A randomized trial of non-synchronized Nasopharyngeal Intermittent Mandatory Ventilation (nsNIMV) vs. Nasal Continuous Positive Airway Pressure (NCPAP) in the prevention of extubation failure in pre-term < 1,500 grams.

OBJECTIVE: To compare the rate of reintubation within 7 days after extubation and study the complications in premature infants who were randomized in the immediate postextubation period to either nsNIMV or NCPAP. MATERIAL AND METHOD: This study was conducted in the neonatal unit of Queen Sirikit National Institute of Child Health between June 1 and November 30, 2006. Intubated premature infants born at GA < or = 34 weeks or with birth weight < or = 1500 gm, ready to be extubated before 4 weeks of age were recruited. Infants were randomized to either nsNIMV or NCPAP after extubation. Non-synchronized NIMV setting was the same as ventilator setting before extubation and NCPAP pressure was set at the same mean airway pressure of pre extubation ventilator value. Extubation was performed after intravenous loading dose of aminophylline. Primary outcome measurement was reintubation within 7 days of initial extubation and the secondary outcome was possible complications such as apnea, abdominal distension, gastrointestinal (GI) perforation, necrotizing enterocolitis (NEC), sepsis and death. RESULTS: A total of 70 VLBW infants were admitted to the neonatal unit during the study period. A total of 57 infants were intubated of which 48 infants were recruited for the study; 24 were in the nsNIMV group and 24 were in the NCPAP group. Infants in the nsNIMV group had mean birth weight and body weight at the start of study less than that in the NCPAP group (984.8 +/- 218 vs. 1067 +/- 214 and 1185 +/- 219 vs. 1205 +/-191, p = 0.003, 0.02). The nsNIMV group also had a higher rate of RDS and antenatal steroid used when compared to the NCPAP group (19/24 vs. 12/24 and 17/24 vs. 8/24, p = 0.03, 0.01). The nsNIMV group had fewer males than in the NCPAP group (8/24 vs. 17/24, p = 0.01). Reintubation was similar in both groups but atelectasis and sepsis were statistically significant risk factor for reintubation in NCPAP group. There were no significant differences in treatment related complications between the two groups, with respect to incidence of apnea (41.7% in nsNIMV vs. 62.5% in NCPAP), abdominal distensions (8.3% in nsNIMVvs. 16.7% in NCPAP), NEC (4.2% in nsNIMVvs. 12.5 in NCPAP), sepsis (4.2% in nsNIMVvs. 8.3% NCPAP). No GI perforation was observed in both groups. CONCLUSION: Non-invasive mode of ventilation, both NIMV and NCPAP, for weaning ofpre-term infants from ventilator may reduce the rate of reintubation in this group. Both modes seem to be equally safe. We believe that the use of non-invasive ventilator techniques will significantly reduce neonatal morbidity in the future. Additional prospective evaluation of these approaches should be conducted in the future.

Comparison outcomes of surfactant therapy in respiratory distress syndrome in two periods.

BACKGROUND: Exogenous surfactant replacement therapy has been a part of the routine care of preterm neonates with respiratory distress syndrome (RDS) since 1990s. In Thailand, the utilization of surfactant replacement therapy had been limited due to the high cost until the National Health Insurance Policy began in 2003 which covered the cost of surfactant. Nowadays surfactant replacement therapy is more frequently used at Queen Sirikit National Institute of Child Health, so the authors were interested in evaluating its use in RDS. OBJECTIVES: To compare the outcome and complications of surfactant replacement therapy in newborns who were diagnosed with moderate to severe RDS during two times period. STUDY DESIGN: Retrospective study. MATERIAL AND METHOD: The data of infants who were diagnosed as moderate to severe RDS and treated with surfactant at Queen Sirikit National Institute of Child Health between January 1st, 2003 and December 31th, 2005 were reviewed. The outcome of this study (Group II) was compared to the previous study conducted in 1999-2002 (Group I). The complications, mortality rate, association time of start surfactant and duration of ventilation were reviewed. RESULTS: The data of ninety-one moderate to severe RDS patients who received surfactant replacement therapy were reviewed. The mean birth weight and gestational age in this group were 1250 +/- 435.57 gm and 29.38 +/- 2.2 week less than in the first group 1,344 +/- 452.37gm and 29.69 +/- 2.61 week. The second group showed statistical differences in antepartum hemorrhage (4.4%) and pregnancy induced hypertension (PIH) (17.6%) while the first group had 33.3% ofantepartum hemorrhage and 3% of PIH. In neonatal conditions, there were statistical significant differences in anemia 28.6% in group II compared to 9% in group I and patent ductus arteriosus 67% in group II compared to 39.4% in group I. Surfactant was given earlier in life (4.75 +/- 2.76 hours) in the second group compared to the first group (7.21 +/- 4.92 hour) and the overall duration ofpatients on mechanical ventilation in Group II (6 days) was shorter than in Group I (16 days). This was especially more evident in patients who received surfactant within the first six hours of life. The immediate complication, pulmonary hemorrhage was found in more cases in Group I (33.3%) than in Group II (12.1%) but bronchopulmonary dysplasia (BPD) was found to be a late complication in more cases in Group II (46.1%) than in Group I (21.2%). The mean length of admission was longer in Group II (61.23 +/- 41.08 days) compared to Group I (38.5 +/- 23.48 days) and the mortality rate in Group II was 18.7% (17 cases) lower than Group I 33.3% (11 cases). CONCLUSION: Surfactant therapy in moderate to severe RDS can shorten the duration of ventilation and decrease the mortality rate, but has no effect in decreasing the incidence of chronic lung disease. Nevertheless the earlier the surfactant therapy is started, the higher the survival rate.

