Publications by authors named "Charles C Roehr"

49 Publications

Should Newborns with Refractory Chylothorax Be Tried on Higher Dose of Octreotide?

Neonatology 2021 Jan 25:1-5. Epub 2021 Jan 25.

Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.

Chylothorax is a rare but life-threatening condition in newborns, often requiring a prolonged hospital stay. To date, no unified guidance exists for best management approach. Octreotide, a somatostatin analogue, has been used to treat neonatal chylothorax due to its effect on the splanchnic circulation and lipid absorption. It is administered either subcutaneously or intravenously; for the latter, a dose range between 1 and 10 µg/kg/h is most commonly used. However, the optimal dose and way of administration remain unclear. Here, we report 2 newborn cases with large volume chylothorax (>500 mL/day), one with congenital chylothorax and one following a repair of a congenital diaphragmatic hernia (post-operative form). In both cases, a significant and sustained reduction in the volume of evacuated chyle was only seen once the dose of intravenous octreotide was increased to 20 µg/kg/h. We suggest that high-dose octreotide can be considered in seemingly refractory cases of neonatal chylothorax.
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http://dx.doi.org/10.1159/000512461DOI Listing
January 2021

Neonatal Life Support 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Resuscitation 2020 Nov 21;156:A156-A187. Epub 2020 Oct 21.

This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
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http://dx.doi.org/10.1016/j.resuscitation.2020.09.015DOI Listing
November 2020

Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Circulation 2020 Oct 21;142(16_suppl_1):S185-S221. Epub 2020 Oct 21.

This (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
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http://dx.doi.org/10.1161/CIR.0000000000000895DOI Listing
October 2020

Neonates in the COVID-19 pandemic.

Pediatr Res 2020 Aug 3. Epub 2020 Aug 3.

Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

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http://dx.doi.org/10.1038/s41390-020-1096-yDOI Listing
August 2020

Inclusion of children and pregnant women in COVID-19 intervention trials.

Pediatr Res 2020 Jul 20. Epub 2020 Jul 20.

Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands.

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http://dx.doi.org/10.1038/s41390-020-1067-3DOI Listing
July 2020

European consensus recommendations for neonatal and paediatric retrievals of positive or suspected COVID-19 patients.

Pediatr Res 2020 Jul 7. Epub 2020 Jul 7.

Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden.

Background: The 2020 novel coronavirus (SARS-Cov-2) pandemic necessitates tailored recommendations addressing specific procedures for neonatal and paediatric transport of suspected or positive COVID-19 patients. The aim of this consensus statement is to define guidelines for safe clinical care for children needing inter-facility transport while making sure that the clinical teams involved are sufficiently protected from SARS-CoV-2.

Methods: A taskforce, composed of members of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) Transport section and the European Society for Paediatric Research (ESPR), reviewed the published literature and used a rapid, two-step modified Delphi process to formulate recommendations regarding safety and clinical management during transport of COVID-19 patients.

Results: The joint taskforce consisted of a panel of 12 experts who reached an agreement on a set of 17 recommendations specifying pertinent aspects on neonatal and paediatric COVID-19 patient transport. These included: case definition, personal protective equipment, airway management, equipment and strategies for invasive and non-invasive ventilation, special considerations for incubator and open stretcher transports, parents on transport and decontamination of transport vehicles.

Conclusions: Our consensus recommendations aim to define current best-practice and should help guide transport teams dealing with infants and children with COVID-19 to work safely and effectively.

Impact: We present European consensus recommendations on pertinent measures for transporting infants and children in times of the coronavirus (SARS-Cov-2 /COVID-19) pandemic.A panel of experts reviewed the evidence around transporting infants and children with proven or suspected COVID-19. Specific guidance on aspects of personal protective equipment, airway management and considerations for incubator and open stretcher transports is presented.Based on scant evidence, best-practice recommendations for neonatal and paediatric transport teams are presented, aiming for the protection of teams and patients. We highlight gaps in knowledge and areas of future research.
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http://dx.doi.org/10.1038/s41390-020-1050-zDOI Listing
July 2020

International comparison of guidelines for managing neonates at the early phase of the SARS-CoV-2 pandemic.

Pediatr Res 2020 Jun 15. Epub 2020 Jun 15.

Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

Background: The COVID-19 pandemic threatens global newborn health. We describe the current state of national and local protocols for managing neonates born to SARS-CoV-2-positive mothers.

Methods: Care providers from neonatal intensive care units on six continents exchanged and compared protocols on the management of neonates born to SARS-CoV-2-positive mothers. Data collection was between March 14 and 21, 2020. We focused on central protocol components, including triaging, hygiene precautions, management at delivery, feeding protocols, and visiting policies.

Results: Data from 20 countries were available. Disease burden varied between countries at the time of analysis. In most countries, asymptomatic infants were allowed to stay with the mother and breastfeed with hygiene precautions. We detected discrepancies between national guidance in particular regarding triaging, use of personal protection equipment, viral testing, and visitor policies. Local protocols deviated from national guidance.

