Publications by authors named "Gerd Schmalisch"

67 Publications

Insights Image for "Rate of rise of total serum bilirubin in very low birth weight preterm infants".

Pediatr Res 2020 05 11;87(6):1135. Epub 2019 Nov 11.

Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany.

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http://dx.doi.org/10.1038/s41390-019-0674-3DOI Listing
May 2020

Rate of rise of total serum bilirubin in very low birth weight preterm infants.

Pediatr Res 2020 05 13;87(6):1039-1044. Epub 2019 May 13.

Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany.

Background: To assess the postnatal rate of rise (ROR) of total serum bilirubin (TSB) in very low birth weight (VLBW) preterm infants, to determine risk factors associated with a rapid rise (>90th percentile), and to compare ROR and hour-specific TSB at postnatal 12-48 h with data of term infants retrieved from the literature.

Methods: Retrospective analysis of 2430 routine TSB concentrations obtained between birth and initiation of phototherapy in 483 VLBW infants.

Results: TSB increased by a median (interquartile range) ROR of 0.15 (0.11-0.19) mg/dL/h. The 50th percentile of TSB was below the 40th percentile of (near-)term counterparts at 12-48 h. TSB ROR correlated with the age at initiation (R = -0.687; p < 0.001) and the duration (R = 0.444; p < 0.001) of phototherapy. ROR >90th percentile (>0.25 mg/dL/h) was associated with lower gestational ages [27.2 (25.4-29.3) vs. 28.4 (26.4-30.4) weeks], lower birth weights [978 (665-1120) vs. 1045 (814-1300) g], and lower 5-min Apgar scores [7 (7-8) vs. 8 (7-9)].

Conclusion: ROR of TSB is an indicator for early and prolonged phototherapy. While hour-specific TSB and ROR at 12-48 h are lower than those reported for (near-)term infants, TSB appears to rise more rapidly in infants with low gestational age, low birth weight, and low 5-min Apgar score.
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http://dx.doi.org/10.1038/s41390-019-0415-7DOI Listing
May 2020

Differential impact of flow and mouth leak on oropharyngeal humidification during high-flow nasal cannula: a neonatal bench study.

World J Pediatr 2018 06 9;14(3):305-309. Epub 2018 Mar 9.

Department of Neonatology, Charité University Medical Center, Charitéplatz 1, 10117, Berlin, Germany.

Background: Heated humidification is paramount during neonatal high-flow nasal cannula (HFNC) therapy. However, there is little knowledge about the influence of flow rate and mouth leak on oropharyngeal humidification and temperature.

Methods: The effect of the Optiflow HFNC on oropharyngeal gas conditioning was investigated at flow rates of 4, 6 and 8 L min with and without mouth leak in a bench model simulating physiological oropharyngeal air conditions during spontaneous breathing. Temperature and absolute humidity (AH) were measured using a digital thermo-hygrosensor.

Results: Without mouth leak, oropharyngeal temperature and AH increased significantly with increasing flow (P < 0.001). Mouth leak did not affect this increase up to 6 L min, but at 8 L min, temperature and AH plateaued, and the effect of mouth leak became statistically significant (P < 0.001).

Conclusions: Mouth leak during HFNC had a negative impact on oropharyngeal gas conditioning when high flows were applied. However, temperature and AH always remained clinically acceptable.
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http://dx.doi.org/10.1007/s12519-018-0138-6DOI Listing
June 2018

Nasal high-frequency oscillatory ventilation impairs heated humidification: A neonatal bench study.

Pediatr Pulmonol 2017 Nov 7;52(11):1455-1460. Epub 2017 Sep 7.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Objective: Nasal high-frequency oscillatory ventilation (nHFOV) is a novel mode of non-invasive ventilation used in neonates. However, upper airway obstructions due to viscous secretions have been described as specific adverse effects. We hypothesized that high-frequency oscillations reduce air humidity in the oropharynx, resulting in upper airway desiccation. Therefore, we aimed to investigate the effects of nHFOV ventilatory settings on oropharyngeal gas conditions.

Methods: NHFOV or nasal continuous positive airway pressure (nCPAP) was applied, along with heated humidification, to a previously established neonatal bench model that simulates oropharyngeal gas conditions during spontaneous breathing through an open mouth. A digital thermo-hygro sensor measured oropharyngeal temperature (T) and humidity at various nHFOV frequencies (7, 10, 13 Hz), amplitudes (10, 20, 30 cmH O), and inspiratory-to-expiratory (I:E) ratios (25:75, 33:66, 50:50), and also during nCPAP.

Results: Relative humidity was always >99%, but nHFOV resulted in lower mean T and absolute humidity (AH) in comparison to nCPAP (P < 0.001). Specifically, decreasing the nHFOV frequency and increasing nHFOV amplitude caused a decline in T and AH (P < 0.001). Mean T and AH were highest during nCPAP (T 34.8 ± 0.6°C, AH 39.3 ± 1.3 g · m ) and lowest during nHFOV at a frequency of 7 Hz and an amplitude of 30 cmH O (T 32.4 ± 0.3°C, AH 34.7 ± 0.5 g · m ). Increasing the I:E ratio also reduced T and AH (P = 0.03).

Conclusion: Intensified nHFOV settings with low frequencies, high amplitudes, and high I:E ratios may place infants at an increased risk of upper airway desiccation. Future studies should investigate strategies to optimize heated humidification during nHFOV.
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http://dx.doi.org/10.1002/ppul.23824DOI Listing
November 2017

Abstracts of the 52nd Workshop for Pediatric Research : Frankfurt, Germany. 27-28 October 2016.

