Lung Recruitment Maneuver during Volume Guarantee Ventilation of Preterm Infants with Acute Respiratory Distress Syndrome

ABSTRACT

Preterm infants need the achievement of adequate lung volume. Lung recruitment maneuver (LRM) is applied during high-frequency oscillatory ventilation. We investigated the effect of an LRM with positive end-expiratory pressure (PEEP) on oxygenation and outcomes in infants conventionally ventilated for respiratory distress syndrome (RDS). Preterm infants in assisted controlled ventilation + volume guarantee for RDS after surfactant randomly received an LRM (group A) or did not (group B). LRM entailed increments of 0.2 cm H₂O PEEP every 5 minutes, until fraction of inspired oxygen (Fio ₂) = 0.25. Then PEEP was reduced and the lung volume was set on the deflation limb of the pressure/volume curve. When saturation of peripheral oxygen fell and Fio ₂ rose, we reincremented PEEP until Spo ₂ became stable. Group A (n = 10) and group B (n = 10) infants were similar: gestational age 25 ± 2 versus 25 ± 2 weeks; body weight 747 ± 233 versus 737 ± 219 g; clinical risk index for babies 9.8 versus 8.1; initial Fio ₂ 56 ± 24 versus 52 ± 21, respectively. LRM began at 86 ± 69 minutes of age and lasted for 61 ± 18 minutes. Groups A and B showed different max PEEP during the first 12 hours of life (6.1 ± 0.3 versus 5.3 ± 0.3 cm H₂O, p = 0.00), time to lowest Fio ₂ (94 ± 24 versus 435 ± 221 minutes; p = 0.000) and O₂ dependency (29 ± 12 versus 45 ± 17 days; p = 0.04). No adverse events and no differences in the outcomes were observed. LRM led to the earlier lowest Fio ₂ of the first 12 hours of life and a shorter O₂ dependency.

Volume guarantee ventilation - open lung concept - lung recruitment maneuver - preterm infants - RDS