Conclusions: At the start of the pandemic, lack of evidence-based guidance on the management of neonates born to SARS-CoV-2-positive mothers has led to ad hoc creation of national and local guidance. Compliance between collaborators to share and discuss protocols was excellent and may lead to more consensus on management, but future guidance should be built on high-level evidence, rather than expert consensus.

Impact: At the rapid onset of the COVID19 pandemic, all countries presented protocols in place for managing infants at risk of COVID19, with a certain degree of variations among regions.A detailed review of ad hoc guidelines is presented, similarities and differences are highlighted.We provide a broad overview of currently applied recommendations highlighting the need for international context-relevant coordination.
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http://dx.doi.org/10.1038/s41390-020-0976-5DOI Listing
June 2020

Pulmonary hypertension in bronchopulmonary dysplasia.

Pediatr Res 2020 Jun 10. Epub 2020 Jun 10.

Division of Pediatric Cardiology, Medical University of Graz, Graz, Austria.

Bronchopulmonary dysplasia (BPD) is a major complication in prematurely born infants. Pulmonary hypertension (PH) associated with BPD (BPD-PH) is characterized by alveolar diffusion impairment, abnormal vascular remodeling, and rarefication of pulmonary vessels (vascular growth arrest), which lead to increased pulmonary vascular resistance and right heart failure. About 25% of infants with moderate to severe BPD develop BPD-PH that is associated with high morbidity and mortality. The recent evolution of broader PH-targeted pharmacotherapy in adults has opened up new treatment options for infants with BPD-PH. Sildenafil became the mainstay of contemporary BPD-PH therapy. Additional medications, such as endothelin receptor antagonists and prostacyclin analogs/mimetics, are increasingly being investigated in infants with PH. However, pediatric data from prospective or randomized controlled trials are still sparse. We discuss comprehensive diagnostic and therapeutic strategies for BPD-PH and briefly review the relevant differential diagnoses of parenchymal and interstitial developmental lung diseases. In addition, we provide a practical framework for the management of children with BPD-PH, incorporating the modified definition and classification of pediatric PH from the 2018 World Symposium on Pulmonary Hypertension, and the 2019 EPPVDN consensus recommendations on established and newly developed therapeutic strategies. Finally, current gaps of knowledge and future research directions are discussed. IMPACT: PH in BPD substantially increases mortality. Treatment of BPD-PH should be conducted by an interdisciplinary team and follow our new treatment algorithm while still kept tailored to the individual patient.We discuss recent developments in BPD-PH, make recommendations on diagnosis, monitoring and treatment of PH in BPD, and address current gaps of knowledge and potential research directions.We provide a practical framework, including a new treatment algorithm, for the management of children with BPD-PH, incorporating the modified definition and classification of pediatric PH (2018 WSPH) and the 2019 EPPVDN consensus recommendations on established and newly developed therapeutic strategies for BPD-PH.
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http://dx.doi.org/10.1038/s41390-020-0993-4DOI Listing
June 2020

Study protocol: NeoCLEAR: Neonatal Champagne Lumbar punctures Every time - An RCT: a multicentre, randomised controlled 2 × 2 factorial trial to investigate techniques to increase lumbar puncture success.

BMC Pediatr 2020 04 15;20(1):165. Epub 2020 Apr 15.

Newborn Care Unit, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, OX3 9DU, UK.

Background: The neonatal period carries the highest risk of bacterial meningitis (~ 1 in 5000 births), bearing high mortality (~ 10%) and morbidity (20-50%) rates. Lumbar puncture (LP) remains essential to the diagnosis of meningitis. Though LP is a common procedure in neonates, success rates are lower (50-60%) than in other patient populations. None of the currently-practised neonatal LP techniques are supported by evidence from adequately-powered, randomised controlled trials (RCTs). NeoCLEAR aims to compare two modifications to the traditional technique which are free, accessible, and commonly practised: sitting (as opposed to lying) position, and 'early' (as opposed to 'late') stylet removal.

Methods/design: Written parental informed consent permitting, infants in neonatal/maternity wards, of 27 to 44 weeks corrected gestational age and weighing ≥1000 g, who require an LP, will be randomly allocated to sitting or lying position, and to early or late stylet removal. The co-primary objectives are to compare success rates (the proportion of infants with cerebrospinal fluid red cell count < 10,000/mm on first LP procedure) in 1020 infants between the two positions, and between the two methods of stylet removal. Secondary outcomes relate to LP procedures, complications, diagnoses of meningitis, duration of antibiotics and hospital stay. A modified intention-to-treat analysis will be conducted.

