Review

Pulmonary support strategies and options for improving lung function in term neonates: warning signs of damage

† Author for correspondence

Email the corresponding author at mattar@med.umich.edu

Department of Pediatrics & Communicable Diseases, Division of Neonatal–Perinatal Medicine, F5790 CS Mott Children’s Hospital, 1500 E Medical Center Drive, Ann Arbor, MI 48109–5254, USA

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Published Online:7 Jun 2010https://doi.org/10.2217/phe.10.21

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Abstract

Term newborn infants with lung injury have varying degrees of pulmonary edema, increased airway resistance and uneven distribution of atelectasis contributing to decreased pulmonary compliance and functional residual capacity. Lung injury is often initiated by the inflammatory process associated with the primary etiology of respiratory failure and is further exacerbated by ventilator-induced lung injury. Volutrauma, atelectotrauma and, to a lesser extent, barotrauma and rheotrauma contribute to inducing biotrauma, which is lung injury that results from uncontrolled inflammation. Recognizing the mechanisms of lung injury and the pattern and limitations of measured changes in lung function and mechanics might also serve as indicators of lung injury and are important in the formulation of lung protective strategies. Maintaining adequate functional residual capacity (open lung strategy), assuring appropriate tidal volumes to avoid both atelectotrauma and volutrauma and avoiding excessive exposure to oxygen should help achieve this goal.

Keywords:

Papers of special note have been highlighted as: • of interest •• of considerable interest

