High frequency oscillatory ventilation: Initial experience in 22 patients

Objectives: To report the outcome of a consecutive cohort of neonates treated with high frequency oscillatory ventilation (HFOV).
Methodology Prospective cohort study of 22 neonates failing conventional mechanical ventilation (CMV) between October 1992 and August 1993. Outcomes evaluated were in-hospital survival rate, comorbidities including patent ductus arteriosus (PDA), cerebroventricular haemorrhages (CVH), necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP), and acute changes in respiratory status.
Results Eighteen of 22 (81.8%) survived. Of the four children who died, one did not respond to HFOV and died within 24 h of treatment. Two died of respiratory failure complicated by pulmonary haemorrhage. The remaining infant responded to HFOV but later developed severe NEC while on minimal CMV and died at 2 weeks of age.
Three subjects were ≥34 weeks' gestation; each responded well to HFOV with no substantial comorbidity. Of the remaining 19 infants <34 weeks' gestation, six (31.6%) had a PDA, and seven (36.8%) had a CVH. One infant developed cystic periventricular leucomalacia. Three infants (15.8%) had NEC. Respiratory failure in the 15 survivors with gestational ages <34 weeks improved dramatically with HFOV. Ten (66.7%) survivors <34 weeks developed BPD and 10 (66.7%) ROP.
Conclusion High frequency oscillatory ventilation was associated with a survival rate of 81.8%, but with significant comorbidity.     

Prophylactic high-frequency oscillatory ventilation in preterm infants

The role of high-frequency oscillatory ventilation (HFOV) for the treatment of respiratory disease in preterm infants remains uncertain. Several randomized trials, comparing HFOV and conventional ventilation (CV) have been performed and their results suggest that HFOV may reduce the incidence of chronic lung disease (CLD) in preterm infants. However, the trials have several limitations and it remains unclear whether HFOV might increase intracranial pathology in very prematurely born infants. UKOS, a large, UK-based, multicentre trial was conducted to establish conclusively the role of prophylactic HFOV for the prevention of CLD in infants born prior to 29 wk of gestational age.
Conclusion : There is still a need to fully evaluate prophylactic HFOV with particular emphasis on both short and long term respiratory and neurological outcomes.     

High-frequency ventilation in the treatment of infants weighing less than 1,500 grams with pulmonary interstitial emphysema: a pilot study

Pulmonary interstitial emphysema is one of the most serious complications of the respiratory distress syndrome. Its presence significantly increases morbidity and mortality. Preliminary reports have demonstrated the success of high-frequency ventilation in the treatment of pulmonary interstitial emphysema. In a previous investigation, we were able to develop a formula for predicting death in infants weighing less than 1,500 g with pulmonary interstitial emphysema. Using this subgroup of severely affected infants, we studied the efficacy of high-frequency ventilation in nine infants. Using the Volumetric Diffusive Respirator, we observed improvement in all respiratory values measured (pH, PCO2, and PO2), a significantly decreased mean airway pressure (MAP), and improvement in neonatal mortality. Complications of severe bleeding diatheses, hypotension, bronchopulmonary dysplasia, and necrotizing tracheobronchitis were observed. Our investigation was the first to systematically choose infants who might benefit from high-frequency ventilation and to compare them with similar infants with known outcomes. We realize that the study was rescue in nature using historical controls, but we felt compelled to assure the safety of the device before randomizing less sick infants. High-frequency ventilation appears to be effective in the acute management of low birth weight infants with pulmonary interstitial emphysema.     