Discussion: Two modifications to the traditional LP technique (sitting vs lying position; and early vs late stylet removal) will be simultaneously investigated in an efficient and appropriately-powered 2 × 2 factorial RCT design. Analysis will identify the optimal techniques (in terms of obtaining easily-interpretable cerebrospinal fluid), as well as the impact on infants, parents and healthcare systems whilst providing robust safety data. Using a pragmatic RCT design, all practitioners will be trained in all LP techniques, but there will inevitably be variation between unit practice guidelines and other aspects of individual care. An improved LP technique would result in: • Fewer uninterpretable samples, repeated attempts and procedures • Reduced distress for infants and families • Decreased antibiotic use and risk of antibiotic resistance • Reduced healthcare costs due to fewer procedures, reduced length of stay, shorter antibiotic courses, and minimised antibiotic-associated complications TRIAL REGISTRATION: ISRCTN14040914. Date assigned: 26/06/2018.
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http://dx.doi.org/10.1186/s12887-020-02050-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160994PMC
April 2020

Cranial ultrasound by neonatologists.

Pediatr Res 2020 03;87(Suppl 1):1-2

Université de Paris, NeuroDiderot, Inserm, Paris, France.

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http://dx.doi.org/10.1038/s41390-020-0779-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098880PMC
March 2020

The development and validation of a cerebral ultrasound scoring system for infants with hypoxic-ischaemic encephalopathy.

Pediatr Res 2020 03;87(Suppl 1):59-66

Department of Neonatology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.

Background: Hypoxic-ischaemic encephalopathy (HIE) is an important cause of morbidity and mortality in neonates. When the gold standard MRI is not feasible, cerebral ultrasound (CUS) might offer an alternative. In this study, the association between a novel CUS scoring system and neurodevelopmental outcome in neonates with HIE was assessed.

Methods: (Near-)term infants with HIE and therapeutic hypothermia, a CUS on day 1 and day 3-7 after birth and available outcome data were retrospectively included in cohort I. CUS findings on day 1 and day 3-7 were related to adverse outcome in univariate and the CUS of day 3-7 also in multivariable logistic regression analyses. The resistance index, the sum of deep grey matter and of white matter involvement were included in multivariable logistic regression analyses. A comparable cohort from another hospital was used for validation (cohort II).

Results: Eighty-three infants were included in cohort I and 35 in cohort II. The final CUS scoring system contained the sum of white matter (OR = 2.6, 95% CI 1.5-4.7) and deep grey matter involvement (OR = 2.7, 95% CI 1.7-4.4). The CUS scoring system performed well in cohort I (AUC = 0.90) and II (AUC = 0.89).

Conclusion: This validated CUS scoring system is associated with neurodevelopmental outcome in neonates with HIE.
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http://dx.doi.org/10.1038/s41390-020-0782-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098882PMC
March 2020

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

Authors:
Jasmeet Soar Ian Maconochie Myra H Wyckoff Theresa M Olasveengen Eunice M Singletary Robert Greif Richard Aickin Farhan Bhanji Michael W Donnino Mary E Mancini Jonathan P Wyllie David Zideman Lars W Andersen Dianne L Atkins Khalid Aziz Jason Bendall Katherine M Berg David C Berry Blair L Bigham Robert Bingham Thomaz Bittencourt Couto Bernd W Böttiger Vere Borra Janet E Bray Jan Breckwoldt Steven C Brooks Jason Buick Clifton W Callaway Jestin N Carlson Pascal Cassan Maaret Castrén Wei-Tien Chang Nathan P Charlton Adam Cheng Sung Phil Chung Julie Considine Keith Couper Katie N Dainty Jennifer Anne Dawson Maria Fernanda de Almeida Allan R de Caen Charles D Deakin Ian R Drennan Jonathan P Duff Jonathan L Epstein Raffo Escalante Raúl J Gazmuri Elaine Gilfoyle Asger Granfeldt Anne-Marie Guerguerian Ruth Guinsburg Tetsuo Hatanaka Mathias J Holmberg Natalie Hood Shigeharu Hosono Ming-Ju Hsieh Tetsuya Isayama Taku Iwami Jan L Jensen Vishal Kapadia Han-Suk Kim Monica E Kleinman Peter J Kudenchuk Eddy Lang Eric Lavonas Helen Liley Swee Han Lim Andrew Lockey Bo Lofgren Matthew Huei-Ming Ma David Markenson Peter A Meaney Daniel Meyran Lindsay Mildenhall Koenraad G Monsieurs William Montgomery Peter T Morley Laurie J Morrison Vinay M Nadkarni Kevin Nation Robert W Neumar Kee-Chong Ng Tonia Nicholson Nikolaos Nikolaou Chika Nishiyama Gabrielle Nuthall Shinichiro Ohshimo Deems Okamoto Brian O'Neil Gene Yong-Kwang Ong Edison F Paiva Michael Parr Jeffrey L Pellegrino Gavin D Perkins Jeffrey Perlman Yacov Rabi Amelia Reis Joshua C Reynolds Giuseppe Ristagno Charles C Roehr Tetsuya Sakamoto Claudio Sandroni Stephen M Schexnayder Barnaby R Scholefield Naoki Shimizu Markus B Skrifvars Michael A Smyth David Stanton Janel Swain Edgardo Szyld Janice Tijssen Andrew Travers Daniele Trevisanuto Christian Vaillancourt Patrick Van de Voorde Sithembiso Velaphi Tzong-Luen Wang Gary Weiner Michelle Welsford Jeff A Woodin Joyce Yeung Jerry P Nolan Mary Fran Hazinski

Resuscitation 2019 12 14;145:95-150. Epub 2019 Nov 14.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.
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http://dx.doi.org/10.1016/j.resuscitation.2019.10.016DOI Listing
December 2019

2019 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces.

