Efficacy of a new technique - INtubate-RECruit-SURfactant-Extubate - "IN-REC-SUR-E" - in preterm neonates with respiratory distress syndrome: Study protocol for a randomized controlled trial

Background: Although beneficial in clinical practice, the INtubate-SURfactant-Extubate (IN-SUR-E) method is not successful in all preterm neonates with respiratory distress syndrome, with a reported failure rate ranging from 19 to 69 %. One of the possible mechanisms responsible for the unsuccessful IN-SUR-E method, requiring subsequent re-intubation and mechanical ventilation, is the inability of the preterm lung to achieve and maintain an "optimal" functional residual capacity. The importance of lung recruitment before surfactant administration has been demonstrated in animal studies showing that recruitment leads to a more homogeneous surfactant distribution within the lungs. Therefore, the aim of this study is to compare the application of a recruitment maneuver using the high-frequency oscillatory ventilation (HFOV) modality just before the surfactant administration followed by rapid extubation (INtubate-RECruit-SURfactant-Extubate: IN-REC-SUR-E) with IN-SUR-E alone in spontaneously breathing preterm infants requiring nasal continuous positive airway pressure (nCPAP) as initial respiratory support and reaching pre-defined CPAP failure criteria. Methods/design: In this study, 206 spontaneously breathing infants born at 24+0-27+6 weeks' gestation and failing nCPAP during the first 24 h of life, will be randomized to receive an HFOV recruitment maneuver (IN-REC-SUR-E) or no recruitment maneuver (IN-SUR-E) just prior to surfactant administration followed by prompt extubation. The primary outcome is the need for mechanical ventilation within the first 3 days of life. Infants in both groups will be considered to have reached the primary outcome when they are not extubated within 30 min after surfactant administration or when they meet the nCPAP failure criteria after extubation. Discussion: From all available data no definitive evidence exists about a positive effect of recruitment before surfactant instillation, but a rationale exists for testing the following hypothesis: a lung recruitment maneuver performed with a step-by-step Continuous Distending Pressure increase during High-Frequency Oscillatory Ventilation (and not with a sustained inflation) could have a positive effects in terms of improved surfactant distribution and consequent its major efficacy in preterm newborns with respiratory distress syndrome. This represents our challenge. Trial registration: ClinicalTrials.gov identifier: NCT02482766. Registered on 1 June 2015

Effects of early dexamethasone therapy on pulmonary fibrogenic mediators and respiratory mechanism in preterm infants

Corticosteroid administration may prevent chronic lung disease in premature newborns, perhaps by modulating the synthesis of various cytokines, including those involved in fibrogenic processes. This study analyses the levels of three fibrogenic cytokines, namely vascular endothelial growth factor, transforming growth factor-beta 1 and basic fibroblast growth factor in tracheobronchial aspirate fluids collected from 20 premature newborns randomly assigned to the early dexamethasone group or to the control group. Furthermore, pulmonary function tests were performed on days 0 and 2 following the start of therapy. The results show that early corticosteroid administration reduces transforming growth factor-beta 1 and basic fibroblast growth factor levels, and abolishes the spontaneous vascular endothelial growth factor increase observed in untreated patients, concomitantly with significant improvement of dynamic lung compliance and shorter duration of the intubation period in the treated group of patients. Significant correlations were observed between the levels of transforming growth factor-beta 1 and vascular endothelial growth factor, indicating that the production of both these cytokines is coordinated. Finally, transforming growth factor-beta 1 ratios (day 2/day 0), representing early variations of the cytokine levels, were significantly different between treated and untreated subjects and correlated with the dynamic lung compliance ratios and the extubation day, suggesting that the downmodulation of some fibrogenic mediators may be involved in the mode of action of dexamethasone

The Effects of Distance between Initial Estimates and Advice on Advice Utilization

