Three key interventions are recommended for managing respiratory distress syndrome (RDS) in preterm infants:
1. Administering a single course of prenatal corticosteroids to mothers at risk of preterm delivery between 23-34 weeks gestation to reduce the risk of RDS.
2. Stabilizing infants immediately after birth using controlled CPAP with supplemental oxygen, aiming for gradual increase in oxygen saturation levels.
3. Giving a natural surfactant preparation to infants with or at high risk of RDS, with early administration improving outcomes. The "INSURE" technique of administering surfactant via brief intubation can reduce need for mechanical ventilation.
New Concepts of Newborn Resuscitation – the new national protocolMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Hello guys, bringing to you the concept of golden hour of neonatology. As in trauma, the first hour of neonatal life is most precious and this ppt is an attempt to highlight a few key aspects of this resuscitative strategy in premature infants.
New Concepts of Newborn Resuscitation – the new national protocolMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Hello guys, bringing to you the concept of golden hour of neonatology. As in trauma, the first hour of neonatal life is most precious and this ppt is an attempt to highlight a few key aspects of this resuscitative strategy in premature infants.
By Prof. ATEF DONIA Professor of Pediatrics Al Azhar University
The role of reactive oxygen species (ROS) in pathogenesis of common disorders of the preterm infant.
The unique susceptibility of premature infants to oxidative stress. Potential for therapeutic interventions using enzymatic and/or non-enzymatic antioxidants
One of lectures given during our Port said fifth neonatology conference, 23-24 October 2014 given by dr Dr El Sayed Khalaf MD Pediatrics,Consultant Pediatric and Neonatology
By dr Rabab Hashem, MRCPCH, pediatrician at El Nasr hospital Port said.
Cranial sonography is the most widely used neuroimaging procedure in premature infants. US helps in assessing the neurologic status of the child, since clinical examination and symptoms are often nonspecific. It gives information about immediate and long term prognosis.
A 100 years ago, when neonatal intensive care units (NICUs) started to be well established, the race never stopped trying to add new regimens to improve neonatal survival. On the other hand, long term sequelae of medications used at NICUs were usually not sufficiently studied and left mostly unnoticed for many years by neonatologists. Here we are trying to understand & & shed the light on some of these sequelae in a trial avoid those sequelae while working on NICU candidates.
Lecture given at the 6th Conference for Nile Basin Pediatrics 2-5 December 2015, Hurgada, Egypt
One of lectures presented in our Port said fifth neonatology conference 23-24 October 2014, presented by prof Olfat Fawzy, M.D, M.Sc.,Professor of Endocrinology Al Azhar university
Lecture given during Port said fifth neonatology conference, 23-24 October 2014 by Dr.Osama Arafa Abd EL Hameed M. B.,B.CH - M.Sc Pediatrics - Ph. D. Consultant Pediatrician & Neonatologist Head of Pediatrics Department - Port-Fouad Hospital
Evidence based medicine, by prof Badr Mesbah. Professor of pediatric, Suez canal university
Lecture presented in Port said fourth neonatology conference, 24-25 October 2013, Port said, Egypt
How to resuscitate, management in meconium aspirated baby, thin and thick meconium, ratio of ventilation and perfusion in new born, latest change in guidelines for resuscitation
Basic concepts in neonatal ventilation - Safe ventilation of neonatemohamed osama hussein
Lecture by by dr Muhammad Ezzat Abdel-Shafy MB.BCh, M.Sc Pediatrics Neonatology Sp. , Benha Children Hospital, provided during our Doctors neonatology workshop, 20th of January 2017
jaundice in neonate, by Dr Nagwa Rizk, pediatric department, Nursing college, Port said University, Port said. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
Care of neonate, by Dr Mona Abo zid, pediatric department Nursing college, Port said University, Port said. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
Neonatal mechanical ventilation by dr Osama Hussein, president of Port said neonatology society. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
Neonatal resuscitation, by Dr Osama Hussein, president of Port said neonatology society. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
Normal newborn needs, by Dr Rehab Hany, pediatric department, Nursing college, Port said University, Port said. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
Normal newborn care, by Dr Amal Khalil, Dean of Nursing college, Port said University, Port said. Presented in the NICU nursing workshop, organized by Nursing syndicate in Suez canal & Sinai in cooperation with Port said university college of nursing & Port said neonatology society, December,2014 Port said
One of lectures presented in our Port said fifth neonatology conference, 23-24 October 2014 by Prof Mohamed El Sawy, Prof in Pediatric department , faculty of medicine, Ain Shams university
Trophic feeding, by dr Amal Ahmed Khalil ,Port Said University, mohamed osama hussein
Trophic feeding is the practice of feeding small volume of enteral feeds in order to stimulate the development of the immature gastrointestinal tract of the preterm infant. This practice has also been termed as minimal enteral nutrition (MEN).
