Respiratory failure in "late preterm" infants: a retrospective cohort study

OBJECTIVE: To evaluate the incidence and characteristics of the respiratory failure in late preterm infants. STUDY DESIGN: Retrospective data analysis in years 2006-2007 in late preterm infants (GA 34(+0)-36(+6) weeks) with respiratory failure, admitted at a tertiary level NICU. RESULT: Data from 1011 late preterm infants, which accounted for 7% of all deliveries and 65% of preterm births were analyzed; 29% (292/1011) required intensive care and 13% (136/1011) presented respiratory failure (16% of all ventilated infants in the period). In late preterms with respiratory failure 23% (32/136) were treated with prenatal steroids 46% (62/136) with non -invasive ventilation (nasal continuous positive airways pressure = nCPAP) while 41% (56/136) were intubated and received exogenous surfactant. Mean days of ventilation were 5.3 +/- 6.5 (0.5-55); 3.7% (5/136) developed bronchopulmonary dysplasia defined as oxygen-dependency at 36 postconceptional age and mortality was 1.5% (2/136). CONCLUSION: Respiratory failure incidence and characteristics in late preterms suggest their peculiarity and relevance in neonatal intensive care

High Flow Nasal Cannula Versus Nasal CPAP in the Management of Respiratory Distress Syndrome : Preliminary Data

BACKGROUND: High flow nasal cannula (HFNC) are gaining in popularity as a form of non invasive ventilation (NIV) alternative to nasal continuous positive airway pressure (NCPAP) in preterm infants. Despite of a greater ease of use and reports of improved tolerance, there is a limited evidence to support its efficacy and safety. OBJECTIVE: To assess efficacy and safety of HFNC compared to NCPAP in preterm newborns with respiratory distress syndrome (RDS). DESIGN/METHODS: Preterm infants with gestational age (GA) between 29+0 and 36+6 weeks and radiological and clinical signs of moderate RDS were randomized to NCPAP (Infant Flow SIPAP- CareFusion) at 4-6 cmH2O or heated humidified HFNC (Precision Flow - Vapotherm) at 4-6 l/min. The primary outcome was the need of intubation within the first 72 hours of life. Secondary outcomes included: the need of surfactant, total duration of respiratory assistance and NIV, length of hospitalization and O2 supplementation, time to full enteral feeding and the incidence of the most common short and long term complications of prematurity (necrotizing enterocolitis, patent ductus arteriosus, intraventricular hemorrhage, bronchopulmonary dysplasia and retinopathy of prematurity). Continuous variables were analyzed by Student t test and categorical variables by Fisher's exact test. Statistical significance was considered for p<0.05. RESULTS: We enrolled 92 infants [NCPAP (n 52): GA 33\ub11.89 wks (mean\ub1SD), BW 1895\ub1487 g; HFNC (n 40): GA 33\ub11.83 wks, BW 1930\ub1513 g]. The baseline characteristics and perinatal risk factors were similar between the two groups (p=NS). Despite the need of intubation within 72 hours was greater in HFNC group (12.5%, 5/40) compared to NCPAP group (5.7%, 3/52), the difference was not statistically significant (p=0.28). Differences in secondary outcomes were not observed; particularly mean duration of NIV was 5.8 days in HFNC group vs 4.3 in NCPAP group, mean total duration of respiratory assistance 6.4 days vs 4.7 and mean length of hospitalization 25.3 days vs 24.4 (p=NS). CONCLUSIONS: According to our preliminary data, HFNC seems as effective and safe as NCPAP in the management of moderate RDS in premature infants. Further trials are needed to validate the use of HFNC as a non invasive respiratory support in situations when NCPAP has traditionally been use

