Randomized Controlled Trial of Nonsynchronized Nasal Intermittent Positive Pressure Ventilation versus Nasal CPAP after Extubation of VLBW Infants.

BACKGROUND AND OBJECTIVES: Nasal continuous positive airway pressure (NCPAP) is a useful method of respiratory support after extubation. However, some infants fail despite CPAP use and require reintubation. Some evidence suggests that synchronized nasal intermittent positive pressure ventilation (NIPPV) may decrease extubation failure in preterm infants. Nonsynchronized NIPPV (NS-NIPPV) is being widely used in preterm infants without conclusive evidence of its benefits and side effects. Our aim was to evaluate whether NS-NIPPV decreases extubation failure compared with NCPAP in ventilated very low birth weight infants (VLBWI) with respiratory distress syndrome (RDS). METHODS: Randomized controlled trial of ventilated VLBWI being extubated for the first time. Before extubation, infants were randomized to receive NCPAP or NS-NIPPV. Primary outcome was the need for reintubation within 72 h. RESULTS: 220 infants were included. The mean ± SD birth weight was 1,027 ± 256 g and gestational age 27.8 ± 1.9 weeks. Demographic and clinical characteristics were similar in both groups. Extubation failure was 32.4% for NCPAP versus 32.1% for NS-NIPPV, p = 0.98. The frequency of deaths, bronchopulmonary dysplasia, intraventricular hemorrhage, air leaks, necrotizing enterocolitis and duration of respiratory support did not differ between groups. CONCLUSIONS: In this population of VLBWI, NS-NIPPV did not decrease extubation failure after RDS compared with NCPAP.

A multicentre study to predict neonatal survival according to lung-to-head ratio and liver herniation in fetuses with left congenital diaphragmatic hernia (CDH): Hidden mortality from the Latin American CDH Study Group Registry.

OBJECTIVE: To evaluate natural history of fetuses congenital diaphragmatic hernia (CDH) prenatally diagnosed in countries where termination of pregnancy is not legally allowed and to predict neonatal survival according to lung area and liver herniation. METHODS: Prospective study including antenatally diagnosed CDH cases managed expectantly during pregnancy in six tertiary Latin American centres. The contribution of the observed/expected lung-to-head ratio (O/E-LHR) and liver herniation in predicting neonatal survival was assessed. RESULTS: From the total population of 380 CDH cases, 144 isolated fetuses were selected showing an overall survival rate of 31.9% (46/144). Survivors showed significantly higher O/E-LHR (56.5% vs 34.9%; P < .001), lower proportion of liver herniation (34.8% vs 80.6%, P < .001), and higher gestational age at birth (37.8 vs 36.2 weeks, P < 0.01) than nonsurvivors. Fetuses with an O/E-LHR less than 35% showed a 3.4% of survival; those with an O/E-LHR between 35% and 45% showed 28% of survival with liver up and 50% with liver down; those with an O/E-LHR greater than 45% showed 50% of survival rate with liver up and 76.9% with liver down. CONCLUSIONS: Neonatal mortality in CDH is higher in Latin American countries. The category of lung hypoplasia should be classified according to the survival rates in our Latin American CDH registry.

Successful orthotopic liver transplantation and delayed delivery of a healthy newborn in a woman with fulminant hepatic failure during the second trimester of pregnancy.

Severe liver dysfunction during pregnancy implies a serious risk for both mother and fetus, and represents a technical and ethical challenge for treating physicians. We report a case of a previously healthy 32-year old woman who was admitted to our hospital with idiopathic fulminant hepatic failure and underwent successful orthotopic liver transplantation (OLT) at gestation week 21. Patient's and fetus' immediate postoperative course were relatively uneventful until week six after OLT, when the mother developed oligohydramnios and preeclampsia. At pregnancy week 27, after inducing baby's lung maturation, a cesarean section was performed with the delivery of an otherwise healthy girl. After 3 years of follow-up, mother and child are leading normal lives with no complications related either to pregnancy or to OLT. We describe the case of a successful emergency liver transplant in a woman during the second trimester of pregnancy, demonstrating that OLT can be a viable option to preserve the life of the mother and an otherwise unviable fetus. Intrauterine baby's growths until the attainment of a viable gestational age was feasible despite the mother's fulminant hepatic failure and liver transplant surgery.

[Extracorporeal membrane oxygenation and plasmapheresis in the treatment of severe pulmonary hemorrhage secondary to nodose polyarteritis]. / Oxigenación por membrana extracorpórea y plasmaféresis en un paciente con hemorragia pulmonar grave secundaria a poliarteritis nodosa.

