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Preliminary data on iNO ventilation in VLBW infants
S88
Abstracts
with years, from 18.4% (BPD) and 13.6% (CLD) in 2004 to 9.9% (BPD) and 4.5% (CLD) in 2007 (p < 0.05). Conclusions We found a successful application of the Infant Flow nCPAP in Poland as a first line treatment for respiratory problems in newborns. We observe an improvement in outcomes probably as a result of the learning curve. doi:10.1016/j.earlhumdev.2008.09.226
Abstract UENPS.211 Refractory persistent pulmonary hypertension of the newborn responsive to neuromuscular blockade
doi:10.1016/j.earlhumdev.2008.09.225
Luca Filippi, Lisa Serafini, Elena Gozzini, Chiara Poggi⁎, Marco Moroni, Patrizio Fiorini “A. Meyer” University Children's Hospital, Florence, Italy Background and aim
Abstract UENPS.210 Noninvasive Respiratory Support Program in newborns — 5 years experience Banasik Karolina⁎,f, Swietlinski Januszf, Gajewska Elzbietaa, Szczapa Jerzyb, Helwich Ewag, Lauterbach Ryszardc, Maruszewski Bohdanf, Bober Klaudiuszd, Skrzypek Michald, Zejda Jand, Bachman Thomase a Medical University, Wroclaw, Poland b University of Medical Sciences, Poznan, Poland c Medical College Jagiellonian University, Cracow, Poland d Medical University of Silesia, Katowice, Poland e California State University, San Bernardino, United States f The Children's Memorial Health Institute, Warsaw, Poland g National Research Institute of Mother and Child, Warsaw, Poland Background and aim The Noninvasive Respiratory Support Program (NRSP) was introduced in Poland in 2003. The aim of this project was to change the standard of newborn care for respiratory insufficiency by widely introducing the use of nasal continuous airway pressure (nCPAP) and using Infant Flow technology. Our goal was better outcomes for our babies. This program is a collaboration of the Polish Neonatal Society and The Great Christmas Charity Foundation which has donated 318 Infant Flow and Infant Flow Advance devices (VIASYS, USA). We present the efficacy of NRSP in the fifth year since implementation. Materials and methods A reporting system was created at the beginning of the NRSP. Data on the demographic characteristics, indications for use and effects of treatment are collected continuously. All participating neonatal units (n = 131) are visited by dedicated staff to monitor all aspects connected with the program. Results 6034 infants (23–45 weeks gestation, birth weight 420–5150 g) were included in this analysis. nCPAP was effective in 74.9% of the cases, with success being defined as no need for intubation for elective use and re-intubation for weaning. The main indications for nCPAP treatment and respective success were (% of population/rate of success): respiratory problems due to low FRC (like RDS) — 71.6%/76.7% and weaning — 19.9%/73%. The same data for babies <1500 g were respectively: 56.9%/73.1% and 38.3%/72.1%. The success rate rose for both indications between 2003 and 2007 (p < 0.05). This result was also statistically significant in babies <1500 g. The complication rate for 2003–2007 years was: pneumothorax 2.3% and nasal injuries 8.8%. The rate of local complications dropped with time, from 11.7% in 2004 to 5.0% in 2007, p < 0.05. The rate of pneumothoraces remained the same. The frequency for BPD and CLD declined
Persistent pulmonary hypertension of the neonate (PPHN) refractory to high frequency oscillatory ventilation (HFOV) and to inhaled nitric oxide (iNO) therapy is a non-exceptional occurrence in the newborn population, showing a high mortality rate. About 34% of infants with severe hypoxic respiratory failure did not respond to iNO. Materials and methods We observed a 2330 g full-term neonate with severe pulmonary hypertension, intubated, ventilated, completely sedated with and fentanyl, unresponsive to the treatment with HFOV and iNO until to 50 ppm, even after the association with prostacyclin (PGI2). This treatment instead produced a profound hypotension that required continuous norepinephrine infusion. Results At 26 h of life a bolus of vecuronium bromide was administered in order to increase chest wall compliance. Immediately after the