ILCOR-AIREACIÓN

Hot Topics 17 Febrero, Madrid 2016
MARÍA GORMAZ MORENO
HOSPITAL UNIVERSITARIO Y POLITÉCNICO LA FE
December 6-9, 2015 Marriott Marquis | Washington,
D.C
2015 International Liaison Committee
on Resuscitation (ILCOR): Highlights of the New
Recommendations for Neonatal Resuscitation
Myra H. Wyckoff, MD
Professor of Pediatrics
UT Southwestern
Myra Medical
H. s Center at Dallas Dallas
UT Southwestern Medical Center at Dallas
2
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ALCANZANDO EL CONSENSO EN LA CIENCIA DE LA
REANIMACIÓN
2000: un grupo de trabajo neonatal ha participado con el
International Liaison Committee on Resuscitation ( ILCOR)
para la revisión completa de la reanimación neonatal cada 5
años
2015: revisión de 27 cuestiones
Australian!
Resuscitation!
Council
3
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PROCESO DE EVALUACIÓN ILCOR
ABORDA REVISION DE NUEVOS DATOS CIENTIFICOS
SOBRE REANIMACIÓN NEONATAL
!
!
!
Identificando y priorizando las cuestiones y asignando revisores
( 2-3 por pregunta)
Requerimientos mínimos para cada estrategia de búsqueda que
es realizada por bibliotecarios profesionales
Medline, Embase y Revisiones Sistemáticas Cochrane
Búsquedas manuales
Puntuación del nivel y calidad de la evidencia mediante un
sistema de evaluación de evidencia estandarizado ( GRADE
system)
Consenso para cada cuestión alcanzado por el Grupo de Trabajo
completo en Feb 2015.
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GUIA DE REANIMACIÓN NEONATAL ILCOR
Nuevo documento “ILCOR”
Consensus on Science and
Treatment Recommendations
( CoSTR) disponible online desde
15 Octubre 2015
!
!
Suplemento copublicado en
Pediatrics, Circulation y
Resuscitation
Descargar en www.heart.org/cpr
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NUEVO
Myra H. s
ALGORITMO
2015
UT
Southwestern Medical Center at Dallas
Perlman J. Circulation
2015;132:S204-S241.
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Perlman et al
LAS PREGUNTAS
eonatal Resuscitation
Algorithm
Part 7: Neonatal Resuscitation
INICIALES NO CAMBIAN….
Birth
Yes, stay
with mother
Term gestation?
Breathing or crying?
Good tone?
Routine Care
r 1rovide warmth
r Ensure open airway
r %ry
r 0ngoing evaluation
No
Warm, open airway,
dry, stimulate
No
Perlman J. Circulation 2015;132:S204-S241.
HR below 100/min,
gasping, or apnea?
No
Labored
breathing
or persistent
cyanosis?
in Temperature
REVISIÓN 2010 ILCOR SOBRE PINZAMIENTO TARDÍO CORDÓN:
OK para RNT que no necesitan reanimación
Yes
Yes
No datos suficientes para hacer una recomendación para
SpO monitoring
PPV, SpO monitoring
prematuros
Consider CPAP
Consider ECG monitoring
60
2
seconds
2
2015: PINZAMIENTO TARDÍO CORDÓN EN PREMATUROS
RESULTADOS EXAMINADOS: mortalidad, HIV severa, cualquier HIV,
estabilidad hemodinámica, transfusión, ECN, hiperbilirrubinemia,
neurodesarrollo.
!
16 artículos incluidos:
RCT 12 artículos ( 691 casos)
No RCT 4 artículos ( 811)
!
NO diferencias en mortalidad, HIV severa, temperatura al ingreso,
hiperbilirrubinemia que precise tratamiento.
!
No datos sobre neurodesarrollo
!!
24/12/15
8
Hot Topics Madrid 2016
RESULTADO: HIV/HPV GRADOS I-IV
!
!
Perlman J. Circulation 2015;132:S204-S241.
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2015: PINZAMIENTO TARDÍO CORDÓN EN PREMATUROS
EFECTO SIGNIFICATIVO:
!
Cualquier HIV ( OR 0.49 95% IC 0.29-0.82)
Estabilidad hemodinámica ( TA 0h y 4h)
Necesidad de transfusión (OR 0.44 IC95% 0.26-0.75)
ECN (OR 0.3 IC 95% 0.19-0.8).
!
!
!
!
SUGERIMOS PINZAMIENTO TARDÍO PARA RNPT QUE NO
PRECISEN REANIMACIÓN
INMEDIATAMENTE TRAS EL NACIMIENTO
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¿ Y EL “CORD MILKING”?
!
!
!
!
Permite iniciar la reanimación de RN que no respiran rápidamente.
Aproximadamente 200 RN randomizados a cord milking vs
pinzamiento cordón inmediato en 4 pequeños estudios RCT, y 1
estudio cohortes
En el momento de la revisión no había estudios comparando “cord
milking” vs pinzamiento tardío de cordón.
Todos los estudios incluidos en esta revisión de la evidencia
exprimieron 20 cm de cordón hacia el ombligo 3 veces mientras el
RN se sostenía al nivel del introito o bajo el nivel de la placenta,
antes del pinzamiento de cordón.
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¿ Y EL “CORD MILKING”?
No diferencias en mortalidad, HIV severa, temperatura,
necesidad de fototerapia.
No datos sobre neurodesarrollo
Evidencia de baja calidad
Mayor TA al ingreso
Menor HIV
Mejor Hb y menos transfusiones.
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RECOMENDACIONES SOBRE TRATAMIENTO CON
EXPRESIÓN DEL CORDÓN
SUGERIMOS CONTRA EL USO RUTINARIO DEL
CORD MILKING PARA RN CON EG < 29 SG
pero el cord milking puede ser una alternativa
razonable al pinzamiento inmediato de cordón
para mejorar la tensión arterial media, los índices
hematológicos y la hemorragia cerebral. Sin
embargo, no hay evidencia de seguridad o mejoría
a largo plazo
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BACKGROUND AND OBJECTIVE: Delayed
cord clamping (DCC) is recommended for premature infants
to improve blood volume. Most preterm infants are born by cesarean delivery (CD),
and placental transfusion may be less effective than in vaginal delivery (VD). We
sought to determine whether infants ,32 weeks born by CD who undergo umbilical
cord milking (UCM) have higher measures of systemic blood flow than infants who
undergo DCC.
Umbilical Cord Milking Versus Delayed
Cord
Clamping
in
Preterm
Infants
This was a 2-center trial. Infants delivered by CD were randomly assigned to
METHODS:
Anup C. Katheria, MD , Giang Truong, MD , Larry Cousins, MD , Bryan Oshiro, MD , Neil N. Finer, MD
undergo
UCM or DCC. Infants delivered by VD were also randomly assigned separately.
UCM (4 strippings) or DCC (45–60 seconds) were performed. Continuous hemodynamic
measurements
andclamping
echocardiography
were doneforatpremature
site 1. infants abstract
D OBJECTIVE:
Delayed cord
(DCC) is recommended
a
b
c
d
a
blood
volume.
Mostof
preterm
infantswere
are born
by cesarean
(CD), age 28 6 2 weeks). Of the 154
RESULTS:
A total
197 infants
enrolled
(meandelivery
gestational
al transfusion may be less effective than in vaginal delivery (VD). We
infants delivered by CD, 75 were assigned to UCM and 79 to DCC. Of the infants delivered by
etermine whether infants ,32 weeks born by CD who undergo umbilical
CD, neonates randomly assigned to UCM had higher superior vena cava flow and right
g (UCM) have higher measures of systemic blood flow than infants who
C. ventricular output in the first 12 hours of life. Neonates undergoing UCM also had higher
hemoglobin,
delivery
temperature,
pressure
over
was
a 2-center trial.