Efficacy and limits of rescue high-frequency oscillatory ventilation in the treatment of hyaline membrane disease in preterm newborns]

Conflicting reports of high-frequency oscillatory ventilation (HFOV) use as an alternative to conventional mechanical ventilation have been published. This retrospective study has evaluated the efficacy and safety of rescue HFOV in preterm infants with severe hyaline membrane disease (HMD) after the failure of conventional mechanical ventilation (CMV). POPULATION AND METHODS: All newborns hospitalized in our neonatal intensive care unit (NICU) from 10.1.1993 to 15.4.1995 with CMV failure, defined as the need for more than 55% FiO2 without any improvement for at least six hours, have been retrospectively studied. The infants were shared according to the absence (Gr I) or the presence (Gr II) of persistent pulmonary hypertension of neonate (PPHN) in addition to HMD before HFOV. RESULTS: Gestational age (GA) was 29.2 +/- 3.7 weeks (mean +/- SD) in Gr I and 30.3 +/- 2.8 in Gr II. Birth weight was 1379 +/- 750 g and 1471 +/- 612 g, respectively. As soon as three hours after the onset of HFOV in both groups, a dramatic improvement was observed with a FiO2 drop from 82 +/- 20% to 64.8 +/- 25.5% (P < 0.01). Among the infants, 62% survived without any major disability and 28% died (46% in Gr II vs 12% in Gr I, P < 0.01). A trend towards a worsening of pre-existing brain lesions has been noticed. An increased risk of mortality was observed when a secondary worsening in O2 requirements occurred 24 hours after the onset of HFOV, despite an initial significant improvement. SGA was also associated with a poor prognosis (46% of the deaths vs 29% for AGA infants, P < 0.05). CONCLUSION: HFOV has been successfully used in premature infants with severe respiratory disease and failure of CMV. Criteria of poor prognosis were PPHN and SGA, or a secondary worsening in oxygen requirements after initial improvement. A trend towards aggravation of pre-existing brain lesions has been noticed after HFOV. This aggravation is more frequent when PPHN is associated with HMD. This observation suggests caution for HFOV use when these conditions are present in premature infants.     

Respiratory Failure in Infants Weighing 1000 g or Less at Birth

Yu, V. Y. H., and Hollingsworth, E. (1979). Aust. Paediatr. J. , 15, 152–159. Respiratory failure in Infants weighing 1000 g or less at birth. The prognosis for infants weighing <1000 g has improved coincident with the improved ventilatory support in their neonatal management. There are many problems leading to respiratory failure which are particularly significant and peculiar to these infants. Of the 55 infants weighing <1000 g admitted in 1977 and 1978, 58% had hyaline membrane disease and 69% had preterm recurrent apnoea. Fifty-one infants required assisted ventilation, or whom 28 were ventilated from birth. Though these infants could be ventilated successfully with low peak airway and positive end-expiratory pressures, 52% of the ventilated infants required it for more than seven days, despite the use of intermittent mandatory ventilation and continuous positive airway pressure during weaning. The neonatal survival rate for assisted ventilation in infants weighing <1000 g was 57%. Seventeen of the ventilated infants developed pulmonary interstitial emphysema, a condition which was associated with an increased incidence of pneumothorax (four infants) and bronchopulmonary dysplasia (ten infants). Infants recovering from bronchopulmonary dysplasia required up to 76 days of assisted ventilation and 84 days of oxygen therapy. No major handicaps were detected on follow-up except for one infant with retrolental fibroplasia. Optimal management of respiratory failure in infants weighing <1000 g can now result in increased survival with morbidity approaching those of larger preterm infants. As our knowledge, skills, techniques and equipment continue to improve, so will survival and morbidity rates.     

Impact of new treatments for respiratory failure on outcome of infants with congenital diaphragmatic hernia

