Pulmonary interstitial emphysema: selective bronchial occlusion with a Swan-Ganz catheter.

A 26 week preterm infant ventilated for hyaline membrane disease developed severe pulmonary interstitial emphysema with extensive right sided bullous formation, mediastinal shift, and subsequent left sided atelectasis. A paediatric Swan-Ganz catheter was used for selective bronchial occlusion with dramatic improvement in the infant''s clinical condition and radiographic findings.     

Treatment of giant pulmonary interstitial emphysema by ipsilateral bronchial occlusion with a Swan-Ganz catheter

Background Unilateral giant pulmonary interstitial emphysema (PIE) can be seen as a complication of chronic ventilation in extremely low-birth-weight babies. Many can be managed by conventional pulmonary care which includes positioning, suctioning, chest physiotherapy, gentle conventional ventilation and high-frequency ventilation. Some may need invasive procedures such as lung puncture, pleurotomies and excisional surgery. This is the group in which single-lung ventilation may be beneficial and circumvent the need for an invasive procedure. Objective We describe the technique of single-lung ventilation using a Swan-Ganz catheter to block the main stem bronchus on the diseased side in air-leak syndromes. Materials and methods A retrospective chart review was done on 17 newborns undergoing single-lung ventilation using this technique at the Children’s Hospital of New York, Columbia University, from 1986 to 2000. Results The technique was successful in the management of severe, neonatal unilateral lung disease not responsive to conventional modes of therapy in all but two neonates as seen by a significant improvement in pH and a decrease in PaCO₂ levels. In one neonate malpositioning of the Swan-Ganz catheter balloon could have contributed to the development of pneumothorax. Conclusion The described technique of single-lung ventilation provides a safe, minimally invasive and economically feasible method of management of unilateral giant PIE in newborns not responsive to conventional modes of therapy with minimal complications.     

Chronic pulmonary disease in neonates after artificial ventilation: distribution of ventilation and pulmonary interstitial emphysema.

To determine pulmonary function abnormalities in patients with neonatal bronchopulmonary dysplasia (BPD), we measured distribution of ventilation by nitrogen washout, minute and tidal volume, and arterial and alveolar gases in three groups of ten preterm infants with similar birth weights (mean = 1,340 g) and gestational ages (mean = 30.3 weeks). Infants in group A were never artificially ventilated, those in group B were ventilated but had no subsequent BPD, and those in group C were ventilated and developed BPD. Infants with BPD had severe maldistribution of ventilation (pulmonary clearance delay 223% versus 47% and 60% for groups A and B). They had decreased tidal volumes (5.3 ml versus 7.0 and 6.2 ml) and higher respiratory rates (60/min versus 47 and 48) but similar minute volumes. They also had increased PaCO2 (53.6 torr versus 41.9 and 43.4 torr) and increased arterial-alveolar carbon dioxide gradients (6.8 torr versus 3.1 and 1.8 torr). There was no statistically significant difference between groups B and C for the time spent in fractional inspired oxygen greater than 0.40 and greater than 0.60, or the time ventilated for intubated, or the incidence of patent ductus arteriosus. Early pulmonary interstitial emphysema was much more common in the infants who subsequently developed BPD (eight of ten versus two of ten, P less than .01).     

One-sided high-frequency oscillating ventilation in the treatment of neonatal unilateral pulmonary emphysema

We describe a preterm infant (31 weeks' gestation) with unilateral pulmonary emphysema. Bronchoscopy showed no bronchial obstruction. After 20 days of right-sided high-frequency oscillating ventilation, the emphysema in the left lung had completely resolved and the patient could be extubated.     

Advances in mechanical ventilation: high frequency ventilation.

High frequency oscillatory ventilation (HFOV) is a technique in which a small tidal volume of airway gas is vibrated by moving a piston at an extremely fast rate (15 Hz). By this technique infants are ventilated in less traumatic ways compared to the conventional mechanical ventilation (CMV). The control study performed in Japan showed the efficacy and safety of HFOV compared to CMV.     

Treatment of unilateral space-occupying pulmonary interstitial emphysema with positioning measures and high-frequency ventilation

Five very low birthweight infants manifested unilateral tension pulmonary interstitial emphysema (PIE). All infants required intermittent positive pressure ventilation for respiratory distress syndrome. PIE was managed by positioning the infant on his (or her) side with PIE and by shortening the inspiratory time, in four patients also by shortening exspiratory time resulting in a higher frequency ventilation. PIE resolved within 3-6 days after institution of this treatment. This was paralleled by a reduction of FiO2 as well as peak inspiratory pressures. All infants could successfully be extubated 2-6 weeks after birth.     

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.     

