Neonatal airway management training using simulation-based educational methods and technology

Airway management is a fundamental component of neonatal critical care and requires a high level of skill. Neonatal endotracheal intubation (ETI), bag-mask ventilation, and supraglottic airway management are complex technical skills to acquire and continually maintain. Simulation training has emerged as a leading educational modality to accelerate the acquisition of airway management skills and train interprofessional teams. However, current simulation-based training does not always replicate neonatal airway management needed for patient care with a high level of fidelity. Educators still rely on clinical training on live patients. In this article, we will a) review the importance of simulation-based neonatal airway training for learners and clinicians, b) evaluate the available training modalities, instructional design, and challenges for airway procedural skill acquisition, especially neonatal ETI, and c) describe the human factors affecting the transfer of airway training skills into the clinical environment.

Respiratory and haemodynamic effects of 6h-pronation in neonates recovering from respiratory distress syndrome, or affected by acute respiratory distress syndrome or evolving bronchopulmonary dysplasia: a prospective, physiological, crossover, controlled cohort study

BACKGROUND

Pronation ameliorates oxygenation in adults with acute respiratory distress syndrome (ARDS); the effect in neonates with ARDS or other types of respiratory failure is unknown. We aimed to verify if pronation has similar respiratory and haemodynamic effects in three common types of neonatal respiratory failure.

METHODS

Prospective, physiologic, crossover, quasi-randomised, controlled cohort study performed in a tertiary academic neonatal intensive care unit. We enrolled neonates with: 1) recovering respiratory distress syndrome (RDS, mild restrictive pattern); 2) neonatal ARDS (NARDS, severe restrictive pattern); or 3) evolving bronchopulmonary dysplasia (BPD), that is chronic pulmonary insufficiency of prematurity (mixed restrictive/obstructive pattern). Neonates with other lung disorders, malformations or haemodynamic impairment were excluded. Patients were started prone or supine and then shifted to the alternate position for 6h; measurements were performed after 30' of "wash out" from the positioning and at the end of 6h period. Primary outcomes were respiratory (PtcCO_2, modified ventilatory index, PtcO₂/FiO₂, SpO₂/FiO₂, oxygenation index, ultrasound-assessed lung aeration) and haemodynamic (perfusion index, heart rate, arterial pressure, cardiac output) parameters.

FINDINGS

Between May 1st, 2019, and May 31st, 2021, 161 participants were enrolled in this study, and included in the final analysis. Pronation improved gas exchange and lung aeration (p always <0.01) and these effects were overturned in the alternate position, except for lung aeration in NARDS where the improvement persisted. The effects were greater in patients recovering from RDS than in those with evolving BPD than in those with NARDS, in this order (p always <0.01). Pronation produced a net recruitment as lung ultrasound score decreased in patients shifted from supine (16.9 (standard deviation: 5.8)) to prone (14.1 (standard deviation: 3.3), p < 0.01) and this reduction correlated with oxygenation improvement. Haemodynamic parameters remained within normal ranges.

INTERPRETATION

6h-pronation can be used to improve gas exchange and lung aeration in neonates with recovering RDS, evolving BPD or NARDS without relevant haemodynamic effects.

FUNDING

None.

Point-of-care ultrasound (POCUS) protocol for systematic assessment of the crashing neonate-expert consensus statement of the international crashing neonate working group

Sudden unexpected clinical deterioration or cardiorespiratory instability is common in neonates and is often referred as a "crashing" neonate. The established resuscitation guidelines provide an excellent framework to stabilize and evaluate these infants, but it is primarily based upon clinical assessment only. However, clinical assessment in sick neonates is limited in identifying underlying pathophysiology. The Crashing Neonate Protocol (CNP), utilizing point-of-care ultrasound (POCUS), is specifically designed for use in neonatal emergencies. It can be applied both in term and pre-term neonates in the neonatal intensive care unit (NICU). The proposed protocol involves a stepwise systematic assessment with basic ultrasound views which can be easily learnt and reproduced with focused structured training on the use of portable ultrasonography (similar to the FAST and BLUE protocols in adult clinical practice). We conducted a literature review of the evidence-based use of POCUS in neonatal practice. We then applied stepwise voting process with a modified DELPHI strategy (electronic voting) utilizing an international expert group to prioritize recommendations. We also conducted an international survey among a group of neonatologists practicing POCUS. The lead expert authors identified a specific list of recommendations to be included in the proposed CNP. This protocol involves pre-defined steps focused on identifying the underlying etiology of clinical instability and assessing the response to intervention.Conclusion: To conclude, the newly proposed POCUS-based CNP should be used as an adjunct to the current recommendations for neonatal resuscitation and not replace them, especially in infants unresponsive to standard resuscitation steps, or where the underlying cause of deterioration remains unclear. What is known? • Point-of-care ultrasound (POCUS) is helpful in evaluation of the underlying pathophysiologic mechanisms in sick infants. What is new? • The Crashing Neonate Protocol (CNP) is proposed as an adjunct to the current recommendations for neonatal resuscitation, with pre-defined steps focused on gaining information regarding the underlying pathophysiology in unexplained "crashing" neonates. • The proposed CNP can help in targeting specific and early therapy based upon the underlying pathophysiology, and it allows assessment of the response to intervention(s) in a timely fashion.

Pharmaceutical Expenditure Is Unchanged with Ultrasound-Guided Surfactant Administration

OBJECTIVE

Semiquantitative lung ultrasound improves the timeliness of surfactant replacement, but its financial consequences are unknown. We aim to investigate if the ultrasound-guided surfactant administration influences the general costs of surfactant therapy for preterm neonates affected by respiratory distress syndrome.

