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Identifying and treating intrinsic PEEP in infants with severe bronchopulmonary dysplasia
Author(s) -
Napolitano Natalie,
Jalal Khair,
McDonough Joseph M.,
Monk Heather M.,
Zhang Huayan,
Jensen Erik,
Dysart Kevin C.,
Kirpalani Haresh M.,
Panitch Howard B.
Publication year - 2019
Publication title -
pediatric pulmonology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.866
H-Index - 106
eISSN - 1099-0496
pISSN - 8755-6863
DOI - 10.1002/ppul.24328
Subject(s) - medicine , bronchopulmonary dysplasia , anesthesia , sedation , dynamic hyperinflation , positive end expiratory pressure , mechanical ventilation , continuous positive airway pressure , airway , gestational age , lung volumes , lung , obstructive sleep apnea , pregnancy , genetics , biology
Abstract Rationale Infants with severe bronchopulmonary dysplasia (sBPD) and airway obstruction may develop dynamic hyperinflation and intrinsic positive end‐expiratory pressure (PEEP i ), which impairs patient/ventilator synchrony. Objectives To determine if PEEP i is present in infants with sBPD during spontaneous breathing and if adjusting ventilator PEEP improves patient/ventilator synchrony and comfort. Methods Interventional study in infants with sBPD. PEEP i measured by esophageal pressure (Pes) and pneumotachometer, during pressure‐supported breaths. PEEP i defined as the difference between Pes at start of the inspiratory effort minus Pes at onset of inspiratory flow. The set PEEP was adjusted to minimize PEEP i . “Best PEEP” was the setting with minimal wasted efforts (WE), an inspiratory effort seen on the Pes waveform without a corresponding ventilator breath. FiO 2 and SpO 2 measured pre‐ and post‐PEEP adjustment. Sedation requirements evaluated 72 hours preprocedure and postprocedure. Results Twelve infants were assessed (gestational age, 24.9 ± 1.4 weeks; study age, 48.8 ± 1.5 weeks, postmenstrual age). Mean baseline ventilator PEEP was 16.4 cm H 2 O (14‐20 cm H 2 O). Eight infants required an increase, one, a reduction, and three, no change in the set PEEP. For the eight infants requiring an increase in set PEEP, there was an 18.9% reduction in WE and a reduction in FiO 2 (0.084 ± 0.058) requirements in the subsequent 24 hours. Conditional sedation was reduced in five infants postprocedure. No adverse events occurred during testing. Conclusion PEEP i is measurable in infants with sBPD with concurrent esophageal manometry and flow‐time tracings without the need for pharmacological paralysis. In those with PEEP i , increasing ventilator PEEP to offset PEEP i improves synchrony.