Authors:
Jasmeet Soar Ian Maconochie Myra H Wyckoff Theresa M Olasveengen Eunice M Singletary Robert Greif Richard Aickin Farhan Bhanji Michael W Donnino Mary E Mancini Jonathan P Wyllie David Zideman Lars W Andersen Dianne L Atkins Khalid Aziz Jason Bendall Katherine M Berg David C Berry Blair L Bigham Robert Bingham Thomaz Bittencourt Couto Bernd W Böttiger Vere Borra Janet E Bray Jan Breckwoldt Steven C Brooks Jason Buick Clifton W Callaway Jestin N Carlson Pascal Cassan Maaret Castrén Wei-Tien Chang Nathan P Charlton Adam Cheng Sung Phil Chung Julie Considine Keith Couper Katie N Dainty Jennifer Anne Dawson Maria Fernanda de Almeida Allan R de Caen Charles D Deakin Ian R Drennan Jonathan P Duff Jonathan L Epstein Raffo Escalante Raúl J Gazmuri Elaine Gilfoyle Asger Granfeldt Anne-Marie Guerguerian Ruth Guinsburg Tetsuo Hatanaka Mathias J Holmberg Natalie Hood Shigeharu Hosono Ming-Ju Hsieh Tetsuya Isayama Taku Iwami Jan L Jensen Vishal Kapadia Han-Suk Kim Monica E Kleinman Peter J Kudenchuk Eddy Lang Eric Lavonas Helen Liley Swee Han Lim Andrew Lockey Bo Lofgren Matthew Huei-Ming Ma David Markenson Peter A Meaney Daniel Meyran Lindsay Mildenhall Koenraad G Monsieurs William Montgomery Peter T Morley Laurie J Morrison Vinay M Nadkarni Kevin Nation Robert W Neumar Kee-Chong Ng Tonia Nicholson Nikolaos Nikolaou Chika Nishiyama Gabrielle Nuthall Shinichiro Ohshimo Deems Okamoto Brian O'Neil Gene Yong-Kwang Ong Edison F Paiva Michael Parr Jeffrey L Pellegrino Gavin D Perkins Jeffrey Perlman Yacov Rabi Amelia Reis Joshua C Reynolds Giuseppe Ristagno Charles C Roehr Tetsuya Sakamoto Claudio Sandroni Stephen M Schexnayder Barnaby R Scholefield Naoki Shimizu Markus B Skrifvars Michael A Smyth David Stanton Janel Swain Edgardo Szyld Janice Tijssen Andrew Travers Daniele Trevisanuto Christian Vaillancourt Patrick Van de Voorde Sithembiso Velaphi Tzong-Luen Wang Gary Weiner Michelle Welsford Jeff A Woodin Joyce Yeung Jerry P Nolan Mary Fran Hazinski

Circulation 2019 12 14;140(24):e826-e880. Epub 2019 Nov 14.

The International Liaison Committee on Resuscitation has initiated a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation science. This is the third annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. It addresses the most recent published resuscitation evidence reviewed by International Liaison Committee on Resuscitation Task Force science experts. This summary addresses the role of cardiac arrest centers and dispatcher-assisted cardiopulmonary resuscitation, the role of extracorporeal cardiopulmonary resuscitation in adults and children, vasopressors in adults, advanced airway interventions in adults and children, targeted temperature management in children after cardiac arrest, initial oxygen concentration during resuscitation of newborns, and interventions for presyncope by first aid providers. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the certainty of the evidence on the basis of the Grading of Recommendations, Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence to Decision Framework Highlights sections. The task forces also listed priority knowledge gaps for further research.
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http://dx.doi.org/10.1161/CIR.0000000000000734DOI Listing
December 2019

Increasing Respiratory Effort With 100% Oxygen During Resuscitation of Preterm Rabbits at Birth.

Front Pediatr 2019 22;7:427. Epub 2019 Oct 22.

School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia.

