ABSTRACT
The historical review of how evidence was developed for the management of respiratory distress syndrome in premature infants has not been clearly characterized. Knowledge of this process is essential to understand the role of equipoise and its influence on the decision to evaluate interventions as they were implemented in the practice of medicine. We suspect that errant approaches to clinical equipoise secondary to states of false certainty and false uncertainty have been important barriers to the timely acquisition and implementation of evidence-based knowledge necessary to improve outcomes in this fragile population of infants. When confronted with the decision to test an intervention, physicians should question whether they have lost clinical equipoise based on opinion, expertise, or observational data rather than evidence obtained from methodological inquiry; doing so facilitates reaching clinical equipoise and promotes the application of scientific methodology to answer relevant clinical questions. Timely acquisition of evidence-based knowledge can be viewed as an ethical imperative when the status quo may have negative consequences on outcomes for generations.
Subject(s)
Continuous Positive Airway Pressure/methods , Glucocorticoids/therapeutic use , Pulmonary Surfactants/therapeutic use , Respiratory Distress Syndrome, Newborn/therapy , Therapeutic Equipoise , Biomedical Research , Bronchopulmonary Dysplasia/prevention & control , Continuous Positive Airway Pressure/history , Disease Management , Evidence-Based Medicine , Glucocorticoids/history , History, 20th Century , History, 21st Century , Humans , Infant, Newborn , Infant, Premature , Perinatal Care , Pulmonary Surfactants/history , Respiratory Distress Syndrome, Newborn/historyABSTRACT
George Gregory, M.D. (1934-), Professor Emeritus at the University of California, San Francisco, has made numerous contributions to neonatology and pediatric anesthesia through his research efforts and authoritative textbook, Gregory's Pediatric Anesthesia. However he identified his defining moment as the occasion he saved the life of an infant suffering from neonatal respiratory distress syndrome by using continuous positive airway pressure (CPAP) ventilation. The development of CPAP by Gregory revolutionized the treatment of premature infants with respiratory failure. Prior to the creation of this treatment, the mortality rate of neonates with respiratory distress syndrome was >50%. The innovation markedly improved the ventilation of infants with respiratory distress and led to significant improvements in survival rates. Based on an interview with Dr. Gregory, this article describes the discovery of CPAP and reviews his career in advancing pediatric anesthesia and critical care medicine.
Subject(s)
Continuous Positive Airway Pressure/history , Respiratory Distress Syndrome, Newborn/history , California , Child , History, 20th Century , Humans , Infant , Infant, Newborn , Infant, Premature , Pediatrics/historyABSTRACT
O uso da continuous positive airway pressure (CPAP) no tratamento do edema agudo de pulmão (EAP) cardiogênico tem sido estudado por alguns autores. Recentemente, a utilização da ventilação não-invasiva com dois níveis de pressão (BiPAP) vem sendo estudada nessa situação clínica; entretanto, os resultados são controversos. Dessa forma, foi realizado, através do MEDLINE, um levantamento dos ensaios clínicos randomizados publicados em língua inglesa que analisaram a utilização do BiPAP em pacientes com EAP cardiogênico, obtendo-se um total de 11 trabalhos. O BiPAP mostrou-se útil no manuseio do EAP, apresentando benefícios similares à CPAP. Nos pacientes hipercápnicos, o BiPAP surge como uma importante estratégia de suporte ventilatório não-invasivo. Porém, faz-se necessário um estudo com grande número de pacientes para esclarecer certas dúvidas ainda persistentes.
The use of continuous positive airway pressure (CPAP) in the treatment of acute cardiogenic pulmonary edema (CPE) has been studied by some authors. Recently, the use of bi-level positive airway pressure (BiPAP) has been studied in this clinical situation, although the results have been controversial. We searched MEDLINE in order to find randomized trials published in English that analyzed the use of BiPAP in patients with CPE. Eleven trials were found. BiPAP was useful in the management of CPE, showing similar benefits to those of CPAP. In hypercapnic patients, BiPAP appears to be an important strategy of noninvasive ventilatory support. However, large trials are necessary to clarify certain doubts that still remain.