Authors:
Rhea van den Bruck Patrick P Weil Thomas Ziegenhals Philipp Schreiner Stefan Juranek Daniel Gödde Silvia Vogel Frauke Schuster Valerie Orth Johannes Dörner Daniel Pembaur Meike Röper Stefan Störkel Hubert Zirngibl Stefan Wirth Andreas C W Jenke Jan Postberg Nikolas Boy Jana Heringer Gisela Haege Esther M Glahn Georg F Hoffmann Sven F Garbade Peter Burgard Stefan Kölker Cho-Ming Chao Faady Yahya Alena Moiseenko Amit Shrestha Negah Ahmadvand Jennifer Quantius Jochen Wilhelm Elie El-Agha Klaus-Peter Zimmer Saverio Bellusci Christian Staufner Stefan Kölker Holger Prokisch Georg F Hoffmann Stephan Seeliger Matthias Müller Andreas Hippe Henrik Steinkraus Roland Wauer Burkhard Lachmann Sigrun R Hofmann Christian M Hedrich Jakob Zierk Farhad Arzideh Rainer Haeckel Wolfgang Rascher Manfred Rauh Markus Metzler Sebastian Thieme Joanna Bandoła Cornelia Richter Martin Ryser Arshad Jamal Michelle P Ashton Malte von Bonin Matthias Kuhn Christian M Hedrich Ezio Bonifacio Reinhard Berner Sebastian Brenner Johanna Hammersen Cristina Has Nora Naumann-Bartsch Daniel Stachel Dimitra Kiritsi Stephan Söder Mathilde Tardieu Markus Metzler Leena Bruckner-Tuderman Holm Schneider F Bohne D Langer R Cencic T Eggermann U Zechner J Pelletier F Zepp T Enklaar D Prawitt Martin Pech Markus Weckmann Femke-Anouska Heinsen Andre Franke Christine Happle Anna-Maria Dittrich Gesine Hansen Oliver Fuchs Erika von Mutius Brian G Oliver Matthias V Kopp Claudia Paret Alexandra Russo Johanna Theruvath Bettina Keller Khalifa El Malki Nadine Lehmann Arthur Wingerter Marie A Neu Gerhold-Ay Aslihan Wolfgang Wagner Clemens Sommer Torsten Pietsch Larissa Seidmann Jörg Faber Felix Schreiner Merle Ackermann Michael Michalik Eva Rother Andras Bilkei-Gorzo Ildiko Racz Laura Bindila Beat Lutz Jörg Dötsch Andreas Zimmer Joachim Woelfle Hendrik S Fischer Tim L Ullrich Christoph Bührer Christoph Czernik Gerd Schmalisch Robert Stein Sigrun R Hofmann Judith Hagenbuchner Ursula Kiechl-Kohlendorfer Petra Obexer Michael J Ausserlechner Niki T Loges Adrien Tobias Frommer Julia Wallmeier Heymut Omran Soner Öner-Sieben Martina Gimpfl Jan Rozman Martin Irmler Johannes Beckers Martin Hrabe De Angelis Adelbert Roscher Eckhard Wolf Regina Ensenauer Karolina Nemes Michael Frühwald Martin Hasselblatt Reiner Siebert Uwe Kordes Marcel Kool Haicui Wang Holly Hardy Osama Refai Katy E S Barwick Holly H Zimmerman Joachim Weis Emma L Baple Andrew H Crosby Sebahattin Cirak C Hellmuth O Uhl M Standl J Heinrich E Thiering B Koletzko Lena Blümel Kornelius Kerl Daniel Picard Michael C Frühwald Max C Liebau Guido Reifenberger Arndt Borkhardt Martin Hasselblatt Marc Remke D Tews M Wabitsch P Fischer-Posovszky Mike-Andrew Westhoff Lisa Nonnenmacher Julia Langhans Lukas Schneele Nancy Trenkler Klaus-Michael Debatin

Mol Cell Pediatr 2017 May;4(Suppl 1)

Department of Pediatrics and Adolescent Medicine, University Medical Center Ulm, Ulm, Germany.

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http://dx.doi.org/10.1186/s40348-017-0071-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435609PMC
May 2017

Lung function in very low birth weight infants after pharmacological and surgical treatment of patent ductus arteriosus - a retrospective analysis.

BMC Pediatr 2017 01 6;17(1). Epub 2017 Jan 6.

Department of Neonatology, Charité University Medical Centre, Charitéplatz 1, 10117, Berlin, Germany.

Background: The indications and strategies for treatment of patent ductus arteriosus (PDA) are controversial, and the safety and long-term benefits of surgical PDA closure remain uncertain. The aim of this study was to compare the lung function of very low birth weight (VLBW) infants after successful PDA treatment with a cyclooxygenase inhibitor or secondary surgical ligation.

Methods: A total of 114 VLBW infants (birth weight < 1500 g), including 94 infants (82%) with a birth weight < 1000 g, who received treatment for hemodynamically significant PDA (hsPDA), were examined at a median postmenstrual age of 48 weeks. All infants were initially given pharmacological treatment, and 40 infants (35%) required PDA ligation. Lung function testing (LFT) included tidal breathing measurements, measurement of respiratory mechanics assessed by the occlusion test, whole-body plethysmography, SF multiple breath washout, forced expiratory flow (V'max) by the rapid thoracoabdominal compression technique, exhaled NO (FeNO), and arterialized capillary blood gas analysis.

Results: On the day of the LFT, the 2 groups had similar postconceptional age and body weight. However, the PDA ligation group was more immature at birth (p < 0.001) and had reduced respiratory compliance (p < 0.001), lower V'max (p = 0.006), increased airway resistance (R) (p < 0.001), and impaired blood gases (p < 0.001). Multivariate analysis showed that PDA surgery was an independent risk factor for increased R.

Conclusion: PDA ligation after failed pharmacological treatment is associated with impaired lung function as compared to successful pharmacological closure in infants at a postmenstrual age of 48 weeks. However, only Raw was independently affected by PDA ligation, while all other differences were merely explained by patient characteristics.
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http://dx.doi.org/10.1186/s12887-016-0762-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217232PMC
January 2017

Influence of mouth opening on oropharyngeal humidification and temperature in a bench model of neonatal continuous positive airway pressure.

Med Eng Phys 2017 02 30;40:87-94. Epub 2016 Dec 30.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Clinical studies show that non-invasive respiratory support by continuous positive airway pressure (CPAP) affects gas conditioning in the upper airways, especially in the presence of mouth leaks. Using a new bench model of neonatal CPAP, we investigated the influence of mouth opening on oropharyngeal temperature and humidity. The model features the insertion of a heated humidifier between an active model lung and an oropharyngeal head model to simulate the recurrent expiration of heated, humidified air. During unsupported breathing, physiological temperature and humidity were attained inside the model oropharynx, and mouth opening had no significant effect on oropharyngeal temperature and humidity. During binasal CPAP, the impact of mouth opening was investigated using three different scenarios: no conditioning in the CPAP circuit, heating only, and heated humidification. Mouth opening had a strong negative impact on oropharyngeal humidification in all tested scenarios, but heated humidification in the CPAP circuit maintained clinically acceptable humidity levels regardless of closed or open mouths. The model can be used to test new equipment for use with CPAP, and to investigate the effects of other methods of non-invasive respiratory support on gas conditioning in the presence of leaks.
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http://dx.doi.org/10.1016/j.medengphy.2016.12.005DOI Listing
February 2017

Computerized wheeze detection in young infants: comparison of signals from tracheal and chest wall sensors.

Physiol Meas 2016 12 21;37(12):2170-2180. Epub 2016 Nov 21.

Department of Neonatology, Charité University Medical Center, Charitéplatz 1, 10117 Berlin, Germany.

