Rib cage and abdominal contributions to ventilatory response to CO2 in infants

Ventilator Liberation in the Pediatric ICU

Despite the accepted importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are often not clear, although a trial of spontaneous breathing on CPAP without pressure support seems an appropriate prerequisite in many cases. Several indexes have been developed to predict weaning and extubation success, but the available literature suggests they offer little or no improvement over clinical judgment. New techniques for assessing readiness for weaning and predicting extubation success are being developed but are far from general acceptance in pediatric practice. While there have been some excellent physiologic, observational, and even randomized controlled trials on aspects of pediatric ventilator liberation, robust research data are lacking. Given the lack of data in many areas, a determined approach that combines systematic review with consensus opinion of international experts could generate high-quality recommendations and terminology definitions to guide clinical practice and highlight important areas for future research in weaning, extubation readiness, and liberation from mechanical ventilation following pediatric respiratory failure.

[Risk of accumulation of CO₂ in the oxygen chamber in "HOOD" (Experimental study on test bed)]

OBJECTIVES

Oxygen hood is largely used to deliver O₂ to newborn infants with respiratory failure in the northern region of France. The oxygen flow is set to obtain the target arterial blood oxygen saturation. Thus, O₂ flow delivers into the hood may be below the recommended gas flow of 6L/min. However, gas flow below 6L/min exposes to CO₂ rebreathing. The aim of this study was to evaluate the effect of various rates of gas flows on the values of partial pressure of CO₂ into the hood.

MATERIAL AND METHODS

We measured CO₂ and O₂ partial pressure into hoods of two different volumes (4 and 10L) under two experimental bench test conditions. Protocol 1: gas flow was constant at 6L/min, while oxygen fraction varied from 0.21 to 1. Partial pressure of CO₂ and O₂ were recorded. Protocol 2: while O₂ fraction was kept constant, oxygen flow varied from 0.5 to 7L/min (by step of 0.5L/min). Partial pressure of CO₂ and O₂ were recorded.

RESULTS

Partial pressure of CO₂ increases proportionally to the decrease in the gas flow delivered into the hood, and reached 14 mmHg at gas flow of 0.5L/min.

CONCLUSION

Risk of CO₂ rebreathing exists as soon as the gas is delivered into the hood at minimal flow rates below 6L/min.

Weaning and extubation readiness in pediatric patients

OBJECTIVE

A systematic review of weaning and extubation for pediatric patients on mechanical ventilation.

DATA SELECTION

Pediatric and adult literature, English language.

STUDY SELECTION

Invited review.

DATA SOURCES

Literature review using National Library of Medicine PubMed from January 1972 until April 2008, earlier cross-referenced article citations, the Cochrane Database of Systematic Reviews, and the Internet.

CONCLUSIONS

Despite the importance of minimizing time on mechanical ventilation, only limited guidance on weaning and extubation is available from the pediatric literature. A significant proportion of patients being evaluated for weaning are actually ready for extubation, suggesting that weaning is often not considered early enough in the course of ventilation. Indications for extubation are even less clear, although a trial of spontaneous breathing would seem a prerequisite. Several indices have been developed in an attempt to predict weaning and extubation success but the available literature would suggest they offer no improvement over clinical judgment. Extubation failure rates range from 2% to 20% and bear little relationship to the duration of mechanical ventilation. Upper airway obstruction is the single most common cause of extubation failure. A reliable method of assessing readiness for weaning and predicting extubation success is not evident from the pediatric literature.

The effects of repeated exposure to hypercapnia on arousal and cardiorespiratory responses during sleep in lambs