REFERENCES

• 1 Bancalari E, Claure N, Sosenko I R. Bronchopulmonary dysplasia: changes in pathogenesis, epidemiology and definition.  Semin Neonatol. 2003;  8 63-71
• 2 Ramanathan R, Sardesai S. Lung protective ventilatory strategies in very low birth weight infants.  J Perinatol. 2008;  28 (Suppl 1) S41-S46
• 3 Allison B J, Crossley K J, Flecknoe S J et al.. Ventilation of the very immature lung in utero induces injury and BPD-like changes in lung structure in fetal sheep.  Pediatr Res. 2008;  64 387-392
• 4 Marchak B E, Thompson W K, Duffty P et al.. Treatment of RDS by high-frequency oscillatory ventilation: a preliminary report.  J Pediatr. 1981;  99 287-292
• 5 Taskar V, John J, Evander E, Robertson B, Jonson B. Surfactant dysfunction makes lungs vulnerable to repetitive collapse and reexpansion.  Am J Respir Crit Care Med. 1997;  155 313-320
• 6 McCulloch P R, Forkert P G, Froese A B. Lung volume maintenance prevents lung injury during high frequency oscillatory ventilation in surfactant-deficient rabbits.  Am Rev Respir Dis. 1988;  137 1185-1192
• 7 Cools F, Henderson-Smart D J, Offringa M, Askie L M. Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants.  Cochrane Database Syst Rev. 2009;  (3) CD000104 (Review)
• 8 Thome U H, Carlo W A, Pohlandt F. Ventilation strategies and outcome in randomised trials of high frequency ventilation.  Arch Dis Child Fetal Neonatal Ed. 2005;  90 F466-F473
• 9 Bollen C W, Uiterwaal C S, van Vught A J. Cumulative metaanalysis of high-frequency versus conventional ventilation in premature neonates.  Am J Respir Crit Care Med. 2003;  168 1150-1155
• 10 McCallion N, Davis P G, Morley C J. Volume-targeted versus pressure-limited ventilation in the neonate.  Cochrane Database Syst Rev. 2005;  (3) CD003666
• 11 Keszler M. State of the art in conventional mechanical ventilation.  J Perinatol. 2009;  29 262-275
• 12 Frank J A, Matthay M A. Science review: mechanisms of ventilator-induced injury.  Crit Care. 2003;  7 233-241
• 13 Dellacà R L, Zannin E, Sancini G et al.. Changes in the mechanical properties of the respiratory system during the development of interstitial lung edema.  Respir Res. 2008;  9 51
• 14 De Jaegere A, van Veenendaal M B, Michiels A, van Kaam A H. Lung recruitment using oxygenation during open lung high-frequency ventilation in preterm infants.  Am J Respir Crit Care Med. 2006;  174 639-645
• 15 van Kaam A H, de Jaegere A, Haitsma J J, Van Aalderen W M, Kok J H, Lachmann B. Positive pressure ventilation with the open lung concept optimizes gas exchange and reduces ventilator-induced lung injury in newborn piglets.  Pediatr Res. 2003;  53 245-253
• 16 Lachmann B. Open up the lung and keep the lung open.  Intensive Care Med. 1992;  18 319-321
• 17 Meredith K S, deLemos R A, Coalson J J et al.. Role of lung injury in the pathogenesis of hyaline membrane disease in premature baboons.  J Appl Physiol. 1989;  66 2150-2158
• 18 Rimensberger P C, Cox P N, Frndova H, Bryan A C. The open lung during small tidal volume ventilation: concepts of recruitment and “optimal” positive end-expiratory pressure.  Crit Care Med. 1999;  27 1946-1952
• 19 Rudolph A J, Desmond M M, Pineda R G. Clinical diagnosis of respiratory difficulty in the newborn.  Pediatr Clin North Am. 1966;  13 669-692
• 20 Mortensson W, Noack G, Curstedt T, Herin P, Robertson B. Radiologic observations in severe neonatal respiratory distress syndrome treated with the isolated phospholipid fraction of natural surfactant.  Acta Radiol. 1987;  28 389-394
• 21 Niermeyer S, Kattwinkel J, Van Reempts P et al.. International Guidelines for Neonatal Resuscitation: An excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science. Contributors and Reviewers for the Neonatal Resuscitation Guidelines.  Pediatrics. 2000;  106 E29
• 22 Chow L C, Wright K W, Sola A. CSMC Oxygen Administration Study Group . Can changes in clinical practice decrease the incidence of severe retinopathy of prematurity in very low birth weight infants?.  Pediatrics. 2003;  111 339-345
• 23 Ehrenkranz R A, Walsh M C, Vohr B R National Institutes of Child Health and Human Development Neonatal Research Network et al. Validation of the National Institutes of Health consensus definition of bronchopulmonary dysplasia.  Pediatrics. 2005;  116 (6) 1353-1360
• 24 Papile L A, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm.  J Pediatr. 1978;  92 529-534
• 25 International Committee for the Classification of Retinopathy of Prematurity . The International Classification of Retinopathy of Prematurity revisited.  Arch Ophthalmol. 2005;  123 991-999
• 26 Lista G, Castoldi F, Fontana P et al.. Lung inflammation in preterm infants with respiratory distress syndrome: effects of ventilation with different tidal volumes.  Pediatr Pulmonol. 2006;  41 (4) 357-363
• 27 Lista G, Castoldi F, Fontana P et al.. Lung inflammation in preterm infants with respiratory distress syndrome.  Pediatr Pulmonol. 2006;  41 357-363
• 28 Lista G, Castoldi F, Bianchi S, Battaglioli M, Cavigioli F, Bosoni M A. Volume guarantee versus high-frequency ventilation: lung inflammation in preterm infants.  Arch Dis Child Fetal Neonatal Ed. 2008;  93 F252-F256
• 29 Valente Barbas C S. Lung recruitment maneuvers in acute respiratory distress syndrome and facilitating resolution.  Crit Care Med. 2003;  31 (4 Suppl) S265-S271
• 30 Maisch S, Reissmann H, Fuellekrug B et al.. Compliance and dead space fraction indicate an optimal level of positive end-expiratory pressure after recruitment in anesthetized patients.  Anesth Analg. 2008;  106 175-181
• 31 Hülskamp G, Pillow J J, Dinger J, Stocks J. Lung function tests in neonates and infants with chronic lung disease of infancy: functional residual capacity.  Pediatr Pulmonol. 2006;  41 1-22
• 32 Nassabeh-Montazami S, Abubakar K M, Keszler M. The impact of instrumental dead-space in volume-targeted ventilation of the extremely low birth weight (ELBW) infant.  Pediatr Pulmonol. 2009;  44 128-133
• 33 Jobe A H. Lung recruitment for ventilation: does it work, and is it safe?.  J Pediatr. 2009;  154 635-636
• 34 Krishnan R K, Meyers P A, Worwa C, Goertz R, Schauer G, Mammel M C. Standardized lung recruitment during high frequency and conventional ventilation: similar pathophysiologic and inflammatory responses in an animal model of respiratory distress syndrome.  Intensive Care Med. 2004;  30 1195-1203