Prognosis of children surviving with the aid of mechanical ventilation in the newborn period

Ventilator-Associated Pneumonia in Low Birth Weight Neonates at a Neonatal Intensive Care Unit: A Retrospective Observational Study

BACKGROUND

Ventilator-associated pneumonia (VAP) is one of the most common healthcare-associated infections among ventilated patients. The aim of this study was to determine the clinical characteristics and risk factors for the development of VAP in intubated low birth weight (LBW) neonates in a neonatal intensive care unit.

METHODS

LBW infants (<2.5 kg) admitted to the neonatal intensive care unit of Kaohsiung Medical University Hospital from January 2005 to December 2009 were enrolled. We retrospectively analyzed perinatal and neonatal data of the enrolled intubated LBW infants by chart review.

RESULTS

Six hundred and five LBW infants were analyzed. One hundred and fourteen of the infants were intubated for >48 hours, 15 (13.2%) of whom had VAP. Of these 15 patients, the average age at onset of VAP was 24.0 ± 11.2 days, the average postmenstrual age was 30.6 ± 1.8 weeks, and the mean gestational age was 27.1 ± 2.3 weeks, which was significantly lower than the mean gestational age in the group without VAP (30.2 ± 3.5 weeks). The mean birth body weight was 944.4 ± 268.4 g in the VAP group and 1340.1 ± 455.4 g in the group without VAP (p < 0.001). Longer duration of intubation (odds ratio: 1.35, 95% confidence interval: 1.12-1.62) and parenteral nutrition (odds ratio: 1.32, 95% confidence interval: 1.14-1.51) were found in the VAP group after adjusting for gestational age and birth weight.

CONCLUSION

VAP was a problem for the LBW infants with intubation for >48 hours in our neonatal intensive care unit. VAP most frequently occurred at a postmenstrual age of 30-32 weeks in this study. Longer duration of tube placement and parenteral nutrition were found in the VAP group. Early removal of the endotracheal tube and adequate enteral nutrition may decrease the occurrence of VAP in LBW infants.

Changes in the utilization of diagnostic codes in neonatology following the introduction of activity-based financing

Activity-based financing was introduced in public hospitals in Norway in 1997. Following this, hospitals have been financed in part by block grants, in part by grants based on productivity as measured through weighted diagnosis-related groups (DRGs). Insufficient national data were available to allow for proper calculation of DRG weights for neonatology. Thus, data from other countries were used to estimate weights. It seemed of interest to examine whether the use of diagnostic codes in neonatal medicine was changed following the introduction of activity-based financing and DRGs. Data from 1994, 1996, 1998, and 2000 were obtained from the proprietary database of the NICU at Rikshospitalet, University of Oslo, as well as from the hospital Patient Information Management System. Diagnoses were organized into 39 categories, counted for each of the 4 years, and analyzed by non-parametric ANOVA. There were significant changes in the use of diagnostic categories during the 1994-2000 time period. Some diagnoses which previously have been only rarely used, became more frequent. The use of other diagnoses varied in ways that could only be understood in terms of tactical usage. It is concluded that the use of DRGs as a basis for activity-based financing may result in changes in the use of certain diagnostic categories which are not related to biological changes in the patient population. This may complicate epidemiological research. On the other hand, activity-based financing may result in increased attention to the diagnostic process, leading to increased use of secondary diagnoses and thus more complete diagnostic coding.

Deaths in a neonatal intensive care unit: a 10-year perspective

OBJECTIVE

To examine changes in the characteristics and management of infants dying in a regional neonatal intensive care unit in 1987-1988 vs. 1997-1998.

SETTING

The level III Neonatal Intensive Care Unit (NICU) at Rikshospitalet, Oslo, Norway, handles both regional and national referrals.

DESIGN/METHODS

The study was retrospective and observational. Patients who died in the neonatal intensive care unit were identified using our own and the hospital's data records. Charts were reviewed by the principal author.