Infantsroom
delivered
by CD wereblood
randomly
assigned
to the first 15 hours, and urine
in thedelivered
first 24 by
hours
of life.
were
no differences
M oroutput
DCC. Infants
VD were
alsoThere
randomly
assigned
separately. for the 43 infants delivered by
VD. or DCC (45–60 seconds) were performed. Continuous hemodynamic
ppings)
nts and echocardiography were done at site 1.
This is the first randomized controlled trial demonstrating higherKatheria.
systemic
blood
Pediatrics
2015
al offlow
197 with
infantsUCM
werein
enrolled
(mean
gestational
age
28
6
2
weeks).
Of
the
154
preterm neonates compared with DCC. UCM may be a more efficient
ered by CD, 75 were assigned to UCM and 79 to DCC. Of the infants delivered by
technique to improve blood volume in premature infants delivered by CD.
CONCLUSIONS:
s randomly assigned to UCM had higher superior vena cava flow and right
output in the first 12 hours of life. Neonates undergoing UCM also had higher
delivery room temperature, blood pressure over the first 15 hours, and urine
24/12/15
Madrid
2016 delivered by
e first 24
hours of life. There were no differencesHot
forTopics
the 43
infants
14
a
Perlman et al
Part 7: Neonatal Resuscitation
S205
Temperature
al Resuscitation Algorithm
Birth
Yes, stay
with mother
Term gestation?
Breathing or crying?
Good tone?
Routine Care
r 1rovide warmth
r Ensure open airway
r %ry
r 0ngoing evaluation
No
Warm, open airway,
dry, stimulate
No
Perlman J. Circulation 2015;132:S204-S241.
HR below 100/min,
gasping, or apnea?
No
5 revisiones sistemáticas diferentes
referentes a la importancia y los
Yes
métodos de estabilización
de la
temperatura en el
paritorio
PPV,
SpO monitoring
2
60
24/12/15
seconds
Consider ECG monitoring
Labored
breathing
or persistent
cyanosis?
Yes
SpO2 monitoring
Consider CPAP
Hot Topics Madrid 2016
15
REVISIÓN SISTEMÁTICA ILCOR
REFERENTE A ESTABILIZACIÓN DE LA TEMPERATURA
36 estudios observacionales de aumento de riesgo de mortalidad
asociada con hipotermia al ingreso ( evidencia de baja calidad
elevada a evidencia de moderada calidad por el tamaño del
efecto, la relación dosis-efecto y la dirección única de la
evidencia)
!
Los RN hipotérmicos tienen aumento de morbilidad
Hipoglucemia, distrés respiratorio, HIV, sepsis de inicio tardío.
!
RECOMENDAMOS QUE LA TEMPERATURA DE RN NO ASFIXIADOS SE
MANTENGA ENTRE 36,5ºC Y 37,5ºC DESDE EL NACIMIENTO HASTA EL
INGRESO Y ESTABILIZACIÓN
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COMBINACIÓN DE MEDIDAS
PARA ESTABILIZAR LA TEMPERATURA
PARA TODOS LOS RN
Tª ambiental al menos 25ºC ( 77 ºF)
Sábanas calientes para secado
Gorros ( lana o plástico)
!
Para RN que precisen reanimación
Calentador radiante
Gases calientes y humidificados
!
Para RNPT
Envoltorio oclusivo de polietileno
Colchones calentados ( Acetato sódico)
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Perlman et al
!
Part 7: Neonatal Resuscitation
MISMOS PASOS INICIALES
eonatal Resuscitation
Algorithm
INDEPENDIENTEMENTE
DEL LÍQUIDO MECONIAL
Birth
Yes, stay
with mother
Term gestation?
Breathing or crying?
Good tone?
Routine Care
r 1rovide warmth
r Ensure open airway
r %ry
r 0ngoing evaluation
No
Warm, open airway,
dry, stimulate
No
Perlman J. Circulation 2015;132:S204-S241.
HR below 100/min,
Abrir la vía aérea posicionando
gasping, or apnea?
No
in Temperature
Limpiar la vía aérea sólo si necesario
Apneico
Yes
Secreciones abundantes
60
seconds
24/12/15
PPV, SpO2 monitoring
Consider ECG monitoring
Hot Topics Madrid 2016
Labored
breathing
or persistent
cyanosis?
Yes
SpO2 monitoring
Consider CPAP
18
2015 ¿ CONTINUAMOS INTUBANDO Y SUCCIONANDO
A CADA RN NO VIGOROSO EXPUESTO A LA MECONIAL?
LA SUCCIÓN TRAQUEAL
RUTINARIA YA NO ESTÁ
RECOMENDADA EN RN NO
VIGOROSOS CON LA MECONIAL
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n, survival or 9 month
ams
122 RN con LA meconial no vigorosos randomizados
61 No succión vs 61 intubación y succión
33% SAM en el grupo de no succión
31% SAM en el grupo de succión.
No diferencias en tasas de neumotórax, HTPP, necesidad
de VM, supervivencia a los 9 meses o seguimiento
neurológico.
Chettri S. J Pediatr. 2015 ;166:1208-1213
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Birth
Yes, stay
with mother
Term gestation?
Breathing or crying?
Good tone?
Routine Care
r 1rovide warmth
r Ensure open airway
r %ry
r 0ngoing evaluation
ESFUERZO RESPIRATORIO Y FRECUENCIA CARDÍACA
No
Warm, open airway,
dry, stimulate
Maintain Temperature
HR below 100/min,
gasping, or apnea?
No
No
Yes
60
seconds
Yes
SpO2 monitoring
Consider CPAP
PPV, SpO2 monitoring
Consider ECG monitoring
HR below 100/min?
Labored
breathing
or persistent
cyanosis?
No
Perlman J. Circulation 2015;132:S204-S241.
Yes
17/02/16
Ensure adequate
ventilation
Hot Topics Madrid 2016 Postresuscitation
Consider ET
care
21
DETERMINACIÓN INICIAL DE LA FC
Valoración inicial mediante AUSCULTACIÓN
Evidencia de baja calidad muestra beneficio ECG:
5 No RCT 213 pacientes ECG vs oximetría
1 No RCT 26 pacientes ECG vs auscultación
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ECG
PULSIOXIMETRO
Van Vonderen J Peds 2015;166:49-53
▪ Pueden llevarse a cabo intervenciones innecesarias si se confía
únicamente en la pulsioximetría para la Fc en el paritorio.
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DETERMINACIÓN INICIAL DE LA FC
SUGERIMOS UTILIZACIÓN DE ECG
PARA OBTENER UNA ESTIMACIÓN RÁPIDA Y PRECISA DE LA FC
EN RN QUE PRECISEN REANIMACIÓN.
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OXÍGENO EN PREMATUROS
▪ Population: prematuros ( < 37 semanas EG) que reciben ventilación con
presión positiva en paritorio
▪ Intervention: oxígeno inicial bajo (21-30%)
▪ Control: oxígeno inicial alto (50-100%)
▪ Outcome: disminuye mortalidad, DBP, ROP, hemorragia intraventricular,
déficit neurológico, tiempo en alcanzar Fc > 100 lpm
▪ Estrategia de búsqueda final AHA: 1752 citaciones, 46 estudios
potencialmente relevantes, 9 estudios incluidos: 8 RCT y 1 cohortes.