Bronchopleural fistula: successful selective bronchial occlusion with a Fogarty's catheter in a preterm infant

A preterm infant (26 weeks'gestation) mechanically ventilated for respiratory distress syndrome developed severe interstitial emphysema of the right lung with a bronchopleural fistula, pneumothorax and mediastinal shift. Selective occlusion of the right main bronchus with a Fogarty's catheter produced rapid improvement in the clinical condition and radiological features. Occlusion of the main bronchus in a newborn with a bronchopleural fistula and pulmonary interstitial emphysema is an easily performed manoeuvre that can be life-saving. Bronchopleural fistula, neonatal respiratory distress syndrome, pulmonary interstitial emphysema, selective bronchial occlusion     

Combined conventional ventilation with high frequency oscillation in neonates

Combined high frequency oscillation (HFO) with conventional ventilation was used on a group of 12 ventilator dependent neonates in order to investigate the frequency response of the respiratory system to HFO. Pressure oscillations were measured at the airway opening with a transducer and volume oscillations at the chest wall using a calibrated respiratory jacket. Pressure oscillations increased with increasing frequency but the oscillating volumes showed a variable pattern with maximum oscillating volumes of up to 4 ml/kg. Three babies showed no change in volume between 2–25 Hz, 3 babies showed increasing volumes up to 25 Hz and the remainder showed a maximum volume (or resonant frequency) at 15–20 Hz. Oscillating volumes were higher when the conventional ventilator was in the expiratory phase. The differences in frequency response were unrelated to severity of lung disease, birth weight, age at testing, or size of the endotracheal (ET) tube. Local factors in the ET tube and large airways may account for some of the observed differences.     

高频振荡通气在新生儿重症肺疾病中的应用

目的　 为观察高频振荡通气 (HFOV)治疗新生儿重症肺疾病的应用价值及安全性。 方法 　 2 7例新生儿重症肺疾病 ,15例应用HFOV治疗 ,12例应用常频机械通气 (CMV)治疗 ,观察治疗前后 2 4h内氧合参数及呼吸机参数的变化。 结果 　HFOV组 2 4h内氧浓度 (FiO2 )迅速从 ( 0 85± 0 11)降至 ( 0 5 3± 0 0 8) ,P <0 0 1;平均气道压 (MAP)从 ( 15 3± 1 8)cmH2 O降至( 11 2± 2 1)cmH2 O(P <0 0 1) ,氧合指数 (OI)从 ( 3 4± 10 )降至 ( 2 0± 4) (P <0 0 1) ,二氧化碳分压 (PCO2 )从 ( 6 9± 0 8)kPa迅速降至 ( 5 4± 0 9)kPa(P <0 0 1)。HFOV期间血压、心率无明显变化。 结论 　HFOV治疗新生儿重症肺疾病 ,通气效果优于CMV ,氧合改善快 ,短时间内氧浓度、MAP下降更快 ,是一种疗效肯定、安全性好的新型机械通气方法。     

肺表面活性物质、一氧化氮吸入联合高频振荡通气治疗新生儿持续肺动脉高压（附3例报告）

<正>新生儿持续肺动脉高压(persistent pulmonary hypertension of the newborn,PPHN)是导致低氧性呼吸衰竭(hypoxic respiratory failure,HRF)最常见的原因,且一直是新生儿领域的一大难题。肺表面活性物质(PS)替代治疗、机械通气(常频或高频)、一     

高频振荡通气下吸人低氧建立大鼠急性肺动脉高压模型

目的观察高频振荡通气(HFO)下吸入12%的氧建立大鼠急性缺氧性肺动脉高压模型的可行性.方法动物麻醉后气管插管,在HFO下给大鼠吸入12%的氧,连续观察肺动脉压(PAP)的变化,测定吸入12%的氧气后5、10、15、30和40min各时间点PAP值,观察基础和吸入12%氧气后的血液气体交换.结果18只大鼠进入实验组,均在30min内达到低氧肺动脉高压的诊断标准①PaO2＜8 kPa,(2)PAP升高幅度〉25%.MPAP下降15min较基础值有显著差异(t=-2.90,P＜0.05);②HR变化较基础值无差异(t=0.32,P〉0.05),PaCO2和肺内动静脉分流(Qs/Qt)均无显著性差异(分别为t=0.25,t=0.70,P＞0.05).结论HFO下吸入12%的氧30min,可复制稳定的急性缺氧大鼠肺动脉高压模型.     