Spontaneous breathing is essential for successful non-invasive respiratory support delivered by a facemask at birth. As hypoxia is a potent inhibitor of spontaneous breathing, initiating respiratory support with a high fraction of inspired O may reduce the risk of hypoxia and increase respiratory effort at birth. Preterm rabbit kittens (29 days gestation, term ~32 days) were delivered and randomized to receive continuous positive airway pressure with either 21% ( = 12) or 100% O ( = 8) via a facemask. If apnea occurred, intermittent positive pressure ventilation (iPPV) was applied with either 21% or 100% O in kittens who started in 21% O, and remained at 100% O for kittens who started the experiment in 100% O. Respiratory rate (breaths per minute, bpm) and variability in inter-breath interval (%) were measured from esophageal pressure recordings and functional residual capacity (FRC) was measured from synchrotron phase-contrast X-ray images. Initially, kittens receiving 21% O had a significantly lower respiratory rate and higher variability in inter-breath interval, indicating a less stable breathing pattern than kittens starting in 100% O [median (IQR) respiratory rate: 16 (4-28) vs. 38 (29-46) bpm, = 0.001; variability in inter-breath interval: 33.3% (17.2-50.1%) vs. 27.5% (18.6-36.3%), = 0.009]. Apnea that required iPPV, was more frequently observed in kittens in whom resuscitation was started with 21% compared to 100% O (11/12 vs. 1/8, = 0.001). After recovering from apnea, respiratory rate was significantly lower and variability in inter-breath interval was significantly higher in kittens who received iPPV with 21% compared to 100% O. FRC was not different between study groups at both timepoints. Initiating resuscitation with 100% O resulted in increased respiratory activity and stability, thereby reducing the risk of apnea and need for iPPV after birth. Further studies in human preterm infants are mandatory to confirm the benefit of this approach in terms of oxygenation. In addition, the ability to avoid hyperoxia after initiation of resuscitation with 100% oxygen, using a titration protocol based on oxygen saturation, needs to be clarified.
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http://dx.doi.org/10.3389/fped.2019.00427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6817611PMC
October 2019

Pigtail catheters versus traditional chest drains for pneumothorax treatment in two NICUs.

Eur J Pediatr 2020 Jan 26;179(1):73-79. Epub 2019 Oct 26.

Department of Biomedical Science and Human Oncology, Neonatology and Neonatal Intensive Care Section, University of Bari "Aldo Moro", Policlinico Hospital - Piazza Giulio Cesare n. 11, 70124, Bari, Italy.

Pneumothorax in newborns can be life-threatening. The traditional treatment of pneumothorax is chest drain placement. Recently, modified pigtail catheter has been proposed as a less traumatic approach despite limited experience in infants. To compare the effectiveness and safety of pigtail catheters versus traditional straight chest drains in term and preterm infants with pneumothorax, in two tertiary neonatal units: Policlinico Hospital in Bari, IT and John Radcliffe Hospital in Oxford, UK. We retrospectively reviewed medical records of 47 newborns with pneumothorax admitted to the two units between October 2009 and June 2017, and treated with either pigtail catheters or straight chest drains. Three newborns (6.7%) were excluded from the study because they were treated with both types of drains. The remaining 44 neonates were included in the analysis. Overall, 56.8% (n = 25/44) of pneumothoraces were drained with pigtail catheters and 43.2% (n = 19/44) with straight drains. No differences in gestational age and birth weight were found. The success rate, defined as complete radiological resolution of the pneumothorax after drainage, was significantly higher in the pigtail group (96.0% versus 73.7%; p < 0.05). Days of drainage, length of hospital stay and duration of respiratory support were not significantly different. Subcutaneous emphysema and drain dislodgement/malfunction occurred only in the straight drain group (0.0% versus 11.1%; p = 0.181). No significant differences in mortality between the two groups were found (28.0% pigtail group versus 26.3% straight drain group; p > 0.05).Conclusion: Pigtail catheters are a safe and effective alternative to traditional chest drains for infants with pneumothorax. What is Known:• Air leaks in newborns can represent an emergency, especially among preterms;• The first treatment in a life-threatening pneumothorax is thoracentesis with needle aspiration or placement of a chest drain.What is New:• Pigtail catheter have been described as an alternative to traditional chest drains;• Pigtail catheters are a safe and effective alternative to traditional chest drains for infants with pneumothorax.
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http://dx.doi.org/10.1007/s00431-019-03478-6DOI Listing
January 2020

European Respiratory Society guideline on long-term management of children with bronchopulmonary dysplasia.

Eur Respir J 2020 01 2;55(1). Epub 2020 Jan 2.

Dept of Pediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.