Term and near-term newborn infants with congenital diaphragmatic hernia (CDH), symptomatic in the first 24 h of life or diagnosed antenatally, without other significant malformations were treated at our hospital with high-frequency oscillatory ventilation (HFOV) as a primary modality of ventilation and elective delay in surgical repair after a period of stabilisation. When unresponsive to HFOV, infants were treated with surfactant, inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) to achieve pre-operative stabilisation. From October 1994 to August 1998, 28 newborn infants with CDH were managed with such treatment; mean birth weight was 3184 ± 535 g and gestational age 38.5 ± 1.85 weeks. Age at operation was 68 ± 35 h. In 9 cases, large diaphragmatic defects required the use of a prosthetic patch (Gore-tex). HFOV was used for primary ventilation in inborn patients (n = 16); outborn infants (n = 12) were placed on HFOV at admittance. A total of 15 patients (53%) were stabilised using only HFOV. Bovine surfactant was administered in 12 infants and 4 responded. iNO was used in eight infants and five responded. ECMO was used in three outborn patients and one survived. Overall, out of 28 infants, 25 survived (89%). Neurological examination (Amiel-Tison and Grenier) of 15 infants showed transient anomalies at 6 months in 40% of infants, while a normal neurological examination was present in all patients at 1 year. The development quotient (Griffiths scales) was within normal values in ten and mildly abnormal in two infants tested at 1 year. Conclusion Management based on early HFOV, eventually associated with surfactant, iNO and ECMO to achieve preoperative stabilisation, resulted in a good survival rate (89%) and good neurodevelopmental outcome at 1 year of age in infants with CDH. Received: 10 November 1998 and in revised form: 3 March 1999 / Accepted: 16 March 1999     

Bronchopulmonary dysplasia in very low birthweight infants

ABSTRACT. Twenty-four (6%) of 375 infants with birthweights ≦1500g developed bronchopulmonary dysplasia (BPD); 16 (15%) of 107 in those ≦100g and 8 (3%) of 268 in those >1000g. The incidence was 10% in those who required assisted ventilation. Perinatal asphyxia, significant respiratory distress, pulmonary interstitial emphysema and patent ductus arteriosus were statistically more common in BPD infants compared with the remaining 351 very low birthweight infants. Hyaline membrane disease was the primary respiratory disease in 54% of BPD infants. The mean durations of oxygen and ventilatory therapy were 68 days and 37 days respectively. Twenty-nine percent did not require more than 60% oxygen for over 24 hours. Only 38% required a peak airway pressure of over 30 cmH₂O. Early postnatal growth was satisfactory on parenteral nutrition support. No perinatal factor was found to be predictive of death from BPD. The prolonged duration of hospital treatment has obvious implications to the psychosocial and economic costs of BPD.     

High frequency oscillatory ventilation and extracorporeal membrane oxygenation in severe persistent pulmonary hypertension of the newborn

We report on 50 term and near-term neonates (birth weight > 1800 g, gestational age > 33 weeks) with severe persistent pulmonary hypertension of the newborn (PPHN), referred to us from January 1987 to July 1991 after failure of maximum conventional treatment. All infants had paO₂<45 mm Hg when ventilated with peak inspiratory pressure >38 cm H₂O and FiO₂=1.0, hence meeting entry criteria for extracorporeal membrane oxygenation (ECMO). High frequency oscillatory ventilation (HFOV) was tried in all patients. If sufficient oxygenation could not be achieved (paO₂<40 mm Hg for at least 2 h), ECMO therapy was begun, which was the case in 25 children. Neonates responding to HFOV (n=25) were of a slightly younger gestational age (37.0 weeks vs 38.8 weeks,P<0.05), had higher Apgar scores and were less hypoxaemic before HFOV (paO₂ 36.6 mm Hg vs 28.8 mm Hg,P<0.01); during HFOV there was a significant rise in paO₂ (> 150 mm Hg;P<0.001) and a fall in pCO₂ to 21.6 mm Hg (P<0.001). Due to air leaks, which was the main complication of HFOV (52%), ECMO therapy had to be begun in two additional infants after an initial positive effect. HFOV tended to be successful in cases of primary PPHN, meconium aspiration and sepsis, but not in infants with lung hypoplasia as a result of diaphragmatic hernia or other reasons. Success or failure of HFOV could not be reliably predicted by any parameter. Mean duration of HFOV was 37.8 h vs 84.9 h of ECMO. PPHN could be overcome in 88% of the HFOV-treated and in 76% of the ECMO-treated infants; overall survival rate was 74% (predicted probability of survival using maximum conventional treatment <10%). There were no significant differences between HFOV/ECMO groups with regard to duration of ventilation following HFOV/ECMO, total time in hospital, rate of bronchopulmonary dysplasia and neurological complications (intracranial haemorrhage, brain infarction). Among the survivors, the rate of mentally handicapped children was equal in both groups (overall 18.9%). Our analysis shows that about 50% of neonates with PPHN who fail to respond to conventional ventilatory support and maximum treatment can be treated successfully with HFOV, thus avoiding ECMO. By applying both forms of therapy, the survival rate of infants with severe PPHN can be increased from an estimated rate of <10% up to 80%.     