administration, an extended skin redness was observed. Moreover, a dramatic increase in PaO2, SaO2 and a rapid fall of FiO2 was noticed. In the following hours PGI2 infusion was stopped. iNO treatment was slowly decreased and stopped after 3 days. Extubation was performed in the sixth day of life and the infant was discharged at age 18 days. Conclusions In this patient vecuronium was used in order to increase the pulmonary compliance and/or to promote vascular smooth cells relaxation. The use of neuromuscular blockers in PPHN was rather common in the pre-iNO era, and beneficial effects of curarization were related to increased effective ventilation and to the release by curare of histamine, a pulmonary vasodilator. The detection of widespread skin redness immediately after vecuronium infusion, could confirm also in this patient a release of histamine. This case suggests considering the use of neuromuscular blocking agents in newborns affected by PPHN refractory to iNO and others pulmonary vasodilators, to accomplish muscle relaxation and, probably, potentate pulmonary vasodilatation. Further studies are required to prove effectiveness and safety of neuromuscular blocker to treat PPHN refractory to iNO and PGI2. doi:10.1016/j.earlhumdev.2008.09.227
Abstract UENPS.212 Preliminary data on iNO ventilation in VLBW infants Cavalli Claudio⁎, Gianotti Daniela, Bussolati Giovanna, Moretti Sabrina, Gambini Lucia, Violante Enrico, Bevilacqua Giulio Neonatology and NICU, University Hospital, Parma, Italy
Abstracts
Background and aim
S89
Patients were selected according both to clinical course and to echocardiography (2D) and ventilation index (VI). Two infants represent our series.
left sided in four and bilateral in one. In utero spontaneous incomplete regression occurred in one case. Five neonates evidenced respiratory distress and two remained asymptomatic. All cases evidenced unspecific findings in the first chest X-ray, and subsequent CT scan supported the diagnosis. Lobectomy was the preferred procedure in the five neonates submitted to surgery. “Prophylactic” surgery was decided in one asymptomatic patient. Good outcome was observed in a symptomatic infant under conservative management. The median postoperative ventilation time was 5 days. Early postoperative complications included pneumothorax (2), septicemia (1) and pneumonia (1). Histopathology confirmed the definitive diagnosis (Stocker classification): type I = 2; type II = 3. After 2 to 10 years of follow-up all patients are asymptomatic and no recurrence occurred.
Results
Conclusions
Case 1. Female, GA: 30 + 2. Cesarean delivery was done for labor onset and breech presentation. BW 1380 g (50°–75° centile), Apgar: 7.6. CPAP ventilation in the DR failed, the infant was intubated and received surfactant. In the NICU: SIMV ventilation. Dopamine (7 mg/kg/min) was added due to border-line mean systemic pressure (32–34 mm Hg). At 11 h of life parameters were as follows. BGA: pH 7.284, pO2 52.1, pCO2 50, B.E. − 3.7, HCO3 23.5, VI = 74, OI = 6. Right ventricular pressure esteem by 2D and Doppler (tricuspid regurgitation) was 60–62 mm Hg (suprasystemic). A tiny ductus arteriosus was present as well with R-to-L shunt. Mechanical ventilation with iNO was the choice at 5 ppm after a positive test at 3 ppm. iNO was promptly efficacious according to serial 2D monitoring. After 24 h iNO was progressively withdrawn and the infant extubated at 2 days of life. No supplemental oxygen since the 2nd week of life. Case#2. Female, GA: 30. Cesarean section for amnionitis. BW: 1180 g (25°–50° centile), Apgar: 2.5. Intubation and ventilation in the DR. Surfactant was administered as well. In the ICU: SIMV ventilation. Dopamine (7 mg/kg/ min) was added due to border-line mean systemic pressure (32–37 mm Hg). Surfactant was repeated at 12 h. At 2D (10 h of life): tiny PDA with 50% bidirectional shunt, myocardial dyskinesia and quasi-systemic (50 mm Hg) right ventricular pressure esteem. Contemporarily OI was 16 and VI 76. A trial was done with iNO 3 ppm and ventilation with 5–6 ppm continued therefore. iNO was stopped after 35 h. A perinatal infection was then diagnosed and the infant was extubated on day 14.