Bibliography

1 Flidel-Rimon O, Shinwell ES: Respiratory distress in the term and near-term infant. Neoreviews6(6),E289–E297 (2005).
Google Scholar
2 Mizgerd JP: Acute lower respiratory tract infection. N. Engl. J. Med.358(7),716–727 (2008).
Medline CASGoogle Scholar
3 Cole FS, Nogee LM, Hamvas A: Defects in surfactant synthesis: clinical implications. Pediatr. Clin. N. Am.53(5),911–927, IX (2006).
MedlineGoogle Scholar
4 Clark RH, Gerstmann DR, Jobe AH, Moffitt ST, Slutsky AS, Yoder BA: Lung injury in neonates: causes, strategies for prevention, and long-term consequences. J. Pediatr.139(4),478–486 (2001).•• Overview of lung injury in neonates and the importance of lung protective strategies.
Medline CASGoogle Scholar
5 Dworetz AR, Moya FR, Sabo B, Gladstone I, Gross I: Survival of infants with persistent pulmonary hypertension without extracorporeal membrane oxygenation. Pediatrics84(1),1–6 (1989).
Medline CASGoogle Scholar
6 McCallion N, Davis PG, Morley CJ: Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database Syst. Rev. (3),CD003666 (2005).
MedlineGoogle Scholar
7 Vidyasagar D, Lukkarinen H, Kaapa P, Zagariya A: Inflammatory response and apoptosis in newborn lungs after meconium aspiration. Biotechnol. Prog.21(1),192–197 (2005).
Medline CASGoogle Scholar
8 Fanaroff AA: Meconium aspiration syndrome: historical aspects. J. Perinatol.28(Suppl. 3),S3–S7 (2008).
MedlineGoogle Scholar
9 Finer NN: Surfactant use for neonatal lung injury: beyond respiratory distress syndrome. Paediatr. Respir. Rev.5(Suppl. A),S289–S297 (2004).
MedlineGoogle Scholar
10 Attar MA, Donn SM: Mechanisms of ventilator-induced lung injury in premature infants. Semin. Neonatol.7(5),353–360 (2002).•• Provides an extensive review of the mechanisms of ventilator-induced injury.
MedlineGoogle Scholar
11 Dreyfuss D, Saumon G: Ventilator-induced lung injury: lessons from experimental studies. Am. J. Respir. Crit. Care Med.157(1),294–323 (1998).• Key reference summarizing studies performed in order to characterize lung injury.
Medline CASGoogle Scholar
12 Donn SM, Sinha SK: Advances in neonatal ventilation. In: Textbook of Perinatal Medicine. Kurjak A, Chervenak F (Eds.) Tyler & Francis Medical Books, UK, 39–48 (2006).
Google Scholar
13 Ward PA, Lentsch AB: The acute inflammatory response and its regulation. Arch. Surg.134(6),666–669 (1999).• Summarizes the process of inflammation associated with lung injury.
Medline CASGoogle Scholar
14 Bose CL, Dammann CE, Laughon MM: Bronchopulmonary dysplasia and inflammatory biomarkers in the premature neonate. Arch. Dis. Child.93(6),F455–F461 (2008).
Medline CASGoogle Scholar
15 Saugstad OD: Oxidative stress in the newborn – a 30-year perspective. Biol. Neonate88(3),228–236 (2005).
Medline CASGoogle Scholar
16 Kumar VH, Patel A, Swartz DD, Wang H, Wynn KA, Nielsen LC: Exposure to supplemental oxygen and its effects on oxidative stress and antioxidant enzyme activity in term newborn lambs. Pediatr. Res.67(1),66–71 (2010).
Medline CASGoogle Scholar
17 Been JV, Debeer A, van Iwaarden JF et al.: Early alterations of growth factor patterns in bronchoalveolar lavage fluid from preterm infants developing bronchopulmonary dysplasia. Pediatr. Res.67(1),83–89 (2010).
Medline CASGoogle Scholar
18 Toews GB: Cellular alterations in fibroproliferative lung disease. Chest116(Suppl. 1),S112–S116 (1999).
Google Scholar
19 Keszler M: State of the art in conventional mechanical ventilation. J. Perinatol.29(4),262–275 (2009).• Describes the variable modes and modality options of mechanical ventilation for newborn infants.
Medline CASGoogle Scholar
20 Gerhardt T, Claure N, Bancalari E: Role of pulmonary function testing in the management of neonates on mechanical ventilation. In: The Neoborn Lung: Neonatology Questions and Controversies. Bancalari E (Ed.). Saunders, PA, USA, 419–445 (2008).
Google Scholar
21 Kugelman A, Keens TG, deLemos R, Durand M: Comparison of dynamic and passive measurements of respiratory mechanics in ventilated newborn infants. Pediatr. Pulmonol.20(4),258–264 (1995).
Medline CASGoogle Scholar
22 Becker MA, Donn SM: Real-time pulmonary graphic monitoring. Clin. Perinatol.34(1),1–17 (2007).
MedlineGoogle Scholar
23 Attar M, Becker MA, Dechert RE, Donn SM: Variability in response to dexamethasone treatment in term neonates with respiratory failure. Arch. Med. Sci.5(3),7 (2009).
Google Scholar
24 Donn SM, Nicks JJ, Becker MA: Flow-synchronized ventilation of preterm infants with respiratory distress syndrome. J. Perinatol.14(2),90–94 (1994).
Medline CASGoogle Scholar
25 Mahmoud RA, Fischer HS, Proquitte H, Shalaby HM, Schmalisch G: Relationship between endotracheal tube leakage and under-reading of tidal volume in neonatal ventilators. Acta Paediatr.98(7),1116–1122 (2009).
Medline CASGoogle Scholar
26 Broughton SJ, Sylvester KP, Page CM, Rafferty GF, Milner AD, Greenough A: Problems in the measurement of functional residual capacity. Physiol. Meas.27(2),99–107 (2006).