This document provides recommendations for monitoring and treatment of children in whom bronchopulmonary dysplasia (BPD) has been established and who have been discharged from the hospital, or who were >36 weeks of postmenstrual age. The guideline was based on predefined Population, Intervention, Comparison and Outcomes (PICO) questions relevant for clinical care, a systematic review of the literature and assessment of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. After considering the balance of desirable (benefits) and undesirable (burden, adverse effects) consequences of the intervention, the certainty of the evidence, and values, the task force made conditional recommendations for monitoring and treatment of BPD based on very low to low quality of evidence. We suggest monitoring with lung imaging using ionising radiation in a subgroup only, for example severe BPD or recurrent hospitalisations, and monitoring with lung function in all children. We suggest to give individual advice to parents regarding daycare attendance. With regards to treatment, we suggest the use of bronchodilators in a subgroup only, for example asthma-like symptoms, or reversibility in lung function; no treatment with inhaled or systemic corticosteroids; natural weaning of diuretics by the relative decrease in dose with increasing weight gain if diuretics are started in the neonatal period; and treatment with supplemental oxygen with a saturation target range of 90-95%. A multidisciplinary approach for children with established severe BPD after the neonatal period into adulthood is preferable. These recommendations should be considered until new and urgently needed evidence becomes available.
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http://dx.doi.org/10.1183/13993003.00788-2019DOI Listing
January 2020

Variations in preterm stabilisation practices and caffeine therapy between two European tertiary level neonatal units.

Acta Paediatr 2020 03 7;109(3):488-493. Epub 2019 Oct 7.

Newborn Services, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

Aim: To investigate interinstitutional differences in preterm infant stabilisation between two European tertiary neonatal centres with particular focus on intubation timing, surfactant administration, caffeine therapy and neonatal morbidity and mortality.

Methods: Retrospective (2012-2014) study of very low birth weight (VLBW) preterm infants admitted to John Radcliffe Hospital (UK centre) and Charité Medical Centre (German centre). Timing of intubation, surfactant and caffeine administration and respiratory outcomes were examined.

Results: Gestational age, birth weight and five-minute Apgar scores of VLBW infants from the UK centre (n = 86) were comparable to those from the German centre (n = 96). Significant differences in antenatal steroid therapy, intubation timing and surfactant therapy were noted. Timing of caffeine initiation differed significantly between centres (median 0 [0-2.5] UK vs. 2 [1.5-4] days German centre); however, caffeine was discontinued at a similar corrected gestational age of 34.7 weeks. Mechanical ventilation was significantly longer at the UK centre, but there was no difference in bronchopulmonary dysplasia (BPD) (44% UK vs. 36% German centre) or mortality (15% UK vs. 13% German centre).

Conclusion: Timing of primary intubation and caffeine therapy differed significantly between centres. However, earlier intubation and caffeine administration in the UK centre were not associated with a changed incidence of BPD.
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http://dx.doi.org/10.1111/apa.15011DOI Listing
March 2020

Platelet and red cell transfusions for neonates: lifesavers or Trojan horses?

Expert Rev Hematol 2019 10 29;12(10):797-800. Epub 2019 Aug 29.

Department of Pediatrics, Division of neonatology, Leiden University Medical Center , Leiden , the Netherlands.

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http://dx.doi.org/10.1080/17474086.2019.1657824DOI Listing
October 2019

Stimulating and maintaining spontaneous breathing during transition of preterm infants.

Pediatr Res 2019 Jun 19. Epub 2019 Jun 19.

Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.

Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.
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http://dx.doi.org/10.1038/s41390-019-0468-7DOI Listing
June 2019

European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update.

Neonatology 2019 11;115(4):432-450. Epub 2019 Apr 11.

Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, United Kingdom.

As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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http://dx.doi.org/10.1159/000499361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6604659PMC
December 2019

Tactile stimulation in the delivery room: do we practice what we preach?

Arch Dis Child Fetal Neonatal Ed 2019 Nov 1;104(6):F661-F662. Epub 2019 Mar 1.

Department of Paediatrics, University of Oxford, Oxford, UK.

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http://dx.doi.org/10.1136/archdischild-2018-316344DOI Listing
November 2019

Nasal High-Flow Therapy as Primary Respiratory Support for Preterm Infants without the Need for Rescue with Nasal Continuous Positive Airway Pressure.

Neonatology 2019 4;115(2):175-181. Epub 2018 Dec 4.

Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom,

Aim: To evaluate the effectiveness of nasal high-flow therapy (nHFT) as primary respiratory support for preterm infants with respiratory distress syndrome (RDS) in two tertiary neonatal units.

Methods: A retrospective outcome analysis of initial respiratory support strategies was performed in two tertiary neonatal units in the UK: John Radcliffe Hospital (JRH), Oxford and St Peter's Hospital (SPH), Chertsey. Infants born between 28+0 and 36+6 weeks gestational age (GA) between May 2013 and June 2015 were included.

Results: A total of 381 infants, 191 from JRH and 190 from SPH, were analysed. Infants were stabilised in the delivery room using mask continuous positive airway pressure followed by nHFT. Endotracheal intubation was performed according to local protocols, depending on the severity of RDS. There were significant differences in initial intubation rates according to GA (26% JRH vs. 16.9% SPH, p < 0.001 for babies < 32 weeks GA, and 8.2% JRH vs. 6.5% SPH, p < 0.001 for babies > 32 weeks GA); however, most infants were successfully transitioned to nHFT. Intubation rates during the first 72 h were comparable between centres (14.7% JRH vs. 11.1% SPH, p = 0.29). There were no differences in neonatal morbidities, including air leak, duration of oxygen supplementation, bronchopulmonary dysplasia, sepsis, retinopathy of prematurity, intraventricular haemorrhage, necrotising enterocolitis, or median time to full-suck feeds.