RESULTS

The mortality rate relative to admissions decreased significantly from 1987-1988 to 1997-1998 (6.9% vs. 3.4%, p <.0001). Infants who died in 1997-1998 were more mature and had higher birth weights than those who died in 1987-1988 (34.0 +/- 5.5 vs. 32 +/- 6.0 wks gestational age [mean +/- sd], p <.05; and 2,186 +/- 1,207 vs. 1,699 +/- 1,038 g, p <.05). There was a significantly higher proportion of infants with complex congenital malformations among those who died in 1997-1998 (54% vs. 28%, p <.005). Forgoing intensive care treatment was more commonly associated with the process of dying in 1997-1998 than 10 yrs earlier (63.5% vs. 22.8%, p <.0001). Parental involvement in the process leading to a decision to forgo life support was more frequently described in the charts from 1997-1998 (72.7% vs. 23.8%, p <.001). During the last time period, parents were also present at the time of death significantly more often.

CONCLUSIONS

The mortality rate of sick infants decreased significantly between 1987-1988 and 1997-1998, showing the improvements in neonatal intensive care during that decade. In 1997-1998, congenital malformations had become the leading cause of death. Parental involvement in life-and-death questions seems to have become the rule, and almost two thirds of neonatal intensive care unit deaths followed a decision to forgo life support.

Transcutaneous oxygen tension measurements during methacholine challenge of prematurity in infants with chronic lung disease

Chronic lung disease (CLD) of prematurity may be caused by a number of insults during mechanical ventilation, including barotrauma and hyperoxia. To evaluate bronchial hyperresponsiveness (BHR) in infants with CLD of prematurity, we measured changes in transcutaneous oxygen tensions (tcPO2) during methacholine inhalation challenge. Twelve infants with CLD and 22 age-matched children without respiratory diseases were enrolled in this study (ages--5 to 36 months; mean age--16.2 months). Serial doses of methacholine were doubled until a 10% decrease in tcPO2 from baseline was reached. The cumulative dose of methacholine inhaled by the time tcPO2 had been reached (Dmin-PO2) was considered to represent the dose at which reactivity to methacholine (RO2meth) had occurred. In the CLD group, Dmin-PO2 (3.50 +/- 0.1 log x milli-units) was significantly lower than in the preterm control infant group (4.31 +/- 0.2 log x milli-units) and the term infant group (4.21 +/- 0.1 log x milli-units) (P = 0.004, P < 0.001). Dmin-PO2 in the preterm control infant group was not significantly different than in the term infant group (P > 0.5). These results suggest that infants who require additional therapeutic oxygen and mechanical ventilation during the early months of life are at risk of developing early-onset, long-lasting respiratory disease that is related to an acquired BHR.

Maternal distress and perceptions of infant development following extracorporeal membrane oxygenation and conventional ventilation for persistent pulmonary hypertension

Neurodevelopmental outcome and concurrent maternal distress were examined for infants who suffered persistent pulmonary hypertension at birth and were treated with either extracorporeal membrane oxygenation (ECMO) (n = 19) or conventional ventilation (CV) (n = 15). Mothers were asked to complete inventories assessing their infant's (mean age 8.74 months) developmental growth as well as their own psychological health. Relevant sociodemographic and treatment parameters were also entered into the analysis. The results indicated that ECMO and CV infants did not differ on developmental indices and impairment rates were 15-23% respectively, similar to previous reports. In addition, ECMO and CV mothers did not differ in their reports of psychological distress. Correlational analyses revealed that length of treatment for ECMO but not CV infants significantly predicted developmental delay and maternal distress. For CV mothers, maternal distress was associated with the perception of delayed language. The results are discussed in terms of the limited morbidity associated with ECMO and CV interventions and the possible role of a 'vulnerable child syndrome' in understanding the maternal-infant relationship following ECMO therapy.

Prediction of respiratory morbidity in the third year of life in children born prematurely

We have tested the hypothesis that recurrent respiratory symptoms in the third year of life in patients born prematurely were more likely to reflect a family history of atopy rather than adverse neonatal events. Comparison of 28 symptomatic and 72 asymptomatic children revealed that a family history of atopy (p < 0.01), prolonged dependence on respiratory support in the neonatal period (p < 0.01) and extreme immaturity (p < 0.02) were significantly commoner in the symptomatic group. The relative risk of having symptoms was 2.27 for a family history of atopy, 2.48 for prolonged dependence on respiratory support and 1.7 for low gestational age. We conclude that respiratory morbidity in the third year of life following premature delivery has a multifactorial aetiology.

