Current Respiratory Medicine Reviews - Volume 8, Issue 1, 2012

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Non-invasive ventilation (NIV) is a form of mechanical ventilation that does not use an endotracheal tube, thus avoiding the complications associated with this invasive form of ventilatoy support. This article will emphasize the use of NIV with two pressure levels in the management of the neonate with respiratory failure. The physiological principles of its application and the main indications of NIV are discussed, such as: (i) prevention and treatment of apnea of prematurity; (ii) early weaning and ventilatory support following tracheal extubation; (iii) treatment of hypoxemic respiratory failure; and (iv) neonatal resuscitation in the delivery room. The modes of administration, the type of devices, the initial ventilatory settings and the necessary interfaces for its use are emphasized. Finally, the authors address the care needed to manage the newborn undergoing NIV and the complications of this type of ventilatory support, as well as the possibility of using new devices, exclusively designed for NIV.

The advent of microprocessor-based technology has revolutionalized the treatment of respiratory failure in the newborn. Clinicians are now able to customize ventilatory strategies to the specific pathophysiology of the patient. Sophisticated monitoring provides breath-to-breath feedback on patient-ventilator interactions. This paper will focus upon the basic principles of mechanical ventilation, and will review various strategies that may be employed to manage the wide range of respiratory disorders encountered by preterm and term newborn infants, including respiratory distress syndrome, meconium aspiration syndrome, persistent pulmonary hypertension of the newborn, and bronchopulmonary dysplasia.

Surfactant replacement therapy for the treatment of respiratory distress syndrome (RDS) and other respiratory diseases in newborns has become one of the most active research areas in neonatology. This research has resulted in improved survival for preterm babies since becoming a routine treatment in the 1990s. The main characteristics of pulmonary surfactant, including its composition, pool, metabolism, inactivation and immediate effects after administration, are well-established. However, some doubts still remain about the use of exogenous surfactants and must be addressed. The new generation of synthetic surfactants has raised questions regarding the choice of surfactant type, the ideal timing for treatment (prophylactic vs early rescue strategy), the adequate dose and number of doses, new administration routes and the effects of the association between the use of antenatal steroids and the surfactant replacement therapy. There is also controversy surrounding the choice between early surfactant administration and the use of a nasal CPAP as an initial strategy to treat RDS and to reduce bronchopulmonary dysplasia (BPD). This article reviews basic and clinical aspects of surfactant replacement therapy for RDS and other respiratory diseases in newborns.

Objective: Present a review about the use of mechanical pulmonary ventilation in Hypertension Pulmonary Persistent Neonatal (HPPN), the conventional mode and the indication of high-frequency oscillatory ventilation (HFOV). Also present other approaches, such as therapeutics use of exogenous surfactant, inhaled nitric oxide, phosphodiesterases inhibitors and extracorporeal membrane oxygenation. Data Source: It has been used in articles obtained in the Pub Med, Medline, Cochrane BVS, databases, in which there are topics about mechanical ventilation in Hypertension Pulmonary Persistent Neonatal and others treatments used in the newborn with HPPN. Conclusion: The effective treatments used in HPPN are a conventional, not very aggressive ventilatory strategy; HFOV; inhaled nitric oxide and vasodilators medications that act on the lungs rather than on the whole system, and, in newborns that do not respond to these treatments, the use of extracorporeal membrane oxygenation.

Neurally adjusted ventilatory assit (NAVA) is a new mode of mechanical ventilation that delivers ventilatory assist in proportion to neural effort. In contrast to all other modes of ventilation, which adopt conventional pneumatic signals (flow, volume, and airway pressure) to drive and control the ventilator operation, NAVA utilizes the electrical activity of the diaphragm. Ventilating neonatal and pediatric patients in this new mode appears to be safe and well tolerated with improved patient-ventilator synchrony and lower peak airway pressure when compared to pressure support ventilation. Concluding, NAVA improves monitoring of respiratory drive, and delivers synchronized assist in relation to patient effort, and the control of assist is not affected by leaks or auto-PEEP.

The application of positive pressure mechanical ventilation can result in complex changes in pulmonary and cardiovascular physiology. These cardiopulmonary interactions are particularly important in pediatric patients undergoing surgery for repair or palliation of congenital cardiac defects. In this article, we review the various effects of mechanical ventilation on right and left ventricular preload, afterload and contractility. We also address specific clinical scenarios, such as mechanical ventilation of the uncomplicated patient following cardiac surgery, ventilation of patients with delayed sternal closure, the Norwood procedure, bidirectional and total cavopulmonary anastomoses and patients with right ventricular diastolic dysfunction.

Objective: Present a review about the use of the analgesia and sedation of the newborn in mechanical ventilation, which are the most common drugs, their beneficial and adverse effects, weaning way of the drugs and the most common levels of pain. Data Source: It has been used articles obtained in the Pub Med, Medline, Cochrane BVS, databases, in which the topics about sedation and analgesia in the newborn and the levels of the pain evaluation were approached. Conclusions: The pain and the discomfort of the newborn in the mechanical ventilation are events that should be avoided. The levels of pain help the physician in the evaluation of the patient and the pharmacological treatment should be applied in an individual way.

This review emphasizes the use of nutrition support how an important priority in the management of children with severe respiratory insufficiency. This situation causes metabolic deregulation leading to muscle proteolysis (hypercatabolism) and can cause hospital malnutrition that constitutes important risk factor for increases in morbidity, lethality, length of hospital stay, and medical costs. Sequential evaluation of nutritional status in the patient with acute respiratory disease should be assessed by clinical and laboratory procedures. Although there is general agreement that nutrition is an important element of critical care, there is much less clarity about the exact requirements of children with specific problems, including acute respiratory diseases. Enteral nutrition is the recommended method of artificial feeding in intensive care unit, including in patients with bronchopulmonary dysplasia and ventilator-associated pneumonia. Combined nutritional support is considered an optional tool to avoid energy deficiency during hypocaloric enteral nutrition. The trend towards earlier initiation of adequate metabolic-nutrition support based on protocols can improve the clinical condition of critically ill children with acute respiratory disease.

Mechanical ventilation is a life-supporting intervention that is used for a significant number of patients in ICUs. The current pediatric literature shows that the science of ventilator weaning and extubation remains undetermined. No optimal weaning method has been described for a more rapid and successful extubation. Protocol-based approaches to weaning may have potential benefits in advancing readiness to extubation, but no significant outcome differences have been found to date. The analysis of clinical markers of extubation success has not revealed any specific physiologic predictor of extubation success in children. However, a daily trial of readiness to extubate is the most effective technique to determine likelihood of success. Extubation failure rates range from 16% to 20% and bear little relation to the duration of mechanical ventilation. Upper airway obstruction is the primary cause of extubation failure in most pediatric studies. Therefore, efforts to decrease airway edema before extubation should be considered. Corticosteroids seem to be beneficial for infants and children, but definitive evidence of their efficacy is lacking.