We report to simultaneous use of extracorporeal life support (ECLS), plasmapheresis, hemodiafiltration and exogenous surfactant for the treatment of pulmonary hemorrhage, arterial hypertension, and renal failure secondary to nodose polyarteritis (NPA) in a 23-month-old patient. NPA is an autoimmune disease that affects small -and medium- caliber muscular arteries. Hypoxemia refractory to treatment with conventional and high frequency oscillatory ventilation was supported by ECMO while awaiting control of the autoimmune disease through the use of plasmapheresis and immunosuppressive treatment. Although the combination of ECLS with plasmapheresis is rare, it has been described during the management of cases of organ transplant, intoxication, cardiac failure, and sepsis. There are only two previous reports describing the use of this combined therapy for the treatment of pulmonary hemorrhage secondary to autoimmune vasculitis in childhood.

Oxigenación por membrana extracorpórea y plasmaféresis en un paciente con hemorragia pulmonar grave secundaria a poliarteritis nodosa / Extracorporeal membrane oxygenation and plasmapheresis in the treatment of severe pulmonary hemorrhage secondary to nodose polyarteritis

Se comunica el caso de un paciente de 23 meses de edad, con hemorragia pulmonar, hipoxemia refractaria, hipertensión arterial y falla renal secundarias a poliarteritis nodosa (PN) que ha requerido asistencia simultánea con soporte cardiopulmonar extracorpóreo (ECMO), plasmaféresis, hemodiafiltración y surfactante exógeno. La PN es una vasculitis autoinmunitaria que afecta los vasos arteriales de pequeño y mediano calibres. La hipoxemia, refractaria al tratamiento con ventilación mecánica convencional y de alta frecuencia oscilatoria, fue sostenida con ECMO mientras se controló la enfermedad autoinmunitaria mediante plasmaféresis y tratamiento inmunosupresor. La combinación de ECMO con plasmaféresis es infrecuente, pero ha sido descripta en relación al trasplante de órganos, intoxicaciones, fallo cardíaco y sepsis. Existen dos casos descriptos en la bibliografía sobre el uso combinado de estas terapéuticas para el tratamiento de hemorragia pulmonar secundaria a vasculitis autoinmunitaria en niños.

We report to simultaneous use of extracorporeal life support (ECLS), plasmapheresis, hemodiafiltration and exogenous surfactant for the treatment of pulmonary hemorrhage, arterial hypertension, and renal failure secondary to nodose polyarteritis (NPA) in a 23-month-old patient. NPA is an autoimmune disease that affects small -and medium- caliber muscular arteries. Hypoxemia refractory to treatment with conventional and high frequency oscillatory ventilation was supported by ECMO while awaiting control of the autoimmune disease through the use of plasmapheresis and immunosuppressive treatment. Although the combination of ECLS with plasmapheresis is rare, it has been described during the management of cases of organ transplant, intoxication, cardiac failure, and sepsis. There are only two previous reports describing the use of this combined therapy for the treatment of pulmonary hemorrhage secondary to autoimmune vasculitis in childhood.

Oxigenación por membrana extracorpórea y plasmaféresis en un paciente con hemorragia pulmonar grave secundaria a poliarteritis nodosa / Extracorporeal membrane oxygenation and plasmapheresis in the treatment of severe pulmonary hemorrhage secondary to nodose polyarteritis

Se comunica el caso de un paciente de 23 meses de edad, con hemorragia pulmonar, hipoxemia refractaria, hipertensión arterial y falla renal secundarias a poliarteritis nodosa (PN) que ha requerido asistencia simultánea con soporte cardiopulmonar extracorpóreo (ECMO), plasmaféresis, hemodiafiltración y surfactante exógeno. La PN es una vasculitis autoinmunitaria que afecta los vasos arteriales de pequeño y mediano calibres. La hipoxemia, refractaria al tratamiento con ventilación mecánica convencional y de alta frecuencia oscilatoria, fue sostenida con ECMO mientras se controló la enfermedad autoinmunitaria mediante plasmaféresis y tratamiento inmunosupresor. La combinación de ECMO con plasmaféresis es infrecuente, pero ha sido descripta en relación al trasplante de órganos, intoxicaciones, fallo cardíaco y sepsis. Existen dos casos descriptos en la bibliografía sobre el uso combinado de estas terapéuticas para el tratamiento de hemorragia pulmonar secundaria a vasculitis autoinmunitaria en niños.(AU)

We report to simultaneous use of extracorporeal life support (ECLS), plasmapheresis, hemodiafiltration and exogenous surfactant for the treatment of pulmonary hemorrhage, arterial hypertension, and renal failure secondary to nodose polyarteritis (NPA) in a 23-month-old patient. NPA is an autoimmune disease that affects small -and medium- caliber muscular arteries. Hypoxemia refractory to treatment with conventional and high frequency oscillatory ventilation was supported by ECMO while awaiting control of the autoimmune disease through the use of plasmapheresis and immunosuppressive treatment. Although the combination of ECLS with plasmapheresis is rare, it has been described during the management of cases of organ transplant, intoxication, cardiac failure, and sepsis. There are only two previous reports describing the use of this combined therapy for the treatment of pulmonary hemorrhage secondary to autoimmune vasculitis in childhood.(AU)