Long-term outcome of infants born preterm

This chapter outlines some of the many long-term health problems to be expected in surviving preterm children. They have higher rates of sensorineural impairments (such as cerebral palsy, and visual, auditory and intellectual impairments) and sensorineural disabilities from these impairments, than children born at term. In addition, they grow poorly and have higher rates of other health problems, including poorer respiratory health in early childhood. There is little doubt that preterm children contribute disproportionately to the prevalence of health problems in childhood. However, there are still many gaps in our knowledge of the outcome for preterm survivors, particularly regarding outcome in adulthood. Obstetricians and neonatologists working in intensive care, as well as parents, want to know the long-term outcome for preterm children born today, not that of children born a generation ago when fewer preterm children (particularly those of extremely low birthweight) survived. Despite the many problems, the conclusion is that most preterm children are as healthy as term children, suffering only usual childhood illnesses; we feel confident that the majority make, and will continue to make, useful contributions to their families and the societies in which they live.

Persistence of respiratory symptoms into the second year of life: predictive factors in infants born preterm

Preterm infants frequently suffer from recurrent respiratory symptoms in the first year of life. Our aims were to assess if such respiratory morbidity persisted beyond the first year and to define the predictive factors. One hundred and seventeen infants (median gestational age 29 weeks) were followed prospectively for two years. Thirty-eight infants had symptoms only in the first year (group A) and in a further 20 infants, symptoms were present in both years (group B). Comparison of these two groups revealed no significant difference in birth weight or gestational age, but the duration of ventilation and increased inspired oxygen concentration were significantly longer in group B. Significantly more infants in group B had had an air leak in the neonatal period, and airways resistance at six months of age was also significantly higher in group B. We conclude that infants with severe neonatal respiratory distress are likely to have persisting respiratory morbidity and that respiratory function measurements at six months of age provide the most accurate predictor of chronic respiratory symptoms.

Respiratory symptoms in children of low birth weight

We recorded the respiratory history by questionnaire in a 7 year old cohort of children whose birth weight was under 2000 g and an unselected reference group of local schoolchildren of the same age. Complete data were obtained in 121 low birthweight children (90% of those studied): 62 who had no neonatal respiratory illness, 25 who had oxygen treatment only, and 34 who received mechanical ventilation (of whom 10 had bronchopulmonary dysplasia). The low birthweight children were no more likely to wheeze than the reference group, but frequent and troublesome cough was significantly more common, especially among children of very low birth weight (under 1500 g) who had received neonatal respiratory treatment. Neonatal mechanical ventilation was not associated with increased symptoms when compared with neonatal oxygen treatment alone. The prevalence of cough at the age of 7 was independently associated with the level of neonatal intensive care as defined by oxygen score. Although there was no excess of wheeze in the cohort compared with the reference group, there was a weak correlation between wheeze and the neonatal oxygen score as well as with maternal smoking. Loss of schooling due to respiratory symptoms in the nine months before this study was no greater in children of low birth weight than in the reference group.

Lung function eight years after neonatal ventilation

Forty children who had had artificial ventilation during the neonatal period were studied at the age of 8-10 years with spirometry, the nitrogen washout test, bicycle exercise test, pulse oximetry, electrocardiogram, vectorcardiogram, and chest radiography. The median gestational age at birth was 29 weeks, and the median birth weight was 1310 g. Hyaline membrane disease was the indication for neonatal ventilation in 25 children. Bronchopulmonary dysplasia was diagnosed from radiographs in 11 infants (27%). Airway obstruction was observed in 10 of 11 children who had had bronchopulmonary dysplasia and in nine of 29 children who had not. After inhalation of terbutaline, the forced expiratory volume in one second (FEV1) was significantly increased. General hyperinflation was found in 16 of 17 children with abnormal chest radiographs (eight who had had bronchopulmonary dysplasia and nine who had not). Functional residual capacity was significantly higher in children with abnormal radiographs. Each child had a normal maximum working capacity and a normal electrocardiogram, and all but two had normal vectorcardiograms. Oxygen saturation at maximum work load decreased significantly in both groups of children. The risk of future respiratory problems calls for further follow up of lung function and chest radiography.