Die Forschung zur Annahme von Ratschlägen geht bislang davon aus, dass Ratschläge umso weniger gewichtet werden, je weiter entfernt sie zur Initialschätzung einer Person liegen. In dieser Dissertation wird hingegen postuliert, dass eine kurvilineare Beziehung zwischen Ratschlagsdistanz und –gewichtung vorliegt; d.h., dass nicht nur sehr weit entfernte, sondern auch sehr nahe Ratschläge vergleichsweise wenig gewichtet werden. In vier Experimenten wurden Probanden dazu aufgefordert, quantitative Urteile auf Grundlage ihrer eigenen Schätzung und dargebotenen Ratschlägen abzugeben. Analysen zeigten, dass sehr nahe Ratschläge als soziale Validierung der Ausgangsmeinungen wahrgenommen wurden und dadurch nahezu keine Veränderung des Initialurteils bewirkten. Moderat unterschiedliche Ratschläge wurden stärker gewichtet als weit entfernte Ratschläge. Dieser Befund erwies sich zudem als unabhängig vom verwendeten Schätzaufgabentyp, der Kompetenz des Ratgebers sowie davon, ob die Entfernung der Ratschläge eher kontinuierlich oder sehr grob gestuft manipuliert wurde. Die Ergebnisse legen somit eine Revision der Annahme einer monoton fallenden Beziehung zwischen Ratschlagsdistanz und –gewichtung nahe

Early pulmonary mechanics changes to predict the severity of broncopulmonary dysplasia in ventilates preterm infants

no abstract availabl

Spontaneous minute ventilation is a predictor of extubation failure in extremely-low-birth-weight infants

OBJECTIVE: To validate the percentage of time spent below a target value of spontaneous expiratory minute ventilation (< 125 ml/min per kg) during a 2-h period of continuous positive airway pressure (CPAP) via an endotracheal tube (ETT) as a predictor of failed extubation in preterm infants. METHODS: Forty-one infants intubated for at least 24 h, with birth weight between 500 and 1000 g, who were clinically stable and at ventilator setting compatible with an extubation attempt, were studied during a 2-h period of ETT CPAP. Dynamic lung compliance and total lung resistance were measured during a period of quiet breathing, while tidal volume (Vt), respiratory rate and the corresponding spontaneous expiratory minute ventilation values were calculated for the complete recording period of 2 h using a customized computer program. The time each patient spent below the target spontaneous expiratory minute ventilation value was reported as a percentage of the total recorded time (% spontaneous expiratory minute ventilation < 125 ml/min per kg). Extubation failure was defined as the need for reintubation within 72 h. RESULTS: Eleven out of 41 babies (26.8%) experienced failure of extubation (failure group) while 30 infants (73.2%) were successfully extubated (success group). There were no significant differences in dynamic lung compliance and lung resistance between the two groups, but the mean values of respiratory rate and spontaneous expiratory minute ventilation were significantly lower in the failure group than in the success group: 43 (37-56) breaths/min and 240 (160-353) ml/min per kg vs. 53 (28-67) breaths/min and 309 (223-434) ml/min per kg, respectively (p = 0.0129 and p = 0.0039). Moreover, the babies in whom extubation failed spent a longer time below the target value of spontaneous expiratory minute ventilation when compared with successfully extubated babies (p < 0.0001). Percentage of time spent with spontaneous expiratory minute ventilation < 125 ml/min per kg had a larger area than transcutaneous (Tc)PCO2, TcPO2 and pulse oxymetry saturation (SpO2) under the receiver operator characteristic curves. CONCLUSION: The measurement of spontaneous expiratory minute ventilation prior to extubation could be useful in identifying those babies who are not ready for spontaneous ventilation

Increased levels of solubile intercellular adhesion molecole-1, neutrophils and elastase in the lung of preterm infants with bronchopulmonary displasia.

Increased levels of solubile intercellular adhesion molecole-1, neutrophils and elastase in the lung of preterm infants with bronchopulmonary displasia