Resp Care
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Although the trend in the neonatal intensive care unit is to use noninvasive ventilation whenever possible, invasive ventilation is still often necessary for supporting pre-term neonates with lung disease. Many different ventilation modes and ventilation strategies are available to assist with the optimization of mechanical ventilation and prevention of ventilator-induced lung injury. Patient-triggered ventilation is favored over machine-triggered forms of invasive ventilation for improving gas exchange and patient-ventilator interaction. ⋯ Over the last decade many new promising approaches to lung-protective ventilation have evolved. The key to protecting the neonatal lung during mechanical ventilation is optimizing lung volume and limiting excessive lung expansion, by applying appropriate PEEP and using shorter inspiratory time, smaller tidal volume (4-6 mL/kg), and permissive hypercapnia. This paper reviews new and established neonatal ventilation modes and strategies and evaluates their impact on neonatal outcomes.
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Pulmonary hypertension is a rare disease in neonates, infants, and children, and is associated with substantial morbidity and mortality. An adequate understanding of the controlling pathophysiologic mechanisms is lacking. Moreover, a minority of research is focused specifically on neonatal and pediatric populations. ⋯ These pathways include nitric-oxide/cyclic guanosine monophosphate (cGMP), prostacyclin, and endothelin-1. The ability to reverse advanced structural changes remains an as yet unattained goal. This paper reviews the epidemiology, pathophysiology, current treatments, and emerging therapies related to neonatal and pediatric pulmonary hypertension.
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Resuscitation of newborn infants occurs in approximately 10% of the more than 100 million infants born annually worldwide. The techniques used during resuscitation, such as positive-pressure ventilation and supplemental oxygen, may revive many infants, but have the potential to harm their lungs. In recent years increasing attention has been applied to providing lung protection from the first breath. ⋯ Finally, intrapartum oropharyngeal and nasopharyngeal suctioning of meconium-stained amniotic fluid does not improve outcomes in meconium-stained infants. Moreover, routine intubation and intratracheal suctioning of apparently vigorous meconium-stained infants do not improve outcomes. In summary, although multiple therapies are touted as protecting the lungs in the delivery room "from the first breath," to date there are scant supportive data.
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The lung and conducting airways are ideal portals for drug delivery. The airways are easily accessible by oral or nasal inhalation; the airway and alveolar surface is large, allowing for drug dispersion; and many drugs do not cross the airway-blood barrier, permitting the use of higher topical drug doses for airway disease than would be practical with systemic administration. On the other hand, alveolar deposition of drugs allows rapid absorption into the pulmonary circulation and back to the left heart and systemic distribution, bypassing the intestinal tract and liver inactivation. Recently, there has been a feast of new aerosol devices and drug formulations that promise the effective delivery of an amazing array of medications far beyond pressurized metered-dose inhalers and nebulizers and asthma medicines.
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Extracorporeal life support (ECLS), or extracorporeal membrane oxygenation (ECMO) as it is also known, has been used to support over 45,000 patients to date. Overall survival is 62%. After many years of no change in equipment and technology, there has been a recent flurry of new pumps, cannulas, and oxygenators available for ECLS use. ⋯ The reported success of ECLS in patients with H1N1 during the 2009-2010 epidemic and the improved survival of patients randomized to the ECMO arm of a recently completed adult study of respiratory failure have also brought ECLS into the spotlight much more than other years. Whether these developments will usher in a new era of ECLS expansion to a wider range of patients will require close consideration and observation. Other areas that need to be further refined include anticoagulation management, treatment of bleeding complications, learning to "nurse" patients in an awake state, such as is done in some European (and a few United States) centers, and neurodevelopmental outcome on a long-term basis.