Changes in ventilator strategies and outcomes in preterm infants

Background: Although life-saving, intubation and mechanical ventilation can lead to complications including bronchopulmonary dysplasia (BPD). In order to reduce the incidence of BPD, non-invasive ventilation (NIV) is increasingly used. Objective: The aim of our study was to describe changes in ventilator strategies and outcomes between 2006 and 2010 in the Italian Neonatal Network (INN). Design: Multicentre cohort study. Settings: 31 tertiary level neonatal units participating in INN in 2006 and 2010. Patients: 2465 preterm infants 23-30 weeks gestational age (GA) without congenital anomalies. Main outcomes measures: Death, BPD and other variables defined according to Vermont Oxford Network. Logistic regressions, adjusting for confounders and clustering for hospitals, were used. Results: Similar numbers of infants were studied between 2006 and 2010 (1234 in 2006 and 1231 in 2010). The baseline risk of populations studied (GA, birth weight and Vermont Oxford Network Risk-Adjustment score) did not change. After adjusting for confounding variables, infants receiving invasive mechanical ventilation decreased (OR=0.72, 95% CI 0.58 to 0.89) while NIV increased (OR=1.75, 95% CI 1.39 to 2.21); intubation in delivery room decreased (OR=0.64, 95% CI 0.51 to 0.79). Considering outcomes, there was a significant reduction in mortality (OR=0.73, 95% CI 0.55 to 0.96) and in the combined outcome mortality or BPD (OR=0.76, 95% CI 0.62 to 0.94). Conclusions: Despite a stable baseline risk, from 2006 to 2010, we observed a lower level of invasiveness, a reduction of mechanical ventilation and an increase of NIV use, and this was accompanied by a decrease in risk-adjusted mortality and BPD

Relationship between respiratory impedance and positive end-expiratory pressure in mechanically ventilated neonates.

PURPOSE: To evaluate the feasibility of forced oscillation technique (FOT) measurements at the bedside and to describe the relationship between positive end-expiration pressure (PEEP) and lung mechanics in different groups of ventilated infants. METHODS: Twenty-eight infants were studied: 5 controls, 16 newborns with respiratory distress syndrome (RDS) and 7 chronically ventilated newborns that developed bronchopulmonary dysplasia. An incremental/decremental PEEP trial was performed by changing PEEP in 1-min steps of 1 cmH(2)O between 2 and 10 cmH(2)O. Forced oscillations at 5 Hz were superimposed on the ventilator waveform. Pressure and flow, measured at the inlet of the ETT, were used to compute resistance (Rrs) and reactance (Xrs). RESULTS: In controls Rrs and Xrs were on average 41 ± 21 and -22 ± 6 cmH(2)O s/l respectively and were almost unaffected by PEEP. RDS infants presented similar Rrs (48 ± 25 cmH(2)O s/l) and reduced Xrs (-71 ± 19 cmH(2)O s/l) at the beginning of the trial. Two behaviours were observed as PEEP was increased: in extremely low birth weight infants Xrs decreased with PEEP with marked hysteresis; in very low and low birth weight infants Xrs and Rrs were less PEEP dependent. Chronically ventilated infants had very high Rrs and very negative Xrs values at very low PEEPs (121 ± 41 and -95 ± 13 cmH(2)O s/l at PEEP = 2 cmH(2)O) that markedly changed as PEEP exceeded 3-4 cmH(2)O. CONCLUSIONS: Rrs and Xrs measurement in preterm newborns is feasible, and data are representative of the lung mechanics and very sensitive to its changes with PEEP, making FOT a promising technique for the non-invasive bedside titration of mechanical ventilation in preterm newborns

Nasal continuous positive airway pressure with heliox in preterm infants with respiratory distress syndrome