Computerized wheeze detection is an established method for objective assessment of respiratory sounds. In infants, this method has been used to detect subclinical airway obstruction and to monitor treatment effects. The optimal location for the acoustic sensors, however, is unknown. The aim of this study was to evaluate the quality of respiratory sound recordings in young infants, and to determine whether the position of the sensor affected computerized wheeze detection. Respiratory sounds were recorded over the left lateral chest wall and the trachea in 112 sleeping infants (median postmenstrual age: 49 weeks) on 129 test occasions using an automatic wheeze detection device (PulmoTrack). Each recording lasted 10 min and the recordings were stored. A trained clinician retrospectively evaluated the recordings to determine sound quality and disturbances. The wheeze rates of all undisturbed tracheal and chest wall signals were compared using Bland-Altman plots. Comparison of wheeze rates measured over the trachea and the chest wall indicated strong correlation (r  ⩾  0.93, p  <  0.001), with a bias of 1% or less and limits of agreement of within 3% for the inspiratory wheeze rate and within 6% for the expiratory wheeze rate. However, sounds from the chest wall were more often affected by disturbances than sounds from the trachea (23% versus 6%, p  <  0.001). The study suggests that in young infants, a better quality of lung sound recordings can be obtained with the tracheal sensor.
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http://dx.doi.org/10.1088/0967-3334/37/12/2170DOI Listing
December 2016

Current methodological and technical limitations of time and volumetric capnography in newborns.

Authors:
Gerd Schmalisch

Biomed Eng Online 2016 Aug 30;15(1):104. Epub 2016 Aug 30.

Department of Neonatology, Charité University Medical Center, Charitéplatz 1, 10117, Berlin, Germany.

Although capnography is a standard tool in mechanically ventilated adult and pediatric patients, it has physiological and technical limitations in neonates. Gas exchange differs between small and adult lungs due to the greater impact of small airways on gas exchange, the higher impact of the apparatus dead space on measurements due to lower tidal volume and the occurrence of air leaks in intubated patients. The high respiratory rate and low tidal volume in newborns, especially those with stiff lungs, require main-stream sensors with fast response times and minimal dead-space or low suction flow when using side-stream measurements. If these technical requirements are not fulfilled, the measured end-tidal CO2 (P et CO 2 ), which should reflect the alveolar CO2 and the calculated airway dead spaces, can be misleading. The aim of this survey is to highlight the current limitations of capnography in very young patients to avoid pitfalls associated with the interpretation of capnographic parameters, and to describe further developments.
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http://dx.doi.org/10.1186/s12938-016-0228-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5004292PMC
August 2016

Basic principles of respiratory function monitoring in ventilated newborns: A review.

Authors:
Gerd Schmalisch

Paediatr Respir Rev 2016 Sep 23;20:76-82. Epub 2016 Mar 23.

Department of Neonatology, Charité University Medical Center, Berlin, Germany. Electronic address:

Respiratory monitoring during mechanical ventilation provides a real-time picture of patient-ventilator interaction and is a prerequisite for lung-protective ventilation. Nowadays, measurements of airflow, tidal volume and applied pressures are standard in neonatal ventilators. The measurement of lung volume during mechanical ventilation by tracer gas washout techniques is still under development. The clinical use of capnography, although well established in adults, has not been embraced by neonatologists because of technical and methodological problems in very small infants. While the ventilatory parameters are well defined, the calculation of other physiological parameters are based upon specific assumptions which are difficult to verify. Incomplete knowledge of the theoretical background of these calculations and their limitations can lead to incorrect interpretations with clinical consequences. Therefore, the aim of this review was to describe the basic principles and the underlying assumptions of currently used methods for respiratory function monitoring in ventilated newborns and to highlight methodological limitations.
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http://dx.doi.org/10.1016/j.prrv.2016.01.004DOI Listing
September 2016

Reliability of Single-Use PEEP-Valves Attached to Self-Inflating Bags during Manual Ventilation of Neonates--An In Vitro Study.

PLoS One 2016 25;11(2):e0150224. Epub 2016 Feb 25.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Introduction: International resuscitation guidelines suggest to use positive end-expiratory pressure (PEEP) during manual ventilation of neonates. Aim of our study was to test the reliability of self-inflating bags (SIB) with single-use PEEP valves regarding PEEP delivery and the effect of different peak inflation pressures (PIP) and ventilation rates (VR) on the delivered PEEP.

Methods: Ten new single-use PEEP valves from 5 manufacturers were tested by ventilating an intubated 1 kg neonatal manikin containing a lung model with a SIB that was actuated by an electromechanical plunger device. Standard settings: PIP 20 cmH2O, VR 60/min, flow 8 L/min. PEEP settings of 5 and 10 cmH2O were studied. A second test was conducted with settings of PIP 40 cmH2O and VR 40/min. The delivered PEEP was measured by a respiratory function monitor (CO2SMO+).

Results: Valves from one manufacturer delivered no relevant PEEP and were excluded. The remaining valves showed a continuous decay of the delivered pressure during expiration. The median (25th and 75th percentile) delivered PEEP with standard settings was 3.4(2.7-3.8) cmH2O when set to 5 cmH2O and 6.1(4.9-7.1) cmH2O when set to 10 cmH2O. Increasing the PIP from 20 to 40 cmH2O led to a median (25th and 75th percentile) decrease in PEEP to 2.3(1.8-2.7) cmH2O and 4.3(3.2-4.8) cmH2O; changing VR from 60 to 40/min led to a PEEP decrease to 2.8(2.1-3.3) cmH2O and 5.0(3.5-6.2) cmH2O for both PEEP settings.

Conclusion: Single-use PEEP valves do not reliably deliver the set PEEP. PIP and VR have an effect on the delivered PEEP. Operators should be aware of these limitations when manually ventilating neonates.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0150224PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4767411PMC
August 2016

Relationship between computerized wheeze detection and lung function parameters in young infants.

Pediatr Pulmonol 2016 Apr 11;51(4):402-10. Epub 2015 Sep 11.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Objective: Computerized respiratory sound analysis (CORSA) has been validated in the assessment of wheeze in infants, but it is unknown whether automatically detected wheeze is associated with impaired lung function. This study investigated the relationship between wheeze detection and conventional lung function testing (LFT) parameters.

Methods: CORSA was performed using the PulmoTrack® monitor in 110 infants, of median (interquartile range) postmenstrual age 50 (46-56) weeks and median body weight 4,810 (3,980-5,900) g, recovering from neonatal intensive care. In the same session, LFT was performed, including tidal breathing measurements, occlusion tests, body plethysmography, forced expiratory flow by rapid thoracoabdominal compression, sulfur hexafluoride (SF6 ) multiple breath washout (MBW), and capillary blood gas analysis. Infants were classified as wheezers or non-wheezers using predefined cut-off values for the duration of inspiratory and expiratory wheeze.

Results: Wheezing was detected in 72 (65%) infants, with 43 (39%) having inspiratory and 53 (48%) having expiratory wheezing. Endotracheal mechanical ventilation in the neonatal period for > 24 hr was associated with inspiratory wheeze (P = 0.009). Airway resistance was increased in both inspiratory (P = 0.02) and expiratory (P = 0.004) wheezers and correlated with the duration of expiratory wheeze (r = 0.394, P < 0.001). Expiratory wheezers showed a significant increase in respiratory resistance (P = 0.001), time constant (0.012), and functional residual capacity using SF6 MBW (P = 0.019). There was no association between wheezing and forced expiratory flow or blood gases.