STUDY DESIGN

This is a pharmacoeconomic, retrospective, and before-and-after study investigating the impact of ultrasound-guided surfactant replacement (echography-guided Surfactant THERapy [ESTHER]) on pharmaceutical expenditure within the ESTHER initiative. Data extracted from the institutional official database hosted by the hospital administration for financial management were used for the analysis. We analyzed the number of surfactant administrations in neonates of gestational age ≤32^6/7 weeks, and the number of surfactant vials used from January 1_, 2014 to June 30, 2014 (i.e., during the period of standard surfactant administration policy) and from July 1, 2016 to December 31, 2018 (that is during ESTHER policy).

RESULTS

ESTHER did not modify surfactant use, as proportion of treated neonates with RDS receiving at least one surfactant dose (Standard: 21.3% vs. ESTHER: 20.9%; p = 0.876) or as proportion of used vials over the total number of vials opened for neonates of any gestational age (Standard: 37% vs. ESTHER: 35%; p = 0.509).

CONCLUSION

Ultrasound-guided surfactant replacement using a semiquantitative lung ultrasound score in preterm infants with RDS does not change the global use of surfactant and the related expenditure.

KEY POINTS

· ESTHER is able to increase the timeliness of surfactant replacement.. · The ultrasound-guided surfactant administration does not increase the cost of surfactant therapy.. · The ultrasound-guided surfactant administration does not change the global surfactant utilization..

"Playing it SAFE in the NICU" SAFE-R: a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU

Rapid diagnosis of sudden, unexpected, and potentially fatal complications in the neonatal intensive care unit (NICU) is essential for the initiation of prompt and life-saving management. Point-of-care ultrasound (POCUS) protocols are widely used in adult emergency situations to diagnose and guide treatment, but none has been specifically developed for the neonate. We propose a targeted diagnostic ultrasound protocol for the suddenly decompensating infant in the NICU for rapid screening for the most common life-threatening complications needing immediate attention. We integrated current knowledge on the use of POCUS for diagnosis of the most critical neonatal complications into the "SAFE-R protocol" (Sonographic Assessment of liFe-threatening Emergencies - Revised). The ultrasound algorithm was evaluated at the bedside for suitability and ease of use. Main features of SAFE-R are the use of standardized ultrasound points and a simple one-probe rule-in/rule-out approach. The flowchart is designed by order of urgency and priority is given to treatable causes. Hence, ruling out cardiac tamponade is the first step in the decision tree, followed by pneumothorax, pleural effusion, then acute critical aortic occlusion, acute abdominal complications, and severe intraventricular hemorrhage.Conclusion: SAFE-R is the first ultrasound algorithm specifically conceived for use in the NICU to screen for the most common urgent neonatal complications leading to sudden deterioration, thereby providing critical information within minutes. The simplified and rapid approach is designed for the neonatologist and is easy to learn and quick to perform. What is Known: • The fields of neonatal and pediatric critical care are undergoing a transformation with the adoption of POCUS and the recent publication of the first international guidelines on POCUS for critically ill children and neonates. • Targeted emergency ultrasound protocols are widely used in adult emergency and critical care medicine, but specific and adapted ultrasound algorithms are lacking for the pediatric and neonatal population. What is New: • We propose the first targeted ultrasound protocol specifically designed for the suddenly decompensating infant in the NICU for rapid screening of the most common life-threatening complications needing immediate attention. • The SAFE-R ultrasound algorithm integrates current knowledge on ultrasound diagnosis of the most critical neonatal complications into a simple and easy-to-perform emergency scanning protocol aimed to guide initial management and resuscitation efforts.

Simulation in neonatal care: towards a change in traditional training?

Simulation has traditionally been used in neonatal medicine for educational purposes which include training of novice learners, maintaining competency of health care providers, and training of multidisciplinary teams to handle crisis situations such as neonatal resuscitation. Current guidelines recommend the use of simulation as an education tool in neonatal practice. The place of simulation-based education has gradually expanded, including in limited resource settings, and is starting to show its impact on improving patient outcomes on a global basis. Over the past years, simulation has become a cornerstone in clinical settings with the goal of establishing high quality, safe, reliable systems. The aim of this review is to describe neonatal simulation training as an effective tool to improve quality of care and patient outcomes, and to encourage the use of simulation-based training in the neonatal intensive care unit (NICU) for not only education, but equally for team building, risk management and quality improvement.

CONCLUSION

Simulation is a promising tool to improve patient safety, team performance, and ultimately patient outcomes, but scarcity of data on clinically relevant outcomes makes it difficult to estimate its real impact. The integration of simulation into the clinical reality with a goal of establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes in neonatology must be a priority.

WHAT IS KNOWN

• Simulation-based education has traditionally focused on procedural and technical skills. • Simulation-based training is effective in teaching non-technical skills such as communication, leadership, and teamwork, and is recommended in neonatal resuscitation.

WHAT IS NEW

• There is emerging evidence for the impact of simulation-based training on patient outcomes in neonatal care, but data on clinically relevant outcomes are scarce. • Simulation is a promising tool for establishing high quality, safe, reliable, and robust systems to improve patient safety and patient outcomes.