Bronchopulmonary dysplasia in very low birthweight infants

Twenty-four (6%) of 375 infants with birthweights less than or equal to 1500g developed bronchopulmonary dysplasia (BPD); 16 (15%) of 107 in those less than or equal to 100g and 8 (3%) of 268 in those greater than 1000g. The incidence was 10% in those who required assisted ventilation. Perinatal asphyxia, significant respiratory distress, pulmonary interstitial emphysema and patent ductus arteriosus were statistically more common in BPD infants compared with the remaining 351 very low birthweight infants. Hyaline membrane disease was the primary respiratory disease in 54% of BPD infants. The mean durations of oxygen and ventilatory therapy were 68 days and 37 days respectively. Twenty-nine percent did not require more than 60% oxygen for over 24 hours. Only 38% required a peak airway pressure of over 30 cmH2O. Early postnatal growth was satisfactory on parenteral nutrition support. No perinatal factor was found to be predictive of death from BPD. The prolonged duration of hospital treatment has obvious implications to the psychosocial and economic costs of BPD.     

Mechanical ventilation of infants with severe hyaline membrane disease in a regional newborn intensive care unit

Thirty (86%) of 35 Infants with birthwelghts >1000 g survived mechanical ventilation for severe hyaline membrane disease. There were no deaths In infants with birthweights >1500 g or gestational ages ≥31 wk.
Most Infants could be ventilated satisfactorlly with intermittent mandatory ventilation using square pressure waveform, low peak airway pressure, positive end-expiratory pressure, low ventilator frequency and an inspiratory: expiratory time ratio <1:1. Seven Infants who were hypoxaemic despite a high fractional inspired oxygen and a peak airway pressure ≥ 25 cm of water showed a sustained improvement in oxygenatiort following muscle relaxation with d-tubocurarine, acute blood volume expansion and isoprenaline Infusion. Xanthine derivatives were used to facilitate weaning from mechanical ventilation In 37% of infants.
Although overall survival of outborn Infants was not significantly different from that of inborn Infants, survival was less common in outborn infants from 27 to 30 weeks gestation. In addition, severe perinatal asphyxia and mechanical ventilation for cardiopulmonary collapse were more common In outborn infants. Fifty percent of outborn infants required mechanical ventilation during transport.     

High frequency oscillatory ventilation in acute respiratory failure

High frequency oscillatory ventilation (HFOV) has emerged over the past 20 years as a safe and effective means of mechanical ventilatory support in patients with acute respiratory failure. During HFOV, lung recruitment is maintained by application of a relatively high mean airway pressure with superimposed pressure oscillations at a frequency of 3 to 15Hz, creating adequate ventilation using tidal volumes less than or equal to the patient's dead space volume. The physiologic rationale for the application of HFOV in the clinical arena comes from its ability to preserve end-expiratory lung volume while avoiding parenchymal overdistension at end-inspiration and theoretically limiting the potential for ventilator-associated lung injury. Data in the neonatal population suggests significant benefits in pulmonary outcomes when HFOV is applied with a recruitment strategy in preterm infants with respiratory distress syndrome (RDS). Use of HFOV in the paediatric and adult populations has not as yet been associated with significant improvements in clinically important outcome measures.     