Continuing care for the preterm infant after dismissal from the neonatal intensive care unit

As more low-birth-weight babies survive, primary-care physicians are facing the responsibility of providing continuing care for those who have been dismissed from neonatal intensive-care units. Premature infants often require outpatient care for bronchopulmonary dysplasia, apnea, retinopathy of prematurity, intraventricular hemorrhage, hearing loss, hypothyroxinemia, anemia, neurodevelopmental sequelae, assessment of growth and nutrition, immunizations, and psychosocial stress. In this review, we present guidelines for the primary-care physician for the management of these conditions in preterm infants.

Childhood sequelae of infant lung disease: exercise and pulmonary function abnormalities after bronchopulmonary dysplasia

To determine the long-term pulmonary sequelae and effect on exercise tolerance of bronchopulmonary dysplasia (BPD), we studied 10 children at a mean age of 10.4 years, who had been born prematurely, survived respiratory distress syndrome, and subsequently developed BPD, and compared them with eight age-matched normal children born at term. Pulmonary function tests and graded exercise stress tests were performed. Residual volume, the ratio between residual volume and total lung capacity, vital capacity, forced expiratory volume in 1 second, forced expiratory flow between 25% and 75% of vital capacity, and maximal expiratory flows at 80%, 70%, and 60% of total lung capacity were all abnormal (P less than 0.02) in the children with BPD, compared with control values. Pre-exercise transcutaneous CO2 tension was higher (P less than 0.05) in the BPD group than in the control group. At maximal workload, tcPCO2 remained high in patients with BPD compared with control values (P less than 0.05). Arterial oxygen saturation at maximal workload fell below pre-exercise levels in the BPD group (P less than 0.05) but not in control children. There were no differences in maximal oxygen consumption between the BPD group and control children. Exercise-induced bronchospasm occurred in 50% of the BPD group, but not in the control group. We conclude that long-term survivors of BPD have evidence of airway obstruction, hyperinflation, and airway hyperreactivity, compared with a control group. Aerobic fitness was not significantly different in the BPD and control groups, but was achieved in the BPD group at the expense of a fall in SaO2 and a rise in tcPCO2.

Long term effects of artificial ventilation in neonates

In order to evaluate long term effects of artificial ventilation, 27 children, who had been ventilated for more than five days in their neonatal period, were reinvestigated at school age. In 5 of them bronchopulmonary dysplasia had been diagnosed. Seven had more than 10 upper respiratory tract infections per year and 9 had recurrent obstructive airway disease. On pulmonary function testing (n = 23) 19% showed some airway obstruction, and in 43% bronchial hyperreactivity was found by bronchial provocation with histamine. There was a significant correlation (p less than 0.05) between bronchial hyperreactivity and the duration of neonatal ventilation. The degree of hyperreactivity (PC20, FEV1) also correlated with birth weight (p less than 0.005) and gestational age (p less than 0.02). It is concluded that prolonged neonatal ventilation might be followed by bronchial hyperreactivity, especially in the small and premature newborn.

Long-term follow-up of ventilator treated low birthweight infants. I. Chest X-ray, pulmonary mechanics, clinical lung disease and growth

Chest X-ray, pulmonary mechanics, clinical lung disease and growth were studied in 48 low birthweight infants surviving after ventilator treatment in the neonatal period. Bronchopulmonary dysplasia (BPD) was present in 14 infants shortly after weaning off ventilator. At 4 to 6 years of age most patients had normal chest radiographs but 13 still showed signs of pulmonary fibrosis and hyperinflation. Most patients had low dynamic compliance and high pulmonary resistance shortly after ventilator treatment. All but 8, however, had normal findings at 1 to 1 1/2 years of age. Pneumonias and bronchitis were common during the first two years but thereafter declined in frequency. Weight and length development were retarded for BPD patients during the first two years and for non-BPD patients for the first year. Both groups had a complete catch-up.

Bronchopulmonary dysplasia

Bronchopulmonary dysplasia has become the most common pulmonary sequelae in neonates receiving mechanical ventilation. The pathogenesis of BPD is multifactorial, but prematurity, positive pressure ventilation, oxygen toxicity and pulmonary edema are some of the most important factors in its development. By minimizing these factors, it is possible to reduce the incidence and severity of BPD.

