Elsevier

Clinics in Perinatology

Volume 28, Issue 3, 1 September 2001, Pages 505-515
Clinics in Perinatology

VOLUTRAUMA: What Is It, and How Do We Avoid It?

https://doi.org/10.1016/S0095-5108(05)70103-2Get rights and content

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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    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]

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