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Original article
Laryngeal closure impedes non-invasive ventilation at birth
  1. Jessica R Crawshaw1,2,
  2. Marcus J Kitchen3,
  3. Corinna Binder-Heschl1,4,
  4. Marta Thio5,
  5. Megan J Wallace1,2,
  6. Lauren T Kerr1,2,
  7. Charles C Roehr1,
  8. Katie L Lee3,
  9. Genevieve A Buckley3,
  10. Peter G Davis5,6,7,
  11. Andreas Flemmer8,
  12. Arjan B te Pas9,
  13. Stuart B Hooper1,2
  1. 1 The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia
  2. 2 Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
  3. 3 School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
  4. 4 Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria
  5. 5 Newborn Research Centre, The Royal Women’s Hospital, Melbourne, Vic, Australia
  6. 6 Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
  7. 7 The Murdoch Children’s Research Institute, Melbourne, Australia
  8. 8 Division of Neonatology, University Children’s Hospital and Perinatal Center, Ludwig Maximilian University, Munich, Germany
  9. 9 Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
  1. Correspondence to Professor Stuart B Hooper, The Ritchie Centre, Hudson Institute for Medical Research, Clayton, Victoria 3168, Australia; stuart.hooper{at}monash.edu

Abstract

Background Non-invasive ventilation is sometimes unable to provide the respiratory needs of very premature infants in the delivery room. While airway obstruction is thought to be the main problem, the site of obstruction is unknown. We investigated whether closure of the larynx and epiglottis is a major site of airway obstruction.

Methods We used phase contrast X-ray imaging to visualise laryngeal function in spontaneously breathing premature rabbits immediately after birth and at approximately 1 hour after birth. Non-invasive respiratory support was applied via a facemask and images were analysed to determine the percentage of the time the glottis and the epiglottis were open.

Hypothesis Immediately after birth, the larynx is predominantly closed, only opening briefly during a breath, making non-invasive intermittent positive pressure ventilation (iPPV) ineffective, whereas after lung aeration, the larynx is predominantly open allowing non-invasive iPPV to ventilate the lung.

Results The larynx and epiglottis were predominantly closed (open 25.5%±1.1% and 17.1%±1.6% of the time, respectively) in pups with unaerated lungs and unstable breathing patterns immediately after birth. In contrast, the larynx and the epiglottis were mostly open (90.5%±1.9% and 72.3%±2.3% of the time, respectively) in pups with aerated lungs and stable breathing patterns irrespective of time after birth.

Conclusion Laryngeal closure impedes non-invasive iPPV at birth and may reduce the effectiveness of non-invasive respiratory support in premature infants immediately after birth.

  • larynx
  • preterm newborn
  • Non-invasive ventilation
  • apnoea
  • glottis

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/archdischild-2017-312681

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    Footnotes

    • Contributors JRC and SBH drafted the work. All authors involved in revising the drafted work critically for important intellectual content; gave final approval of the version published; all are in agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

    • Funding This research was supported by the Australian Research Council, the Australian National Health and Medical Research Council and the Victorian Government’s Operational Infrastructure Support Program. We acknowledge travel funding provided by the International Synchrotron Access Program (ISAP) managed by the Australian Synchrotron and funded by the Australian Government. C. Binder is supported by the Austrian Science Fund (FWF): J 3595-B19. M. J. Kitchen is the recipient of an ARC Australian Research Fellowship (DP110101941). A. B. te Pas is recipient of a Veni-grant, The Netherlands Organisation for Health Research and Development (ZonMw), part of the Innovational Research Incentives Scheme Veni-Vidi-Vici. S.B. Hooper is a recipient of an Australian National Health and Medical Research Council, Principal Research Fellowship.

    • Competing interests None declared.

    • Ethics approval All experimental procedures received approval from SPring-8 Animal Care and Monash University’s School of Biomedical Science’s Animal Ethics Committees

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional unpublished work from the study.

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