Hypoxic ischemic insult, by prof Ayman Galhom, ass prof neurosurgery, Suez ca...mohamed osama hussein
A lecture given by dr Ayman Galhom, assistant professor neurosurgery, Suez canal university, during Port said fourth neonatology conference, at 24-25 October, 2013. This lecture was a discussion of the pathophysiology & management of hypoxic ischaemic insult to an infant in PICU
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Top 10 Best Ayurvedic Kidney Stone Syrups in India
Egyptian guidelines for RDS management 2014
1.
2.
3.
4. Prof Abdelhalim Badr Eldin
Prof Abla El Alfy
Prof Afaf Koraa
Prof Amira Idris
Prof Atef Nouseir
Prof Basma Shouman
Prof Emad Ibrahim
Prof Gehan Fahmy
Prof Hesham Abdelhady
Prof Hesham Awad
Prof Hesham Ghazal
Prof Iman Iskandar
Prof Iman Soud
Prof Khaled Taman
Prof Magda Badawy
Prof Mahmoud kamal
Prof Mariam Abo Shady
Prof Moataza Basheer
Prof Mohamed Sabry Abo Allam
Prof Mohamed EL Maraghy
Prof Mohamed Fathallah
Prof Mohamed Khashaba
Prof Mohamed reda bassiouny
Dr Mourad Alfy
Prof Nadia Badrawy
Prof Nahed Fahmy
Prof Nashwa Samra
Prof Nayera Ismaeil
Dr Nouran Baioumy
Dr Osama Hussein
Prof Osama kasem
Prof Raghda Ali
Prof Ragia labib
Prof Safaa El Menaza
Prof Safaa Shafik
Prof Shadia El Salab
Prof Sonia El Sharkawy
Prof Yahia Basha
5. 1) Prenatal Care
2) Delivery Room Stabilization
3) Surfactant Therapy
4) Oxygen Supplementation beyond Stabilization
5) Non-Invasive Respiratory Support
6) Mechanical Ventilation Strategies
7) Prophylactic Treatment for Sepsis
8) Supportive Care
9) Miscellaneous Considerations
6.
7.
8. Interventions to prevent RDS should begin before birth
and involve both pediatricians and obstetricians as part
of the perinatal team.
Preterm delivery can be delayed by using antibiotics in
the case of preterm, pre-labour rupture of the
membranes, although co-amoxiclav should be avoided if
possible because of an association with an increased risk
of necrotizing enterocolitis (NEC) .
9. Prenatal steroids given to women with anticipated pre-
term delivery reduce the risk of neonatal death, and the
use of a single course of prenatal corticosteroids does not
appear to be associated with any significant maternal or
short-term fetal adverse effects.
Prenatal steroids decrease the risk of RDS and additionally
decrease the risk of intraventricular haemorrhage and
NEC.
10. Prenatal corticosteroid therapy is recommended in all
pregnancies with threatened pre-term labor below 34
weeks’ gestation.
In pregnancies delivering between 34 and 36 weeks
prenatal steroids do not appear to improve outcome ,
although when given before elective caesarean section at
term they reduce the risk of admission to the neonatal
intensive care unit, albeit with a high number needed to
treat.
The optimal treatment to delivery interval is more than 24
h and less than 7 days after the start of steroid treatment.
11. Beyond 14 days after administration the benefits of
antenatal steroids are diminished .
A single repeat course of antenatal betamethasone given a
week after the first course to women with threatened
preterm labor reduces RDS and other short-term health
problems, although birth weight is reduced.
Effects of multiple courses of steroids on fetal growth have
raised concerns about recommending more than a single
additional rescue course until further long-term studies are
completed.
12. Recommendations;
1. Women at high risk of very preterm birth should be
transferred to perinatal centers with experience in
management of RDS (C).