Inhaled nitric oxide in newborns with severe hypoxic respiratory failure.

BACKGROUND: Respiratory failure in term and near term infants is often associated with persistent pulmonary hypertension of the newborn and contributes to hypoxemia in these infants. Inhaled nitric oxide (iNO) is currently used as a pulmonary vasodilator to improve oxygenation in neonates with severe respiratory failure. OBJECTIVE: To determine outcome of administration of iNO in severe hypoxic respiratory failure. MATERIAL AND METHOD: The present study was conducted from 1999 to 2004 in the neonatal intensive care unit (NICU) at Queen Sirikit National Institute of Child Health. Patients were selected from all infants > or = 34 weeks gestational age who required high frequency oscillatory ventilation (SLE 2000 HFO, SLE, UK) or conventional mechanical ventilation for hypoxemic respiratory failure caused by PPHN. Diagnosis was confirmed by 2-D echocardiogram visualization with right to left shunt through the foramen ovale or patent ductus arteriosus. Inhaled nitric oxide was given as standard therapy in patients who had two oxygenation indices > or = 20 at least 30 minutes apart after being on a mechanical ventilator. RESULTS: Fifty-five cases were enrolled and male to female ratio was 22.2 tol. The survival rate was 76.4 percent. Inhaled nitric oxide significantly improved oxygenation index, arterial alveolar oxygen tension ratio (a/A O2), and alveolar arterial oxygen gradient in survivors at one hour after treatment. The earliest improvement in oxygen saturation was within ten minutes. Meconium aspiration syndrome was the most common underlying cause of PPHN. No acute complication was found during nitric oxide administration. Chronic lung diseases, delayed development and severe hearing loss in long-term follow up were found in 10, 5, and 2 cases, respectively. CONCLUSION: Inhaled nitric oxide should be used early in severe hypoxic respiratory failure with persistent pulmonary hypertension of newborn and can improve survival rates without any major immediate side effects.

Inhaled iloprost for severe persistent pulmonary hypertension of the newborn.

The authors report one case of persistent pulmonary hypertension that had hypoxia although receiving treatment with high frequency oscillation, inotropic drugs, blood transfusion, and oral sildenafil for pulmonary vasodilatation. The patient developed hypotension after two doses of oral sildenafil and no response to high dose of inotropic drugs. So aerosolized iloprost was given via endotracheal tube and oxygen saturation improved within 10 minutes. Oxygen was weaned at 36 hours after treatment with this drug and no any side effect was found.

A comparison of oral ibuprofen and intravenous indomethacin for closure of patent ductus arteriosus in preterm infants.

BACKGROUND: Indomethacin is widely accepted as the treatment for patent ductus arteriosus (PDA) in preterm infants but it has various side effects. Ibuprofen is the alternative treatment and believed to be less likely to induce side effects. OBJECTIVE: To compare efficacy and side effects of ibuprofen versus indomethacin treatment for symptomatic patent ductus arteriosus (PDA) in preterm infants. METHOD: The authors studied 30 infants (gestational age < or = 35 weeks, aged < or = 10 days) who were diagnosed as having symptomatic PDA confirmed by echocardiogram. The infants were randomly assigned to receive three intravenous doses of indomethacin given at 12-hour intervals or three doses of ibuprofen given at 24-hour intervals, starting within ten days of life. The demographic data, rate of clinical closure, need for additional treatment, side effects, complications and the infants' clinical course were recorded within 28 days. RESULTS: The rate of ductal closure was similar with the two treatment regimes. Ductal closure occurred in 7 of 15 infants given ibuprofen (46.67%) and 10 of 15 infants given indomethacin (66.67%). (Relative risk 0.669; 95% confidence interval, 0.328 to 1.364; p = 0.462) The number of infants who needed a second pharmacologic treatment was not significantly different between the two groups, (6 cases in the ibuprofen group, 5 cases in the indomethacin group) but surgical ligation was performed in two cases in the indomethacin group. There was a significant difference in using the diuretic drug (furosemide) in the indomethacin group (11 cases), compared to the ibuprofen group (3 cases), (p = 0.009). More cases of necrotizing enterocolitis were seen in the indomethacin group (66.67% compared to 40% in the ibuprofen group) but there was no statistically significant difference. CONCLUSION: Ibuprofen has the same efficiency as indomethacin for the treatment of symptomatic patent ductus arteriosus in preterm infants and less likely to induce necrotizing enterocolitis and renal toxicity than indomethacin.

