Abstract
Background:
To describe the interrelationship between antenatal steroids, exogenous surfactant, and two approaches to lung recruitment at birth on oxygenation and respiratory system compliance (Cdyn) in preterm lambs.
Methods:
Lambs (n = 63; gestational age 127 ± 1 d) received either surfactant at 10-min life (Surfactant), antenatal corticosteroids (Steroid), or neither (Control). Within each epoch lambs were randomly assigned to a 30-s 40 cmH2O sustained inflation (SI) or an initial stepwise positive end-expiratory pressure (PEEP) open lung ventilation (OLV) maneuver at birth. All lambs then received the same management for 60-min with alveolar–arterial oxygen difference (AaDO2) and Cdyn measured at regular time points.
Results:
Overall, the OLV strategy improved Cdyn and AaDO2 (all epochs except Surfactant) compared to SI (all P < 0.05; two-way ANOVA). Irrespective of strategy, Cdyn was better in the Steroid group in the first 10 min (all P < 0.05). Thereafter, Cdyn was similar to Steroid epoch in the OLV + Surfactant, but not SI + Surfactant group. OLV influenced the effect of steroid and surfactant (P = 0.005) on AaDO2 more than SI (P = 0.235).
Conclusions:
The antenatal state of the lung influences the type and impact of a recruitment maneuver at birth. The effectiveness of surfactant maybe enhanced using PEEP-based time-dependent recruitment strategies rather than approaches solely aimed at initial lung liquid clearance.
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References
Jobe AH, Hillman N, Polglase G, Kramer BW, Kallapur S, Pillow J. Injury and inflammation from resuscitation of the preterm infant. Neonatology 2008;94:190–6.
Rojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev 2012;3:CD000510.
Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2006:CD004454.
Lista G, Castoldi F, Cavigioli F, Bianchi S, Fontana P. Alveolar recruitment in the delivery room. J Matern Fetal Neonatal Med 2012;25:S(1):39–40.
te Pas AB, Siew M, Wallace MJ, et al. Establishing functional residual capacity at birth: the effect of sustained inflation and positive end-expiratory pressure in a preterm rabbit model. Pediatr Res 2009;65:537–41.
Tingay DG, Rajapaksa A, Zonneveld CE, et al. Spatiotemporal aeration and lung injury patterns are influenced by the first inflation strategy at birth. Am J Respir Cell Mol Biol 2016;54:263–72.
Dargaville PA, Tingay DG. Lung protective ventilation in extremely preterm infants. J Paediatr Child Health 2012;48:740–6.
Björklund LJ, Ingimarsson J, Curstedt T, et al. Manual ventilation with a few large breaths at birth compromises the therapeutic effect of subsequent surfactant replacement in immature lambs. Pediatr Res 1997;42:348–55.
te Pas AB, Siew M, Wallace MJ, et al. Effect of sustained inflation length on establishing functional residual capacity at birth in ventilated premature rabbits. Pediatr Res 2009;66:295–300.
Polglase GR, Tingay DG, Bhatia R, et al. Pressure- versus volume-limited sustained inflations at resuscitation of premature newborn lambs. BMC Pediatr 2014;14:43.
Tingay DG, Bhatia R, Schmölzer GM, Wallace MJ, Zahra VA, Davis PG. Effect of sustained inflation vs. stepwise PEEP strategy at birth on gas exchange and lung mechanics in preterm lambs. Pediatr Res 2014;75:288–94.
Tingay DG, Wallace MJ, Bhatia R, et al. Surfactant before the first inflation at birth improves spatial distribution of ventilation and reduces lung injury in preterm lambs. J Appl Physiol (1985) 2014;116:251–8.
Tingay DG, Polglase GR, Bhatia R, et al. Pressure-limited sustained inflation vs. gradual tidal inflations for resuscitation in preterm lambs. J Appl Physiol (1985) 2015;118:890–7.
Siew ML, Te Pas AB, Wallace MJ, et al. Positive end-expiratory pressure enhances development of a functional residual capacity in preterm rabbits ventilated from birth. J Appl Physiol (1985) 2009;106:1487–93.
Siew ML, Wallace MJ, Kitchen MJ, et al. Inspiration regulates the rate and temporal pattern of lung liquid clearance and lung aeration at birth. J Appl Physiol (1985) 2009;106:1888–95.
Wheeler K, Wallace M, Kitchen M, et al. Establishing lung gas volumes at birth: interaction between positive end-expiratory pressures and tidal volumes in preterm rabbits. Pediatr Res 2013;73:734–41.
Probyn ME, Hooper SB, Dargaville PA, McCallion N, Harding R, Morley CJ. Effects of tidal volume and positive end-expiratory pressure during resuscitation of very premature lambs. Acta Paediatr 2005;94:1764–70.
McCall KE, Davis PG, Owen LS, Tingay DG. Sustained lung inflation at birth: what do we know, and what do we need to know. Arch Dis Child Fetal Neonatal Ed 2016;101:F175–80
Schmölzer GM, Kumar M, Aziz K, et al. Sustained inflation versus positive pressure ventilation at birth: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2015;100:F361–8.