2. Clinicians should offer a single course of prenatal
corticosteroids to all women at risk of preterm delivery
from about 23 weeks up to 34 completed weeks’ gestation
(A) (Highly recommended to use Betamethasone)
13. Recommendations;
3. A second course of antenatal steroids may be appropriate if
the first course was administered more than 2–3 weeks earlier
and the baby is <33 weeks’ gestation when another obstetric
indication arises (A).
4. Antenatal steroids should also be considered for women
undergoing a caesarean section prior to labor up to term (B).
14. Recommendations
6. Antibiotics should be given to mothers with preterm pre-
labor rupture of the membranes as this reduces the risk of
preterm delivery (A) .
7. Clinicians should consider short-term use of tocolytic drugs
to allow completion of a course of prenatal corticosteroids
and/or in utero transfer to a perinatal center (B).
15. There is evidence supporting a clinical benefit of delayed
umbilical cord clamping (30–60 s) in preterm infants.
This practice results in higher hematocrit, less need for
later transfusion, less NEC and an almost 50% reduction
in intraventricular hemorrhage .
16. Pure oxygen may also be harmful to preterm infants, and
current guidelines suggest titrating supplemental oxygen with a
blender aiming for saturations that correspond to the normal
incremental increase in saturation that occurs after birth.
During the transitional phase after birth, saturations measured
by pulse oximetry on the right hand should rise gradually from
about 60 to 80% over 5 min, reaching 85% and above by about
10 min after birth.
Babies of less than 32 weeks’ gestation can in most cases be
stabilized starting with 21–30% inspired oxygen concentration,
increasing only if persistently bradycardic or cyanosed .
17. Provision of controlled early CPAP with the ability to
provide additional controlled inflations is now the main
means of providing safe stabilization of preterm babies
immediately after birth, reducing the need for MV and
surfactant treatment .
T-piece devices enable a controlled delivery of a set
background CPAP with a measured peak inspiratory
pressure.
18. Reducing hypothermia in babies less than 28 weeks’
gestation can be achieved by performing initial
stabilization and transfer to the neonatal intensive care
unit inside a polyethylene bag .
Heating and humidifying the gases used for stabilization
may also help to preserve body temperature. The
temperature of the delivery room environment is also very
important.
Delivery room should be equipped with:
- Facilities that allow resuscitation before clamping of the
umbilical cord.
- Plastic bags to prevent hypothermia.
- Servo-controlled radiant warmer.
19. - Blender.
- Pulse oximeter.
- CPAP machine or T-piece.
- Surfactant for use once indicated
20. Recommendations;
1. If possible delay clamping of the umbilical cord for at least 60
s with the baby held below the mother to promote placento-
fetal transfusion (A).
21. Recommendations;
2. Oxygen for resuscitation should be controlled by using a
blender. A concentration of 21–30% oxygen is appropriate to
start stabilization and adjustments up or down should be
guided by applying pulse oximetry to the right wrist from
birth to give information on heart rate and saturation (B).
22. Recommendations;
3. In spontaneously breathing babies stabilize with CPAP of
at least 5–6 cm H 2 O via mask or nasal prongs (A).
4. Intubation should be reserved for babies who have not
responded to positive pressure ventilation via face mask
(A). Babies who require intubation for stabilization should
be given surfactant (A).
23. Recommendations;
5. Plastic bags or occlusive wrapping under
radiant warmers should be used during
stabilization in the delivery suite for
babies <28 weeks’ gestation to reduce the
risk of hypothermia (A).
6. Babies stabilized under a radiant warmer
should be servo controlled within 10 min to
avoid overheating (B). in absence of
servo-control, close monitoring of body
temperature is required.
24. Respiratory failure secondary to surfactant deficiency is a
major cause of morbidity and mortality in preterm infants.
Surfactant therapy, given to babies with or at risk of
developing RDS, reduces the risk of pneumothorax and
neonatal death.
25. An experienced neonatal resuscitation/stabilization team is
essential for surfactant administration.
At least 100 mg/kg of phospholipid is required, but there
are pharmacokinetic and clinical data suggesting that 200
mg/kg has a longer half-life and a better acute response.
26. If surfactant replacement is needed, the earliest possible
administration improves survival.
More recent clinical trials show that with a policy of early
initiation of CPAP and selective surfactant administration
rather than routine prophylaxis babies may do better, with
some avoiding intubation altogether and reduced rates of
death or chronic lung disease in the CPAP group.
