Feasibility of combining two individualized lung recruitment maneuvers at birth for very low gestational age infants: a retrospective cohort study

Kanaan, Zalfa; Bloch-Queyrat, Coralie; Boubaya, Marouane; Lévy, Vincent; Bolot, Pascal; Waszak, Paul

doi:10.21203/rs.2.16455/v1

Cited by 3 publications

(3 citation statements)

References 27 publications

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“…It is also important to consider that the timing after birth when the support is applied is also relevant, with the lung being more resistant to the adverse effects of higher pressures when liquid-filled. This is consistent with the finding that the risk of a pneumothorax was not increased when using PEEP levels ≤15 cmH 2 O in very preterm infants [54][55][56] . Nevertheless, it would appear that there is a limit to how much pressure is appropriate in the first few minutes after birth.…”

Section: Discussionsupporting

confidence: 91%

Higher CPAP levels improve functional residual capacity at birth in preterm rabbits

et al. 2021

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IMPACT STATEMENT• Although preterm infants are commonly supported with 4-8 cmH 2 O CPAP at birth, preclinical studies have shown that higher PEEP levels improve lung aeration.• In this study, CPAP levels of 15 cmH 2 O improved lung aeration and reduced apnea in preterm rabbit kittens immediately after birth. 15 cmH 2 O CPAP did not increase the risk of lung over-expansion (indicated by bulging between the ribs), pneumothorax, or CPAP belly.• These results can be used when designing future studies on CPAP strategies for preterm infants in the delivery room.

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Section: Discussionsupporting

confidence: 91%

Higher CPAP levels improve functional residual capacity at birth in preterm rabbits

et al. 2021

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“…An important aspect of these PEEP strategies is the transient high PEEP exposure whilst the lung is clearing fetal lung fluid. Current clinical approaches to DynPEEP also constrain PEEP increases to clinical need, based on oxygen and heart rate response, 30,31 rather than pre-fixed PEEP values which should further limit any potential risk of inadvertent high intrathoracic pressure on haemodynamics.…”

Section: Discussionmentioning

confidence: 99%

Aeration Strategy at Birth Does Not Impact Carotid Haemodynamics in Preterm Lambs

Dahm

Kenna

Stewart

et al. 2022

Preprint

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ObjectiveTo examine the effect of three different ventilation strategies at birth on markers of cerebral haemodynamics and oxygenation.DesignAnimal research.SettingAnimal research facility.Subjects124-127 day gestation apnoeic preterm lambs (n=68) born via caesarean section.InterventionsLambs were randomised to either positive pressure ventilation with positive end-expiratory pressure (PEEP) 8 cmH2O (No-RM; n=12), sustained inflation (SI; n=15) or a dynamic PEEP strategy (DynPEEP; n=41) at birth, followed by 90 minutes of standardised ventilation. Prior to birth a carotid artery flow probe was placed, with occlusive cannulation of the contralateral carotid artery. Carotid blood flow, ventilation data, peripheral oxygen saturation (SpO2), heart rate and arterial blood pressure were continuously recorded, with intermittent arterial blood gas analysis at set time points.Main outcome measuresCarotid blood flow, carotid artery oxygen content and carotid oxygen delivery (product of carotid artery blood flow and oxygen content).ResultsOverall carotid blood flow measures were comparable between strategies. The exception being mean carotid blood flow during the first 3 minutes after birth, which was significantly lower for the SI group compared to the No-RM and DynPEEP groups respectively (p<0.0001; repeated-measure mixed effect ANOVA). Carotid arterial oxygen content (p=0.19) and oxygen delivery (p=0.50) were similar between strategies. Maximum PEEP did not alter cerebral haemodynamic measures.ConclusionsThis is the first study to compare cerebral haemodynamics during different PEEP strategies with SI at birth. Although there were some short-term variations, there were no sustained differences.What is already known on this topicFacilitating the respiratory transition at birth for preterm infants is essential for the lungs as well as the brain. Whilst our understanding of the impact of different respiratory strategies on the lungs is well understood, preclinical data involving other organs is sparse. Concerns have been raised that aggressive lung recruitment may impede cerebral haemodynamics in the preterm infant.What this study addsTo our knowledge, this is the first study that assesses the effect of the three different aeration strategies currently being considered in clinical practice; sustained inflation, dynamic and static positive end-expiratory pressure (PEEP), on cerebral haemodynamics. We found that differing ventilation strategies did not alter carotid blood flow, carotid oxygen content or carotid oxygen delivery. Specifically, there was no difference between sustained inflation (to 35 cmH2O) and maximum PEEP levels of 8, 14 and 20 cmll.O applied during the first three minutes after birth.How this study might affect research, practice or policyFollowing preterm birth it is important to consider the effect of ventilation strategies on other organs, especially the brain. This preclinical study provides some reassurance that respiratory strategies designed to focus on lung aeration at birth may not impact cerebral haemodynamics in preterm neonates.

