be between 24 and 28 minute and the inspiratory:expiratory ratio should be fixed at 1:2. There are technical difficulties in the assessment of adequacy of ventilation by minute volume estimations. A comparison of minute volume requirements estimated by the recent E.H.N. nomogram and by the older Radford nomogram shows higher values with the former. Blood gas analysis by micro-Astrup estimations of PCO,, pH and standard bicarbonate is an important advance and requires only capillary blood except in situations where peripheral circulation is very poor, but a radial artery cannula maintained after pump-oxygenator use will permit better specimens for these estimations. Adequacy of humidification is essential either by drawover humidifiers which can be incorporated in volume-cycled machines or by compression nebulizers which can deliver aerosolforming drugs. The recent ultrasonic aerosol generator can be used with volume-controlled ventilation, but as relative humidity can be up to 300 per cent in infants, care to avoid overloading is essential and is indicated chiefly in the presence of severe crusting of secretions and tracheobronchitis and where bronchodilator aerosol drugs are desired. Mechanical ventilation is playing an increasing and important part in lowering the mortality from severe cardiopulmonary disease.--F. H. Rob&s.
ABSTRACTS OF PEDIATRIC SURGERY
SYMPOSIUM ON RESPIRATORY THERAPY. Clin.
Anes.
1:
1965.
This symposium, edited by Peter Safar, is devoted entirely to respiratory therapy. The entire volume contains interesting and informative papers on inhalation therapy and resuscitation. Chapter 12, dealing with “The Management of Newborn Resuscitation and the Respiratory Distress Syndrome” was written by Otto C. Phillips and Paul M. Taylor. This is an important article summarizing existing information on: (1) Evaluation of the newborn; (2) descriptions of available apparatus for resuscitation; (3) management of the depressed newborn; and, (4) the respiratory-distress syndrome-pathology, chemistry and physiology changes, etiology and treatmentMilton J. Marmer. THE
IMPORTANCE THE
OF TEMPERATURE
LATION
IN
INFANT
DURING
OPERATION
OPERATIVE PHASE.
Prax. 4:619-622,
AND
AND
IN
THE
Schweder.
N.
REGU-
NEWBORN POST-
Padiat.
1965.
In infants hypothermia may be harmful and can lead to postoperative disturbances of circulation, respiration and metabolism. Observation and regulation of temperature during and after operation are therefore of importance, more so the younger the child is. The author uses a heating mat which is kept at a temperature of 3840 C. All solutions for infusions including blood are used at room temperature. In this way the body temperature during operation ranges maximally up to 0.5 C. Stabilization of temperature has a beneficial effect on the general condition of the child.-W. Leuterer. VOLUME-PRESSURE SYSTEM
OF
Nightingale thesiology
OF
THE
RESPIRATORY
CURARIZED
INFANTS.
and
Richards.
C.
26:710-714,
C.
D. A. Anes-
1965.
Thirty-four infants under 6 months of age who had elective inguinal hernioplasty or pyloroplasty were selected for this study to determine the static compliance of the respiratory system when total paralyzation was produced with intravenous d-tubocurarine. Comparison of the data from this