CCAML is a rare condition with a broad clinical spectrum. Intrauterine regression can occur. Although definitive diagnosis is based on histopathology, CT scan is an excellent complimentary tool supporting the diagnosis. The therapeutic options are controversial, particularly in asymptomatic patients in whom surgical intervention may be considered, taking into account the risk of late malignancy.
Elevated pulmonary vascular resistances often characterize the transitional period of critical newborns. Administration of inhaled nitric oxide (iNO) has been introduced more than 10 years ago but its utilization in preterm infants is still in progress particularly below 34 weeks' gestation. We refer about our preliminary experience with iNO in selected VLBW infants. Materials and methods
Conclusions Little information is presently available regarding iNO ventilation in preterms. At present iNO could remain as a choice in selected VLBWs until larger series will confirm this opportunity. Our initial experience seems encouraging. doi:10.1016/j.earlhumdev.2008.09.228
Abstract UENPS.213 Congenital cystic adenomatoid malformation of the lung — Outcomes of a referral third level NICU Garcia Pedro⁎, Henriques João, Pinto Sérgio, Serelha Micaela Hospital Dona Estefânia, Lisbon, Portugal Background and aim To assess the prenatal diagnosis, postnatal presentation, medical and surgical management, and outcome of infants with congenital cystic adenomatoid malformation of the lung (CCAML). Materials and methods Case series of consecutive CCAML admitted to the Hospital Dona Estefânia medical–surgical NICU over a ten year period (1998 to 2007).
doi:10.1016/j.earlhumdev.2008.09.229
Abstract UENPS.214 Effect of angiotensin converting enzyme (ACE) gene polymorphism on endurance of respiratory muscles in infants Papakonstantinou Despina⁎, Staurou Eleana, Tzifas Sotirios, Mermiga Alexandra, Athanassiadou Aglaia, Mantagos Stefanos, Dimitriou Gabriel University of Patras Medical School, Patras, Greece Background and aim The human ACE gene contains a two allele polymorphism specified by the presence (I) and absence (D) of an intronic 287-bp fragment. The ACE Iallele is associated with enhanced fatigue resistance/endurance performance, partly through improved skeletal muscle metabolic efficiency. Thus, respiratory muscle endurance may be similarly influenced. Diaphragmatic tension-time index (TTdi), which describes the pressure-generating activity of the diaphragm, is a measure of diaphragmatic endurance and hence a high TTdi can predict diaphragmatic fatigue. Determination of TTdi, however, is invasive. Recently, a non-invasive method of measuring tension time index of respiratory muscles (TTmus) has been validated in adults. The objective of the study was to test the hypothesis that infants homozygous for the I allele may have enhanced respiratory muscle endurance compared to infants homozygous for the D-allele or heterozygous ID allele. Materials and methods A hundred infants, median gestational age 35 weeks were studied. ACE genotyping was performed by PCR amplification, using two sets of primers and DNA from peripheral blood. Transdiaphragmatic pressure (Pdi) was calculated by subtraction of oesophageal pressure from gastric pressure, measured by a dual pressure catheter. TTdi was calculated as the product of the mean to the maximum transdiaphragmatic pressure (Pdimean/Pdimax) and the inspiratory duty cycle (Ti/Ttot). TTmus was calculated as (5 × P0.1 × Ti/ Pimax) × (Ti/ Ttot). The Pdimean during a breath was electronically determined over the inspiratory time interval where the maximal transdiaphragmatic (Pdimax) and inspiratory (Pimax) pressures were the largest negative pressures generated during brief airway occlusions performed at the end of a crying effort. The inspiratory pressure generated at the mouth 100 ms after occlusion (P0.1) was measured during quiet breathing. Results
Results Six term neonates and one preterm of 31 weeks with CCAML were identified. Prenatal diagnosis was established in three cases, at a median gestational age of 24 weeks. The malformation was right sided in two cases,
Infants homozygous for the I-allele had lower TTdi and TTmus than infants homozygous for the D-allele (p = 0.0026 and p = 0.0255, respectively) or heterozygous ID (p = 0.0005 and p = 0.0003, respectively). A significant relationship between TTdi and TTmus was found (p < 0.001).