Conclusion: CORSA can help identify neonates and young infants with subclinical airway obstruction and may prove useful in the follow-up of high-risk infants.
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http://dx.doi.org/10.1002/ppul.23310DOI Listing
April 2016

The lung clearance index in young infants: impact of tidal volume and dead space.

Physiol Meas 2015 Jul 18;36(7):1601-13. Epub 2015 Jun 18.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Lung clearance index (LCI), measured by multiple breath washout (MBW), is one of the most frequently used measures of ventilation inhomogeneity. This study was designed to investigate the effect of lung volumes on LCI in young infants. The dependence of LCI on dead space volume (VD), tidal volume (VT) and functional residual capacity (FRC) was investigated by mathematical modeling and by MBW measurements using sulfur hexafluoride (SF6) as a tracer gas. MBW was performed in 150 infants, of median postmenstrual age 46.7 weeks, followed up after neonatal intensive care. Wheezing was assessed in 90 of these infants by computerized respiratory sound analysis during quiet sleep. The strongest correlation was observed between LCI and the volume ratios VT/FRC (Spearman rank order correlation coefficient Rs = 0.688, p < 0.001), VD/VT (Rs = 0.733, p < 0.001) and VD/FRC (Rs = 0.854, p < 0.001). LCI calculated from VD, VT, and FRC was linearly related to measured LCI with a coefficient of determination of 75%. There were no significant differences between wheezers and non-wheezers in postmenstrual age and body weight, but FRC was significantly increased (p < 0.001) and median (interquartile range) LCI significantly decreased (5.83 (5.45-6.51) versus (6.54 (6.03-7.22), p < 0.001) in wheezing compared to non-wheezing infants. Model calculations also showed that LCI was significantly reduced in wheezing infants (5.09 (4.79-5.62) versus 5.43 (5.08-5.82), p < 0.018), indicating that the reduction can be explained by differences in the lung volumes, not by improved ventilation homogeneity. In conclusion, the strong dependence of LCI on lung volumes in young infants can lead to misinterpretations regarding the homogeneity of alveolar ventilation.
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http://dx.doi.org/10.1088/0967-3334/36/7/1601DOI Listing
July 2015

Postnatal lung function in congenital cystic adenomatoid malformation of the lung.

Ann Thorac Surg 2015 Apr 14;99(4):1164-9. Epub 2015 Feb 14.

Department of Neonatology, Charité University Medical Centre, Berlin, Germany.

Background: Management of prenatally diagnosed but postnatal asymptomatic pulmonary lesions remains controversial. The aim of this study was to investigate the effect of congenital cystic adenomatoid malformation of the lung (CCAM) on postnatal lung function tests (LFT) and to elucidate whether LFTs help identify infants who would benefit from early surgery.

Methods: The LFTs were performed in 26 CCAM infants at a median (interquartile range) postmenstrual age of 42.4 (39.6 to 44.0) weeks and compared with LFT from 30 healthy controls. The LFT included the measurement of tidal breathing, functional residual capacity by body plethysmography, respiratory mechanics (respiratory compliance), and respiratory resistance by occlusion test and blood gas analysis.

Results: The CCAM infants showed a restrictive ventilation disorder with increased respiratory rates (p = 0.006) and marginally decreased tidal volumes (p = 0.043). Furthermore, respiratory compliance was significantly reduced as compared with controls (p < 0.001). No statistically significant differences were seen in the respiratory resistance, functional residual capacity, and capillary blood gases. Particularly in CCAM infants who had surgery in the first 2 years of life, a marked reduction of respiratory compliance (p < 0.001) was seen preoperatively.

Conclusions: Congenital cystic adenomatoid malformation can cause restrictive ventilation disorders, which can be detected and monitored by postnatal LFT. Thus, LFT represents an additional tool to support the decision for or against surgical intervention.
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http://dx.doi.org/10.1016/j.athoracsur.2014.11.018DOI Listing
April 2015

Validation of computerized wheeze detection in young infants during the first months of life.

BMC Pediatr 2014 Oct 9;14:257. Epub 2014 Oct 9.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Background: Several respiratory diseases are associated with specific respiratory sounds. In contrast to auscultation, computerized lung sound analysis is objective and can be performed continuously over an extended period. Moreover, audio recordings can be stored. Computerized lung sounds have rarely been assessed in neonates during the first year of life. This study was designed to determine and validate optimal cut-off values for computerized wheeze detection, based on the assessment by trained clinicians of stored records of lung sounds, in infants aged <1 year.

Methods: Lung sounds in 120 sleeping infants, of median (interquartile range) postmenstrual age of 51 (44.5-67.5) weeks, were recorded on 144 test occasions by an automatic wheeze detection device (PulmoTrack®). The records were retrospectively evaluated by three trained clinicians blinded to the results. Optimal cut-off values for the automatically determined relative durations of inspiratory and expiratory wheezing were determined by receiver operating curve analysis, and sensitivity and specificity were calculated.

Results: The optimal cut-off values for the automatically detected durations of inspiratory and expiratory wheezing were 2% and 3%, respectively. These cutoffs had a sensitivity and specificity of 85.7% and 80.7%, respectively, for inspiratory wheezing and 84.6% and 82.5%, respectively, for expiratory wheezing. Inter-observer reliability among the experts was moderate, with a Fleiss' Kappa (95% confidence interval) of 0.59 (0.57-0.62) for inspiratory and 0.54 (0.52 - 0.57) for expiratory wheezing.

Conclusion: Computerized wheeze detection is feasible during the first year of life. This method is more objective and can be more readily standardized than subjective auscultation, providing quantitative and noninvasive information about the extent of wheezing.
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http://dx.doi.org/10.1186/1471-2431-14-257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287542PMC
October 2014

Nasal high-frequency oscillation ventilation in neonates: a survey in five European countries.

Eur J Pediatr 2015 Apr 18;174(4):465-71. Epub 2014 Sep 18.

Department of Neonatology, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany,

Unlabelled: Nasal high-frequency oscillation ventilation (nHFOV) is a non-invasive ventilation mode that applies an oscillatory pressure waveform to the airways using a nasal interface. nHFOV has been shown to facilitate carbon dioxide expiration, but little is known about its use in neonates. In a questionnaire-based survey, we assessed nHFOV use in neonatal intensive care units (NICUs) in Austria, Switzerland, Germany, the Netherlands, and Sweden. Questions included indications for nHFOV, equipment used, ventilator settings, and observed side effects. Of the clinical directors of 186 NICUs contacted, 172 (92 %) participated. Among those responding, 30/172 (17 %) used nHFOV, most frequently in premature infants <1500 g (27/30) for the indication nasal continuous positive airway pressure (nCPAP) failure (27/30). Binasal prongs (22/30) were the most common interfaces. The median (range) mean airway pressure when starting nHFOV was 8 (6-12) cm H2O, and the maximum mean airway pressure was 10 (7-18) cm H2O. The nHFOV frequency was 10 (6-13) Hz. Abdominal distension (11/30), upper airway obstruction due to secretions (8/30), and highly viscous secretions (7/30) were the most common nHFOV side effects.