Effect of cisapride on corrected QT interval in neonates.

OBJECTIVE: To evaluate the effect of cisapride on corrected QT (QTc) interval in neonates at the Queen Sirikit National Institute of Child Health. METHOD: A prospective study was performed to see the effects of cisapride on QTc interval in 20 neonates between 1st July 2001 and 31st January 2002. QTc interval was determined just before, 48 hours, 7 days and 15 days after the start of treatment with cisapride. QTc interval was calculated by averaging QT/square root(RR) values obtained from 5 consecutive beats in lead II of the EKG. Baseline electrolyte and calcium levels were drawn on all infants before treatment of cisapride. Drug dose ranged from 0.1-0.2 mg/kg every 6 to 8 hours. RESULTS: Twenty infants were enrolled in the survey but complete data was obtained on 18 infants only. QTc interval of > 0.45 seconds was not found in any neonate. There was no significant difference of QTc interval before and 48 hours, 7 days and 15 days after cisapride administration (p = 0.861). There were also no statistically significant effects of age at starting cisapride, weight, gestational age and dose on QTc interval (p = 0.581, 0.65, 0.8, and 0.497). There were no adverse effects such as diarrhea or jaundice during the study. CONCLUSION: Term and preterm infants using cisapride at the doses of 0.4-0.8 mg/kg/day did not develop QTc prolongation, arrhythmias or adverse effects. In the absence of risk factors, cisapride may be safe for use in neonates.

Vertical transmission of dengue infection in Thai infants: two case reports.

Dengue infection is hyperendemic in tropical countries especially in Thailand. Most dengue infections occur during childhood but some adults may remain susceptible to infection. About 30 per cent of dengue infection are reported in patients > 15 years old. Some pregnant women may also be susceptible to dengue and if they experience dengue infection, they can transmit the dengue viruses to their babies. The authors report two babies who developed mild dengue illness, dengue hemorrhagic fever (DHF) grade II, beginning on their 6th day of life. Both of them had low grade fever, hepatomegaly and generalized petechial rash. The first baby had Hct ranging from 46 to 40 per cent with minimal right pleural effusion. The lowest platelet count was 19,000 cells/mm3. His mother had dengue shock syndrome with masssive post partum bleeding. The second baby had dengue 2 infection while his mother had dengue fever. His Hct had also risen from 52 per cent to 61 per cent with right pleural effusion. His lowest platelet count was 7,000 cells/mm3. Both mothers and their babies had a complete recovery although the first baby had prolonged thrombocytopenia for two months.

Outcome of neonates with persistent pulmonary hypertension of the newborn treated with inhaled nitric oxide.

OBJECTIVE: This study assessed the outcome of nitric oxide treatment in infants with persistent pulmonary hypertension of the newborn (PPHN) who failed high frequency oscillatory ventilation (HFOV). METHOD: This study was conducted from July 1, 2000 to June 30, 2001 at the neonatal intensive care unit of Queen Sirikit National Institute of Child Health. Nitric oxide was administered to 20 infants, > or = 34 weeks gestational age who were diagnosed with PPHN and had two oxygenation index > or = 20 at least 30 minutes apart after HFOV treatment. RESULTS: Nitric oxide inhalation significantly improved the oxygenation index, a/A ratio, A-a gradient (p<0.05) and directly measured partial pressure arterial oxygenation. Oxygen saturation improved within ten minutes after nitric oxide inhalation. The survival rate was 85 per cent. Meconium aspiration syndrome was the most common cause of PPHN. No acute complication was found during nitric oxide administration. CONCLUSION: Inhalation of nitric oxide increased the blood oxygen tension of infants with PPHN without using a surfactant and ECMO. The authors suggest that inhalation nitric oxide is a useful adjunctive therapy for these patients.