Lung ultrasound features and relationships with respiratory mechanics of evolving BPD in preterm rabbits and human neonates

Evolving broncho-pulmonary dysplasia (BPD) is a regionally heterogeneous disorder characterized by impaired alveolarization leading to lung aeration inhomogeneities. Hyperoxia-exposed preterm rabbits have been proposed to mimic evolving BPD and we aim to verify if this model has the same lung ultrasound and mechanical features of evolving BPD in human neonates. Twenty-five preterm rabbits and twenty-five neonates with evolving BPD were enrolled and subjected to semi-quantitative lung ultrasound and lung mechanics measurement. A modified rabbit lung ultrasound score (rLUS), the previously validated neonatal lung ultrasound score (LUS) and classical mechanics measurements were obtained. Lung ultrasound images were also recorded and evaluated by two independent observers with different expertise blinded to each other's evaluation. Lung ultrasound findings were equally heterogeneous both in rabbits as in human neonates: images were very similar and encompassed all the classical lung ultrasound semiology. The inter-rater absolute agreement for the evaluation of lung ultrasound images in rabbits was very high (ICC: 0.989 (95%CI: 0.975-0.995); p<0.0001) and there was no difference between the two observers. Lung mechanics parameters were similarly altered both in rabbits and human neonates. There were significant correlations between airway resistances and lung ultrasound scores both in rabbits (r=0.519; p=0.008) and in neonates (r=0.409; p=0.042). No significant correlation between rLUS, LUS and any other mechanics parameter. Lung ultrasound was easy to be performed and accurate even in these small animals and with a short training. In conclusion, the preterm rabbit model fairly reproduces the lung ultrasound and mechanical characteristics of preterm neonates with evolving BPD.

Desulphurisation kinetics of thiophenic compound by sulphur oxidizing Klebsiella oxytoca SOB-1

AIMS

The major aims of this study are to determine the capability of sulphur oxidizing bacterium (SOB-1) to desulphurize dibenzothiophene (DBT) and crude oil, detection of the reaction kinetics and identify the proposed pathway of DBT desulphurization.

METHODS AND RESULTS

The isolate was genetically identified based on 16S rRNA gene sequencing as Klebsiella oxytoca and deposited in the Genebank database under the accession number: MT355440. The HPLC analysis of the remaining DBT concentration revealed that, SOB-1 could desulphurize 90% of DBT (0·25 mmol l^-1 ) within 96 h. The maximum production of sulphate ions from the desulphurization of DBT (0·36 mmol l^-1 ) and crude oil (0·4 mmol l^-1 ) could be quantitatively detected after 48 h of incubation at 30°C. The high values of correlation coefficient (R² ) obtained at all studied concentrations; suggested that biodesulfurization kinetics of DBT follows the first-order reaction model. The kinetics studies showed that, DBT may have an inhibitory effect on SOB-1 when the initial concentration exceeded 0·75 mmol l^-1 . The GC-MS analysis exhibited four main metabolites rather than DBT. The most important ones are 2-hydroxybiphenyl (2-HBP) and methoxybiphenyl n(2-MBP).

CONCLUSIONS

Klebsiella oxytoca SOB-1 catalyzes the desulphurization of DBT through 4S pathway and forms four main metabolic products. The release of sulphate ion and formation of 2-HBP indicating the elimination of sulphur group without altering the carbon skeleton of DBT. The bacterial strain could also catalyzes desulphurization of crude oil. The desulphurization kinetics follows the first-order reaction model.

SIGNIFICANCE AND IMPACT OF THE STUDY

Klebsiella oxytoca SOB-1 could be used as a promising industrial and environmental biodesulfurizing agent as it is not affecting carbon skeleton of thiophenic compounds and forming less toxic metabolic product (2-MBP).

Introduction of point-of-care neonatal lung ultrasound in a developing country

Despite neonatal lung ultrasound (LU) being diffused worldwide, its introduction in limited-resource areas has not been formally investigated. We conceived a project to introduce it in a level 3 NICU of a developing country and verify if, after a short protocolized training, clinicians may efficaciously use LU. Inter-rater agreement between ultrasound trainees and trainers was analyzed within both the local test and the diffusion phases of the project. High inter-rater agreements were found between expert trainers and the two neonatologists who were trained in a skilled European center (Cohen's Kappa, 0.951; 95%CI, 0.882-0.999), as well as between the two and the second round of locally trained colleagues (Cohen's Kappa, 0.896; 95%CI, 0.797-0.996). Moreover, a high agreement was found between the clinical respiratory diagnosis (used as the "gold standard") and the LU diagnosis given by the first two trainees (intraclass correlation, 0.992; 95%CI, 0.987-0.996) and the locally trained physicians (intraclass correlation, 0.97; 95%CI, 0.95-0.98). A final survey demonstrated that the project was perceived as efficacious and that LU was going to be integrated into routine clinical practice.Conclusions: А short LU training provided sufficient proficiency and allowed the LU introduction in clinical practice in the neonatal intensive care unit in a developing country.What is Known:• Lung ultrasound is a promising technique for evaluating neonatal respiratory distress at least in high-income countries. Previous studies revealed high specificity and sensitivity in diagnosing specific neonatal disorders.• An important barrier to the more extensive use of lung ultrasound in neonatal critical care is a lack of efficient and suitable training solutions.What is New:• Descriptive LU performed by neonatologist in a developing country after a short formal training is feasible with good quality.• A short formal LU training program provided good proficiency and allowed a correct descriptive diagnosis in a neonatal unit in a developing country.