The contribution of fetal-newborn complications to motor and cognitive deficits

A total of 364 selected high-risk premature and mature infants were studied prospectively to assess the relationship between fetal-newborn complications and motor and cognitive deficits identified during the first year of life. Deficits occurred in 24 per cent of the children: 14 per cent had one or more major deficit and the other 10 per cent had one or more minor deficit. Prematurity was one of the fetal-newborn complications not associated with deficits at one year. Complications that were associated with deficits included fetal hypoxia, respiratory difficulties, infection and newborn encephalopathy. There was also a significant association between fetal hypoxia, newborn respiratory complications, infection and newborn encephalopathy, which is in keeping with the concept that the first three may be mechanisms in CNS injury and subsequent deficits, while newborn encephalopathy reflects the injury and is an important predictor of such deficits.

Long-term follow-up of infants and children treated with extracorporeal membrane oxygenation (ECMO): a preliminary report

Extracorporeal Membrane Oxygenation (ECMO) has been used clinically as a life-saving treatment modality in infants and children who are dying of respiratory insufficiency. From 1973 to 1980 47 children less than 10 years of age were treated in a study to determine the feasibility and effectiveness of ECMO in the pediatric population. Despite a predicted mortality of 90% or greater, 24 patients survived. Eighteen of those patients have been seen in long-term follow-up. Thirteen patients (72%) demonstrate basically normal growth and development. Five patients (28%) have definite handicaps which are severe in two. Despite ligation of one common carotid artery and systemic heparinization, the risk of intracranial hemorrhage and/or neurodevelopmental problems appears to be no higher in this ECMO group and may even be lower than in the high-risk population treated with conventional therapy. The incidence of chronic respiratory problems, especially bronchopulmonary dysplasia, is zero in this group of patients. Only one patient (4%) has a defect that lateralizes to the right hemisphere which may have been affected by ligation of the carotid artery. Further study is required; however, it appears that ECMO offers life-saving intervention without increasing morbidity in select children with severe respiratory insufficiency.

Bronchopulmonary dysplasia. Chronic pulmonary disease following neonatal respiratory failure

Infants with respiratory failure in the first weeks of life may develop a chronic pulmonary condition called bronchopulmonary dysplasia. Their lungs have areas of atelectasis and areas of air trapping from variable obstruction of the airways. These infants may be dependent on supplemental oxygen or a ventilator and may require hospitalization for months, and have symptoms of airway obstruction which last for years. They require meticulous medical management to avoid a number of common complications such as patent ductus arteriosus, cor pulmonale, tracheal stenosis, recurrent aspiration, and death. The condition of most infants improves over the first two years. Preliminary studies suggest that their exercise and pulmonary function is usually close to normal by school-age. The long-term implications for the increasing number of children with this disease who will soon reach adulthood are still unknown.

Unsuspected cardiopulmonary abnormalities complicating bronchopulmonary dysplasia

Bronchopulmonary dysplasia is a serious chronic lung disease of infancy but despite numerous problems such as poor growth, recurrent lower respiratory tract infections, and cor pulmonale, steady improvement and recovery may generally be expected. We report four infants with bronchopulmonary dysplasia in whom the cardiopulmonary course did not show the usual steady improvement. Each infant was found to have an unsuspected cardiopulmonary lesion in addition to lung disease: two had congenital heart disease and two upper airway obstruction. Three improved after surgical intervention but one patient died immediately after this. Persistent right ventricular hypertrophy in patients with bronchopulmonary dysplasia maintained on supplemental oxygen, and a particularly slow rate of recovery from the need for supplemental oxygen are markers that should lead to evaluation for coexisting cardiopulmonary abnormalities.

Severe bronchopulmonary dysplasia. Predictors of survival and outcome

Predictors of survival and outcome were evaluated following severe bronchopulmonary dysplasia in 35 neonates, 15 of whom died during the initial hospitalization and four following discharge. There was no difference in the clinical characteristics between those infants who survived or died. The survival rate was 47 percent when the length of stay in the hospital was three months and was 17 percent when the length of stay was five months. The survival rate was 27 percent when the time receiving oxygen was three months. There were no survivors when the time receiving oxygen was longer than five months. Follow-up of 13 survivors revealed that four had neurologic sequelae, and two had severe retrolental fibroplasia. When comparing infants with a mean mental developmental index of less than 84 (n = 8) to those with more than 85 (n = 5) on the Bayley Scales of Infant Development, mean length of hospitalization was 125 days vs 72 days (p less than 0.05), and the time receiving oxygen was 84 days vs 46 days (p less than 0.05). When comparing infants with growth parameters below the 5th percentile (n = 4) to those above the 5th percentile (n = 9), the mean time receiving oxygen was 94 days compared to 58 days (p less than 0.05). Severe bronchopulmonary dysplasia is associated with a high mortality and morbidity, both in and beyond the neonatal period.