Abstracts
with years, from 18.4% (BPD) and 13.6% (CLD) in 2004 to 9.9% (BPD) and 4.5% (CLD) in 2007 (p < 0.05). Conclusions We found a successful application of the Infant Flow nCPAP in Poland as a first line treatment for respiratory problems in newborns. We observe an improvement in outcomes probably as a result of the learning curve. doi:10.1016/j.earlhumdev.2008.09.226
Abstract UENPS.211 Refractory persistent pulmonary hypertension of the newborn responsive to neuromuscular blockade
doi:10.1016/j.earlhumdev.2008.09.225
Luca Filippi, Lisa Serafini, Elena Gozzini, Chiara Poggi⁎, Marco Moroni, Patrizio Fiorini “A. Meyer” University Children's Hospital, Florence, Italy Background and aim
Abstract UENPS.210 Noninvasive Respiratory Support Program in newborns — 5 years experience Banasik Karolina⁎,f, Swietlinski Januszf, Gajewska Elzbietaa, Szczapa Jerzyb, Helwich Ewag, Lauterbach Ryszardc, Maruszewski Bohdanf, Bober Klaudiuszd, Skrzypek Michald, Zejda Jand, Bachman Thomase a Medical University, Wroclaw, Poland b University of Medical Sciences, Poznan, Poland c Medical College Jagiellonian University, Cracow, Poland d Medical University of Silesia, Katowice, Poland e California State University, San Bernardino, United States f The Children's Memorial Health Institute, Warsaw, Poland g National Research Institute of Mother and Child, Warsaw, Poland Background and aim The Noninvasive Respiratory Support Program (NRSP) was introduced in Poland in 2003. The aim of this project was to change the standard of newborn care for respiratory insufficiency by widely introducing the use of nasal continuous airway pressure (nCPAP) and using Infant Flow technology. Our goal was better outcomes for our babies. This program is a collaboration of the Polish Neonatal Society and The Great Christmas Charity Foundation which has donated 318 Infant Flow and Infant Flow Advance devices (VIASYS, USA). We present the efficacy of NRSP in the fifth year since implementation. Materials and methods A reporting system was created at the beginning of the NRSP. Data on the demographic characteristics, indications for use and effects of treatment are collected continuously. All participating neonatal units (n = 131) are visited by dedicated staff to monitor all aspects connected with the program. Results 6034 infants (23–45 weeks gestation, birth weight 420–5150 g) were included in this analysis. nCPAP was effective in 74.9% of the cases, with success being defined as no need for intubation for elective use and re-intubation for weaning. The main indications for nCPAP treatment and respective success were (% of population/rate of success): respiratory problems due to low FRC (like RDS) — 71.6%/76.7% and weaning — 19.9%/73%. The same data for babies <1500 g were respectively: 56.9%/73.1% and 38.3%/72.1%. The success rate rose for both indications between 2003 and 2007 (p < 0.05). This result was also statistically significant in babies <1500 g. The complication rate for 2003–2007 years was: pneumothorax 2.3% and nasal injuries 8.8%. The rate of local complications dropped with time, from 11.7% in 2004 to 5.0% in 2007, p < 0.05. The rate of pneumothoraces remained the same. The frequency for BPD and CLD declined
Persistent pulmonary hypertension of the neonate (PPHN) refractory to high frequency oscillatory ventilation (HFOV) and to inhaled nitric oxide (iNO) therapy is a non-exceptional occurrence in the newborn population, showing a high mortality rate. About 34% of infants with severe hypoxic respiratory failure did not respond to iNO. Materials and methods We observed a 2330 g full-term neonate with severe pulmonary hypertension, intubated, ventilated, completely sedated with and fentanyl, unresponsive to the treatment with HFOV and iNO until to 50 ppm, even after the association with prostacyclin (PGI2). This treatment instead produced a profound hypotension that required continuous norepinephrine infusion. Results At 26 h of life a bolus of vecuronium bromide was administered in order to increase chest wall compliance. Immediately after the administration, an extended skin redness was observed. Moreover, a