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pted Article
MORTALIDAD ANTES DEL ALTA:
TODOS
LOS RCT Y CASI RCT
Figure 1. Mortality
Relative risk meta-analysis plot (random effects)
Lundstrøm, 1995
0.34 (0.08, 1.37)
See, 2008
0.80 (0.09, 7.35)
Wang, 2008
1.28 (0.14, 11.72)
Vento, 2009
1.48 (0.39, 5.61)
Rabi, 2011
0.71 (0.10, 4.69)
Rook, 2012
0.57 (0.22, 1.45)
Kumar, 2012
0.39 (0.00, 3.96)
Aguar, 2013
0.44 (0.15, 1.26)
Kapadia, 2013
0.77 (0.16, 3.59)
combined [random]
0.62 (0.37, 1.04)
0.01
0.1
0.2
0.5
1
2
5
10
100
relative risk (95% confidence interval)
Relative risk of
(95%
0.37-1.04)
RR0.62
< 1 favours
low CI:
oxygen
Saugstad. Acta pediatrica 2014
Figure 2. Bronchopulmonary
dysplasia RCP
(BPD)
NO HAY DIFERENCIAS
AL INICIAR
CON FiO2 elevada en:
-DBP
-HIV
-ROP
17/02/16
Relative risk meta-analysis plot (random effects)
Lundstrøm, 1995
2,57 (0,62, 11,03)
Wang, 2008
2,98 (0,98, 9,57)
See, 2008
1,07 (0,31, 3,85)
Vento, 2009
Rabi, 2011
Hot Topics Madrid 2016
0,51 (0,22, 1,16)
0,92 (0,61, 1,29)
26
ILCOR 2015: OXÍGENO EN PREMATUROS
!
!
!RECOMENDAMOS NO iniciar la RCP de prematuros ( <35 SG)
!con concentraciones elevadas de O2 ( 65-100%).
!!
!
RECOMENDAMOS iniciar la RCP con baja concentración de
oxígeno (21-30%) ( recomendación fuerte, evidencia
moderada)
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Hot Topics Madrid 2016
What initial oxygen is best for preterm infants in the delivery
room?—A response to the 2015 neonatal resuscitation guidelines
Máximo Vento, Georg Schmölzer, Po-Yin Cheung, Neil Finer, Anne Lee Solevåg, Ju Lee Oei, Ola D. Saugstad
!
DOI: http://dx.doi.org/10.1016/j.resuscitation.2015.12.020
!
!
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TARGETED OXYGEN IN THE RESUSCITATION OF PRETERM INFANTS
AND THEIR DEVELOPMENTAL OUTCOMES (To2rpido): a randomised
control study
Oei J, Lui K, Wright I, Craven P, Saugstad O, Coates E, Tarnow-Mordi W.
PAS 2015 P-3130.2
▪ Multicéntrico, RCT abierto en prematuros ( < 32 semanas EG)
▪ Comparación RCP con oxígeno inicial bajo (21%) vs 100%, con incrementos 10% /min para
objetivo a los 5’ de 65-95%.
▪ Cese con 287 pacientes reclutados por no aceptación del 100% por potenciales investigadores.
▪ NO diferencias en ROP severa, mortalidad o morbilidad, lesión cerebral, DAP, ECN, peso al
alta o reingresos.
▪ La mortalidad neonatal en < 29 SG fue mayor del doble en el grupo 21% ( 12/74 /16,2%) vs
100% ( 5/84 6%) OR ( IC95%) 0,32 (0.11-0-97)P=0.04.
▪
El aumento en la mortalidad inesperado, no preespecificado es sólo estadísticamente
significativo marginalmente y no respalda un cambio en la práctica. Pero resalta la
urgente necesidad de mayores RCT. La Randomización simultánea a un objetivo mayor
o menor de saturación tras 3´añadiría valor significativo.
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Hot Topics Madrid 2016
Oei J. PAS 2015 P 3130.2
29
OUTCOMES OF PRETERM INFANTS FOLLOWING THE INTRODUCTION
OF ROOM AIR RESUSCITATION
Rabi Y, Lodha A, Soraisham A, Singhal N, Barrington K, Shah P.
▪ Estudio retrospectivo de cohortes EG≤27 SG
▪ Resultados 2326 prematuros: 1244 OXtitrate (21-40%) vs 1082 OX (100%)
100
.
▪ 17 UCIN participantes, 12 OX21 (21%) y 5 OXtitrate (22-100%).
▪ COMPARACIÓN ENTRE OXtitrate comparado con el OX
100
▪ Mayor lesión neurológica severa o muerte ( resultado principal) AOR 1,36;IC
95% 1.11-1.66).
▪ Mayor lesión neurológica severa AOR 1.33; IC95% 1.07-1.66.
▪ Mayor mortalidad AOR 1.32; IC95% 1.04-1.67.
▪ Menor DAP tratado médicamente o quirúrgicamente AOR 0.53;IC95% 0.37-0.74
Rabi Y. Resucitation 2015;96:252-259
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OUTCOMES OF PRETERM INFANTS FOLLOWING THE INTRODUCTION
OF ROOM AIR RESUSCITATION
Rabi Y, Lodha A, Soraisham A, Singhal N, Barrington K, Shah P.
!
▪ COMPARACIÓN ENTRE OX21 o OXtitrate con OX
100
▪ Mayor lesión neurológica severa o muerte ( resultado principal) para ambos grupos
▪ OX21 : AOR 1.33;IC 95% 1.04-1.069).
▪ OXtitrate : AOR 1.43;IC 95% 1.01-2.03).
▪ Menor DAP tratado médicamente o quirúrgicamente
▪ CONCLUSIÓN: el estudio informa de un aumento significativo de lesión neurológica
severa o muerte en <27 SG tras cambios en las recomendaciones de RCP de Canadá.
Estos resultados no deben ser considerados recomendaciones de tratamiento. El
contraste entre los resultados de las revisiones sistemáticas y los datos observacionales
resalta la importancia de realizar estudios prospectivos adecuadamente potentes.
Rabi Y. Resusitation 2015;96:252-259
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Hot Topics Madrid 2016
ILCOR 2020: OXÍGENO EN PREMATUROS
¿?
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Hot Topics Madrid 2016
INSUFLACIÓN SOSTENIDA
Gran heterogenicidad en la definición de Insuflación sostenida ( 5-20
segundos, PIP de 20-30 cmH20), dispositivo para adminsitrarla
3 RCT (N= 404), 2 cohortes ( N=331)
No ventajas en mortalidad, DBP, escape aéreo o Apgar.
Ventaja: disminución de la necesidad de intubación y de ventilación
mecánica en las primeras 72 horas.
RECOMENDACIÓN 2015: sugerimos contra el uso rutinario de insuflación
sostenida inicial (> 5 segundos duración) para RNPT sin respiraciones
espontáneas inmediatamente tras el nacimiento, pero una insuflación
sostenida puede considerarse en circunstancias clínicas individuales o en
investigación.
33
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Hot Topics Madrid 2016
ILCOR 2010
ILCOR 2015
RECOMENDACIONES 2015 : SIN CAMBIOS
!
!
!
!
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Hot Topics Madrid 2016
Perlman J. Circulation 2015;132:S204-S241.
RECOMENDACIONES 2015: RESUMEN NOVEDADES
SUGERIMOS PINZAMIENTO CORDÓN > 30” PARA RNT Y RNPT QUE NO PRECISAN REANIMACIÓN AL NACIMIENTO.
NO EVIDENCIA PARA RN QUE PRECISAN REANIMACIÓN.
!
!
SUGERIMOS CONTRA EL USO DE RUTINA DE “CORD MILKING” PARA RN DE 28 SG O < EG.
! !
!
!
!
RECOMENDAMOS MANTENER Tª DE RN no asfícticos entre 36,5ºC-37,5ºC
!
RECOMENDAMOS INICIAR LA REANIMACIÓN DE RNPT CON CONCENTRACIÓN DE OXÍGENO BAJA (21-30%).
SUGERIMOS CONTRA EL USO RUTINARIO DE INSUFLACIÓN SOSTENIDA (IS) PARA RNPT SIN RESPIRACIÓN
ESPONTÁNEA TRAS EL NACIMIENTO.
!
!
SUGERIMOS UTILIZAR PEEP DURANTE LA VENTILACIÓN DE PREMATUROS
SUGERIMOS EL USO INICIAL DE CPAP Y NO LA INTUBACIÓN E IPPV EN PACIENTES PREMATUROS CON RESPIRACIÓN
ESPONTÁNEA Y DISTRÉS RESPIRATORIO .
!