Semiquantitative Ultrasound Assessment of Lung Aeration Correlates With Lung Tissue Inflammation

We studied the relationship between ultrasound-assessed lung aeration and inflammation in a particular population of ventilated preterm neonates with mild-to-moderate lung inflammation and no congenital heart defect. Lung aeration estimated by a semiquantitative lung ultrasound score significantly correlated with several inflammatory markers both at cellular (neutrophil count in bronchoalveolar lavage: ρ = 0.400, p = 0.018) and molecular level (total proteins: ρ = 0.524, p = 0.021; interleukine-8: ρ = 0.523, p = 0.021; granulocytes-macrophages colony stimulating factor: ρ = 0.493, p = 0.020; all measured in bronchoalveolar lavage and expressed as epithelial lining fluid concentrations). Lung ultrasound might detect changes in lung aeration attributable to mild-to-moderate local inflammation if cardiogenic lung edema is excluded. Thus, it is possible to describe some levels of lung inflammation with semiquantitative lung ultrasound.

International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

BACKGROUND

Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children.

METHODS

Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document.

RESULTS

Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C).

CONCLUSIONS

Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Less invasive surfactant administration: a word of caution

Surfactant is a cornerstone of neonatal critical care, and the presumed less (or minimally) invasive techniques for its administration have been proposed to reduce invasiveness of neonatal critical care interventions. These techniques are generally known as less invasive surfactant administration (LISA) and have quickly gained popularity in some neonatal intensive care units. Despite the increase in the use of LISA, we believe that the pathobiological background supporting its possible clinical benefits is unclear. Similarly, it is unclear whether there are any ignored drawbacks, as LISA has been tested in only a few trials and some physiopathological issues seem to have gone unnoticed. Active research is warranted to fill these knowledge gaps before LISA can be firmly recommended. In this Viewpoint, we provide an in-depth analysis of LISA techniques, based on physiological and pathobiological factors, followed by a critical appraisal of available clinical data, and highlight some possible future research directions.

Short- and long-term respiratory outcomes in neonates with ventilator-associated pneumonia

BACKGROUND AND OBJECTIVE

Ventilator-associated pneumonia (VAP) is a common nosocomial infection in critical care settings and might have important long-term consequences in neonates. Our aim is to clarify the short- and long-term respiratory outcomes of neonates affected by VAP.

METHODS

Prospective, population-based, cohort study with 12 months follow-up based on clinical examinations and diary-based respiratory morbidity score, conducted in an academic tertiary referral neonatal unit with dedicated follow-up program.

RESULTS

A total of 199 inborn neonates consecutively ventilated for at least 48 hours were eligible for the study. One hundred fifty-one were finally enrolled and classified as "exposed" or "unexposed" to VAP, if they fulfilled (or not) VAP criteria once during their stay. Bronchopulmonary dysplasia (BPD) incidence was significantly higher in exposed (75%) than in unexposed babies (26.8%; relative risk [RR]: 2.8 [1.9-4.0]; _Adj RR: 3.5 [1.002-12.7]; P = .049; number needed to harm = 2.07), although the composite BPD/mortality did not differ. Exposed patients showed longer intensive care unit stay (87 [43-116] vs 14 [8-52] days; St.β = 0.24; P < .0001) and duration of ventilation (15 [10-25] vs 5 [4-8] days; St.β = 0.29; P < .0001) than unexposed neonates. Exposed patients also showed less ventilator-free days (11 [5-17.7] vs 22 [14-24] days; St.β = -0.15; P = .05) compared to unexposed. Respiratory infections, use of drugs, rehospitalization for respiratory reasons, home oxygen therapy, their composite outcome, and diary-based clinical respiratory morbidity score were similar between the cohorts.

CONCLUSION

Neonatal VAP seems associated to higher incidence of BPD, longer ventilation, and intensive care stay but it does not affect long-term respiratory morbidity.

Echography-Guided Surfactant Therapy to Improve Timeliness of Surfactant Replacement: A Quality Improvement Project

OBJECTIVE

To improve time of surfactant administration with a surfactant replacement protocol based on semiquantitative lung ultrasound score (LUS) thresholds.

STUDY DESIGN

Quality improvement (QI), prospective, before-after, pilot study. In a 6-month period surfactant replacement was based only on inspired oxygen fraction (FiO₂) thresholds. In the second 6-month period, surfactant was given when either the FiO₂ or LUS exceeded the limits. The main QI measures were the proportion of neonates receiving surfactant within the first 3 hours of life and maximal FiO₂ reached before surfactant replacement. Secondary QI measures were the duration of respiratory support and ventilator-free days. Data were also collected for 1 year after the study to verify sustainability.

RESULTS

Echography-guided Surfactant THERapy (ESTHER) increased the proportion of neonates receiving surfactant within the first 3 hours of life (71.4%-90%; P < .0001) and reduced the maximal FiO₂ reached before surfactant replacement (0.33 [0.26-0.5]) vs 0.4 [0.4-0.55]; P = .005). The global need for surfactant did not significantly change. ESTHER also resulted in a significant decrease in duration of invasive ventilation and ventilator-free days.

CONCLUSIONS

ESTHER improved the timeliness of surfactant administration and secondary QI indicators related to surfactant replacement.

A Multicenter Lung Ultrasound Study on Transient Tachypnea of the Neonate

BACKGROUND AND AIM

Discordant results that demand clarification have been published on diagnostic lung ultrasound (LUS) signs of transient tachypnea of the neonate (TTN) in previous cross-sectional, single-center studies. This work was conducted to correlate clinical and imaging data in a longitudinal and multicenter fashion.

METHODS

Neonates with a gestational age of 34-40 weeks and presenting with TTN underwent a first LUS scan at 60-180 min of life. LUS scans were repeated every 6-12 h if signs of respiratory distress persisted. Images were qualitatively described and a LUS aeration score was calculated. Clinical data were collected during respiratory distress.

