Recent advances: care of near term infants with respiratory failure

Introduction

Neonatology is a fairly young specialty and has dramatically improved outcomes for premature infants. How to care for infants born at or near term (after 34–35 weeks' gestation) who are experiencing life threatening respiratory failure has become an increasingly important issue. In near term infants hypoxia and persistent pulmonary hypertension of the newborn often complicate meconium aspiration, pneumonia, pulmonary hypoplasia, and hyaline membrane disease—diseases which until recently had a high mortality once the infant had become severely hypoxic. New techniques and treatments seem to be resulting in improved survival rates. These include extracorporeal membrane oxygenation, inhaled nitric oxide, administration of exogenous surfactant, high frequency ventilation, and, potentially, liquid ventilation.

Methods

We have included references that we believe are pivotal to recent advances in neonatology, most of them referring to randomised controlled trials. We ensured that all important randomised trials were included by performing a Medline search using the search engine Melvyl Medline Plus. We searched under the following terms:

• Subject heading—“infant or newborn”

• Publication type—“randomised controlled trials or controlled clinical trials”

• Keywords—“extracorporeal or nitric or liquid ventilation or surfactant or high frequency ventilation.”

We then deleted references to trials in premature infants. We included all of the relevant randomised controlled trials of extracorporeal membrane oxygenation, high frequency ventilation, surfactant, and nitric oxide. There were no such trials available of liquid ventilation. We included other references that illustrated important issues, and these were retrieved from our own databases.

Extracorporeal membrane oxygenation

Neonatal extracorporeal membrane oxygenation entails the continuous circulation of blood from the patient through an extracorporeal circuit, where heparin and oxygen are added and carbon dioxide removed. Then the blood is warmed and reinjected to supply all of the patient's oxygen requirements. The technique was first used successfully in an adult in 1972 and in a neonate in 1975. Two small prospective controlled trials …