dramatic increase in PaO2, SaO2 and a rapid fall of FiO2 was noticed. In the following hours PGI2 infusion was stopped. iNO treatment was slowly decreased and stopped after 3 days. Extubation was performed in the sixth day of life and the infant was discharged at age 18 days. Conclusions In this patient vecuronium was used in order to increase the pulmonary compliance and/or to promote vascular smooth cells relaxation. The use of neuromuscular blockers in PPHN was rather common in the pre-iNO era, and beneficial effects of curarization were related to increased effective ventilation and to the release by curare of histamine, a pulmonary vasodilator. The detection of widespread skin redness immediately after vecuronium infusion, could confirm also in this patient a release of histamine. This case suggests considering the use of neuromuscular blocking agents in newborns affected by PPHN refractory to iNO and others pulmonary vasodilators, to accomplish muscle relaxation and, probably, potentate pulmonary vasodilatation. Further studies are required to prove effectiveness and safety of neuromuscular blocker to treat PPHN refractory to iNO and PGI2. doi:10.1016/j.earlhumdev.2008.09.227
Abstract UENPS.212 Preliminary data on iNO ventilation in VLBW infants Cavalli Claudio⁎, Gianotti Daniela, Bussolati Giovanna, Moretti Sabrina, Gambini Lucia, Violante Enrico, Bevilacqua Giulio Neonatology and NICU, University Hospital, Parma, Italy
Abstracts
Background and aim
S89
Patients were selected according both to clinical course and to echocardiography (2D) and ventilation index (VI). Two infants represent our series.
left sided in four and bilateral in one. In utero spontaneous incomplete regression occurred in one case. Five neonates evidenced respiratory distress and two remained asymptomatic. All cases evidenced unspecific findings in the first chest X-ray, and subsequent CT scan supported the diagnosis. Lobectomy was the preferred procedure in the five neonates submitted to surgery. “Prophylactic” surgery was decided in one asymptomatic patient. Good outcome was observed in a symptomatic infant under conservative management. The median postoperative ventilation time was 5 days. Early postoperative complications included pneumothorax (2), septicemia (1) and pneumonia (1). Histopathology confirmed the definitive diagnosis (Stocker classification): type I = 2; type II = 3. After 2 to 10 years of follow-up all patients are asymptomatic and no recurrence occurred.
Results
Conclusions
Case 1. Female, GA: 30 + 2. Cesarean delivery was done for labor onset and breech presentation. BW 1380 g (50°–75° centile), Apgar: 7.6. CPAP ventilation in the DR failed, the infant was intubated and received surfactant. In the NICU: SIMV ventilation. Dopamine (7 mg/kg/min) was added due to border-line mean systemic pressure (32–34 mm Hg). At 11 h of life parameters were as follows. BGA: pH 7.284, pO2 52.1, pCO2 50, B.E. − 3.7, HCO3 23.5, VI = 74, OI = 6. Right ventricular pressure esteem by 2D and Doppler (tricuspid regurgitation) was 60–62 mm Hg (suprasystemic). A tiny ductus arteriosus was present as well with R-to-L shunt. Mechanical ventilation with iNO was the choice at 5 ppm after a positive test at 3 ppm. iNO was promptly efficacious according to serial 2D monitoring. After 24 h iNO was progressively withdrawn and the infant extubated at 2 days of life. No supplemental oxygen since the 2nd week of life. Case#2. Female, GA: 30. Cesarean section for amnionitis. BW: 1180 g (25°–50° centile), Apgar: 2.5. Intubation and ventilation in the DR. Surfactant was administered as well. In the ICU: SIMV ventilation. Dopamine (7 mg/kg/ min) was added due to border-line mean systemic pressure (32–37 mm Hg). Surfactant was repeated at 12 h. At 2D (10 h of life): tiny PDA with 50% bidirectional shunt, myocardial dyskinesia and quasi-systemic (50 mm Hg) right ventricular pressure esteem. Contemporarily OI was 16 and VI 76. A trial was done with iNO 3 ppm and ventilation with 5–6 ppm continued therefore. iNO was stopped after 35 h. A perinatal infection was then diagnosed and the infant was extubated on day 14.