NO HAY EVIDENCIA SUFICIENTE PARA RECOMENDAR LA INTUBACIÓN TRAQUEAL RUTINARIA PARA LA SUCCIÓN DE
MECONIO EN RN NO VIGOROSOS CON LA MECONIAL frente a la no intubación traqueal para aspiración.
35
!
17/02/16
Hot Topics Madrid 2016
AIREACIÓN PULMONAR AL NACIMIENTO
PROF. STUART HOOPER
17/02/16
Hot Topics Madrid 2016
1
TRANSICIÓN RESPIRATORIA DEL RECIÉN NACIDO
!Review
!
Respiratory transition in the newborn: a three-phase process
!
Arch Dis Child Fetal Neonatal Ed doi:10.1136/archdischild-2013-305704
Stuart B Hooper1,2, Arjan B te Pas3, Marcus J Kitchen4
“Respiratory transition in the newborn: a three-phase We propose that the respiratory transition at
birth passes through three distinct, but overlapping phases, which reflect different physiological
states of the lung… During the first phase, the airways are liquid-filled and so no pulmonary gas
exchange can occur. Respiratory support should, therefore, be focused on clearing the gas exchange
regions of liquid. In the absence of gas exchange, little or no CO2 will accumulate within the
airways and, therefore, interrupting inflation pressures to allow the lung to deflate and exhale
CO2 is unnecessary. This is the primary rationale for administering a sustained inflation at birth”
Hooper S. ADCFN 2015;0:F1-F6
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Hot Topics Madrid 2016
Downloaded from http://fn.bmj.com/ on February 1, 2016 - Published by group.bmj.com
VENTILACIÓN PULMONAR TRAS EL
NACIMIENTO
Review
!
TRES FASES DISTINTAS
Final inspiración
Review
Downloaded from http://fn.bmj.com/ on February 1, 2016
Final espiración
1. VÍA AÉREA LLENA DE LÍQUIDO
Movilización de líquido vs aire a través deReview
la vía aérea
Dura 30 segundos a 5 minutos
Downloaded from http://fn.bmj.com/ on February 1, 2016 - Published by group.bmj.com
Figure 1 The lung passes through three distinct phases as it transitions from a liquid-filled organ with a low blood flow into the sole organ
exchange after birth. During the first phase, the liquid-filled
airways
must
be cleared of lung
liquid so that
gas exchange
canbycommence.
Airw
Downloaded
from
http://fn.bmj.com/
on February
1, 2016
- Published
group.bmj.com
liquid clearance primarily results from transepithelial pressure gradients generated during inspiration, which provides the pressure gradient for
to move from the upper Review
into the lower airways and then across the epithelium into the surrounding lung tissue. In most infants, it is likely th
phase is very short in duration (ie, seconds), but can extend for many minutes, which will be reflected by continuing low oxygenation and he
rates immediately after birth. During the second phase, the liquid cleared from the airways resides within the interstitial tissue, which increas
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liquid clearance from lung tissue is much slower than it is from the airways, this phase can last for hours (∼4 h); however, application of a p
end-expiratory pressure will reduce the pressure gradient for airway liquid re-entry. The third phase depicts the lung following all airway liquid
Downloaded from http://fn.bmj.com/
on February
2016resulting
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clearance
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PHASE 1: AIRWAY LIQUID CLEARANCE
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15
liquid clearance primarily resultsinfrom
pressure
gradients
generated
inspiration,
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for liquid this increases abd
flexion.
for gradient
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to move from the upper Review
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tribution will likely differ depending on the timing (gestational
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the diaphragm,
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and mode
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mouth.CLEARANCE
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delivery).
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PHASE
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AIRWAY
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interstitial tissue pressures and increases the likelihood of liquid re-entering the airways at end-expiration (ie, at functional residual capacity). As
have
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com
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2. LÍQUIDO EN EL TEJIDO PULMONAR
El líquido en tejido aumenta lasReview
posibilidades de
encharcamiento pulmonar y disminución de la CFR
Dura 4 horas aproximadamente
LIQUID
CLEARANCE
BIRTH
descriptio
end-expiratory pressure will reduce
the pressure
gradientBEFORE
for airway
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depicts
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lung following
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6 11 12 gradients, which
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in subatmospheric
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that pressures
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little resi
this process
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Na reabsorption
5 13
assist in keeping the airways cleared
of
liquid.
Al,
alveolus;
BV,
blood
vessels;
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pressure.
Figure
1
The
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passes
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as
it
transitions
from
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liquid-filled
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decrease days before birth,
this has not been
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shoulders
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Until
the primary
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pregnancies with established
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15
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known
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the
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PHASE 1: AIRWAY LIQUID to
CLEARANCE
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much
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fol
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of
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LIQUID
CLEARANCE
BEFORE
6
4
5
a
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pregnancies
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cle
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in the immature
human
Oligohydramnios
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mouth.
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process
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that
delivery).
epithelium,
withthe
little
being
lostAIRWAY
via
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nose
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mouth.
delivery
of
the
infant’s
head.
Thi
PHASE
1:
LIQUID
CLEARANCE
Clearly,
preterm
infants
cannot
use
this
mechanism
to
an increase
in transpulmonary
pressure, causing the loss of
ent leadin
interstitial tissue pressures and increases the likelihood of liquid re-entering the airways at end-expiration (ie,have
at functional
residual
capacity).
As
19
been
observed
following
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ofthe
the20that
infant’s
loss
ishead.
commonly
referred to as ‘vagi
There
has for
been
considerable
debate
in15the
literature
about
liquid.
lung
liquid.
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the available
liquid clearance from lung tissue is much slower than it is from the airways, this phase
can last
hours
(∼4 h); however,
application
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positive
stimulated
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entirely
accurate
mechanisms
of
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birth liquid
and
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at
LIQUID
CLEARANCE
BIRTH
LIQUID
CLEARANCE
DURING
BIRTH
adrenaline
infusions
inhib
space,
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may
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for airway
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theliquid
lungintrauterine
following
levels,
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6 11 12
resistance
tocondelivery late
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can
Fetal
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in
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in subatmospheric
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andwhich
thevolumes
generation
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volumeswhich
before
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However,
whenreabsorption
Na reabsorption
a conven
17
5 13
21–23
shoulders.
Instead,
it is organ
thought
tha
altogether
(seeinbelow),
itasisitrecently,
evident
airway
clearance
decrease
days Al,
before
birth,
this
haspasses
not
been
confirmed
assist in keeping the airways cleared
of liquid.
alveolus;
BV,
blood
vessels;
P, pressure.
reports
in
the
literature
have
described
theinthat
loss
ofa liquid-filled
pharmacological
doses
are liquid
required
to
achieve
tion,
sidered
relation
toliquid
the lung’s
capacity
toblood
clear
airway
Until
the
primary
mechanism
responsible
for
Figure
1Numerous
The
lung
through
three
distinct
phases
transitions
from
organ
with
a low
flow
into
the
sole
of gas
higher
ris
3. ACLARAMIENTO DE LÍQUIDO DEL PULMÓN
Foco en la homeostasis de los gases respiratorios y
sanguíneos.
Hooper S. ADCFN 2015;0:F1-F6
38
17/02/16
Hot Topics Madrid 2016
ACLARAMIENTO DE LÍQUIDO TRAS EL NACIMIENTO
!
1. Aumentos de la presión transpulmonar inducidos por la postura
2. Reabsorción de Na+ y reversión del gradiente osmótico a través del epitelio
3. Aumentos en la presión transepitelial generados por la inspiración
!
ROL DE LOS CANALES DE NA+ MENOS SIGNIFICATIVO DE LO ASUMIDO:
Demasiado lento ( máximo de 10 ml/kg/h)
La adrenalina debe estar elevada durante horas
NO activo en prematuros
El aclaramiento de líquido de la vía aérea puede ocurrir 2h después de la muerte
!
!