Conclusion: Use of nHFT for primary respiratory support, without use of nasal continuous positive airway pressure as "rescue" treatment, resulted in intubation rates lower or comparable to published data from randomised controlled trials.
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http://dx.doi.org/10.1159/000492930DOI Listing
December 2019

Delivery of positive end-expiratory pressure to preterm lambs using common resuscitation devices.

Arch Dis Child Fetal Neonatal Ed 2019 Jan 2;104(1):F83-F88. Epub 2018 Mar 2.

The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.

Background: In neonatal resuscitation, a ventilation device providing positive end-expiratory pressure (PEEP) is recommended. There is limited information about PEEP delivery in vivo, using different models of self-inflating bag (SIB) at different inflation rates and PEEP settings.

Methods: We compared PEEP delivery to intubated preterm lambs using four commonly available models of paired SIBs and PEEP valves, with a T-piece, with gas flow of 8 L/min. Peak inspiratory pressure inflations of 30 cmHO, combined with set PEEP of 5, 7 and 10 cmHO, were delivered at rates of 20, 40 and 60/min. These combinations were repeated without gas flow. We measured mean PEEP, maximum and minimum PEEP, and its difference (PEEP reduction).

Results: A total of 3288 inflations were analysed. The mean PEEP delivered by all SIBs was lower than set PEEP (P<0.001), although some differences were <0.5 cmHO. In 55% of combinations, the presence of gas flow resulted in increased PEEP delivery (range difference 0.3-2 cmHO). The mean PEEP was closer to set PEEP with faster inflation rates and higher set PEEPs. The mean (SD) PEEP reduction was 3.9 (1.6), 8.2 (1.8), 2 (0.6) and 1.1 (0.6) cmHO with the four SIBs, whereas it was 0.5 (0.2) cmHO with the T-piece.

Conclusions: PEEP delivery with SIBs depends on the set PEEP, inflation rate, device model and gas flow. At recommended inflation rates of 60/min, some devices can deliver PEEP close to the set level, although the reduction in PEEP makes some SIBs potentially less effective for lung recruitment than a T-piece.
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http://dx.doi.org/10.1136/archdischild-2017-314064DOI Listing
January 2019

The physiology of neonatal resuscitation.

Curr Opin Pediatr 2018 04;30(2):187-191

Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.

Purpose Of Review: As the infant's physiology changes dramatically after birth, modern neonatal resuscitation approaches should detect and be modified in response to these changes. This review describes the changes in respiratory physiology at birth and highlights approaches that can assist these changes.

Recent Findings: To better target assistance given to infants at birth, the changes in lung physiology have been classified into three phases. The first phase involves lung aeration. As little or no gas exchange can occur, assistance should focus on airway liquid clearance. During the second phase, as airway liquid resides in lung tissue, assistance should focus on minimizing the complications associated with lung edema. The third phase occurs whenever the liquid is cleared from the tissue and respiratory mechanics stabilize. Although more traditional approaches are most effective during this phase, this is not the case for the first two phases. Furthermore, the glottis actively adducts during apnea in newborns and so noninvasive respiratory support requires the infant to be breathing so that the glottis will open.

Summary: The respiratory support provided to infants at birth should match the infant's changing physiology during transition, which requires a more sophisticated approach and equipment than current recommendations.
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http://dx.doi.org/10.1097/MOP.0000000000000590DOI Listing
April 2018

The Use of Peritoneal Dialysis in Phenobarbitone Toxicity in a Critically Unwell Neonate.

Neonatology 2018 24;113(2):117-121. Epub 2017 Nov 24.

Department of Nephrology, Monash Children's Hospital, Clayton, VIC, Australia.

Background: Phenobarbitone (PB) is the first-line anti-convulsant for neonatal seizures. The use of peritoneal dialysis (PD) to enhance drug elimination in cases of neonatal PB overdose has not been reported.

Objective: To report a case of neonatal severe PB toxicity and review the elimination of PB by PD.

Methods: Assessment of PD drug clearance.

Results: A neonate with prolonged seizures was administered PB. Encephalopathy and myocardial failure developed, which were initially suspected to be secondary to hypoxia. At 42 h of age, the serum PB concentration was in the toxic range at 131 mg/L. Despite supportive care, the infant's condition deteriorated with escalating inotropes and the need for CPR. Enhanced PB elimination via multiple-dose activated charcoal and exchange transfusion were considered too risky. Hourly PD cycles via Tenckhoff catheter were commenced, based on reports suggesting that PD enhances PB clearance. The clinical state of the infant then improved. PD administration was continued for 60 h, recovering 20% of the estimated total PB body load. The infant survived and there were no PD complications.