MedlineGoogle Scholar
27 Dellaca RL, Ventura ML, Zannin E, Natile M, Pedotti A, Tagliabue P: Measurement of total and compartmental lung volume changes in newborns by optoelectronic plethysmography. Pediatr. Res.67(1),11–16 (2010).
MedlineGoogle Scholar
28 Garg M, Lew CD, Ramos AD, Platzker AC, Keens TG: Serial measurement of pulmonary mechanics assists in weaning from extracorporeal membrane oxygenation in neonates with respiratory failure. Chest100(3),770–774 (1991).
Medline CASGoogle Scholar
29 Roberts JD Jr, Fineman JR, Morin FC 3rd et al.: Inhaled nitric oxide and persistent pulmonary hypertension of the newborn. The Inhaled Nitric Oxide Study Group. N. Engl. J. Med.336(9),605–610 (1997).
Medline CASGoogle Scholar
30 Kurl S, Heinonen KM, Kiekara O: The first chest radiograph in neonates exhibiting respiratory distress at birth. Clin. Pediatr.36(5),285–289 (1997).
Medline CASGoogle Scholar
31 Angoulvant F, Llor J, Alberti C et al.: Inter-observer variability in chest radiograph reading for diagnosing acute lung injury in children. Pediatr. Pulmonol.43(10),987–991 (2008).
MedlineGoogle Scholar
32 da Costa DE, Nair AK, Pai MG, Al Khusaiby SM: Steroids in full term infants with respiratory failure and pulmonary hypertension due to meconium aspiration syndrome. Eur. J. Pediatr.160(3),150–153 (2001).
Medline CASGoogle Scholar
33 Escobar GJ, Shaheen SM, Breed EM et al.: Richardson score predicts short-term adverse respiratory outcomes in newborns ≥34 weeks gestation. J. Pediatr.145(6),754–760 (2004).
MedlineGoogle Scholar
34 Donn SM, Sinha SK: Invasive and noninvasive neonatal mechanical ventilation. Respir. Care48(4),426–439; discussion 439–441 (2003).
MedlineGoogle Scholar
35 Greenough A, Sharma A: What is new in ventilation strategies for the neonate? Eur. J. Pediatr.166(10),991–996 (2007).
MedlineGoogle Scholar
36 Gupta S, Sinha SK, Donn SM: Ventilatory management and bronchopulmonary dysplasia in preterm infants. Semin. Fetal Neonatal Med.14(6),367–373 (2009).
MedlineGoogle Scholar
37 Sharma A, Milner AD, Greenough A: Performance of neonatal ventilators in volume targeted ventilation mode. Acta Paediatr.96(2),176–180 (2007).
MedlineGoogle Scholar
38 De Jaegere A, van Veenendaal MB, Michiels A, van Kaam AH: Lung recruitment using oxygenation during open lung high-frequency ventilation in preterm infants. Am. J. Respir. Crit. Care Med.174(6),639–645 (2006).
MedlineGoogle Scholar
39 Jobe AH: Lung recruitment for ventilation: does it work, and is it safe? J. Pediatr.154(5),635–636 (2009).
MedlineGoogle Scholar
40 Singh J, Sinha SK, Clarke P, Byrne S, Donn SM: Mechanical ventilation of very low birth weight infants: is volume or pressure a better target variable? J. Pediatr.149(3),308–313 (2006).
MedlineGoogle Scholar
41 van Kaam AH, Rimensberger PC: Lung-protective ventilation strategies in neonatology: what do we know – what do we need to know? Crit. Care Med.35(3),925–931 (2007).
MedlineGoogle Scholar
42 Neonatal and Pediatric Pulmonary Graphics: Principles and Clinical Applications. Donn SM (Ed.). Futura Publishing Co., NY, USA (1998).•• Comprehensive reference regarding pulmonary graphics in neonates.
Google Scholar
43 Fisher JB, Mammel MC, Coleman JM, Bing DR, Boros SJ: Identifying lung overdistention during mechanical ventilation by using volume–pressure loops. Pediatr. Pulmonol.5(1),10–14 (1988).
Medline CASGoogle Scholar
44 Wilson BJ Jr, Becker MA, Linton ME, Donn SM: Spontaneous minute ventilation predicts readiness for extubation in mechanically ventilated preterm infants. J. Perinatol.18(6 Pt 1),436–439 (1998).
MedlineGoogle Scholar
45 Dargaville PA, Rimensberger PC: Lung volume measurement in the neonate-throwing light on the subject: commentary on the article by Dellaca’ et al.: on page 11. Pediatr. Res.67(1),9–10 (2010).
MedlineGoogle Scholar
46 Merritt TA, Deming DD, Boynton BR: The ‘new’ bronchopulmonary dysplasia: challenges and commentary. Semin. Fetal Neonatal Med.14(6),345–357 (2009).
MedlineGoogle Scholar
47 Claure N, Bancalari E: Automated respiratory support in newborn infants. Semin. Fetal Neonatal Med.14(1),35–41 (2009).
MedlineGoogle Scholar
48 Sinderby C: Neurally adjusted ventilatory assisst for infants in critical condition. Pediatr. Health3,297–301 (2009).
Google Scholar

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Published online 7 June 2010

Published in print June 2010

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Financial & competing interests disclosure

Steven Donn serves as a paid consultant to CareFusion, Inc. and has grant support from CareFusion. He is also a member of the Speaker’s Bureau for Ikaria, Inc. and has received honoraria for this activity. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

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