39
17/02/16
Hot Topics Madrid 2016
LA PRESIÓN GENERADA POR LA INSPIRACIÓN
DIRIGE EL MOVIMIENTO DEL LÍQUIDO DE LA VÍA ÁEREA
!
INSPIRACIÓN
asses through three distinct phases as it transitions from a liquid-filled organ with a low blood flow into the sole org
During the first phase, the liquid-filled airways must be cleared of lung liquid so that gas exchange can commence. A
rily results from transepithelial pressure gradients generated during inspiration, which provides the pressure gradient f
er into the lower airways and then across the epithelium into the surrounding lung tissue. In most infants, it is likely
duration (ie, seconds), but can extend for many minutes, which will be reflected by continuing low oxygenation and
S. ADCFN 2015;0:F1-F6
r birth. During the second phase, the liquid cleared from the airways resides within theHooper
interstitial
tissue, which incre
ures and increases the likelihood of liquid re-entering the airways at end-expiration (ie, at functional residual40capacity
ung tissue
is much slower than it is from the airways,
thisMadrid
phase2016
can last for hours (∼4 h); however, application of a
17/02/16
Hot Topics
e will reduce the pressure gradient for airway liquid re-entry. The third phase depicts the lung following all airway liq
VENTILACIÓN: LAS BASES
Cuando el pulmón está lleno de líquido:
Inspiración: necesaria para el aclaramiento del líquido de la vía aérea
Espiración: superflua al no existir intercambio gaseoso
CO2
O2
¿ Porqué no mantener la insuflación hasta que el pulmón
se airee completamente?
41
17/02/16
Hot Topics Madrid 2016
Downloaded from http://fn.bmj.com/ on February 1, 2016 - Published by group.bmj.com
CONSECUENCIAS DE LA ACUMULACIÓN DE LÍQUIDO TISULAR
Final espiración
Final inspiración
Hooper S. ADCFN 2015;0:F1-F6
asses through three distinct phases as it transitions from a liquid-filled organ with a low blood flow into the42sole org
17/02/16
Hotbe
Topics
Madridof
2016
uring the
first phase, the liquid-filled airways must
cleared
lung liquid so that gas exchange can commence. A
ily results from transepithelial pressure gradients generated during inspiration, which provides the pressure gradient
PRESIÓN INTERSTICIAL TRAS EL NACIMIENTO
!
El aclaramiento de líquido de la vía aérea resulta
predominantemente de los gradientes de presión generados por la
inspiración/insuflación.
El aclaramiento de líquido de la vía aérea al tejido perialveolar
aumenta las presiones tisulares y el potencial de que el líquido
entre de nuevo en la vía aérea.
!
Mayores volúmenes de líquido aumenta el potencial de que el
líquido entre de nuevo en la vía aérea y de que se reduzca la
compliance y la capacidad residual funcional
¿ SON ESTOS CONCEPTOS TRASLADABLES A LA CLÍNICA?
43
17/02/16
Hot Topics Madrid 2016
4–6 h to permanently become subatmospheric (at rest).
15 minutos
TA tónicamente activo durante la apnea
Hooper S. ADCFN 2015;0:F1-F6
Figure 2 Phase-contrast X-ray image of the upper chest, trachea, 44
17/02/16
Topics Madrid
larynx and pharynx in a nearHotterm
(302016
days), spontaneously breathing
PARA LLEVAR A CASA…..
La glotis puede estar aducida al nacimiento y obstruir la ventilación
no invasiva
!
Estimular la respiración al nacimiento abre la glotis y hace la
ventilación no invasiva más efectiva
!
Muchos factores pueden inhibir la respiración al nacimiento,
particularmente la hipoxia.
45
17/02/16
Hot Topics Madrid 2016
SUSTAINED INFLATION
AND ITS ROLE IN THE DELIVERY ROOM MANAGEMENT
Gianluca Lista MD
NICU
Ospedale dei Bambini “V. Buzzi” ICP
Milán
46
17/02/16
Hot Topics Madrid 2016
EVITAR LA VENTILACIÓN MECÁNICA DISMINUYE LA MORTALIDAD/DBP….
REVIEW ARTICLE
Avoiding endotracheal intubation to prevent bronchopulmonary dysplasia: a meta-analysis.
Fischer Pediatrics 2013
FIGURE 2
Effect of avoiding eMV on death or BPD.
Reducción en mortalidad/DBP en <32 SG: NNT 35
Fischer Pediatrics 2013:132:1351-1360
Non-invasive versus invasive respiratory support in preterm infants at birth: systematic review and meta-analysis.
Schmölzer. BMJ 2013
Morley 2008
Support 2010
Sandri 2010
Dunn 2011
Reducción en mortalidad/DBP en <30 SG: NNT 25
Schmölzer BMJ 2013;347:f5980
47
17/02/16
Hot Topics Madrid 2016
TASA DE FRACASO DE LA nCPAP
Requirieron VM entre los pacientes inicialmente en nCPAP:
50-67% RNMBP ( COIN TRIAL 2008 y SUPPORT TRIAL 2010)
52% 26-29+6 ( VON TRIAL 2011)
48
17/02/16
Hot Topics Madrid 2016
TRANSICIÓN RESPIRATORIA DEL RECIÉN NACIDO
!Review
!
Respiratory transition in the newborn: a three-phase process
!
Arch Dis Child Fetal Neonatal Ed doi:10.1136/archdischild-2013-305704
Stuart B Hooper1,2, Arjan B te Pas3, Marcus J Kitchen4
“Respiratory transition in the newborn: a three-phase We propose that the respiratory transition at
birth passes through three distinct, but overlapping phases, which reflect different physiological
states of the lung… During the first phase, the airways are liquid-filled and so no pulmonary gas
exchange can occur. Respiratory support should, therefore, be focused on clearing the gas exchange
regions of liquid. In the absence of gas exchange, little or no CO2 will accumulate within the
airways and, therefore, interrupting inflation pressures to allow the lung to deflate and exhale
CO2 is unnecessary. This is the primary rationale for administering a sustained inflation at birth”
Hooper S. ADCFN 2015;0:F1-F6
49
17/02/16
Hot Topics Madrid 2016
SUSTAINED LUNG INFLATION AT BIRTH : A RANDOMIZED CONTROLLED TRIAL
Gianluca Lista, Luca Boni, Fabio Scopesi, Fabio Mosca, Daniele Trevisanuto, Hubert Messner, Giovanni Vento, Rosario
Magaldi, Antonio Del Vecchio, Massimo Agosti, Camilla Gizzi, Fabrizio Sandri, Paolo Biban, Massimo Bellettato, Diego
Gazzolo, Antonio Boldrini, Carlo Dani, for the SLI Trial Investigators
Population: prematuros intramuros (25.0-28.6 semanas EG, 16 UCINs).
Intervention: SLI + CPAP + posibles intervenciones según la AAP
Control: CPAP + posibles intervenciones según la AAP
Outcome: necesidad de VM en las primeras 72 horas de vida.
Time: septiembre 2011-enero 2013
Lista Pediatrics 2015:135:e457-3464
50
17/02/16
Hot Topics Madrid 2016
died during the study (cumulative
supports (bilevel nCPAP, nasal IMV)
sum test was used to
mortality
during the in-hospital
stay:
and MV (synchronized
intermittentAT BIRTH
SUSTAINED
LUNG INFLATION
: A RANDOMIZED
CONTROLLED
TRIAL
nuous outcomes with
MV/synchronized intermittent
8% vs 11%; P = .39) (Table 2).
distribution.Gianluca
As
Lista, Luca Boni, Fabio Scopesi, Fabio Mosca, Daniele Trevisanuto, Hubert Messner, Giovanni Vento, Rosario Magaldi, Antonio Del Vecchio,
Agosti,
yses, the Massimo
estimates
of Camilla Gizzi, Fabrizio Sandri, Paolo Biban, Massimo Bellettato, Diego Gazzolo, Antonio Boldrini, Carlo Dani, for the SLI Trial Investigators
effect were also
he use of statistical
cluded terms for
and study center
enters that enrolled
ere combined in the
Subgroup analyses
d with exploratory
asis of the test for
statistical tests were
values #.05 were
be statistically
adjustment for multiple
as made. Statistical
performed by 1 of the
using SAS version 9.2
Inc, Cary, NC).
of infants deemed
study and the
omly assigned to
procedure or standard
he delivery room are
. A total of 294 infants
between October 1,
ary 31, 2013. Three
neously randomized to
e and 2 stillborn) were
17/02/16
the intention-to-treat
Lista Pediatrics 2015:135:e457-3464
FIGURE 1
Topics Madrid 2016
Consolidated Standards of Reporting TrialsHot
diagram.