Fetal diaphragmatic hernia: prenatal evaluation of lung hypoplasia and effects of immediate operation

The outcome of fetuses with diaphragmatic hernia (CDH) has been reported to be related to the severity of lung hypoplasia. As an index of pulmonary hypoplasia, we attempted to measure the lung-thorax transverse area ratio (L/T) using ultrasonic echography in eight fetuses with left-sided CDH. Two cases with L/T more than 0.28 (controls: 0.52±0.04) were transported postnatally and recovered after early operation without episodes of persistent fetal circulation. Elective surgical repair was performed in six infants immediately after cesarean delivery at 35–37 weeks' gestation. In three cases with L/T between 0.21 and 0.24 who recovered with no complications, surgical reduction of the abdominal organs improved arterial blood gases and high-frequency oscillation ventilation (HFOV) was fully effective for respiratory management. In three with L/T between 0.11 and 0.17, extracorporeal membrane oxygenation (ECMO) was required from the 1st to the 12th postoperative day despite HFOV. Although two infants died of combined cardiovascular anomalies and airway bleeding caused by prolonged HFOV, respectively, one infant with minimal L/T survived. Measurement of L/T may help to predict the outcome of fetuses with CDH and to determine the indications for various treatments including immediate operation after cesarean delivery, HFOV, and ECMO. Offprint requests to: S. Kamata     

Risk factors for fatal pulmonary interstitial emphysema in neonates

Among 315 infants treated for respiratory distress syndrome (RDS) over a 2 year period, 32 prematures were studied retrospectively with the diagnosis of pulmonary interstitial emphysema (PIE). Eighteen died. In this group, birth weight below 1600 g, need for oxygen above 0.6 on the 1st day and appearance of bilateral pulmonary interstitial emphysema within the first 48h of life were significant risk factors, with a mortality rate of 94%. In order to recognize one or more early criteria predictive of fatal PIE, we compared ventilation parameters on day 1 between neonates with fatal PIE and those with the same birth weight and initial severity of RDS but without PIE treated during the same period. High positive inspiratory pressure on day 1 was found to be the most significant parameter associated with further appearance of fatal pulmonary interstitial emphysema. A cut-off level of 26 cm H₂O was found to be discriminant. These criteria may be useful in selecting those neonates who might best benefit from a new therapy such as high frequency ventilation, before irreversible lesions appear.     

Pulmonary interstitial emphysema in very low birthweight infants.

Forty six of 142 infants weighing less than 1500 g at birth, who had chest radiographs in the first 5 days of life, developed pulmonary interstitial emphysema (PIE) and in 19 this occurred in the first 24 hours. PIE was seen more frequently in infants weighing less than 1000 g at birth (24 of 57) than in those weighing 1000-1500 g (22 of 85). Ventilation for hyaline membrane disease was strongly associated with PIE, and only babies who were resuscitated, or ventilated, or had hyaline membrane disease developed the disorder. Most pneumothoraces were preceded by x-ray appearances of PIE (17 of 21). Mortality was increased in ventilated infants who developed PIE and was high in those with severe x-ray changes.     

High-frequency oscillatory ventilation combined with intermittent mandatory ventilation in critically ill neonates: 3 years of experience

