ABSTRACT
BACKGROUND: Noninvasive ventilation (NIV) may be superior to conventional therapy in immunocompromised children with respiratory failure. METHODS: Mortality, success rate, prognostic factors and side effects of NIV for acute respiratory failure (ARF) were investigated retrospectively in 41 in children with primary immunodeficiency, after stem cell transplantation or chemotherapy for oncologic disease. RESULTS: In 11/41 (27%) children invasive ventilation was avoided and patients were discharged from ICU. In children with NIV failure ICU-mortality was 19/30 (63%). 8/11 (72%) children with NIV success had recurrence of ARF after 27 days. Only 4/11 (36%) children with first episode NIV success and 8/30 (27%) with NIV failure survived to hospital discharge. Lower FiO2, SpO2/FiO2 and blood culture positive bacterial sepsis were predictive for NIV success, while fungal sepsis or culture negative ARF were predictive for NIV failure. We observed catecholamine treatment in 14/41 (34%), pneumothorax in 2/41 (5%), mediastinal emphysema in 3/41 (7%), a life threatening nasopharyngeal hemorrhage and need for resuscitation during intubation in 5/41 (12%) NIV-episodes. CONCLUSIONS: The prognosis of ARF in immunocompromised children remains guarded independent of initial success or failure of NIV due to a high rate of recurrent ARF. Reversible causes like bacterial sepsis had a higher NIV response rate. Relevant side effects of NIV were observed.
Subject(s)
Immunocompromised Host/immunology , Noninvasive Ventilation , Respiratory Insufficiency/etiology , Respiratory Insufficiency/immunology , Respiratory Insufficiency/therapy , Acute Disease , Child , Child, Preschool , Female , Germany , Hospital Mortality , Humans , Infant , Intensive Care Units, Pediatric , Male , Patient Readmission , Prognosis , Recurrence , Respiratory Insufficiency/mortality , Retrospective Studies , Risk Factors , Sepsis/etiology , Sepsis/mortality , Sepsis/therapy , Survival Rate , Treatment OutcomeABSTRACT
BACKGROUND: Sustained lung inflations improve oxygenation but may impair hemodynamics. This study aimed to determine effects of short sustained inflations on cerebral blood flow and cerebral tissue oxygenation in experimental lung injury. METHODS: Experiments were performed in 6 juvenile ventilated New Zealand white rabbits. The effects of a series of sustained inflations at 20, 25 and 30 cmH2O pressure for 15 seconds duration each on hemodynamics, cerebral blood flow and cerebral tissue oxygenation were determined by laser Doppler flowmetry and cerebral tissue oxygen tension measurement in naive animals, after surfactant depletion and subsequent fluid filling of the lung. RESULTS: During the series of sustained inflations the mean arterial blood pressure decreased by 73%, 52% and 32% and the mean cerebral blood flow decreased by 73%, 39% and 30% in naive animals, after surfactant depletion and with fluid filling of the lung respectively. Arterial oxygen saturation was maintained or increased, while mean cerebral tissue oxygenation decreased by 48% (naive), 8% (surfactant depletion) or increased by 81% (surfactant depletion and fluid filling). Three minutes after the sustained inflations blood gases were similar to the blood gases prior to the sustained inflations. CONCLUSION: A series of short sustained lung inflations of 15 seconds duration can impair cerebral blood flow but increase arterial oxygen saturation in this juvenile animal model. The combination of these effects resulted in either a decrease or increase in regional cerebral tissue oxygenation.
Subject(s)
Brain/blood supply , Brain/metabolism , Cerebrovascular Circulation , Insufflation , Lung Injury/physiopathology , Lung , Oxygen/metabolism , Regional Blood Flow , Animals , Cardiac Output , Female , Insufflation/methods , Pulmonary Gas Exchange , Rabbits , Time FactorsABSTRACT
INTRODUCTION: Delivery room management using early nasal continuous positive airway pressure (nCPAP) may delay surfactant therapy. OBJECTIVE: To identify factors associated with early nCPAP failure and effects of various intubation criteria on rate and time of intubation. DESIGN: Retrospective analysis of the first 48 h in infants of 23-28 weeks gestational age (GA) treated with sustained inflations followed by early nCPAP. RESULTS: Of 225 infants (GA 26.2±1.6 weeks) 140 (62%) could be stabilised with nCPAP in the delivery room, of whom 68 (49%; GA 26.9±1.5 weeks) succeeded on nCPAP with favourable outcome and 72 infants (51%; GA 26.3±1.4 weeks) failed nCPAP within 48 h at a median (IQR) age of 5.6 (3.3-19.3) h. History or initial blood gases were poor predictors of subsequent nCPAP failure. Intubation at fraction of inspired oxygen (FiO(2))≥0.35 versus 0.4 versus 0.45 instead of ≥0.6 would have resulted in unnecessary intubations of 16% versus 9% versus 6% of infants with nCPAP success but decreased the age at intubation of infants with nCPAP failure to 3.1 (2.2-5.2) versus 3.8 (2.5-8.7) versus 4.4 (2.7-10.9) h. CONCLUSIONS: Medical history or initial blood gas values are poor predictors of subsequent nCPAP failure. A threshold FiO(2) of ≥0.35-0.45 compared to ≥0.6 for intubation would shorten the time to surfactant delivery without a relevant increase in intubation rate. An individualised approach with a trial of early nCPAP and prompt intubation and surfactant treatment at low thresholds may be the best approach in very low birthweight infants.