Tingay DG, Polglase GR, Bhatia R, et al. Pressure-limited sustained inflation vs. gradual tidal inflations for resuscitation in preterm lambs. J Appl Physiol (1985) 2015;118:890–7.
Hillman NH, Kemp MW, Miura Y, Kallapur SG, Jobe AH. Sustained inflation at birth did not alter lung injury from mechanical ventilation in surfactant-treated fetal lambs. PLoS One 2014;9:e113473.
Hillman NH, Kemp MW, Noble PB, Kallapur SG, Jobe AH. Sustained inflation at birth did not protect preterm fetal sheep from lung injury. Am J Physiol Lung Cell Mol Physiol 2013;305:L446–53.
Tingay DG, Lavizzari A, Zonneveld CE, et al. An individualized approach to sustained inflation duration at birth improves outcomes in newborn preterm lambs. Am J Physiol Lung Cell Mol Physiol 2015;309:L1138–49.
te Pas AB, Walther FJ. A randomized, controlled trial of delivery-room respiratory management in very preterm infants. Pediatrics 2007;120:322–9.
Lista G, Boni L, Scopesi F, et al.; SLI Trial Investigators. Sustained lung inflation at birth for preterm infants: a randomized clinical trial. Pediatrics 2015;135:e457–64.
Grasso C, Sciacca P, Giacchi V, et al. Effects of sustained lung inflation, a lung recruitment maneuver in primary acute respiratory distress syndrome, in respiratory and cerebral outcomes in preterm infants. Early Hum Dev 2015;91:71–5.
Klingenberg C, Sobotka KS, Ong T, et al. Effect of sustained inflation duration; resuscitation of near-term asphyxiated lambs. Arch Dis Child Fetal Neonatal Ed 2013;98:F222–7.
Polglase GR, Hooper SB, Gill AW, et al. Cardiovascular and pulmonary consequences of airway recruitment in preterm lambs. J Appl Physiol (1985) 2009;106:1347–55.
Sobotka KS, Hooper SB, Allison BJ, et al. An initial sustained inflation improves the respiratory and cardiovascular transition at birth in preterm lambs. Pediatr Res 2011;70:56–60.
Ikegami M, Jobe AH. Injury responses to different surfactants in ventilated premature lamb lungs. Pediatr Res 2002;51:689–95.
Tingay DG, Mills JF, Morley CJ, Pellicano A, Dargaville PA. The deflation limb of the pressure-volume relationship in infants during high-frequency ventilation. Am J Respir Crit Care Med 2006;173:414–20.
Dargaville PA, Rimensberger PC, Frerichs I. Regional tidal ventilation and compliance during a stepwise vital capacity manoeuvre. Intensive Care Med 2010;36:1953–61.
Tingay DG, Mills JF, Morley CJ, Pellicano A, Dargaville PA. Indicators of optimal lung volume during high-frequency oscillatory ventilation in infants. Crit Care Med 2013;41:237–44.
Zannin E, Ventura ML, Dellacà RL, et al. Optimal mean airway pressure during high-frequency oscillatory ventilation determined by measurement of respiratory system reactance. Pediatr Res 2014;75:493–9.
Pellicano A, Tingay DG, Mills JF, Fasulakis S, Morley CJ, Dargaville PA. Comparison of four methods of lung volume recruitment during high frequency oscillatory ventilation. Intensive Care Med 2009;35:1990–8.
Siew ML, Te Pas AB, Wallace MJ, et al. Surfactant increases the uniformity of lung aeration at birth in ventilated preterm rabbits. Pediatr Res 2011;70:50–5.
Ikegami M, Jobe AH, Newnham J, Polk DH, Willet KE, Sly P. Repetitive prenatal glucocorticoids improve lung function and decrease growth in preterm lambs. Am J Respir Crit Care Med 1997;156:178–84.
Polk DH, Ikegami M, Jobe AH, Sly P, Kohan R, Newnham J. Preterm lung function after retreatment with antenatal betamethasone in preterm lambs. Am J Obstet Gynecol 1997;176:308–15.
Smolich JJ, Kenna KR, Cheung MM. Onset of asphyxial state in nonrespiring interval between cord clamping and ventilation increases hemodynamic lability of birth transition in preterm lambs. J Appl Physiol (1985) 2015;118:675–83.
van Vonderen JJ, Hooper SB, Hummler HD, Lopriore E, te Pas AB. Effects of a sustained inflation in preterm infants at birth. J Pediatr 2014;165:903–8.e1.
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Tingay, D., Rajapaksa, A., McCall, K. et al. The interrelationship of recruitment maneuver at birth, antenatal steroids, and exogenous surfactant on compliance and oxygenation in preterm lambs. Pediatr Res 79, 916–921 (2016). https://doi.org/10.1038/pr.2016.25
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DOI: https://doi.org/10.1038/pr.2016.25
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