Conclusion: In a number of European NICUs, clinicians use nHFOV. The present survey identified differences in nHFOV equipment, indications, and settings. Controlled clinical trials are needed to investigate the efficacy and side effects of nHFOV in neonates.
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http://dx.doi.org/10.1007/s00431-014-2419-yDOI Listing
April 2015

Development of left ventricular longitudinal speckle tracking echocardiography in very low birth weight infants with and without bronchopulmonary dysplasia during the neonatal period.

PLoS One 2014 3;9(9):e106504. Epub 2014 Sep 3.

Department of Pediatric Cardiology, Charité University Medical Center, Berlin, Germany.

Objectives: In preterm infants, postnatal myocardial adaptation may be complicated by bronchopulmonary dysplasia (BPD). We aimed to describe the development of left ventricular function by serial 2D, Doppler, and speckle tracking echocardiography (2D-STE) in infants with and without BPD during the neonatal period and compare these to anthropometric and conventional hemodynamic parameters.

Study Design: Prospective echocardiography on day of life (DOL) 1, 7, 14, and 28 in 119 preterm infants <1500 g birth weight of whom 36 developed BPD (need for oxygen supplementation at 36 weeks gestational age). Non-BPD and BPD infants differed significantly in median (IQR) gestational age (25.5(24-26.5) weeks vs. 29(27-30) weeks, p<0.001) and birth weight (661(552-871) g vs. 1100(890-1290) g, p<0.001).

Results: The intra- and inter-observer variability of the 2D-STE parameters measured did not depend on time of measurement, although there were significant differences in the reproducibility of the parameters. Low intra- and inter-observer variability was seen for longitudinal systolic strain and strain rate mid septum with a median CV (coefficient of variation) of <4.6%. Much higher CVs (>10%) were seen for the apical segment. While anthropometric parameters show rapid development during the first 4 weeks of life, the speckle tracking parameters did not differ statistically significantly during the neonatal period. Infants with and without BPD differed significantly (p<0.001) in the development of anthropometric parameters, conventional hemodynamic parameters except for heart rate, and 2D-STE parameters: global longitudinal systolic strain rate (GLSSR) and longitudinal systolic strain for the mid left wall (LSSR). The largest differences were seen at DOL 1 and 7 in GLSSR (p<0.001) and in LSSR (p<0.01).

Conclusions: Reproducible 2D-STE measurements are possible in preterm infants <1500 g. Cardiac deformation reveals early (DOL 1 and 7) ventricular changes (GLSSR and LSSR) in very low birth weight infants who develop BPD.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0106504PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4153617PMC
May 2015

Effect of intubation and mechanical ventilation on exhaled nitric oxide in preterm infants with and without bronchopulmonary dysplasia measured at a median postmenstrual age of 49 weeks.

BMC Res Notes 2014 Jun 24;7:389. Epub 2014 Jun 24.

Department of Neonatology, Charité University Medicine, Charitéplatz 1, D - 10117 Berlin, Germany.

Background: Exhaled nitric oxide (eNO) is a marker of established airway inflammation in adults and children, but conflicting results have been reported in preterm infants when postnatal eNO is measured during tidal breathing. This study investigated the extent to which intubation and mechanical ventilation (MV) affect eNO and NO production (V'NO) in preterm infants with and without bronchopulmonary dysplasia (BPD).

Patients And Methods: A total of 176 very low birth weight (VLBW) infants (birth weight <1500 g), including 74 (42%) with and 102 (58%) without BPD, were examined at a median postmenstrual age of 49 weeks. Of the 176 infants, 84 (48%) did not require MV, 47 (27%) required MV for <7 days and 45 (26%) required MV for ≥7 days. Exhaled NO and tidal breathing parameters were measured in sleeping infants during tidal breathing, respiratory mechanics were assessed by occlusion tests, and arterialized capillary blood gas was analyzed.

Results: eNO was significantly correlated with tidal breathing parameters, while V'NO was correlated with growth parameters, including age and body length (p < 0.001 each). Infants who were intubated and received MV for <7 days had significantly lower eNO (p < 0.01) and V'NO (p < 0.01) than non-ventilated infants. In contrast, eNO and V'NO did not differ significantly in non-ventilated infants and those receiving MV for ≥7 days. Multivariate analysis showed that independent on the duration of MV eNO (p = 0.003) and V'NO (p = 0.018) were significantly increased in BPD infants comparable with the effects of intubation and MV on eNO (p = 0.002) and V'NO (p = 0.017).

Conclusions: Preterm infants with BPD show only weak postnatal increases in eNO and V'NO, but these changes may be obscured by the distinct influences of breathing pattern and invasive respiratory support. This limits the diagnostic value of postnatal eNO measurements in the follow-up of BPD infants.
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http://dx.doi.org/10.1186/1756-0500-7-389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4102333PMC
June 2014

How ABBA may help improve neonatal resuscitation training: auditory prompts to enable coordination of manual inflations and chest compressions.

J Paediatr Child Health 2014 Jun 26;50(6):444-8. Epub 2014 Feb 26.

Neonatal Research Unit, The Royal Women's Hospital, Melbourne, Victoria, Australia; The Ritchie Centre, Monash Institute of Medical Research, Monash University, Melbourne, Victoria, Australia; Department of Neonatology, Charité University Medical Centre, Berlin, Germany.

Aim: Resuscitation guidelines recommend 90 chest compressions (CCs) and 30 inflations (INFs) per minute for neonatal cardiopulmonary resuscitation (nCPR). We hypothesised that auditory prompts would help coordinate these actions. Our aim was to investigate the effect of musical prompts during nCPR training on adherence to recommended CC and INF rates and on the quality of delivered INFs.

Methods: A simulation study was conducted employing 30 experienced neonatal staff, a respiratory function monitor and a neonatal manikin. The effects of five different auditory prompts on adherence to recommended rates of CC and INF were tested against baseline (no music). The five auditory prompts (popular musical tunes) were investigated in random order. Quality of INFs was assessed by comparing the peak inflation pressures (PIP), positive end-expiratory pressures (PEEP), percentage mask leak and tidal volumes (VT).