Arousal and cardio-respiratory responses to respiratory stimuli during sleep are important protective mechanisms that rapidly become depressed in the active sleep state when episodes of hypoxia or asphyxia are repeated: whether responses to repeated hypercapnia are similarly depressed is not known. This study aimed to determine if arousal and cardio-respiratory responses also become depressed with repeated episodes of hypercapnia during sleep and whether responses differ in active sleep and quiet sleep. Eight newborn lambs were instrumented to record sleep state and cardio-respiratory variables. Lambs were subjected to two successive 12 h sleep recordings, assigned as either sequential control and test days, or test and control days performed between 12.00 and 00.00 h. The control day was a baseline study in which the lambs breathed air to determine spontaneous arousal probability. During the test day, lambs were exposed to a 60 s episode of normoxic hypercapnia (Fractional inspired CO2 (F(ICO2)) = 0.08 and Fractional inspired O2(F(IO2)) = 0.21 in N2) during every quiet sleep and active sleep epoch. The probability of lambs arousing during the hypercapnic exposure exceeded the probability of spontaneous arousal during quiet sleep (58% versus 21%, chi2 = 54.0, P < 0.001) and active sleep (39% versus 20%, chi2 = 10.0, P < 0.01), though the response was less in active sleep. Exposure to hypercapnia also resulted in a significant increase in ventilation in quiet sleep (150 +/- 22%) and active sleep (97 +/- 23%, P < 0.05), though the increase was smaller in active sleep (P < 0.05). Small (< 5%) blood pressure increases and heart rate decreases were evident during hypercapnia in quiet sleep, but not in active sleep. Arousal and cardio-respiratory responses persisted with repetition of the hypercapnic exposure. In summary, although arousal and cardio-respiratory responses to hypercapnia are less in active sleep compared with quiet sleep, these protective responses are not diminished with repeated exposure to hypercapnia.

Respiratory responses to hypoxia/hypercapnia in small for gestational age infants influenced by maternal smoking

AIM

To determine any variation in the respiratory responses to hypoxia/hypercapnia of infants born small for gestational age (SGA) to smoking and to non-smoking mothers.

METHODS

A total of 70 average for gestational age (AGA) infants (>36 weeks gestation, >2500 g, >25th centile for gestational age, and no maternal smoking), and 47 SGA infants (<10th centile for gestational age) were studied at 1 and 3 months of age, in quiet and active sleep. Respiratory test gases were delivered through a Perspex hood to simulate face down rebreathing by slowly allowing the inspired air to be altered to a CO(2) maximum of 5% and O(2) minimum of 13.5%. The change in ventilation with inspired CO(2) was measured over 5-6 minutes of the test. The slope of a linear curve fit relating inspired CO(2) to the logarithm of ventilation was taken as a quantitative measure of ventilatory asphyxial sensitivity (VAS).

RESULTS

There was no significant difference in VAS between the AGA and SGA infants (0.25 v 0.24). However within the SGA group, VAS was significantly higher (p = 0.048) in the infants whose mothers smoked during pregnancy (0.26 (0.01); n = 24) than in those that did not (0.23 (0.01); n = 23). The change in minute ventilation was significantly higher in the smokers than the non-smokers group (141% v 119%; p = 0.03) as the result of a significantly larger change in respiratory rate (8 v 4 breaths/min; p = 0.047) but not tidal volume.

CONCLUSIONS

Maternal smoking appears to be the key factor in enhancing infants' respiratory responses to hypoxia/hypercapnia, irrespective of gestational age.

Prone versus supine sleep position: a review of the physiological studies in SIDS research

A number of physiological studies, published over the last 10 years, have investigated the links between prone sleeping and sudden infant death syndrome (SIDS). This review evaluates those studies and derives an overview of the different affects of sleeping prone or supine in infancy. Generally, compared with the supine, the prone position raises arousal and wakening thresholds, promotes sleep and reduces autonomic activity through decreased parasympathetic activity, decreased sympathetic activity or an imbalance between the two systems. In addition, resting ventilation and ventilatory drive is improved in preterm infants, but in older infants (>1 month), there is no improvement in ventilation, and in 3-month-old infants, the position is adverse in terms of poorer ventilatory drive (in active sleep only). The majority of findings suggest a reduction in physiological control related to respiratory, cardiovascular and autonomic control mechanisms, including arousal during sleep in the prone position. Since the majority of these findings are from studies of healthy infants, continued reinforcement of the supine sleep recommendations for all infants is emphasized.