A heterogeneous group of 45 neonates with severe pulmonary disease and inadequate gas exchange on conventional intermittent mandatory ventilation (IMV) was treated with a high-frequency oscillator combined with an IMV (HFO-IMV) system (Emerson Airway Vibrator connected to a BABYBird 1 ventilator). The mean gestational age was 33 weeks (25.5–43) and mean birth weight 2.02 kg (0.66–4.24). Primary diagnoses included respiratory distress syndrome (RDS; 23), pneumonia (12), persistent fetal circulation (PFC; 6), diaphragmatic hernia/hypoplastic lungs (4). The IMV rate was reduced from 78 to 29 BPM (P0.0005), while maintaining lower partial pressure of carbon dioxide (PaCO₂) (P<0.005) and higher partial pressure of oxygen (PaO₂) (P0.0025). Active air leaks were present in 20 infants and these infants responded most favourably to HFO-IMV. HFO-IMV failed to improve ventilation in neonates with diaphragmatic hernia/hypoplastic lungs. Complications during HFO-IMV were increased pulmonary secretions (11), worsening or recurrence of pre-existing air leaks (11), or occurrence of new air leaks (10). In 4 patients death was related to major air leak complications. Twenty-four infants died, 18 of them of a respiratory cause. Twenty-one infants finally survived. We assembled a well-tolerated system to provide HFO-IMV and to successfully ventilate neonates with severe respiratory disease, who failed to respond to conventional IMV. Initiation of HFO-IMV earlier in the course of the disease in this type of infant may improve survival.Abbreviations BPM breaths per minute - FiO₂ fraction of inspired oxygen - HFI high-frequency flow interrupter - HFJ(V) high-frequency jet (ventilation) - HFO high-frequency oscillation - HFO-IMV high-frequency oscillation combined with intermittent mandatory ventilation - HFPP(V) high-frequency positive pressure (ventilation) - IMV intermittent mandatory ventilation - P(a)CO₂ partial pressure of (arterial) carbon dioxide - P(a)O₂ partial pressure of (arterial) oxygen - Paw mean airway pressure - PFC persistent fetal circulation - PIE pulmonary interstitial emphysema - PIP peak inspiratory pressure - RDS (infant) respiratory distress syndrome     

Pulmonary interstitial emphysema in low birth weight infants: characteristics of survivors

Twenty out of 303 ventilated low birth weight infants, hospitalized in the Beilinson Medical Center's Intensive Care Unit, during the years 1984-1986, developed pulmonary interstitial emphysema. Eighteen infants had very low birth weight (less than 1500 grams) and 17 were less than 30 weeks' gestation. The mean birth weight was 987 +/- 311 and mean gestational age 27.7 +/- 2.5. Eight infants survived the pulmonary disease. There were no significant differences in the neonatal parameters between infants who died or survived. However, the survivors had a significantly lower maximal peak inspiratory pressure and FiO2 on the first day of ventilation. The incidence of pneumothorax and asphyxia was the same in both groups.     

Neonatal high-frequency jet ventilation

Ten neonates with intractable respiratory failure were treated with high-frequency jet ventilation (HFJV). Nine had progressive pulmonary air leaks with either bronchopleural fistulas or pulmonary interstitial emphysema as the primary cause of their respiratory failure. Following HFJV, x-ray film evidence of pulmonary air leaks decreased in seven of the nine neonates. PaO2/FIO2 increased in eight of the ten patients (P less than .05), and PaCO2 values decreased in nine of the ten patients (P less than .01). Five patients survived. Three of the six patients exposed to HFJV for more than 20 hours developed significant tracheal obstruction. From this experience, it may be concluded that HFJV can successfully ventilate certain neonates with intractable respiratory failure secondary to progressive pulmonary air leaks. In its present form, long-term neonatal HFJV carries a risk of airway obstruction and/or damage.     

Innovative neonatal ventilation and meconium aspiration syndrome

Respiratory failure remains a major cause of morbidity and mortality in the neonatal population. Infants with hypoxemic respiratory failure because of meconium aspiration syndrome (MAS), persistent pulmonary hypertension of the newborn (PPHN), and pneumonia/sepsis have a potential for increased survival with extracorporeal membrane oxygenation (ECMO). Other treatment options previously limited to inotropic support, conventional ventilatory management, respiratory alkalosis, paralysis and intravenous vasodilators have been replaced by high-frequency oscillatory ventilation (HFOV), surfactant, and inhaled nitric oxide (iNO). HFOV has been advocated for use to improve lung inflation while potentially decreasing lung injury through volutrauma. Other reports describe enhanced efficacy of HFOV when combined with iNO. Subsequent to studies reporting surfactant deficiency or inactivation may contribute to neonatal respiratory failure exogenous surfactant therapy has been implemented with apparent success. Recent studies have shown that iNO therapy in the neonate with hypoxemic respiratory failure can result in improved oxygenation and decreased need for ECMO. In this article, the authors place in context of a system-based strategy the prenatal, natal and postnatal management of babies delivered through meconium stained amniotic fluid (MSAF) so that adverse outcomes are minimized, and the least number of babies require innovative ventilatory support. At Pennsylvania Hospital, over a six-year period (1995 to 2000), 14.5% (3370/23,175 of live births babies were delivered with MSAF. These data show that 4.6% (155/3370) of babies with MSAF sustained MAS. Overall, 26% (40/155) of babies with MAS needed ventilatory support or 0.17% of all live-births); of these only 20% (8/40 or 0.035% of live births) needed innovative ventilatory support. None died or needed ECMO. These data describe the impact of a system-based approach to prevent and manage adverse outcomes related to MSAF at regional Level III perinatal center.     