51
SUSTAINED LUNG INFLATION AT BIRTH : A RANDOMIZED CONTROLLED TRIAL
Gianluca Lista, Luca Boni, Fabio Scopesi, Fabio Mosca, Daniele Trevisanuto, Hubert Messner, Giovanni Vento, Rosario Magaldi, Antonio Del Vecchio,
Massimo Agosti, Camilla Gizzi, Fabrizio Sandri, Paolo Biban, Massimo Bellettato, Diego Gazzolo, Antonio Boldrini, Carlo Dani, for the SLI Trial Investigators
DISCUSSION
TABLE 1 Baseline Clinical Characteristics of the Infants and Their Mothers
Characteristic
Control Group (n = 143)
SLI Group (n = 148)
This multicente
Mothers
controlled trial
Antenatal steroids
125 (87)
134 (91)
determine if th
Cesarean delivery
116 (81)
120 (81)
delivery room
Placental abruption
15 (10)
21 (14)
nCPAP would r
Hypertension disorders
42 (29)
35 (24)
and improve re
pPROM
39 (27)
39 (26)
Chorioamnionitis
14 (10)
19 (13)
preterm infants
Other complications
43 (30)
48 (32)
sole use of nCP
Infants
found to be effe
Gestational age, mean 6 SD, wk
26.8 6 1.2
26.8 6 1.1
need for MV wi
25–26
55 (38)
52 (35)
of life: during t
27–28
88 (62)
96 (65)
Birth weight, mean 6 SD, g
894 6 247
893 6 241
infants were m
Male sex
65 (45)
86 (58)
compared with
Birth weight ,10th percentile for
31 (22)
32 (22)
group, with no
gestational age
effects. These o
Singleton birth
98 (69)
101 (68)
explained by th
Unless otherwise indicated, data are n (%). pPROM, prolonged premature rupture of membranes.
and FRC achiev
SLI, as well as
Lista Pediatrics 2015:135:e457-3464
Moreover, the overall rate of BPD was
occurred in 1% (n = 2) of infants in the
collapse
52 allowe
35%
(50
of
143)
in
the
control
group
control
group
compared
with
6%
strategy might
17/02/16
Hot Topics Madrid 2016
and 38.5% (57 of 148) in the SLI
(n = 9) of infants in the SLI group, with
distribution of
in the control group and 15.4%
(16 of 104) in the SLI group.
overall need for and dura
heterogeneity in the effects of the SLI
noninvasive respiratory s
maneuver on the primary end point
MV, need for surfactant, o
SUSTAINED
LUNG INFLATION
: A RANDOMIZED
No significant
differences
were foundAT BIRTH
according
to any of theCONTROLLED
mother and TRIAL
of BPD. Our re
the Fabio
2 groups
theMosca,
other
infant Hubert
characteristics
tested
inRosario
the Magaldi, occurrence
Gianluca between
Lista, Luca Boni,
Scopesi,in
Fabio
Daniele Trevisanuto,
Messner, Giovanni
Vento,
Antonio Del Vecchio,
Massimo Agosti, Camilla Gizzi, Fabrizio Sandri, Paolo Biban, Massimo Bellettato, Diego Gazzolo, Antonio Boldrini, Carlo Dani, for the
SLI Trial
with
the Investigators
randomized cont
secondary outcomes. Pneumothorax
subgroup analyses (Fig 2).
of Harling et al22 and Lin
although both these studi
TABLE 2 Primary and Secondary Outcomes
power because of small s
Outcome
Control Group SLI Group Unadjusted Odds
P
Adjusted Odds
te Pas et al5 found a decr
(n = 143)
(n = 148)
Ratio (95% CI)
Ratio (95% CI)a
need for MV at 72 hours o
Primary outcome, n (%)
their study, the SLI proce
MV within the first 72 h
93 (65)
79 (53)
0.62 (0.38–0.99) .04
0.57 (0.33–0.96)
decreased the average du
of life
ventilatory support and th
Secondary outcomes, n (%)
MV within the first 3 h
73 (51)
66 (45)
0.77 (0.49–1.22) .27
0.72 (0.43–1.22)
occurrence of moderate/s
of life
These differences may ha
BiPAP
47 (33)
63 (43)
1.51 (0.94–2.44) .09
1.51 (0.93–2.43)
explanations: the infants i
Nasal IMV
36 (25)
39 (26)
1.06 (0.63–1.80) .85
1.07 (0.63–1.81)
et al study received “resc
Surfactant
110 (77)
109 (74)
0.84 (0.49–1.43) .52
0.88 (0.50–1.56)
they had “no signs of spo
SIMV/SIPPV/PSV
90 (63)
86 (58)
0.82 (0.51–1.31) .43
0.84 (0.51–1.39)
HFV
31 (22)
32 (22)
1.00 (0.57–1.74) .99
1.03 (0.58–1.83)
breathing or spontaneous
Any mechanical ventilation
98 (69)
88 (59)
0.67 (0.42–1.10) .11
0.68 (0.41–1.13)
present, but signs of poor
BPDb,c
50 (35)
57 (39)
1.17 (0.80–1.71)d .42
1.14 (0.78–1.69)d
whereas our infants had p
Deathc
12 (8)
17 (11)
1.37 (0.66–2.88)d .40
1.39 (0.66–2.93)d
treatment; they were also
BiPAP, bilevel positive airway pressure; HFV, high-frequency ventilation; PSV, pressure support ventilation; SIMV, synmature than infants in ou
chronized intermittent MV; SIPPV, synchronized intermittent positive pressure ventilation.
a Adjusted for center and gestational age.
(,33 vs ,29 weeks of ge
b Defined by the use of supplemental oxygen at a postmenstrual age of 36 weeks.
fewer therefore had RDS
c Proportions are estimates of cumulative incidence of events in the presence of competing risks.
d Unadjusted hazard ratio (95% confidence interval).
94% in the control group
Lista Pediatrics 2015:135:e457-3464
PEDIATRICS Volume 135, number 2, February 2015
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53
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Hot Topics Madrid 2016
according to the devices used for SI. However, there were not
rhages (RR 1.59 (0.83 to 3.03), ARR 0.03 (−0.01 to 0.06))
enough studies using each type of device to conduct subgroup
(table 3, figure 5). We did not find any difference in the rate of
analysis and reach any meaningful conclusion.
other neonatal outcomes (table 3).
In sensitivity analyses, when the data from Harling et al17
were excluded (as the two groups were somewhat similar in the
DISCUSSION
SUSTAINED LUNG vs POSITIVE PRESSURE VENTILATION
AT BIRTH : A SYSTEMATIC
delivered intervention), the results for the outcomes of death,
The results of this meta-analysis demonstrate that providing SI
BPD, combined outcome of BPD/death or mechanical ventilato preterm infants in the delivery room results in beneficial
REVIEW AND META-ANALYSIS
tion <72 h did not change.
short term respiratory effects with significantly lower numbers
We were able to include data from three trials in a sensitivity
of infants mechanically ventilated within the first 72 h of life.