Furosemide acutely decreases airways resistance in chronic bronchopulmonary dysplasia

We studied the effects of furosemide on pulmonary mechanics in 10 infants with bronchopulmonary dysplasia aged 41 +/- 1 (SE) weeks post-conception, gestational age at birth 30 +/- 1 wk, birth weight 1370 +/- 200 gm. Thoracic gas volume, airways resistance, and specific airway conductance were measured in an infant body pressure plethysmograph during quiet breathing. Dynamic pulmonary compliance was measured using an esophageal balloon. Infants with BPD had greater Raw, lower SGaw, and lower Cdyn than did 16 normal control infants. Within one hour after administration of furosemide 1 mg/kg IV to infants with BPD, Raw fell 36 +/- 13%, SGaw increased 84 +/- 22%, and Cdyn increased 54 +/- 13%; TGV did not change. Diuretic treatment of BPD in infants is associated with rapid, short-term improvement in Raw and Cdyn.

A follow-up of the survivors of mechanical ventilation in a paediatric intensive care unit

Fifty-eight long-term survivors of mechanical ventilation have been traced and examined for evidence of auditory, visual, behavioural, developmental and central nervous system abnormalities. There were four children with serious neurological or intellectual handicaps, the causes of which did not seem to be related to deficiencies of their ventilator treatment but rather to events preceding ventilation or to the disease which had necessitated ventilation. There were an additional eight children who may have some intellectual damage. The occurrence of convulsions or hypoxic episodes during or preceding the period of treatment was significantly more common among the 12 children with a poor outcome, than those with a good outcome.

Growth and development in children recovering from bronchopulmonary dysplasia

Of 26 patients with bronchopulmonary dysplasia, 20 (77%) survived and were followed prospectively for two years post-term. Lower respiratory tract infections occurred in 17 of the 20 children (85%), and required hospitalization in ten (50%) during the first and in four (20%) during the second year. At two years post-term only two patients had significant respiratory symptoms at rest, but 78% had residual radiographic changes. The average weight and height at term were at or below the third percentile. Growth occurred at an accelerated rate with improvement of respiratory symptoms, with average weight reaching the third to tenth percentile for both sexes, and tenth to twenty-fifth percentile for height in the boys and the twenty-fifth percentile for the girls by two years post-term. Growth retardation was associated with severe and prolonged respiratory dysfunction. Fifteen (75%) were free of major developmental defects. Five had mean Bayley scores less than 85 at 18 months post-term; one also had hydrocephalus. Developmental outcome seems related to perinatal and neonatal events rather than to the presence or absence of BPD.

Outcome for survivors of mechanical ventilation weighing less than 1,250 gm at birth

We investigated the outcome in 28 survivors of mechanical ventilation weighing less than 1,250 gm at birth. Fifteen infants (54%) had neurodevelopmental sequelae, of whom eight had major handicaps. These eight infants differed significantly from the rest of the infants studied in the following manner: lower mean birth weight and gestational age, delay in transportation to our Neonatal Intensive Care Unit, and high incidence of bacterial sepsis. The remaining seven infants with NDS were functionally normal or minimally impaired at the time of the study, although significant problems may yet emerge with continued follow-up. Retrolental fibroplasia was diagnosed in 11 infants (39%) and resolved in two. The development of RLF was associated with prolonged oxygen exposure and the presence of bacterial sepsis. However, since major handicap, RLF, and sepsis were all problems observed in the smallest infants, a cause-and-effect relationship between sepsis and these sequelae remains speculative.