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“…An important aspect of these PEEP strategies is the transient nature of high PEEP exposure while the lung is clearing foetal lung fluid. Current clinical approaches to DynPEEP also constrain PEEP increases to clinical need, based on oxygen and heart rate response, 31,33 rather than pre-fixed PEEP values that should further limit any potential risk of inadvertent high intrathoracic pressure on haemodynamics.…”

Section: Discussionmentioning

confidence: 99%

Aeration strategy at birth does not impact carotid haemodynamics in preterm lambs

et al. 2022

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Background The impact of different respiratory strategies at birth on the preterm lung is well understood; however, concerns have been raised that lung recruitment may impede cerebral haemodynamics. This study aims to examine the effect of three different ventilation strategies on carotid blood flow, carotid artery oxygen content and carotid oxygen delivery. Methods 124–127-day gestation apnoeic intubated preterm lambs studied as part of a larger programme primarily assessing lung injury were randomised to positive pressure ventilation with positive end-expiratory pressure (PEEP) 8 cmH2O (No-RM; n = 12), sustained inflation (SI; n = 15) or dynamic PEEP strategy (DynPEEP; maximum PEEP 14 or 20 cmH2O, n = 41) at birth, followed by 90 min of standardised ventilation. Haemodynamic data were continuously recorded, with intermittent arterial blood gas analysis. Results Overall carotid blood flow measures were comparable between strategies. Except for mean carotid blood flow that was significantly lower for the SI group compared to the No-RM and DynPEEP groups over the first 3 min (p < 0.0001, mixed effects model). Carotid oxygen content and oxygen delivery were similar between strategies. Maximum PEEP level did not alter cerebral haemodynamic measures. Conclusions Although there were some short-term variations in cerebral haemodynamics between different PEEP strategies and SI, these were not sustained. Impact Different pressure strategies to facilitate lung aeration at birth in preterm infants have been proposed. There is minimal information on the effect of lung recruitment on cerebral haemodynamics. This is the first study that compares the effect of sustained lung inflation and dynamic and static positive end-expiratory pressure on cerebral haemodynamics. We found that the different ventilation strategies did not alter carotid blood flow, carotid oxygen content or carotid oxygen delivery. This preclinical study provides some reassurance that respiratory strategies designed to focus on lung aeration at birth may not impact cerebral haemodynamics in preterm neonates.

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Feasibility of combining two individualized lung recruitment maneuvers at birth for very low gestational age infants: a retrospective cohort study

Cited by 3 publications

References 27 publications

Higher CPAP levels improve functional residual capacity at birth in preterm rabbits

Higher CPAP levels improve functional residual capacity at birth in preterm rabbits

Aeration Strategy at Birth Does Not Impact Carotid Haemodynamics in Preterm Lambs

Aeration strategy at birth does not impact carotid haemodynamics in preterm lambs

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