To assess the therapeutic effects of breathing a low-density helium and oxygen mixture (heliox, 80% helium and 20% oxygen) in premature infants with respiratory distress syndrome (RDS) treated with nasal continuous positive airway pressure (NCPAP). METHODS: Infants born between 28 and 32 weeks of gestational age with radiologic findings and clinical symptoms of RDS and requiring respiratory support with NCPAP within the first hour of life were included. These infants were randomly assigned to receive either standard medical air (control group) or a 4:1 helium and oxygen mixture (heliox group) during the first 12 hours of enrollment, followed by medical air until NCPAP was no longer needed. RESULTS: From February 2008 to September 2010, 51 newborn infants were randomly assigned to two groups, 24 in the control group and 27 in the heliox group. NCPAP with heliox significantly decreased the risk of mechanical ventilation in comparison with NCPAP with medical air (14.8% vs 45.8%). CONCLUSIONS: Heliox increases the effectiveness of NCPAP in the treatment of RDS in premature infants

264 Increased Levels of Insulin-Like Growth Factor-I (IGF-I) and  2-Micro-Globulin ( 2-Mg) In Balf of Preterm Neonates with Chronic Lung Disease (CLD)

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Positional effects on lung mechanics of ventilated preterm infants with acute and chronic lung disease

Background: The role of prone position in preterm infants has not been completely clarified. We investigated prone versus supine posture-related changes in respiratory system resistance (Rrs) and reactance (Xrs) measured by the Forced Oscillation Technique (FOT) in mechanically ventilated preterm newborns. Methods: Patients were studied in the supine versus prone positions in random order. Oxygen saturation, transcutaneous partial pressure of oxygen (ptcO2), carbon dioxide (ptcCO2), Rrs and Xrs were measured in each position. Results: Nine patients with respiratory distress syndrome (RDS) and nine with evolving broncho-pulmonary dysplasia (BPD) were studied. Rrs was, on average, 9.8 (1.3, 18.3 as 95%CI) cmH2O*s/l lower in the prone compared to the supine position (P=0.02), while no differences in Xrs, ptcO2, ptcCO2, and breathing pattern were observed between postures. Only patients with evolving BPD showed a significant reduction of Rrs from 69.0\ub127.4 to 53.0\ub116.7 cmH2O*s/l, P=0.01. No significant correlations were found between changes in lung mechanics and ptcO2, ptcCO2, or breathing pattern. Conclusions: On short-term basis, prone positioning does not offer significant advantages in lung mechanics in mechanically ventilated infants with RDS, while it is associated with lower Rrs values in patients with evolving BPD. \ua9 2014 Wiley Periodicals, Inc

Prevention of complications during reoperative thyroid surgery.

BACKGROUND: Thyroidectomy performed by an experienced surgeon is associated with a low incidence of recurrent laryngeal nerve injury and permanent hypoparathyroidism. During reoperative thyroid surgery there is a higher technical risk because detection and preservation of the recurrent laryngeal nerves and parathyroid glands are more difficult than in the primary surgery. AIM: Our retrospective cohort study was to assess short- and long-term complications associated with reoperative thyroid surgery in order to suggest a technical approach to lower the morbidity rate. MATERIALS AND METHODS: From January 2005 to September 2013, 745 patients underwent surgery for thyroid disease. Before surgery all patients underwent clinical examination, laboratory blood tests, hormonal assays, neck ultrasound, chest radiography and indirect laryngoscopy. Patients were followed up at 1, 3, 6 months and then annually after operation with hormonal assays, blood tests and neck ultrasound. RESULTS: Eighty (10.7%) out of 745 patients (mean-age= 52.5 years; age-range 18-80) underwent reoperative surgery for recurrent thyroid disease. The primary treatments were enucleoresection (11.2%), thyroid lobectomy(56,3%), thyroid lobectomy with isthmectomy(10%) and subtotal thyroidectomy (22,5%). In the reoperative surgery group (Group Re) the transient RLN complications were 1.3% compared to 0.2% in the primary surgery group (Group P) (p= 0.51). The incidence of temporary hypocalcemia was 45% in the reoperative surgery group vs. 42.7% in the primary surgery group (p=0.72). CONCLUSIONS: Reoperative surgery should be reserved to experienced surgeons. However, even in this case, when surgical maneuvers reserved for primary surgery are applied, then this surgery is associated with a low complications rate