Pulmonary mechanics, chest X-ray and lung disease after mechanical ventilation in low birth weight infants

Pulmonary mechanics, chest X-ray and the incidence of clinical lung disease were studied in 41 low birth weight infants treated with intermittent positive pressure ventilation (IPPV) in the neonatal period. Shortly after IPPV most patients, irrespective of X-ray findings, had signs of lung damage reflected in low dynamic compliance or high pulmonary resistance. Both parameters, however, had a strong tendency towards normalization during the first year of life. Overdistention on chest X-ray was common at 6--12 months of age. Pneumonia and bronchitis were common during the first two years of life but subsided later on. Development of BPD or later respiratory disease were not correlated to treatment with high inspired oxygen concentrations but commonest in patients with hyaline membrane disease. The combined findings of pulmonary mechanics and chest X-ray shortly after IPPV were correlated to later clinical lung disease.

Progressive central nervous system deterioration: a complication of advanced chronic lung disease of prematurity

Fifteen premature infants with severe chronic lung disease of prematurity were treated with ventilatory assistance and continuous positive airway pressure for at least 28 days. Fourteen developed progressive central nervous system deterioration following right heart failure and pulmonary hypertension. Two patterns of deterioration were observed: (1) cerebral, with loss of developmental milestones, increasing a hypotonia, and eventual EEG deterioration and death; and (2) brainstem, with progressive apnea, bradycardia, or both, and sudden death or irreversible apnea.

Evaluation of mechanical ventilation in newborn infants. II. Pulmonary and neuro-developmental sequelae in relation to original diagnosis

The incidence of bronchopulmonary dysplasia (BPD) and neuro-developmental sequelae in 135 infants surviving intermittent positive pressure ventilation (IPPV) in the newborn period were studied in relation to primary disorders requiring IPPV. The rate of BPD increased over the 6-year study period in hyaline membrane disease survivors from 14% to 28%, but decreased in infants with apnoea repetens from 38% to 13%. Immaturity seemed to be one important factor for development of BPD. The incidence of neuro-developmental sequelae in IPPV treated infants fell from 22% to 13% over the years. In infants with birth weight below 1501 g the rate of neurological handicaps was 11%.

Long-term prognosis of infants with idiopathic respiratory distress syndrome. Follow-up studies in infants surviving after the introduction of continuous positive airway pressure

Fifty-one children surviving IRDS with CPAP alone or CPAP and IPPV were studied at the age of 2.5 to 4.0 years. One child had developed tetraplegia and mental retardation and 6 children were speech-retarded. Correlation with perinatal events showed that this group of children had a significantly lower gestational age and birth weight, a lower Apgar score and a higher PCO2 prior to ventilatory treatment than the remainder. Re-examination by age 4.0 to 5.0 years showed persistent handicaps in only four of the seven children.

Hyaline membrane disease: prognostic factors and medium-term follow-up

One hundred and twenty two cases of severe hyaline membrane disease are reported. 68 of them survived (57%). Adverse clinical, radiological and laboratory factors, and their effects on the early mortality rate, are analysed with particular reference to the referring centers, delay in admission, transport and the critical state of most infants on admission. The follow-up of 29 survivors treated before 1974 has been examined with reference to birthweight and assisted respiration. Four (30%) of the twelve infants with birthweights below 2000 g had major neurological sequelae. Only two out of the 17 babies with a birthweight over 2000 g had minor mental disturbances.

Prognosis of neonates with symptomatic respiratory insufficiency surviving with the aid of ventilator therapy

Twenty-one survivors representing all survivors of neonatal symptomatic respiratory distress treated with intermittent positive pressure ventilation have been follow-up at an age of 2.9 to 7.0 years. The chance of survival proved to be relatively favourable in infants ventilated for perinatal pneumonias and unfavourable in infants ventilated for haemorrhagic diseases and respiratory insufficiency secondary to surgical conditions. At the follow-up half of the children presented with neurological symptoms but only 10% were found severely handicapped. One infant had a tracheostomy due to a laryngeal stenosis, while none developed broncho-pulmonary dysplasia. The late prognosis seemed unfavourable when the children had suffered from severe birth asphyxia and in infants ventilated for prolonged recurrent apnoeic spells. The relation between the clinical indications for ventilator therapy and later outcome is obscured however, by a vase number of complicating perinatal events.