M Schmölzer,
Manojage
Kumar,
Gerhard
Megan O`Reilly, Gianluca Lista, Po-Yin Cheung.
analysisGeorg
examining
gestational
<29Khalid
weeks.Aziz,
Data
for Pichler,
There was no significant difference noted in the outcomes of
<29 weeks were assessed separately; the results were not signifiBPD, death or the combined outcome of death or BPD among
cant for any of the outcomes studied (figure 6A–D, online supsurvivors. There was an increase in the number of infants requirplement). We also planned to carry out assessments of reporting
ing either medical treatment or surgical ligation of a patent
Table 3 Neonatal outcomes
Death at latest follow-up
BPD at 36 weeks’ postmenstrual age
Death or BPD
Pneumothorax
Mechanical ventilation <72 h after birth
IVH ≥ 3
PVL
NEC
PDA
ROP
Studies
SI
IPPV
RR (95% CI)
ARR (95% CI)
414–17
414–17
414–17
414–17
414–17
414–17
414–17
315–17
414–17
414–17
28/309
89/281
118/309
15/309
167/309
23/309
8/309
9/278
127/309
19/306
19/302
100/283
118/302
14/302
194/302
14/302
14/302
5/272
94/302
18/302
1.39
0.84
0.92
1.03
0.87
1.59
0.53
1.62
1.27
1.06
0.03
−0.05
−0.02
−0.00
−0.10
0.03
−0.02
0.01
0.10
−0.01
(0.79 to 2.46)
(0.57 to 1.22)
(0.66 to 1.29)
(0.25 to 4.21)
(0.77 to 0.97)
(0.83 to 3.03)
(0.17 to 1.65)
(0.56 to 4.5)
(1.05 to 1.54)
(0.58 to 1.95)
(−0.03 to 0.09)
(−0.15 to 0.05)
(−0.14 to 0.09)
(−0.07 to 0.07)
(−0.17 to −0.03)
(−0.01 to 0.06)
(−0.06 to 0.02)
(−0.03 to 0.05)
(0.03 to 0.16)
(−0.03 to 0.02)
NNT/NNH
10
10
Data are numbers.
ARR, absolute risk reduction; BPD, bronchopulmonary dysplasia; IVH, intraventricular haemorrhage; IPPV, intermittent positive pressure ventilation; NEC, necrotising enterocolitis; NNH,
number needed to harm; NNT, number needed to treat; PDA, patent ductus arteriosus; PVL, periventricular leukomalacia; ROP, retinopathy of prematurity; RR, relative risk; SI, sustained
inflation.
F4
17/02/16
Schmölzer GM, et al. Arch Dis Child Fetal Neonatal Ed 2014;0:F1–F8. doi:10.1136/archdischild-2014-306836
Schmölzer GM, et al Arch Dis Child Fetal Neonatal Ed 2014;0:F1-F8.
54
Hot Topics Madrid 2016
Cochrane Database Syst Rev. 2015 Jul 1;7:CD004953. doi: 10.1002/14651858.CD004953.pub2.
!
Sustained versus standard inflations during neonatal resuscitation to prevent
mortality and improve respiratory outcomes.
O'Donnell CP1, Bruschettini M, Davis PG, Morley CJ, Moja L, Calevo MG, Zappettini S.
RESULTADOS
Dos ensayos incluyendo 352 pacientes cumplían los criterios de inclusión. No hubo diferencias en las
tasas de mortalidad durante la hospitalización ( RR 1.59, 95% CI 0.81 a 3.10; 2 ensayos, 352 niños),
intubación en los primeros tres días de vida ( RR 0.85, 95% CI 0,72-1.02; 2 ensayos, 352 pacientes ) o
enfermedad pulmonar crónica (RR 1.06 95% CI 0.79-1.42; 2 ensayos, 349 pacientes) entre niños que
recibieron insuflaciones mantenidas vs estandar. La tasa de ductus arterioso persistente ( necesidad de
tratamiento farmacológico) fue mayor en el grupo de insuflación mantenida ( RR 1.27 95% CI
1.03-1,56;2 ensayos, 352 niños).
!
CONCLUSIONES
En el momento actual no hay suficiente evidencia procedente de ensayos clínicos para determinar la
eficacia y seguridad de la insuflación mantenida inicial para los recién nacidos reanimados con presión
positiva. RCT comparando ventilación con presión positiva con o sin insuflaciones mantenidas durante
la reanimación neonatal son necesarios.
!
!!
55
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Perlman Circulation 2015
Wyllie Resuscitation 2015
56
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Hot Topics Madrid 2016
on CPAP. For infants who continue to have inadequate respiratory effortFoglia
and/or
bradycardia,
ventilation corrective
et al. Trials
(2015) 16:95
DOI 10.1186/s13063-015-0601-9
steps will be performed
as needed and a second SI of
25 cm H2O for 15 seconds will be performed (Figure 1).
At that point, the intervention is complete, and all subsequent care will follow
S T U Dlocal
Y P Rresuscitation
O T O C O L protocols.
quiring IPPV within 6 hours, ≥6 apneic events requiring
stimulation within 6 hours, cardiovascular instability, or
need for surgery.
TRIALS
Primary outcome measure
The primary outcome is theOpen
composite
Accessoutcome of either
BPD or death, as assessed by standard oxygen reduction
test at 36 weeks PMA [21].
Sustained Aeration of Infant Lungs (SAIL) trial:
study protocol for a randomized controlled trial
Extubation guidelines
Because the duration of invasive respiratory support is a
critical end point, guidelines related to extubation are Secondary outcomes
defined. Extubation should be
attempted within 24 hours We will capture important secondary outcomes, including
Elizabeth E Foglia1,2, Louise S Owen3,4,5, Marta Thio3,4,5, Sarah J Ratcliffe6, Gianluca Lista7, Arjan te Pas8,
after meeting all
the
following
criteria: PCO ≤ 55 mm short-term respiratory morbidity and potential harms
9
Helmut Hummler , Vinay Nadkarni10, Anne2 Ades1,2, Michael Posencheg1,2, Martin Keszler11,12, Peter Davis3,4,5
and Haresh Kirpalani1,2*
Abstract
Background: Extremely preterm infants require assistance recruiting the lung to establish a functional residual
capacity after birth. Sustained inflation (SI) combined with positive end expiratory pressure (PEEP) may be a superior
method of aerating the lung compared with intermittent positive pressure ventilation (IPPV) with PEEP in extremely
preterm infants. The Sustained Aeration of Infant Lungs (SAIL) trial was designed to study this question.
Methods/Design: This multisite prospective randomized controlled unblinded trial will recruit 600 infants of 23 to
26 weeks gestational age who require respiratory support at birth. Infants in both arms will be treated with PEEP 5
to 7 cm H2O throughout the resuscitation. The study intervention consists of performing an initial SI (20 cm H20 for
15 seconds) followed by a second SI (25 cm H2O for 15 seconds), and then PEEP with or without IPPV, as needed.
The control group will be treated with initial IPPV with PEEP. The primary outcome is the combined endpoint of
bronchopulmonary dysplasia or death at 36 weeks post-menstrual age.
Trial Registration: www.clinicaltrials.gov, Trial identifier NCT02139800, Registered 13 May 2014
Keywords: Preterm infants, Resuscitation, Bronchopulmonary dysplasia, Sustained inflation, Continuous positive
airway pressure
Background
At birth, the newborn infant faces immediate and significant challenges for successful transition to the
extrauterine environment. The critical physiological
tasks to accomplish are to aerate the liquid-filled lung
and thereby maintain aerated lung volume to establish
a functional residual capacity (FRC). While term infants
begin to establish the FRC with the first breath after
birth [1], preterm infants are hampered by a greater instability of the thorax [2-4], limited muscle strength,
and immature epithelial sodium channels, surfactant
composition and production [5]. Use of positive end
expiratory pressure (PEEP) during intermittent positive
pressure ventilation (IPPV) or use of continuous positive
airway pressure (CPAP) alone is currently recommended
* Correspondence: [email protected]
1
Division of Neonatology, The Children’s Hospital of Philadelphia, 34th and
Civic Center Blvd., 2nd Floor Main Building, Philadelphia, PA 19104, USA
2
Department of Pediatrics, University of Pennsylvania Perelman School of
Medicine, 34th and Civic Center Blvd, Philadelphia, PA 19104, USA
Full list of author information is available at the end of the article
17/02/16
after birth to facilitate alveolar recruitment and to avoid
baro-volu-trauma from mechanical ventilation [6]. However, well-performed trials indicate that despite a strategy
of CPAP use after birth in extremely low gestational age
neonates, rates of bronchopulmonary dysplasia (BPD) or
death at 36 weeks postmenstrual age (PMA) remain high,
ranging from 41 to 64% [7-9].