RESULTS

We enrolled 65 TTN patients. Thirty-one (47.6%) had a sharp echogenicity increase in the lower lung fields (the "double lung point" or DLP sign). On admission, there was no significant difference between patients with and without DLP in Silverman scores (4 ± 1.5 vs. 4 ± 2.1; p = 0.9) or LUS scores (7.6 ± 2.6 vs. 5.6 ± 3.8; p = 0.12); PaO2/FiO2 (249 ± 93 vs. 252 ± 125; p = 0.91). All initial LUS scans (performed at the onset of distress) and 99.5% of all scans showed a regular pleural line with no consolidation, with only 1 neonate showing consolidation in the follow-up scans. The Silverman and LUS scores were significantly correlated (rho = 0.27; p = 0.02).

CONCLUSION

A regular pleural line with no consolidation is a consistent finding in TTN. The presence of a DLP is not essential for the LUS diagnosis of TTN. A semi-quantitative LUS score correlates well with the clinical course and could be useful in monitoring changes in lung aeration during TTN.

Lung Ultrasound Findings in Congenital Pulmonary Airway Malformation

BACKGROUND AND OBJECTIVE

Congenital pulmonary airway malformation (CPAM) is a group of rare congenital malformations of the lung and airways. Lung ultrasound (LU) is increasingly used to diagnose neonatal respiratory diseases since it is quick, easy to learn, and radiation-free, but no formal data exist for congenital lung malformations. We aimed to describe LU findings in CPAM neonates needing neonatal intensive care unit (NICU) admission and to compare them with a control population.

METHODS

A retrospective review of CPAM cases from three tertiary academic NICUs over 3 years (2014-2016) identified five patients with CPAM who had undergone LU examination. LU was compared with chest radiograms and computed tomography (CT) scans that were used as references.

RESULTS

CPAM lesions were easily identified and corresponded well with CT scans; they varied from a single large cystic lesion, multiple hypoechoic lesions, and/or consolidation. The first two LU findings have not been described in other respiratory conditions and were not found in controls.

CONCLUSION

We provide the first description of LU findings in neonates with CPAM. LU may be used to confirm antenatally diagnosed CPAM and to suspect CPAM in infants with respiratory distress if cystic lung lesions are revealed. Further studies are necessary to define the place of LU in the management of CPAM.

Lung Ultrasound Score Predicts Surfactant Need in Extremely Preterm Neonates

BACKGROUND AND OBJECTIVES

There are several lung ultrasound scores (LUS) for evaluating lung aeration in critically ill adults with restrictive lung disorders. A modified LUS adapted for neonates correlates well with oxygenation and is able to be used to predict the need for surfactant in preterm neonates with respiratory distress syndrome (RDS). However, no data are available for extremely preterm neonates for whom timely surfactant administration is especially important. We hypothesized that LUS might be reliable in extremely preterm neonates with RDS who are treated with continuous positive airway pressure. We aimed to determine the diagnostic accuracy of LUS in predicting the need for surfactant treatment and re-treatment in this population.

METHODS

We performed a prospective cohort diagnostic accuracy study between 2015 and 2016 in a tertiary-care academic center. Inborn neonates at ≤30 weeks' gestation with RDS treated with continuous positive airway pressure were eligible. Surfactant was given on the basis of oxygen requirement thresholds derived from European guidelines, and a LUS was not used to guide surfactant treatment. We calculated the LUS after admission and analyzed its diagnostic accuracy to predict surfactant treatment and re-treatment.

RESULTS

We enrolled 133 infants; 68 (51%) received 1 dose of surfactant and 19 (14%) received 2 surfactant doses. A LUS is significantly correlated with oxygenation index (ρ = 0.6; P < .0001) even after adjustment for gestational age (P < .0001). A LUS can be used to accurately predict the need for the first surfactant dose (area under the curve = 0.94; 95% confidence interval: 0.90-0.98; P < .0001) and also the need for surfactant redosing (area under the curve = 0.803; 95% confidence interval: 0.72-0.89; P < .0001). The global accuracy for the prediction of surfactant treatment and re-treatment is 89% and 72%, respectively.

CONCLUSIONS

LUS may be used to predict the need for surfactant replacement in extremely preterm neonates with RDS.

The Role of Lung Ultrasound in Viral Lower Respiratory Tract Infections

Despite being a bedside technique under rapid development and diffusion, lung ultrasound has not been often used in the management of viral low respiratory tract infections, although these infections represent a significant burden of care in neonatology and pediatrics. The aim of this article is to review the lung ultrasound findings and the evidence-based data available on this topic. Guidance on bedside imaging interpretation and future research direction are also discussed in this article.

Lung Ultrasound for Diagnosing Pneumothorax in the Critically Ill Neonate

OBJECTIVES

To evaluate the accuracy of lung ultrasound for the diagnosis of pneumothorax in the sudden decompensating patient.

STUDY DESIGN

In an international, prospective study, sudden decompensation was defined as a prolonged significant desaturation (oxygen saturation <65% for more than 40 seconds) and bradycardia or sudden increase of oxygen requirement by at least 50% in less than 10 minutes with a final fraction of inspired oxygen ≥0.7 to keep stable saturations. All eligible patients had an ultrasound scan before undergoing a chest radiograph, which was the reference standard.