Long term prognosis of infants with severe idiopathic respiratory distress syndrome. I. Neurological and mental outcome

76 out of 77 children surviving IRDS with the aid of intermittent positive pressure ventilation have been followed-up by the age 2.6-7.6 years together with 68 matched controls. Moderate or severe neurological, developmental or mental abnormalities were present in 17% of all IRDS survivors. Statistical comparison of the matched pairs of IRDS survivors and controls revealed no significant differences in the prevalence of abnormalities. In the IRDS survivors the occurrence of cerebral palsy related to prematurity while the development of psycho-motor and mental retardation related to low birth weight and low milk intake during the first week suggesting that both prenatal and postnatal growth retardation may have been of importance. Statistical analysis of a number of preventilatory and ventilatory parameters did not show significant differences between these groups of IRDS survivors and the remainder. Ventilator treatment is recommended as a promising adjunct to the therapy of severe IRDS in centers where the necessary experience and equipment is at hand.

Bronchopulmonary dysplasia in premature infants. A radiological and pathological correlation

In a group of 70 premature and newborn infants, treated with artificial ventilation, 24.3% developed bronchopulmonary dysplasia (BPD). Only in a very few cases did the typical radiological stages, as described by Northway, succeed each other in a chronological order. It is impossible to differentiate BPD stage I or II from RDS stage III and IV without a knowledge of the clinical course and of the duration of artificial ventilation. The lower the gestational age, the more severe and earlier do the radiological and histological changes occur. The radiological differential diagnosis of BPD includes Wilson-Mikity-syndrome, congenital pulmonary lymphangiectasia, neonatal tuberculosis, cystic fibrosis and Hamman-Rich-syndrome.

Neurological sequelae in children surviving mechanical ventilation in the neonatal period

The incidence of mental defect, visual and hearing disability, major neurological handicap, and such minor neurological handicap as can be detected on examination at 2--9 years without formal intelligence testing, is presented among survivors of neonatal mechanical ventilation at Hammersmith Hospital between the years 1966--1973 inclusive. 77(21%) of 367 children survived, over three-quarters of them being born elsewhere. 3 died before the age of 6 months, 2 suddenly and unexpectedly at home, the third accidentally. 1 child was lost to follow up. 11 (15%) of the remaining 73 children had neurological sequelae as defined. In two-thirds this was moderate to severe. Spastic diplegia may no longer be the commonest form of cerebral palsy among those of low birthweight, particularly those surviving severe neonatal illness.

Neurological and phychometric studies in children surviving freshwater immersion accidents

A study of the neurological and intellectual sequelae of childhood near-drowning is reported. Results are from a total population study, without selection, of all freshwater immersion accidents in which consciousness was lost in the water. Such accidents affected 56 children in the city of Brisbane and environs over the period 1971-75. 54 of these children have been re-examined medically and psychometrically. Over 95 per cent of children who survived such accidents were neurologically normal. The median i.q. of survivors was 110 (range 90-137), which is higher than that of the general population. There is a suggestion that visualmotor (performance)) skills are particularly vulnerable to freshwater immersion hypoxia. In 20 per cent of survivors subscale disparities between verbal and performance skills exceeded 15 i.q. points. No correlation between the post-immersion I.Q. and either estimated immersion-time or water temperature was demonstrated in this study. No long-term emotional or personality disorders were encountered. Uncommon gross clinical sequelae of prolonged immersion in fresh water included spastic quadriplegia and gross mental retardation. All children in this study were apparently dead at the moment of rescue; despite this, the prognosis of near-drowning in childhood is excellent

Bronchopulmonary dysplasia: the pulmonary pathologic sequel of necrotizing bronchiolitis and pulmonary fibrosis

A light and electron microscopic study was carried out in 21 infants in whom the pathologic diagnosis of bronchopulmonary dysplasia had been made. All the infants except two had the respiratory distress syndrome at birth, and all 21 had been treated with respirator and oxygen therapy for various periods of time. The pathologic alterations observed in all the infants studied were primarily damage of the bronchial and bronchiolar ciliary apparatus and mucous membranes, severe necrotizing bronchiolitis, and marked bronchiolar and alveolar fibrosis. These changes were more pronounced in infants who survived the longest period of time. Such inflammatory and fibrotic changes are known to predispose to destruction of lung tissue, emphysema, and pulmonary hypertension. Six of these 21 infants developed symptoms and signs of cardiac atrial or ventricular stress, including cor pulmonale, prior to their demise. These infants were among those that survived the longest periods of time, had the longest exposure to supplemental oxygen, and showed histopathologically severe pulmonary fibrosis and emphysema.