Muscimol dialysis in the rostral ventral medulla reduced the CO(2) response in awake and sleeping piglets

Some victims of sudden infant death syndrome have arcuate nucleus abnormalities. The arcuate nucleus may be homologous with ventral medullary structures in the cat known to be involved in the control of breathing and the response to systemic hypercapnia. We refer to putative arcuate homologues in the piglet collectively as the rostral ventral medulla (RVM). We inhibited the RVM in awake and sleeping, chronically instrumented piglets by microdialysis of the GABA(A) receptor agonist muscimol. Muscimol dialysis (10 and 40 mM) had no effect on eupnea but caused a significant reduction in the response to hypercapnia during both wakefulness (34.8 +/- 8.7 and 30.7 +/- 10.1%, respectively) and sleep (36.7 +/- 6.7 and 49.5 +/- 8.9%, respectively). The effect of muscimol on the CO(2) response was entirely via a reduction in tidal volume and appeared to be greater during non-rapid-eye-movement sleep. We conclude that the piglet RVM contains neurons of importance in the response to systemic CO(2) during both wakefulness and non-rapid-eye-movement sleep. We hypothesize that dysfunction of homologous regions in the human infant could lead to impaired ability to respond to hypercapnia, particularly during sleep, which could potentially be involved in the pathogenesis of sudden infant death syndrome.

Ventilatory sensitivity to mild asphyxia: prone versus supine sleep position

AIMS

To compare the effects of prone and supine sleep position on the main physiological responses to mild asphyxia: increase in ventilation and arousal.

METHODS

Ventilatory and arousal responses to mild asphyxia (hypercapnia/hypoxia) were measured in 53 healthy infants at newborn and 3 months of age, during quiet sleep (QS) and active sleep (AS), and in supine and prone sleep positions. The asphyxial test mimicked face down rebreathing by slowly altering the inspired air: CO(2), maximum 5% and O(2), minimum 13.5%. The change in ventilation with inspired CO(2) was measured over 5-6 minutes of the test. The slope of a linear curve fit relating inspired CO(2) to the logarithm of ventilation was taken as a quantitative measure of ventilatory asphyxial sensitivity (VAS). Sleep state and arousal were determined by behavioural criteria.

RESULTS

At 3 months of age, prone positioning in AS lowered VAS (0.184 prone v 0.269 supine, p = 0.050). At newborn age, sleep position had no effect on VAS. Infants aged 3 months were twice as likely to arouse to the test than newborns (p = 0.013). Placing infants prone as opposed to supine increased the chances of arousal 1.57-fold (p = 0.035).

CONCLUSION

Our findings show 3 month old babies sleeping prone compared to supine have poorer ventilatory responses to mild asphyxia, particularly in AS, but the increased prevalence of arousal is a protective factor.

Responses to an increasing asphyxia in infants: effects of age and sleep state

Infants aged 0-6 months were assessed for respiratory and arousal responses to mild asphyxia during sleep. Ventilatory sensitivity was assessed from the relationship between inspired carbon dioxide (FICO2) and ventilation. Arousal and ventilatory sensitivity were significantly related. Respiratory response increased with age and was greater in quiet sleep than in REM sleep. Arousal occurred more frequently in REM sleep (55/102) than quiet sleep (38/165, P < 0.05) and more frequently at the newborn age (54/117) than at 6 months (13/58, P < 0.05). Arousal in quiet sleep occurred in babies with high ventilatory sensitivities (mean ventilatory asphyxial sensitivity (VAS) 0.476 +/- 0.288) and in REM sleep was more associated with low ventilatory sensitivities (mean VAS 0.194 +/- 0.334, P <0.05). We conclude infants respond to mild asphyxia during sleep with an increase in ventilation, an arousal or both. The exact response is dependent on age and sleep state.

Vulnerability of respiratory control in healthy preterm infants placed supine

OBJECTIVE

We tested the hypothesis that healthy preterm infants have attenuated ventilatory responses to hypercapnia, associated with a decreased rib cage contribution to ventilation, in the supine versus prone position.

STUDY DESIGN

We elicited hypercapnic ventilatory responses from 19 healthy preterm infants (postconceptional age 35 +/- 1 weeks) who were being prepared for hospital discharge. The O2 saturation was continuously monitored. Before and during CO2 rebreathing, ventilation was measured with a nasal mask pneumotachygraph and was derived from chest wall motion as determined by respiratory inductance plethysmograph. This measuring method allowed us to compare both ventilation and the percentage rib cage contribution to ventilation between supine and prone positions. Statistical analysis employed analysis of variance with repeated measures.