An additional approach to promote lung liquid clearance and aeration, ‘sustained inflation’ (SI), holds an inflating pressure for a period in order to facilitate lung fluid
clearance and to establish the FRC. Initial human studies
described inflations of up to 5 seconds in term infants
[10]. Subsequently, SI has been increased to up to
30 seconds in animal models [11-16]. Earlier studies
comparing SI to conventional resuscitative measures in
preterm infants have shown promise but have been
hampered by major limitations, including observational
study design, lack of PEEP use in the control groups,
early stopping, or lack of power to detect the outcomes
of BPD or death at 36 weeks PMA [17-20].
© 2015 Foglia et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article,
abbreviations
in figure: CPAP, continuous positive airway pressure; FiO2,fraction of inspired
unless otherwise stated.
Figure 1 Resuscitation algorithm.
Hot Topics Madrid 2016
rate; NRP, neonatal resuscitation program; PPV, positive pressure ventilation; SI, sustained inflation; SpO2, oxygen saturation.
57
oxygen; HR, heart
Respiratory Function Monitor (RFM)
T-piece resuscitator
Volumetric CO2 monitor
Respiratory Inductance Plethysmography (RIP)
58
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4–6 h to permanently become subatmospheric (at rest).
15 minutos
TA tónicamente activo durante la apnea
Hooper S. ADCFN 2015;0:F1-F6
Figure 2 Phase-contrast X-ray image of the upper chest, trachea, 59
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Topics Madrid
larynx and pharynx in a nearHotterm
(302016
days), spontaneously breathing
Arch Dis Child Fetal Neonatal Ed doi:10.1136/archdischild-2014-307412
Effectivity of ventilation by measuring expired CO2 and RIP during stabilisation of preterm
infants at birth
Jeroen J van Vonderen1, Gianluca Lista2, Francesco Cavigioli2, Stuart B Hooper3, Arjan B te Pas1
!
Estudio observacional prospectivo
2 UCIn ( Leiden y Milán)
15 prematuros; EG 28 (27-31) SG; PN 1080 (994-1300) g
Mediciones: Vte, cambios en pletismografía, ECO2 ( monitor volumétrico)
Durante SI, PPV, CPAP
!
Van Vonderen et al ADCFN 2014;100:F514-518
60
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Al final de la 1ª
INSUFLACIÓN SOSTENIDA
INSUFLACIÓN SOSTENIDA
Respiración espontánea
(11 de 15)
INSUFLACIÓN SOSTENIDA
Apnea
(4 de 15)
Respiraciones espontáneas
( media) nº
4(3)
0
VTe( rango) ml/kg
5.9 (2.4-8.2)
5.2 (0.2-6.0) p<0.05
ECO2 (rango) mmHg
16.0 (10-30)
5.0 (2.0-15) p<0.01
Al final de la 2ª
INSUFLACIÓN SOSTENIDA
INSUFLACIÓN SOSTENIDA
Respiración espontánea
(4 de 5)
INSUFLACIÓN SOSTENIDA
Apnea
(1 de 5)
Respiraciones espontáneas
( media) nº
2(1)
0
VTe( rango) ml/kg
5.2(0.2-6.0)
4.6 (ns)
ECO2 (rango) mmHg
16.0(4-25
4 (ns)
Modificado de Lista
Van Vonderen et al ADCFN 2014;100:F514-518
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Arch Dis Child Fetal Neonatal Ed doi:10.1136/archdischild-2014-307412
Effectivity of ventilation by measuring expired CO2 and RIP during stabilisation of
preterm infants at birth
Jeroen J van Vonderen1, Gianluca Lista2, Francesco Cavigioli2, Stuart B Hooper3, Arjan B te Pas1
CONCLUSIÓN
Durante la reanimación de prematuros, la respiración espontánea resultó en niveles de ECO2
significativamente mayores y un mayor incremento de CRF por respiración comparado con PPV,
indicando que la respiración era más eficiente en establecer intercambio gaseoso y CRF.
LA! RESPIRACIÓN ESPONTÁNEA JUEGA UN IMPORTANTE
Mientras que el Vte durante la respiración en CPAP fue inferior comparado con PPV coincidiendo con
PAPEL
EN EL
ÉXITO enDE
LA
AL gaseoso
NACIMIENTO
la respiración,
la respiración
CPAP
fueVENTILACIÓN
más eficaz en intercambio
y en aumento de
amplitud en pletismografía comparado con PPV y PPV coincidiendo con respiración.
!
Hay varios factores que pueden influir la medida de CO2 durante la ventilación con mascarilla, y se
debe ser cauto a la hora de utilizar esta información como feedback durante la reanimación.
Van Vonderen et al ADCFN 2014;100:F514-518
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Lista 2015, submitted
63
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G.Lista et al. 2015, data submitted
Grupo 1
(no respiraciones
espontáneas)
n=11
Grupo 2
(respiraciones
espontáneas)
n=19
Estadística
EG (semanas)
26 (25-26.5)
28 (26.5-29)
P=0.004
PN (g)
700 (591-810)
839 (725-932)
p=0.04
Duración IS (seg)
15 (13-18)
15 (13-18)
p=NS
Resp espontáneas (nº)
NA
3 (1.5-5-5)
NA
Ti de las respiraciones
espontáneas ( seg)
NA
0.52 (0.45-0.56)
NA
Vti (ml/kg)
NA
5.9 (3.3-11)
NA
Vte (ml/kg)
NA
2.7 (0.3-1)
NA
Ganancia de volumen
pulmonar calculada (ml/
kg)
4.1 (3.2-6)
21.8 (11.1-27.4)
p=0.02
Modificado de LIsta
64
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COMENTARIOS FINALES
•
El neonatólogo en el paritorio debe considerar y permitir la transición neonatal
!
•
Los recién nacidos tratados inicialmente con INSUFLACIÓN SOSTENIDA (IS) tuvieron
mejor pronóstico respiratorio a corto plazo: reducción de la necesidad de
intubación y VM en las primeras 72h de vida ( NNT=10) ( sin mejoría en DBP y/o
muerte ).
!
•
IS es sólo 1 paso ( 1ª fase de la transición respiratoria) dentro de una estrategia
respiratoria ( del paritorio a la UCIn) para intentar mejorar el pronóstico respiratorio
a largo plazo.
!
•
IS mayor de 5” puede considerarse en circunstancias clínicas individuales o en el
contexto de investigación ( Neonatal Resuscitation Guidelines 2015).
65
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COMENTARIOS FINALES
!
•
Para evaluar la eficiencia de la IS: se debería considerar tanto los volúmenes tidal
como el ECO2.
!
•
El éxito de la IS parece estar relacionado con la edad gestacional ( menos actividad
en las EG inferiores) y la presencia de respiración activa ( glotis abierta).
!
•
Se necesitan más estudios clínicos para evaluar la eficacia de IS incluyendo:
•
Parámetros de la maniobra de IS ( duración óptima y presión pico)
•
Selección de pacientes (rescate o profiláctico).
•
Evaluación del pronóstico a largo plazo ( DBP/ muerte) como resultado primario
•
Momento de administración del surfactante.
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!
!
!
GRACIAS
!
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ES/SYN/0116/0099i
67