Nasal high frequency ventilation in neonates with moderate respiratory insufficiency

AIM—To investigate the efficacy of nasal high frequency ventilation (nHFV) in newborn infants with moderate respiratory insufficiency.METHOD—Twenty one preterm and term neonates were treated with nHFV for respiratory insufficiency. Criteria for starting nHFV were: deterioration on nasal CPAP expressed by a median pH of 7.24 and pCO₂ of 8.3 kPa, or increasing FIO₂. nHFV was delivered using the Infant Star ventilator. Ventilator setting amplitude was 35cm H₂O; mean airway pressure 7 cm H₂O; and frequency 10Hz.RESULTS—pCO₂ decreased significantly from 8.3 kPa to 7.2 kPa after nHFV was started. In five patients nHFV was discontinued after a median period of 61/2 hours due to CO₂ retention and high oxygen need, and endotracheal mechanical ventilation was started.CONCLUSIONS—nHFV can reduce pCO₂ in neonates with moderate respiratory insufficiency and, therefore, could be used to decrease the need for endotracheal mechanical ventilation.     

Necrotizing tracheobronchitis following high frequency ventilation: effect of hydrocortisone

A piglet model of acute respiratory failure was used to determine whether necrotizing tracheobronchitis (NTB) produced during high-frequency pneumatic flow interrupter (HFFI) ventilation could be attenuated by prior administration of 2 mg/kg hydrocortisone IV. Fourteen piglets (means age 3.6 days, means wt 1.4 kg) were anesthetized and paralyzed before saline lung lavage. The animals were randomly assigned to either placebo (P) or hydrocortisone (H) group. Continuous HFFI (10 Hz) was interrupted five times per minute by a 1-second deflationary pause. All animals were kept on 1.0 FI02 with ventilators adjusted to maintain adequate arterial blood gases. Airway pressures were similar for both groups. After 8 hours of ventilation the animals were sacrificed and their lungs inflated with formalin to 40 cm H2O. Sections were obtained from trachea, carina, main stem, and peripheral bronchi. A total airway injury (TAIS) was calculated by a pathologist unaware of treatment assignment. There was a significant difference (p less than 0.01, Wilcoxon rank sum) in TAIS scores between P (means 21.3) and H (means 7.8). In five out of seven P animals and in one out of seven H animals, NTB was severe and extended to the hilar bronchi. Although NTB is multifactorial in origin, the prior use of hydrocortisone may decrease the severity and extent of lesions by modifying the inflammatory response to this specific airway injury.     

胎粪吸入性肺炎应用常频与高频通气的研究

目的　 评估常频通气和高频通气治疗胎粪吸入性肺炎 (MAS)所致呼吸衰竭的临床与实验对比疗效。 方法 　实验方面 :健康白兔 ,气管注入胎粪混悬液 ( 3～ 5ml/kg) ,呼吸衰竭模型出现后随机分组 :①继续常频通气 (CMV) 3h后转为高频通气 (HFV) 3h(CMV HFV组 ) ;②转为HFV 3h后再转为CMV 3h(HFV CMV组 )。 2 0例MAS患儿入院后即用CMV治疗 ,当所用吸入氧浓度 (FiO2 ) >0 82h左右 ,经皮氧饱和度 (TcPO2 )仍 <90 %,改为HFV治疗 ;当FiO2 >0 82h左右 ,TcPO2 能维持在90 %以上 ,继续用CMV治疗。 10例继续应用CMV治疗 ,10例改用HFV治疗。 结果 　动物出现呼吸衰竭模型时 ( 0h)的氧合指数 (OI)二组无差异 ,CMV HFV组在治疗后 3hOI无明显变化 ,至 6hOI有上升 ;HFV CMV组治疗后 3hOI较 0h时有下降 ,两组动物治疗后 3h的OI的组间比较有差异。 2 0例患儿中 ,CMV组治愈 7例 ,死亡 2例 ,放弃 1例 ;HFV组治愈 7例 ,放弃 2例 ,死亡1例。HFV组患儿治疗后 1hOI较 0h有下降 ,至治疗后 6h ,OI与 0h比较差异显著 ;CMV组治疗后 1hOI有明显下降 ,但至治疗后 6h下降幅度不明显。二组患儿的呼吸机应用时间和用氧时间均无差异。 结论 　MAS用HFV治疗后的氧合作用较CMV改善明显和吸入氧浓度下降迅速     

高频振荡通气治疗新生儿肺透明膜病文献的Meta分析

目的　综合比较高频振荡通气 (HFOV)与传统机械通气 (CMV)对新生儿肺透明膜病的治疗作用及其潜在危害性。方法　通过数据库检索出符合纳入分析条件的相关文献 12篇 ,采用Meta分析方法进行定性、定量综合分析 ,得出合并OR值及其 95 %可信区间。结果　与CMV相比 ,HFOV能明显改善肺透明膜病患儿的呼吸功能 (P <0 0 0 5 )以及降低慢性肺部疾病的发生率 (P <0 0 1) ,但增加新生儿颅内出血的危险性 (P <0 0 5 ) ;在两种通气方式引起的气漏方面 ,无明显差异 (P >0 0 5 )。结论　应用HFOV治疗新生儿肺透明膜病的效果优于CMV ,并可减少慢性肺部疾病的发生 ,但应注意其它并发症的出现。