RESULTS

The supine position was associated with a higher respiratory rate (p < 0.02) and lower O2 saturation (p < 0.007) than the prone position. The increase in ventilation in response to hypercapnia was lower in the supine than in the prone position. This was statistically significant for the respiratory inductance plethysmograph (p < 0.008) but not the pneumotachygraph (p = 0.077), and was associated with a smaller rib cage contribution to ventilation in the supine than in the prone position (p < 0.0001).

CONCLUSION

Respiratory control may be vulnerable when healthy preterm infants are placed supine. Widespread avoidance of the prone position may not be appropriate for such patients.

Cardiorespiratory adaptation during sleep in infants and children

The cardiorespiratory control system undergoes functional maturation after birth. Until this process is completed, the cardiorespiratory system is unstable, placing infants at risk for cardiorespiratory disturbances, especially during sleep. The profound influence of states of alertness on respiratory and cardiac control has been the focus of intense scrutiny during the last decade. The effects of rapid-eye movement (REM) sleep on various mechanisms involved in cardiorespiratory control are of particular significance during the postnatal period since newborns spend much of their time in this sleep state. In fullterm newborns, REM sleep occupies more than 50% of total sleep time, and this percentage is even greater in preterm newborns. From term to six months of age, the proportion of REM sleep decreases. Since respiratory and cardiac disturbances are known to occur selectively during REM sleep, the predominance of REM sleep may be a risk factor for abnormal sleep-related events during early infancy. Awareness of these developmental changes in sleep patterns is important for clinicians dealing with problems such as apparent life-threatening events (ALTE), sudden infant death syndrome (SIDS), and/or cardiorespiratory responses to respiratory disorders. Our current understanding of respiratory and cardiac control rests mainly on studies conducted during the first months of life. There is a paucity of data on late infancy and early childhood. The present paper will review available data on how sleep affects 1) ventilatory mechanics, in particular of the upper airways and the chest wall; ventilation and apnea; gas exchange; chemoreceptor function; and arousal responses; 2) changes in heart rate and heart rate variability, and the occurrence and mechanisms of bradycardia.

The reproducibility of the response of the human newborn to CO2 measured by rebreathing and steady-state methods

The ventilatory response (VR) of the full-term newborn to CO2 was studied during quiet sleep using rebreathing and steady-state methods. Rebreathing responses were obtained under normoxic (fractional inspired oxygen concentration, Fi,O2 = 0.21) and hyperoxic (Fi,O2 = 0.4) conditions. Ten infants were tested three to five times using each of the two rebreathing protocols and the results averaged. Overall, there was no significant difference between either the mean variability (coefficient of variation) or slope of the VR measured under normoxic and hyperoxic conditions. Four infants were studied using a steady-state technique. There was marked test-to-test variability in VRs measured by this method. The results appear to indicate that the variability of the VR of the newborn to CO2 is not a result of chemoreflex changes in ventilation elicited in response to fluctuations in arterial PO2.

The measurement of thoraco-abdominal asynchrony in infants with severe laryngotracheobronchitis

Retractions of the lower ribcage (chest wall distortion [CWD]) during inspiration are frequently observed with moderate to severe respiratory disease in the infant. Laryngotracheobronchitis (LTB) results in a reversible partial airway obstruction with severe CWD. We wished to measure the motion of the chest wall during distortion to determine the changes in minute ventilation (VE) and to evaluate this clinical sign as a means of assessing disease severity. The respiratory inductance plethysmograph was used to determine the distortion of the lower chest wall, and distortion was correlated with VE, measured at the mouth, in six infants with severe LTB and ventilatory failure. As the conditions of these infants improved, the CWD decreased with decreasing transcutaneous carbon dioxide tension (tcPCO2), VE increased from 0.27 +/- 0.12 L.min-1 x kg-1 at a tcPCO2 of 64 mm Hg to 0.64 +/- 0.06 L.min-1 x kg-1 when the tcPCO2 had fallen to 28 mm Hg. Over the same change in tcPCO2, the tidal volume (VT) increased from 4.8 +/- 0.5 ml.kg-1 to 15.7 +/- 1.4 ml.kg-1. In the most severe disease state, the excursion of the chest wall (as an inductance) was -14 +/- 3 mV in severe obstruction, but increased to 75 mV +/- 4 mV with resolution of the illness. The timing and vector of movement of the abdomen and chest wall were expressed as a Lissajous figure, which is measured as a phase angle. The severity of the disease process, as determined by tcPCO2 was directly related to the phase relationship, and thus reflected both VE and VT. The severity of the CWD may be assessed rapidly by the use of Lissajous figures.