RESULTS

Forty-two infants (birth weight = 1531 ± 812 g; gestational age = 31 ± 3.5 weeks) were enrolled in 6 centers; pneumothorax was detected in 26 (62%). Lung ultrasound accuracy in diagnosing pneumothorax was as follows: sensitivity 100%, specificity 100%, positive predictive value 100%, and negative predictive value 100%. Clinical evaluation of pneumothorax showed sensitivity 84%, specificity 56%, positive predictive value 76%, and negative predictive value 69%. After sudden decompensation, a lung ultrasound scan was performed in an average time of 5.3 ± 5.6 minutes vs 19 ± 11.7 minutes required for a chest radiography. Emergency drainage was performed after an ultrasound scan but before radiography in 9 cases.

CONCLUSIONS

Lung ultrasound shows high accuracy in detecting pneumothorax in the critical infant, outperforming clinical evaluation and reducing time to imaging diagnosis and drainage.

Aldosterone-Signaling Defect Exacerbates Sodium Wasting in Very Preterm Neonates: The Premaldo Study

CONTEXT

The neonatal period, notably in preterm infants, is characterized by high sodium wasting, implying that aldosterone, the main hormone regulating sodium reabsorption, is unable to maintain sodium homeostasis.

OBJECTIVE

This study sought to assess aldosterone secretion and action in neonates according to gestational age (GA).

DESIGN AND SETTING

This was a multicenter prospective study (NCT01176162) conducted between 2011 and 2014 at five neonatology departments in France. Infants were followed during their first 3 months.

PARTICIPANTS

The 155 newborns included were classified into three groups: Group 1 (n = 46 patients), <33 gestational weeks (GW); Group 2 (n = 67 patients), 33-36 GW; and Group 3 (n = 42 patients), ≥37 GW.

MAIN OUTCOME MEASURES

Plasma aldosterone was measured in umbilical cord blood. Urinary aldosterone (UAldo) was assessed at day 0, day 3, month 1, and month 3 postnatal. The correlation between UAldo and the urinary Na/K ratio was determined as an index of renal aldosterone sensitivity.

RESULTS

UAldo significantly increased with GA: from 8.8 ± 7.5 μg/mmol of creatinine (Group 1) to 21.1 ± 21.0 (Group 3) in correlation with plasma aldosterone levels in all groups (P < .001), demonstrating its reliability. The aldosterone/renin ratio significantly increased with GA, suggesting an aldosterone secretion defect in preterm infants. UAldo and urinary Na/K were correlated in very preterm but not in term neonates, consistent with very preterm neonates being renal-aldosterone sensitive and term neonates being aldosterone resistant.

CONCLUSIONS

Very preterm infants have a previously unrecognized defective aldosterone secretion but conserved renal aldosterone sensitivity in the neonatal period, which modifies the current view of sodium balance in these infants and suggests alternative management approaches.

Lung Ultrasonography Score to Evaluate Oxygenation and Surfactant Need in Neonates Treated With Continuous Positive Airway Pressure

IMPORTANCE

Lung ultrasonography (LUS) is a bedside technique useful to diagnose neonatal respiratory problems, but, to our knowledge, no data are available about its use for monitoring lung function or eventually guiding surfactant therapy.

OBJECTIVE

To determine the diagnostic accuracy of a neonatal-adapted LUS score to evaluate oxygenation and predict need for surfactant administration.

DESIGN, SETTING, AND PARTICIPANTS

Prospective diagnostic accuracy study following STARD (Standards for the Reporting of Diagnostic Accuracy Studies) guidelines at a tertiary level academic neonatal intensive care unit in 2014. All neonates admitted to the neonatal intensive care unit with signs of respiratory distress were eligible, and 130 neonates were enrolled. The LUS score was calculated in the first hours of life under continuous positive airway pressure. The transcutaneous partial pressure of oxygen (Ptco2) to fraction of inspired oxygen (Fio2) ratio, alveolar-arterial gradient, oxygenation index, and arterial to alveolar ratio were calculated within 30 minutes from LUS, using transcutaneous blood gas monitoring. Surfactant was administered according to 2013 European guidelines.

MAIN OUTCOMES AND MEASURES

Correlation between LUS score and indices of oxygenation and prediction of surfactant administration.

RESULTS

Among the 130 neonates in this study, the LUS score was significantly correlated with all indices of oxygenation, independent from gestational age (GA) (Ptco2 to Fio2 ratio: GA ≥ 34 weeks: ρ = -0.57; GA <34 weeks: ρ = -0.62; P < .001; alveolar-arterial gradient: GA ≥ 34 weeks: ρ = 0.62; GA <34 weeks: ρ = 0.59; P < .001; oxygenation index: GA ≥ 34 weeks: ρ = 0.63; GA <34 weeks: ρ = 0.69; P < .001; and arterial to alveolar ratio: GA ≥ 34 weeks: ρ = -0.60; GA <34 weeks: ρ = -0.56; P < .001). The LUS score predicted the need for surfactant better in preterm babies with a GA less than 34 weeks (area under the curve = 0.93; 95% CI, 0.86-0.99; P < .001) than in term and late-preterm neonates with a GA of 34 weeks or greater (area under the curve = 0.71; 95% CI, 0.54-0.90; P = .02); the areas under the curve for these 2 GA subgroups are significantly different (P = .02). In babies with a GA less than 34 weeks, a LUS score cutoff of 4 predicted surfactant administration with 100% sensitivity and 61% specificity, yielding a posttest probability of 72%.

CONCLUSIONS AND RELEVANCE

The LUS score is well correlated with oxygenation status in both term and preterm neonates, and it shows good reliability to predict surfactant administration in preterm babies with a GA less than 34 weeks under continuous positive airway pressure.