Conclusions: PD increased PB clearance in this neonate, correlating with clinical recovery. Where other techniques are not possible, PD may have a role to play in enhancing PB elimination.
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http://dx.doi.org/10.1159/000481879DOI Listing
September 2019

Devices used for stabilisation of newborn infants at birth.

Arch Dis Child Fetal Neonatal Ed 2018 Jan 27;103(1):F66-F71. Epub 2017 Oct 27.

Department of Neonatology, James Cook University Hospital, Middlesbrough, UK.

This review examines devices used during newborn stabilisation. Evidence for their use to optimise the thermal, respiratory and cardiovascular management in the delivery room is presented. Mechanisms of action and rationale of use are described, current developments are presented and areas of future research are highlighted.
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http://dx.doi.org/10.1136/archdischild-2016-310797DOI Listing
January 2018

Laryngeal closure impedes non-invasive ventilation at birth.

Arch Dis Child Fetal Neonatal Ed 2018 Mar 20;103(2):F112-F119. Epub 2017 Oct 20.

The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia.

Background: Non-invasive ventilation is sometimes unable to provide the respiratory needs of very premature infants in the delivery room. While airway obstruction is thought to be the main problem, the site of obstruction is unknown. We investigated whether closure of the larynx and epiglottis is a major site of airway obstruction.

Methods: We used phase contrast X-ray imaging to visualise laryngeal function in spontaneously breathing premature rabbits immediately after birth and at approximately 1 hour after birth. Non-invasive respiratory support was applied via a facemask and images were analysed to determine the percentage of the time the glottis and the epiglottis were open.

Hypothesis: Immediately after birth, the larynx is predominantly closed, only opening briefly during a breath, making non-invasive intermittent positive pressure ventilation (iPPV) ineffective, whereas after lung aeration, the larynx is predominantly open allowing non-invasive iPPV to ventilate the lung.

Results: The larynx and epiglottis were predominantly closed (open 25.5%±1.1% and 17.1%±1.6% of the time, respectively) in pups with unaerated lungs and unstable breathing patterns immediately after birth. In contrast, the larynx and the epiglottis were mostly open (90.5%±1.9% and 72.3%±2.3% of the time, respectively) in pups with aerated lungs and stable breathing patterns irrespective of time after birth.

Conclusion: Laryngeal closure impedes non-invasive iPPV at birth and may reduce the effectiveness of non-invasive respiratory support in premature infants immediately after birth.
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http://dx.doi.org/10.1136/archdischild-2017-312681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5868244PMC
March 2018

Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge.

Neonatology 2017 2;112(2):163-171. Epub 2017 Jun 2.

Department of Paediatrics and Child Health, Cork University Maternity Hospital and University College Cork, Cork, Ireland.

Volume resuscitation (VR) for the treatment of newborn shock is a rare but potentially lifesaving intervention. Conducting clinical studies to assess the effectiveness of VR in the delivery room during newborn stabilization is challenging. We review the available literature and current management guidelines to determine which infants will benefit from VR, the frequency of VR, and the choice of agents used. In addition, the potential role for placental transfusion in the prevention of newborn shock is explored.
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http://dx.doi.org/10.1159/000475456DOI Listing
May 2018

Lung hypoplasia in newborn rabbits with a diaphragmatic hernia affects pulmonary ventilation but not perfusion.

Pediatr Res 2017 Sep 31;82(3):536-543. Epub 2017 May 31.

Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Australia.

BackgroundA congenital diaphragmatic hernia (DH) can result in severe lung hypoplasia that increases the risk of morbidity and mortality after birth; however, little is known about the cardiorespiratory transition at birth.MethodsUsing phase-contrast X-ray imaging and angiography, we examined the cardiorespiratory transition at birth in rabbit kittens with DHs. Surgery was performed on pregnant New Zealand white rabbits (n=18) at 25 days' gestation to induce a left-sided DH. Kittens were delivered at 30 days' gestation, intubated, and ventilated to achieve a tidal volume (V) of 8 ml/kg in control and 4 ml/kg in DH kittens while they were imaged.ResultsFunctional residual capacity (FRC) recruitment and V in the hypoplastic left lung were markedly reduced, resulting in a disproportionate distribution of FRC into the right lung. Following lung aeration, relative pulmonary blood flow (PBF) increased equally in both lungs, and the increase in pulmonary venous return was similar in both control and DH kittens.ConclusionThese findings indicate that nonuniform lung hypoplasia caused by DH alters the distribution of ventilation away from hypoplastic and into normally grown lung regions. During transition, the increase in PBF and pulmonary venous return, which is vital for maintaining cardiac output, is not affected by lung hypoplasia.
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http://dx.doi.org/10.1038/pr.2017.91DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605670PMC
September 2017