Compact apparatus for measurement of ventilatory response to carbon dioxide in newborns and infants

We developed a rebreathing system for measuring response to carbon dioxide (CO2) of newborns and infants for use at the bedside. The system based on Read's method is small, easy to operate, and includes a computer-controlled gas switching sequence, computerized calculation, and display functions. We measured the CO2 response in 11 infants with or without apnea, who were born at 26-33 weeks gestation and were 12 to 215 days old at the time of the study. Our results suggest that the presence of apnea in premature infants may correspond to a low CO2 response. The method was convenient for clinical use because it allowed an investigator to carry out bedside tests in only a few minutes. With our system we were able to assess respiratory center function in newborns and infants.

Respiratory adaptation during sleep in infants

Respiratory adaptation during sleep improves with growth. The most vulnerable period for respiratory adaptation to sleep is from birth to 3 months of age. Factors that favor vulnerability are immaturity in ventilatory control and high rib cage compliance which impairs its effectiveness for ventilation. Improvement in respiratory adaptation during sleep is rapid during the first year of life. Sleep, and especially active (REM) sleep, is a risk period for respiratory disturbances in infants. Numerous factors may trigger apparent life threatening events. Respiratory disorders such as bronchiolitis, upper airway obstruction, and bronchopulmonary dysplasia impair respiratory adaptation during sleep. Treatment of respiratory disorders in infants must take into account the exacerbation of respiratory disturbances during sleep.

Respiratory monitoring of the infant in anaesthesia and intensive care

Respiratory monitoring of children during general anaesthesia and critical care is in its early stages. Acquisition of physical information remains of great importance because of the difficulties in obtaining specific and objective data from paediatric patients. Many of the obstacles presented by them, such as small and rapid respiration, lack of patient cooperation, use of an uncuffed tracheal tube and relatively higher airway humidity to keep the small airway patent, have been overcome recently by sophisticated technology based on well known principles and thoughtful use of computers. It is now possible to monitor and apply many pulmonary function tests at the bedside that were once confined to the laboratory.

Relative contribution of ribcage and abdomen during augmented breaths in infants

Changes in the relative contribution of ribcage and abdomen during augmented breaths were assessed in two groups of infants (less than 2 weeks and 4-12 weeks old). In both groups ribcage and abdominal movements increased during augmented breaths in quiet sleep. In the older infants the relative increase was greater for the ribcage (P less than 0.05) when expressed either as a ribcage to abdominal movement ratio or as a percent of the respective movements during control breaths. In contrast, no significant change of the relative contribution was observed in the younger age group. During active sleep paradoxical movement of the ribcage, observed during tidal breaths, continued during the first phase of the augmented breath; however, during the second phase of inspiration, the ribcage moved outward in all but one infant. Our results show that marked increases in tidal volume are associated with greater increases in ribcage contribution in infants beyond the neonatal period. This may reflect differences in recruitment patterns of intercostal muscles during development.

Ventilatory response to CO2 in infants with alleged sleep apnoea

Twenty-eight children whose parents reported sleep apnoea were investigated. In 15 infants apnoeic periods during sleep could be confirmed during clinical observation. Ventilatory responses to CO2 were measured in all infants, in 23 during sleep in 5 only when awake. A very wide range of CO2 sensitivities was found. In four children there was no ventilatory response or even a paradox one: a decrease in ventilation as PACO2 was increased. Two of these non-responding children died later, one still sleeps in a respirator aged three, and one developed a normal CO2 sensitivity a few months later. It is concluded that the parent's account of an apnoeic incident during sleep is not always reliable. A ventilatory response to CO2 is a useful tool with which to identify infants at risk of death, possibly related to a defective control of ventilation. The actual value of the CO2 sensitivity hardly gives any useful information, due to the wide range of "normal" reactions. No or negative ventilatory responses to CO2 seem to be indicators of high risk children, and may possibly play a role in SIDS incidents.