Early functional echocardiogram and inhaled nitric oxide: usefulness in managing neonates born following extreme preterm premature rupture of membranes (PPROM)

Aim: Poor neonatal outcome of preterm premature rupture of membranes (PPROM) <24 weeks' gestational age (GA) is probably a result of abnormalities in both airway and vascular developments, ventilation perfusion mismatch, and possibly persistent pulmonary hypertension of the newborn (PPHN). Perinatal mortality of 50–90% has been reported in the past, with recent literature reporting significant improvement in neonatal survival. We report our 8‐year experience in this group of infants using early diagnostic functional echocardiography (fECHO), high‐frequency ventilation (HFV) and inhaled nitric oxide (iNO). Methods: The obstetric and neonatal databases were searched to identify babies with PPROM (<20 weeks' gestation) or rupture earlier than 25 weeks for more than 14 days. Results: Twenty‐six infants were identified, of whom 20 were admitted to the neonatal intensive care unit (NICU; mean GA 27.8 weeks, mean birth weight (BW) 1207 g). Early echocardiographic data were available in 12/15 infants requiring mechanical ventilation of whom 10 had evidence of PPHN. All infants who received iNO therapy survived to discharge and only two infants died. Survival to discharge was 69% for the whole cohort of infants and 90% for infants admitted to the NICU. In contrast, for the cohort from pre‐iNO and ‐HFV era, the overall survival to discharge was 62% and 66% for the infants admitted to the NICU. Conclusion: Premature infants with PPROM and presumed severe hypoxemic respiratory failure because of hypoplastic lungs often have significant PPHN and may show improvement in oxygenation after treatment with HFV and iNO. Early fECHO results in earlier identification and treatment of infants with PPHN in this high‐risk group.     

The use of Dexamethasone in full-term infants with severe respiratory failure and pulmonary barotrauma

Eight full-term infants (mean gestation 39.9 weeks [range 37-42] and mean birthweight 3642 g [range 3060-4200]) with severe respiratory failure (median oxygenation index 28 [range 16-65] and median arterial/alveolar PO2 ratio (a/APO2) 0.094 [range 0.038-0.165]) and pulmonary barotrauma were treated with Dexamethasone, 0.5 mg/kg per day, from the median age of 5 days (range 3-22). Six of the eight (75%) infants survived. They were weaned from mechanical ventilation and extubated a median of 2.5 days after commencing treatment with Dexamethasone. Two infants died and one of them suffered recurrent pneumothoraces. There was a significant improvement in oxygenation in the seven infants who survived the 72 h period of observation. Their median oxygenation index was 24 when Dexamethasone was commenced compared with 8 after 12 h (P less than 0.05) and 10 after 36 h (P less than 0.025). Their a/APO2 ratio was 0.095 when Dexamethasone was commenced compared with 0.289 after 12 h (P less than 0.05) and 0.207 after 36 h (P less than 0.025). There was a significant increase in the infants' arterial mean blood pressure associated with Dexamethasone therapy and one infant developed Staphylococcus aureus septicaemia. In this uncontrolled study of eight full-term infants with severe respiratory failure and pulmonary barotrauma, the use of Dexamethasone was associated with significant improvement in oxygenation and rapid weaning from mechanical ventilation.