Results: Mean baseline rates at which CCs and INFs were delivered were 80 (SD 6) per minute and 28 (SD 2) per minute, respectively. Listening to auditory prompts had varying effects on CC and INF delivery rates. For CCs, a significant difference to baseline was found only when participants listened to ABBA's 'SOS', with 86 (SD 7) per minute (P = 0.04). For INFs, we found a statistically significant improvement to baseline rate only for 'SOS', with 29 (SD 2) per minute (P = 0.04), and there was no significant difference in INF quality among the auditory prompts.

Conclusions: Musical prompts can help with adherence to recommended CC and INF rates but do not improve the quality of INFs during nCPR training. The lasting effect of auditory prompts as musical mnemonics on nCPR performance in vivo needs to be established.
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http://dx.doi.org/10.1111/jpc.12507DOI Listing
June 2014

Dead space reduction by Kolobow's endotracheal tube does not justify the waiving of volume monitoring in small, ventilated lungs.

J Clin Monit Comput 2014 Dec 28;28(6):605-11. Epub 2014 Jan 28.

Department of Neonatology, Charité University Medical Center, Charitéplatz 1, 10117, Berlin, Germany.

In ventilated preterm infants the flow sensor contributes significantly to the total apparatus dead space, which may impair gas exchange. The aim of the study was to quantify to which extent a dead space reduced Kolobow tube (KB) without flow sensor improves the gas exchange compared with a conventional ventilator circuit with flow sensor [Babylog 8000 (BL)]. In a cross-over trial in 14 tracheotomized, surfactant-depleted (saline lavage) and mechanically ventilated newborn piglets (age <12 h; body weight 705-1200 g) BL and KB was applied alternately for 15 min and blood gases were recorded. The inner diameter of the endotracheal tube was 3.6 mm and the apparatus dead space of BL and KB including the endotracheal tube were 3.0 and 1.34 mL. Despite a 50 % apparatus dead space reduction with KB compared to BL statistically significant improvements were only observed for body weights <900 g. In this weight group median paCO2 was decreased by 5 mmHg (p < 0.01), whereas the improvement decreased with decreasing baseline paCO2. Furthermore, median paO2 was increased by 4 mmHg (p < 0.05) and O2 saturation was increased by 2.5 % (p < 0.05). No significant changes were seen in the circulatory parameters. In very small, ventilated lungs the use of KB improved the gas exchange; however, the improvement was moderate and does not justify the waiving of volume monitoring.
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http://dx.doi.org/10.1007/s10877-014-9559-5DOI Listing
December 2014

Influence of nose and mouth leaks on peripheral oxygen saturation during continuous positive airway pressure in neonates.

World J Pediatr 2013 Nov 21;9(4):318-22. Epub 2013 Oct 21.

Department of Neonatology, Charité University Medicine Berlin, Berlin, Germany,

Background: Nose and mouth leaks impair effective pressure transmission during neonatal continuous positive airway pressure (CPAP), but little is known about how these leaks affect physiological parameters. This study investigated the influence of nose leaks and spontaneous mouth opening on peripheral oxygen saturation (SpO₂) and respiratory rate (RR) using nasopharyngeal CPAP.

Methods: In 32 neonates with a gestational age of 30 (24-38) weeks and a birth weight of 1435 (710-2730) g, SpO₂ and RR measurements were taken with and without occlusion of the contralateral nostril in a randomized cross-over trial in 1-minute intervals over a 10-minute period during each condition. Mouth opening and newborn activity were documented.

Results: SpO₂ with open nostril was comparable to that with occluded nostril [93 (78.5-99.5)% vs. 94 (80-100)%, P=0.20]. RR decreased from 51 (26-82)/min to 48 (32-85)/min (P=0.027). In infants with an SpO₂ ≤ 93% during open nostril (n=17), SpO₂ increased after nostril occlusion [91 (80-96)% vs. 89.5 (78.5-93)%, P=0.036]. The mouth was open in 78.5% of measurements with open nostril, and in 87.4% of measurements after nostril occlusion (P=0.005). No significant influence of mouth opening or closure on SpO₂ or RR was detected.

Conclusions: In neonates on unilateral nasopharyngeal CPAP with an SpO₂ ≤ 93%, occlusion of the contralateral nostril significantly increased SpO₂ and reduced RR. The beneficial physiological effects further support using binasal prongs to minimize nose leaks in this population. Future studies should investigate the beneficial effects of reducing mouth leaks when applying CPAP to these infants.
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http://dx.doi.org/10.1007/s12519-013-0435-zDOI Listing
November 2013

Fetal and neonatal samples of a precursor surfactant protein B inversely related to gestational age.

BMC Pediatr 2013 Oct 10;13:164. Epub 2013 Oct 10.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Background: Alveolar-capillary membrane leaks can increase the amount of surfactant protein B (SP-B) in the bloodstream. The purpose of this study was to measure the concentration of C-proSP-B, a SP-B precursor that includes C-terminal domains, in various body fluids of newborn infants and determine its dependence on gestational age.

Methods: C-pro-SPB was measured in amniotic fluid and umbilical cord blood at birth, and in peripheral blood and urine on postnatal day 3 in 137 newborn infants with a median birth weight of 2015 g (range, 550-4475 g) and gestational age of 34 weeks (range, 23-42 weeks).

Results: C-proSP-B levels differed more than 100-fold among samples. The levels (median; interquartile range) were highest in peripheral blood (655.6 ng/mL; 419.0-1467.0 ng/mL) and lowest in urine (3.08 ng/mL; 2.96-3.35 ng/mL). C-proSP-B levels in amniotic fluid (314.9 ng/mL; 192.7-603.6 ng/mL) were approximately half of those in peripheral blood. In cord blood C-proSP-B was slightly lower (589.1 ng/mL; 181.2-1129.0 ng/mL) compared with peripheral blood. C-proSP-B levels significantly increased in all the fluids sampled except urine with decreasing gestational age (p < 0.001).

Conclusions: This novel assay allows for the quantitative measurement of C-proSP-B in blood and amniotic fluid. The dependence of C-proSP-B on gestational age may hamper its use for the detection of alveolar leaks in preterm newborns.
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http://dx.doi.org/10.1186/1471-2431-13-164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852371PMC
October 2013

Time to adjust to changes in ventilation settings varies significantly between different T-piece resuscitators, self-inflating bags, and manometer equipped self-inflating bags.

Am J Perinatol 2014 Jun 2;31(6):505-12. Epub 2013 Sep 2.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Objective: Resuscitation guidelines give no preference over use of self-inflating bags (SIBs) or T-piece resuscitators (TPR) for manual neonatal ventilation. We speculated that devices would differ significantly regarding time required to adjust to changed ventilation settings.

Study Design: This was a laboratory study. Time to adjust from baseline peak inflation pressure (PIP) (20 cmH2O) to target PIP (25 and 40 cmH2O), ability to adhere to predefined ventilation settings (PIP, PEEP, and inflation rate [IR]), and the variability within and between operators were assessed for a SIB without manometer, SIB with manometer (SIBM), and two TPRs.