Lung ultrasound findings in meconium aspiration syndrome

Meconium aspiration syndrome (MAS) is a rare and life-threatening neonatal lung injury induced by meconium in the lung and airways. Lung ultrasound (LUS) is a quick, easy and cheap imaging technique that is increasingly being used in critical care settings, also for newborns. In this paper we describe ultrasound findings in MAS. Six patients with MAS of variable severity were examined by LUS during the first hours of life. Chest X-rays were used as reference. The following dynamic LUS signs were seen in all patients: (1) B-pattern (interstitial) coalescent or sparse; (2) consolidations; (3) atelectasis; (4) bronchograms. No pattern was observed for the distribution of signs in lung areas, although the signs varied with time, probably due to the changing localisation of meconium in the lungs. LUS images corresponded well with X-ray findings. In conclusion, we provide the first formal description of LUS findings in neonates with MAS. LUS is a useful and promising tool in the diagnosis and management of MAS, providing real-time bedside imaging, with the additional potential benefit of limiting radiation exposure in sick neonates.

Transcutaneous bilirubinometry is not influenced by term or skin color in neonates

BACKGROUND

The utility of transcutaneous bilirubin measurements (TcB) in screening for hyperbilirubinemia in preterm infants (<34 weeks) and in non-white infants remains a matter of debate.

AIM

To evaluate accuracy of TcB in preterm and term infants of different ethnic backgrounds, using a second generation bilirubinometer.

STUDY DESIGN

The Draeger JM-103® device was used to measure TcB. Eighty five measurements of TcB and total serum bilirubin (TSB) were retrospectively compared. Neonates were stratified into groups according to gestational age: <34 weeks (group 1, n=44) and >34 weeks (group 2, n=41), and according to ethnic origin: Caucasians (group A, n=49) and non-Caucasians (group B, n=36). Statistical analysis, using Pearson's correlation coefficient (r) and Bland-Altman analysis were performed to evaluate correlation and agreement between TSB and TcB values. Multiple linear regression was used to control for confounders for TSB values.

RESULTS

Correlation between TSB and TcB was high. Pearson's correlation coefficients were over 0.9 in all groups (0.910, 0.908, 0.916 and 0.934, p<0.0001 in groups 1, 2, A, and B respectively). Bland-Altman plots showed acceptable and close limits of agreements (56.8/-57.7, 54.2/-67.2, 57.7/-55.8, and 51.3/-69.9μmol/L in groups 1, 2, A and B respectively) with a trend for TcB to overestimate TSB in groups 2 and B. Birth term and skin color were not identified as confounding factors for predicting TSB in multiple linear regression.

CONCLUSIONS

TcB measurements using the Draeger JM-103® device correlate significantly with TSB, regardless of term and skin color. Transcutaneous bilirubinometry seems to be a safe and cost-effective screening method for severe hyperbilirubinemia in newborns of different terms and ethnic origins.

Impact of phosphorus fertilization in alleviating the adverse effects of salinity on wheat grown on different soil types

Optimum fertilization management is an important technique to alleviate the adverse effects of salinity stress on plants. A pot experiment was conducted to evaluate the ameliorative role of inorganic phosphorus (P) and organic P sources on wheat grown under salt stress in three soil types deficient in available P. Wheat (Triticum aestivum L. cv. Shakha 93) was grown on alluvial, sandy and calcareous soils at salinity levels of 4, 8 and 12 dS/m of saturated paste extract (ECe) and supplied with a constant rate of 30 mg P2O5/kg soil as superphosphate (SP), cattle manure (CM) and a 1:1 mixture of SP and CM. The results revealed that plants grown on the sandy soil were more susceptible to the adverse effects of salinity than those planted on the alluvial one, especially at zero P. Plants grown on the calcareous soil were moderately affected. The varying soil type caused significant differences in the aboveground biomass and the uptake of N, K, P and Zn. It was obvious that P ameliorated wheat growth under salt stress, and this role was greater under moderate and high salinity. The increases in N, P, K and Zn uptake driven by P application were more conspicuous in the sandy and calcareous soils. The results also indicated that the combined application of inorganic and organic P sources surpassed that of either when applied alone on all soil types and salinity levels.

Claudin-1 involved in neonatal ichthyosis sclerosing cholangitis syndrome regulates hepatic paracellular permeability

Neonatal ichthyosis and sclerosing cholangitis (NISCH) syndrome is a liver disease caused by mutations of CLDN1 encoding Claudin-1, a tight-junction (TJ) protein. In this syndrome, it is speculated that cholestasis is caused by Claudin-1 absence, leading to increased paracellular permeability and liver injuries secondary to paracellular bile regurgitation. We studied the role of claudin-1 in hepatic paracellular permeability. A NISCH liver and polarized rat cell lines forming TJs, the hepatocellular Can 10 and the cholangiocellular normal rat choloangiocyte (NRC), were used. In contrast to NRC, Can 10 does not express claudin-1. Can 10 cells were transfected with a plasmid encoding Claudin-1, and stable Claudin-1-expressing clones were isolated. Claudin-1 expression was silenced by transfection with short interfering RNA in Can 10 clones and with short hairpin RNA in NRC. Claudin-1 expression was evaluated by quantitative reverse-transcriptase polymerase chain reaction, immunoblotting, and immunolocalization. Paracellular permeability was assessed by fluorescein isothiocyanate-dextran passage in both lines and by transepithelial resistance measurements in NRC. In the NISCH liver, Claudin-1 was not detected in hepatocytes or cholangiocytes. In Claudin-1 expressing Can 10 clones, Claudin-1 was localized at the TJ and paracellular permeability was decreased, compared to parental Can 10 cells, this decrease correlating with claudin-1 levels. Silencing of Claudin-1 in Can 10 clones increased paracellular permeability to a level similar to that of parental cells. Similarly, we observed an increase of paracellular permeability in NRC cells silenced for claudin-1 expression.

