VOLUTRAUMA: What Is It, and How Do We Avoid It?
Section snippets
STRUCTURAL LIMITATIONS TO INITIATION OF VENTILATION IN NEWBORNS
Immediately following delivery, the lung is full of fluid that must be reabsorbed or mobilized. The chest wall is very compliant and fails to act as a counterbalance to the collapsing force of the noncompliant collapsing lung. The chest wall does not stabilize lung recruitment. The most common reason infants need respiratory support is because of respiratory distress syndrome. Surfactant dysfunction or deficiency increases the likelihood that atelectasis develops.
The pathophysiology of
Alveolar Capillary Leak.
In animals with normal lungs, large tidal volume ventilation can damage the pulmonary capillary endothelium, alveolar and airway epithelium, and basement membranes.9, 12, 13 This mechanical damage causes fluid, protein, and blood to leak into the airways, alveoli, and lung interstitium, initiating a sequence that can lead to death from progressive respiratory failure. In addition, antenatal events prime the lung for injury after preterm delivery. Antecedent lung inflammation or injury makes the
Inadequate Alveolar Stability and Lung Injury.
The term atelectrauma was coined following the observation that loss of alveolar recruitment is both a consequence and cause of lung injury.35, 41 In patients with acute respiratory distress syndrome or respiratory distress syndrome in which there is surfactant dysfunction, alveolar units are prone to collapse. The cycle of recruitment and subsequent derecruitment of these units with each breath causes lung injury.30 This mechanism of injury explains the observation that lung recruitment
How to Promote Optimal Lung Inflation and Normalize Functional Residual Capacity.
The tidal volume of spontaneous breaths may guide the choice of mechanically administered tidal volume. The tidal volumes may be quite low (approximately 5 mL/kg), particularly in tiny, extremely premature infants. Because tidal volume breaths act to recruit lung volume and to establish functional residual capacity, these tiny breaths alone usually do not establish adequate lung recruitment. With adequate positive end-expiratory pressure and a higher rate of smaller mechanical breaths,
SUMMARY
Lung injury can be initiated at birth with the delivery room resuscitation. Adequate tidal volume must be achieved gradually and adjusted with each subsequent breath to achieve adequate, but not excessive, tidal volume delivery. Time constants vary greatly within the lung because some alveoli are collapsed, and some are inflated. Excessive pressure or volume may lead to high stretch injury when already open alveoli are overdistended. Sufficient alveoli must be recruited to establish the optimal
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Cited by (63)
Bronchopulmonary Dysplasia
2019, Kendig's Disorders of the Respiratory Tract in ChildrenMechanisms of Neonatal Lung Injury
2017, Fetal and Neonatal Physiology, 2-Volume SetManaging Preterm Infants in the First Minutes of Life
2015, Paediatric Respiratory ReviewsCitation Excerpt :Preterm babies with RDS often need intubation and mechanical ventilation in the delivery room. These aggressive interventions although life-saving may cause trauma to the lung structure and lead to chronic lung disease [11] Therefore, there is a search for ventilatory strategies in the delivery room (DR) capable of helping spontaneously breathing infants to adequately perform postnatal transition whilst reducing the risk of lung damage.
Comparison of devices for newborn ventilation in the delivery room
2014, Journal of PediatricsCitation Excerpt :Recognizing the limitations of the subgroup analysis,24 we consider that some other differences observed between the groups could contribute to these findings. BPD is a complex disease associated with volutrauma and atelectrauma, among other factors.25-28 In the self-inflating bag group, the average maximum ventilation pressure applied to infants was significantly higher and highly variable; in addition, a greater proportion of these infants received a pressure >25 cm of H2O.
Bronchopulmonary Dysplasia
2012, Kendig and Chernick's Disorders of the Respiratory Tract in ChildrenVentilation Strategies
2011, Assisted Ventilation of the Neonate
Address reprint requests to Reese H. Clark, MD Director of Research Pediatrix Medical Group, Inc. 1301 Concord Terrace Ft. Lauderdale, FL 33323–2825 e-mail: [email protected]