Results: Adjustment time was significantly longer with TPRs, compared with SIB and SIBM. The SIBM and TPRs were < 5% (median) off target PIP, and the SIB was 14% off target PIP. Significant variability between operators (interquartile range [IQR]: 71%) was seen with SIBs.

Conclusion: PIP adjustment takes longer with TPRs, compared with SIB/SIBM. TPRs and SIBM allow satisfactory adherence to ventilation parameters. SIBs should only be used with manometer attached.
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http://dx.doi.org/10.1055/s-0033-1354562DOI Listing
June 2014

A comparison of conventional surfactant treatment and partial liquid ventilation on the lung volume of injured ventilated small lungs.

Physiol Meas 2013 Aug 26;34(8):915-24. Epub 2013 Jul 26.

Clinic of Neonatology, Charité University Medicine, Berlin, Germany.

As an alternative to surfactant therapy (ST), partial liquid ventilation (PLV) with perfluorocarbons (PFC) has been considered as a treatment for acute lung injury (ALI) in newborns. The instilled PFC is much heavier than the instilled surfactant and the aim of this study was to investigate whether PLV, compared to ST, increases the end-expiratory volume of the lung (VL). Fifteen newborn piglets (age <12 h, mean weight 678 g) underwent saline lung lavage to achieve a surfactant depletion. Thereafter animals were randomized to PLV (n = 8), receiving PFC PF5080 (3M, Germany) at 30 mL kg(-1), and ST (n = 7) receiving 120 mg Curosurf®. Blood gases, hemodynamics and static compliance were measured initially (baseline), immediately after ALI, and after 240 min mechanical ventilation with either technique. Subsequently all piglets were killed; the lungs were removed in toto and frozen in liquid N2. After freeze-drying the lungs were cut into lung cubes (LCs) with edge lengths of 0.7 cm, to calculate VL. All LCs were weighed and the density of the dried lung tissue was calculated. No statistically significant differences between treatment groups PLV and ST (means ± SD) were noted in body weight (676 ± 16 g versus 679 ± 17 g; P = 0.974) or lung dry weight (1.64 ± 0.29 g versus 1.79 ± 0.48 g; P = 0.48). Oxygenation index and ventilatory efficacy index did not differ significantly between both groups at any time. VL (34.28 ± 6.13 mL versus 26.22 ± 8.1 mL; P < 0.05) and the density of the dried lung tissue (48.07 ± 5.02 mg mL(-1) versus 69.07 ± 5.30 mg mL(-1); P < 0.001), however, differed significantly between the PLV and ST groups. A 4 h PLV treatment of injured ventilated small lungs increased VL by 30% and decreased lung density by 31% compared to ST treatment, indicating greater lung distension after PLV compared to ST.
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http://dx.doi.org/10.1088/0967-3334/34/8/915DOI Listing
August 2013

Left ventricular longitudinal strain and strain rate measured by 2-D speckle tracking echocardiography in neonates during whole-body hypothermia.

Ultrasound Med Biol 2013 Aug 4;39(8):1343-9. Epub 2013 Jun 4.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

The purpose of the study was to assess changes in cardiac performance in newborn infants with hypoxic-ischemic encephalopathy during therapeutic hypothermia and rewarming with two-dimensional speckle tracking echocardiography. For eight asphyxiated neonates (median birth weight (range): 3038 (2725-3253) g; umbilical artery pH: 6.9 (6.8-7.18) undergoing whole-body hypothermia (33-34°C), left ventricular longitudinal strain and strain rate, as well as heart rate, cardiac output and left ventricular fractional shortening, were determined at four points in time: the start (T1) and end of hypothermia (T2), immediately after rewarming (T3) and the age of 5 to 7 d (T4). Mean (standard deviation) heart rate increased from 93 (12) beats/min at T1 to 133 (12) beats/min at T4 (p < 0.001). Cardiac output was low during hypothermia (T1: 207 [43] mL/kg/min, T2: 240 [70] mL/kg/min) and increased significantly (p < 0.001) afterward (T3: 329 [70] mL/kg/min, T4: 388 [78] mL/kg/min). Left ventricular fractional shortening remained unchanged. Left ventricular global longitudinal peak systolic strain did not differ significantly between hypothermia and rewarming, whereas the systolic strain rate increased from -1.1 (0.3) s(-1) at T1 to -1.8 (0.26) s(-1) at T4 (p = 0.001). Hypothermia affects peak systolic strain rate, heart rate and cardiac output, with complete recovery after rewarming, whereas peak systolic strain and fractional shortening remain stable.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2013.03.024DOI Listing
August 2013

Repeated thermo-sterilisation further affects the reliability of positive end-expiratory pressure valves.

J Paediatr Child Health 2013 Sep 3;49(9):741-5. Epub 2013 Jun 3.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Aim: Positive end-expiratory pressure (PEEP) valves are used together with self-inflating bags (SIB) to provide a preset PEEP during manual ventilation. It has recently been shown that these valves deliver highly variable levels of PEEP. We hypothesised that material fatigue due to repeated thermo-sterilisation (TS) may contribute to varying reliability of PEEP valves.

Methods: In a laboratory study 10 new PEEP valves were tested before and after 10, 20 and 30 cycles of routine TS (7 min at 134°C) by using a neonatal lung model (compliance 0.2 mL/kPa). Settings were positive inflation pressure = 20 and 40 cm H(2)O, PEEP = 5 and 10 cm H(2)O, respiratory rate = 40 and 60/min, flow = 8l/min. PEEP was recorded using a respiratory function monitor.

Results: Before TS, a mean (standard deviation) PEEP of 4.0 (0.9) and 7.7 (1.0) cm H(2)O was delivered by the 10 valves when the PEEP was set to 5 and 10 cm H(2)O, respectively. One new valve only delivered 2.0 (0.0) and 5.0 (0.0) cm H(2)O when the PEEP was adjusted to 5 and 10 cm H(2)O, respectively. Four of the 10 investigated valves showed significant variations in PEEP (coefficient of variation >10%) throughout the autoclaving process. One valve completely lost its function after the 20th TS. Common defects were tears in the softer materials or displacement of the rubber seal. Six of the 10 valves continued to provide PEEP in spite of repeated TS.

Conclusion: The reliability of PEEP valves is affected by repeated TS. Multi-use PEEP valves should be tested for reliable PEEP provision following TS.
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http://dx.doi.org/10.1111/jpc.12258DOI Listing
September 2013

Training neonatal cardiopulmonary resuscitation: can it be improved by playing a musical prompt? A pilot study.

Am J Perinatol 2014 Mar 21;31(3):245-8. Epub 2013 May 21.

Department of Neonatology, Charité University Medical Centre, Berlin, Germany.

Objective: Effective neonatal cardiopulmonary resuscitation (CPR) requires 3:1 coordinated manual inflations (MI) and chest compressions (CC). We hypothesized that playing a musical prompt would help coordinate CC and MI during CPR.

