Resp Care
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The current trend for supporting neonates with respiratory distress syndrome is nasal continuous positive airway pressure (CPAP). Nearly half of all neonates who are supported with CPAP will still develop respiratory failure that requires potentially injurious endotracheal intubation and invasive ventilation. ⋯ With the inception of nasal airway interfaces, clinicians have ushered in many different forms of NIV in neonates, often with very little experimental data to guide management. This review will explore in detail all of the different forms of neonatal NIV that are currently focused within an area of intense clinical investigation.
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Although the trend in the neonatal intensive care unit is to use noninvasive ventilation whenever possible, invasive ventilation is still often necessary for supporting pre-term neonates with lung disease. Many different ventilation modes and ventilation strategies are available to assist with the optimization of mechanical ventilation and prevention of ventilator-induced lung injury. Patient-triggered ventilation is favored over machine-triggered forms of invasive ventilation for improving gas exchange and patient-ventilator interaction. ⋯ Over the last decade many new promising approaches to lung-protective ventilation have evolved. The key to protecting the neonatal lung during mechanical ventilation is optimizing lung volume and limiting excessive lung expansion, by applying appropriate PEEP and using shorter inspiratory time, smaller tidal volume (4-6 mL/kg), and permissive hypercapnia. This paper reviews new and established neonatal ventilation modes and strategies and evaluates their impact on neonatal outcomes.
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The lung and conducting airways are ideal portals for drug delivery. The airways are easily accessible by oral or nasal inhalation; the airway and alveolar surface is large, allowing for drug dispersion; and many drugs do not cross the airway-blood barrier, permitting the use of higher topical drug doses for airway disease than would be practical with systemic administration. On the other hand, alveolar deposition of drugs allows rapid absorption into the pulmonary circulation and back to the left heart and systemic distribution, bypassing the intestinal tract and liver inactivation. Recently, there has been a feast of new aerosol devices and drug formulations that promise the effective delivery of an amazing array of medications far beyond pressurized metered-dose inhalers and nebulizers and asthma medicines.
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Extracorporeal life support (ECLS), or extracorporeal membrane oxygenation (ECMO) as it is also known, has been used to support over 45,000 patients to date. Overall survival is 62%. After many years of no change in equipment and technology, there has been a recent flurry of new pumps, cannulas, and oxygenators available for ECLS use. ⋯ The reported success of ECLS in patients with H1N1 during the 2009-2010 epidemic and the improved survival of patients randomized to the ECMO arm of a recently completed adult study of respiratory failure have also brought ECLS into the spotlight much more than other years. Whether these developments will usher in a new era of ECLS expansion to a wider range of patients will require close consideration and observation. Other areas that need to be further refined include anticoagulation management, treatment of bleeding complications, learning to "nurse" patients in an awake state, such as is done in some European (and a few United States) centers, and neurodevelopmental outcome on a long-term basis.
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As the basis for this paper, it must be acknowledged that children are not simply small adults. But this acknowledgment must go further: infants are not simply small adolescents. ⋯ Hopefully, with the collaboration of multicenter investigator networks, additional and definitive pediatric data may be on the horizon. In the meantime, sharing data between adult and pediatric populations seems to be an essential approach to the management of critically ill patients.