CONCLUSION

Defect in claudin-1 expression increases paracellular permeability in polarized hepatic cell lines, supporting the hypothesis that paracellular bile leakage through deficient TJs is involved in liver pathology observed in NISCH syndrome.

New management options for end-stage chronic liver disease and acute liver failure: potential for pediatric patients

The management of children with end-stage chronic liver disease and acute liver failure mandates a multidisciplinary approach and intense monitoring. In recent years, considerable progress has been made in developing specific and supportive medical measures, but studies and publications have mainly concerned adult patients. Therapeutic approaches to complications of end-stage chronic liver disease and acute liver failure (e.g. refractory ascites, hepatorenal syndrome, encephalopathy, and cerebral edema) that may be applied to children are reviewed in this article.Mild-to-moderate ascites should be managed by modest salt restriction and oral diuretic therapy in the first instance. Large volume paracentesis associated with colloid volume expansion and diuretic therapy may be effective for acute relief. Treatment of hepatorenal syndrome type 1 with vasopressin analogs (terlipressin) is recommended prior to liver transplantation in order to improve renal function. Prevention and treatment of chronic hepatic encephalopathy are directed primarily at controlling the events that may precipitate hepatic encephalopathy and at reducing ammonia generation and increasing its detoxification or removal. In addition to reduction of gut ammonia production using non-absorbable disaccharides such as lactulose and/or antibacterials such as neomycin, sodium benzoate may be used on a long-term basis to prevent, stabilize, or improve hepatic encephalopathy. The management of hepatic encephalopathy in acute liver failure is considerably more unsatisfactory; treatment is aimed at preventing brain edema and intracranial hypertension. Extracorporeal liver support devices are now used commonly in critically ill children with acute renal failure, advanced hepatic encephalopathy, cerebral edema, intracranial hypertension, and severe coagulopathy. Continuous renal replacement therapy could potentially help support patients until liver transplantation is performed or liver regeneration occurs. The Molecular Adsorbent Recirculating System (MARS or albumin dialysis) is the liver support system most frequently used worldwide in adults and appears to offer distinct advantages over hepatocyte-based systems. There are no specific medical therapies or devices that can correct all of the functions of the liver. Apart from a few metabolic diseases presenting with severe liver dysfunction for which specific medical therapies may preclude the need for liver transplantation, liver transplantation still remains the only definitive therapy in most instances of end-stage chronic liver disease and acute liver failure. Future research should focus on gaining a better understanding of the mechanisms responsible for liver cell death and liver regeneration, as well as developments in hepatocyte transplantation and liver-directed gene therapy.

Effects of adjuvant on neuropeptide-like immunoreactivity in the temporomandibular joint and trigeminal ganglia

To study the role of the nervous system in temporomandibular joint arthritis, substance P-, calcitonin gene-related peptide-, and neuropeptide Y-like immunoreactivity in the trigeminal ganglia and temporomandibular joint of rats was examined. Arthritis was induced in female Lewis rats through bilateral injection of a suspension of heat-killed Mycobacterium butyricum in paraffin oil into the temporomandibular joint. Control rats received paraffin oil via the same route. Tissues were collected for neuropeptide extraction 28 days after injection and analyzed by radioimmunoassay and reverse-phase high-performance liquid chromatography. Calcitonin gene-related peptide was significantly increased in the arthritic trigeminal ganglia. Substance P, calcitonin gene-related peptide, and neuropeptide Y in the arthritic temporomandibular joint were significantly increased as compared to controls. The results of this study show that sensory and sympathetic neuropeptides may possibly be associated with the development of arthritis in the temporomandibular joint of rats.

Effects of capsaicin in temporomandibular joint arthritis in rats

Temporomandibular joint (TMJ) arthritis was induced in female Lewis rats by unilateral injection of a suspension of heat-killed Mycobacterium butyricum in paraffin oil into the TMJ. Control rats received paraffin oil by the same route. Arthritic and control rats were pretreated either with capsaicin or denervation of the mandibular branch of the trigeminal nerve. Tissues were collected for neuropeptide extraction and analysed by radioimmunoassay and reverse-phase high-performance liquid chromatography. In all groups, the levels of substance P-(SP), calcitonin gene-related peptide- (CGRP) and neuropeptide Y- (NPY) like immunoreactivity (LI) were higher in the trigeminal ganglia than in the TMJs. In control rats, capsaicin significantly lowered the levels of SP-LI in the trigeminal ganglia and TMJ, but not CGRP-LI and NPY-LI. In the arthritic rats, capsaicin pretreatment significantly lowered the SP-LI and CGRP-LI in the trigeminal ganglia and TMJ, but not the NPY-LI. In the trigeminal ganglia the unilateral denervation significantly lowered SP-LI in control rats, and in arthritic rats SP-LI and CGRP-LI. On the denervated side of the arthritic TMJ, NPY-LI, SP-LI and CGRP- LI were significantly lowered as compared to the arthritic control rats and to the contralateral side. In this rat model, pretreatment with capsaicin and surgical denervation decreased the neuropeptide content in the trigeminal ganglia and the TMJ. The results clearly demonstrate a close interaction between increased neuropeptide release from sensory and sympathetic neurones after induction of arthritis in the rat.