Study Design: In this pilot trial we studied the effect the "Radetzkymarsch" (110 beats per minute) on neonatal CPR. Thirty-six medical professionals performed CPR on a neonatal manikin. CC and MI were recorded with and without the music played, using a respiratory function monitor and a tally counter. Statistical analysis included Wilcoxon test.

Results: Without music, the median (interquartile range) rate of CC was 115 (100 to 129) per minute and the rate of MI was 38 (32 to 42) per minute. When listening to the auditory prompt, the rate of CC decreased significantly to 96 (96 to 100) per minute (p = 0.002) and the rate of MI to 32 (30 to 34) per minute (p = 0.001). The interquartile range of interoperator variability decreased up to 86%.

Conclusion: Listening to an auditory prompt improved compliance with the recommended delivery rates of CC and MI during neonatal CPR.
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http://dx.doi.org/10.1055/s-0033-1345261DOI Listing
March 2014

Differential effects of immaturity and neonatal lung disease on the lung function of very low birth weight infants at 48-52 postconceptional weeks.

Pediatr Pulmonol 2013 Dec 8;48(12):1214-23. Epub 2013 Feb 8.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Background: The pathogenesis of chronic lung disease of prematurity involves maturational arrest and neonatal lung disease (NLD) followed by mechanical ventilation (MV). However, the effect of these factors on postnatal lung function is not well established. Therefore, the aim of this study was to examine the differential effects of immaturity and NLD requiring MV on lung function test (LFT) parameters within 4 months after discharge.

Patients And Methods: A total of 386 very low birth weight (VLBW) infants (birth weight <1,500 g) were examined at a median postmenstrual age of 49 weeks. Two hundred twenty-six infants (59%) were born before the 28th week of gestation, and 247 infants (64%) had NLD requiring invasive MV. LFTs included tidal breathing measurements, measurement of respiratory mechanics assessed by occlusion test, body plethysmography, SF6 multiple breath washout, forced expiratory flow (VmaxFRC') by rapid thoraco-abdominal compression technique, end-expiratory CO2 (Pet CO2 ), exhaled NO (FeNO), and arterialized capillary blood gas analysis.

Main Results: Multivariate analysis indicated that severe immaturity was mainly associated with changes in the breathing pattern (reduced tidal volume (P = 0.003) and increased respiratory rate (P = 0.03)), a reduced VmaxFRC' (P = 0.004) and lower respiratory compliance (P < 0.001). NLD requiring MV, but not immaturity, was significantly and independently associated with increased respiratory and airway resistances (both P = 0.003), reduced FRCSF6 (P = 0.03), increased Pet CO2 (P = 0.019) and lower FeNO (P < 0.001). Both immaturity and NLD requiring MV caused a lower paO2 (P < 0.001) and higher a paCO2 .

Conclusions: Lung function after discharge of VLBW infants is differentially affected by both immaturity and NLD requiring MV. With increasing prematurity, intubated and mechanically ventilated infants are at increased risk of developing impaired lung function which can be detected by LFT.
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http://dx.doi.org/10.1002/ppul.22770DOI Listing
December 2013

Manual neonatal ventilation training: a respiratory function monitor helps to reduce peak inspiratory pressures and tidal volumes during resuscitation.

J Perinat Med 2012 Sep;40(5):583-6

Klinik für Neonatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany.

Background: Neonatal resuscitation training is considered to be multifarious and includes manual ventilation as an essential competence for any health-care provider. Usually, ventilation is applied with self-inflating bags (SIBs). These devices have been shown to produce highly variable, operator-dependent peak inspiratory pressures (PIPs) and tidal volumes (V(T)). Excessive PIP and V(T) contribute to lung injury. We studied a simple tool to improve resuscitation skills.

Objective: The objectives of this study were to train healthcare providers to avoid excessive PIP and V(T) by visualizing these values by using a respiratory function monitor (RFM) and to study the sustainability of such a training.

Material And Methods: Previously untrained medical professionals were educated and trained to ventilate a neonatal preterm manikin. PIP and V(T) were measured with an RFM. Graphical representations of the measurements were displayed during training, but the RFM was blinded during subsequent recordings. Participants were reassessed directly after training and 1 month later.

Results: In total, 37 participants were trained and assessed three times during the study. Median PIPs (range) were 32.3 (4.1 – 44) cm H(2)O before training, 17.8 (9.6 – 23.6) cm H(2)O directly after training (P < 0.05), and 18.7 (7.5 – 41.6) cm H(2)O 1 month later, and the values remained low, compared with before training (P < 0.05). Median V(T)s were 6.7 (4.2 – 44) mL before training, 3.5 (1.8 – 7.3) mL directly after training (P < 0.05), and 4.1 (1.9 – 9.7 mL) 1 month after training (P < 0.05).

Conclusion: Using a SIB, untrained staff produced excessive PIP and V(T). Training with a simple RFM significantly reduced the occurrence of excessive PIP and V(T). The effect was sustained for at least 1 month.
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http://dx.doi.org/10.1515/jpm-2012-0023DOI Listing
September 2012

Persistently elevated right ventricular index of myocardial performance in preterm infants with incipient bronchopulmonary dysplasia.

PLoS One 2012 1;7(6):e38352. Epub 2012 Jun 1.

Department of Neonatology, Charité University Medical Center, Berlin, Germany.

Objectives: Elevated pulmonary vascular resistance occurs during the first days after birth in all newborn infants and persists in infants at risk for bronchopulmonary dysplasia (BPD). It is difficult to measure in a non-invasive fashion. We assessed the usefulness of the right ventricular index of myocardial performance (RIMP) to estimate pulmonary vascular resistance in very low birth weight infants.

Study Design: Prospective echocardiography on day of life (DOL) 2, 7, 14, and 28 in 121 preterm infants (median [quartiles] gestational age 28 [26]-[29] weeks, birth weight 998 [743-1225] g) of whom 36 developed BPD (oxygen supplementation at 36 postmenstrual weeks).

Results: RIMP derived by conventional pulsed Doppler technique was unrelated to heart rate or mean blood pressure. RIMP on DOL 2 was similar in infants who subsequently did (0.39 [0.33-0.55]) and did not develop BPD (0.39 [0.28-0.51], p = 0.467). RIMP declined steadily in non-BPD infants but not in BPD infants (DOL 7: 0.31[0.22-0.39] vs. 0.35[0.29-0.48], p = 0.014; DOL 14: 0.23[0.17-0.30] vs. 0.35[0.25-0.43], p<0.001; DOL 28: 0.21[0.15-0.28] vs. 0.31 [0.21-0.35], p = 0.015).

Conclusions: In preterm infants, a decline in RIMP after birth was not observed in those with incipient BPD. The pattern of RIMP measured in preterm infants is commensurate with that of pulmonary vascular resistance.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0038352PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3365901PMC
October 2012