CCAML is a rare condition with a broad clinical spectrum. Intrauterine regression can occur. Although definitive diagnosis is based on histopathology, CT scan is an excellent complimentary tool supporting the diagnosis. The therapeutic options are controversial, particularly in asymptomatic patients in whom surgical intervention may be considered, taking into account the risk of late malignancy.
Elevated pulmonary vascular resistances often characterize the transitional period of critical newborns. Administration of inhaled nitric oxide (iNO) has been introduced more than 10 years ago but its utilization in preterm infants is still in progress particularly below 34 weeks' gestation. We refer about our preliminary experience with iNO in selected VLBW infants. Materials and methods
Conclusions Little information is presently available regarding iNO ventilation in preterms. At present iNO could remain as a choice in selected VLBWs until larger series will confirm this opportunity. Our initial experience seems encouraging. doi:10.1016/j.earlhumdev.2008.09.228
Abstract UENPS.213 Congenital cystic adenomatoid malformation of the lung — Outcomes of a referral third level NICU Garcia Pedro⁎, Henriques João, Pinto Sérgio, Serelha Micaela Hospital Dona Estefânia, Lisbon, Portugal Background and aim To assess the prenatal diagnosis, postnatal presentation, medical and surgical management, and outcome of infants with congenital cystic adenomatoid malformation of the lung (CCAML). Materials and methods Case series of consecutive CCAML admitted to the Hospital Dona Estefânia medical–surgical NICU over a ten year period (1998 to 2007).
doi:10.1016/j.earlhumdev.2008.09.229
Abstract UENPS.214 Effect of angiotensin converting enzyme (ACE) gene polymorphism on endurance of respiratory muscles in infants Papakonstantinou Despina⁎, Staurou Eleana, Tzifas Sotirios, Mermiga Alexandra, Athanassiadou Aglaia, Mantagos Stefanos, Dimitriou Gabriel University of Patras Medical School, Patras, Greece Background and aim The human ACE gene contains a two allele polymorphism specified by the presence (I) and absence (D) of an intronic 287-bp fragment. The ACE Iallele is associated with enhanced fatigue resistance/endurance performance, partly through improved skeletal muscle metabolic efficiency. Thus, respiratory muscle endurance may be similarly influenced. Diaphragmatic tension-time index (TTdi), which describes the pressure-generating activity of the diaphragm, is a measure of diaphragmatic endurance and hence a high TTdi can predict diaphragmatic fatigue. Determination of TTdi, however, is invasive. Recently, a non-invasive method of measuring tension time index of respiratory muscles (TTmus) has been validated in adults. The objective of the study was to test the hypothesis that infants homozygous for the I allele may have enhanced respiratory muscle endurance compared to infants homozygous for the D-allele or heterozygous ID allele. Materials and methods A hundred infants, median gestational age 35 weeks were studied. ACE genotyping was performed by PCR amplification, using two sets of primers and DNA from peripheral blood. Transdiaphragmatic pressure (Pdi) was calculated by subtraction of oesophageal pressure from gastric pressure, measured by a dual pressure catheter. TTdi was calculated as the product of the mean to the maximum transdiaphragmatic pressure (Pdimean/Pdimax) and the inspiratory duty cycle (Ti/Ttot). TTmus was calculated as (5 × P0.1 × Ti/ Pimax) × (Ti/ Ttot). The Pdimean during a breath was electronically determined over the inspiratory time interval where the maximal transdiaphragmatic (Pdimax) and inspiratory (Pimax) pressures were the largest negative pressures generated during brief airway occlusions performed at the end of a crying effort. The inspiratory pressure generated at the mouth 100 ms after occlusion (P0.1) was measured during quiet breathing. Results
Results Six term neonates and one preterm of 31 weeks with CCAML were identified. Prenatal diagnosis was established in three cases, at a median gestational age of 24 weeks. The malformation was right sided in two cases,
Infants homozygous for the I-allele had lower TTdi and TTmus than infants homozygous for the D-allele (p = 0.0026 and p = 0.0255, respectively) or heterozygous ID (p = 0.0005 and p = 0.0003, respectively). A significant relationship between TTdi and TTmus was found (p < 0.001).