There will still be babies who require intubation for
stabilization in the delivery suite and these should be given
surfactant before the diagnosis of RDS has been confirmed
radiologically.
27. Most clinical trials used bolus instillation via an
endotracheal tube as a standard method for surfactant
administration, with babies maintained on MV. MV can be
avoided by using the ‘INSURE’ (INtubate – SURfactant –
Extubate to CPAP) technique and this method has been
shown in randomized trials to reduce the need for MV and
subsequent bronchopulmonary dysplasia (BPD).
More recently techniques have been developed to deliver
surfactant intratracheally whilst avoiding traditional
intubation by using a fine catheter with the baby
spontaneously breathing on CPAP.
28. Following surfactant administration there may, after a
variable period of time, be a need for a further dose of
surfactant.
It is practical to use a flexible dosing schedule basing the
time of repeat doses on the baby’s clinical condition and
oxygen requirements.
Repeated use of the INSURE technique may also be
suitable for some babies with RDS who are managing on
CPAP but have increasing oxygen requirements
29. Recommendations:
1. Babies with RDS should be given a natural surfactant
preparation (A).
2. Early Rescue of Surfactant Therapy (within 2 hours of birth)
should be considered for babies ≤ 31weeks if they need
intubation in the delivery room and for extremely premature
babies if their mothers did not get full course of antenatal
steroid (A).
30. Recommendations:
3. For babies with evidence of RDS it is recommended to give
one dose of surfactant, however some babies will require
more than one dose according to clinical situation.
4. A second, and sometimes a third dose of surfactant should
be administered if there is evidence of ongoing RDS such
as a persistent oxygen requirement (FiO2 > 40%) and
need for MV (A).
5. If repeated doses are required, the time interval between
doses should be flexible, according to the clinical
situation & Manufacturer recommendations
31. Recommendations:
6. Babies with RDS should be given rescue surfactant early in
the course of the disease. A suggested protocol would be to
treat babies ≤ 26 weeks’ gestation when FiO2 requirements
> 30% and babies >26 weeks when FiO2 requirements >
40% (B).
7. At least 100 mg/kg of phospholipid is required, but there are
pharmacokinetic and clinical data suggesting that 200
mg/kg has a longer half-life.
32. Recommendations:
8. Consider the INSURE (INtubate – SURfactant –Extubate
to CPAP) technique or other non-invasive techniques.
More mature babies can often be extubated to CPAP or
nasal intermittent positive pressure ventilation (NIPPV)
immediately following surfactant (B).
9. Repeated use of the INSURE technique may also be
suitable for some babies with RDS who are managing on
CPAP but have increasing oxygen requirements
33. Excess supplemental oxygen exposure is clearly linked
with development of retinopathy of prematurity and to a
lesser extent BPD . Fluctuations in oxygen saturation are
also associated with an increased incidence of retinopathy
of prematurity .
Oxygen supplementation targeting between 85-89% was
associated with increased mortality in babies less than 27
weeks’ gestation .
34. Recommendations:
1. In preterm babies receiving oxygen, the saturation target
should be between 90 and 95% (B).
2. After giving surfactant a hyperoxic peak should be avoided
by rapid reduction in FiO2 (C).
3. Fluctuations in SaO2 should be avoided in the postnatal
period (C).
35. For the spontaneously breathing preterm infant <30 weeks
gestation , CPAP should be applied as early as possible as a
mean of non-invasive respiratory support using T-piece
resuscitator, various CPAP devices or high flow nasal
cannulae (if available) with humidified air Oxygen
mixture.
The interface is preferred to be with short bi-nasal prongs
or nasal mask which proved to be better than single longer
prongs.
Starting CPAP pressure should be at least 6 cms water.
CPAP should be then adjusted according to the clinical
improvement, chest expansion , oxygenation and
perfusion.
36. If high flow nasal cannula (which is a special device not the
ordinary nasal cannula ) is used as an alternative to CPAP, a
flow of 2–4 l/min of humidified gas mixture is typically used
in babies <1 kg and 4–6 l/min in heavier babies.
Early rescue surfactant should be considered for Pt<30 weeks
with RDS, requiring >30% O2 to maintain PaO2>60 mmHg
or SaO2> 90% despite optimal CPAP (7cms H2O).
CPAP can be used for both initial respiratory support and for
prevention of extubation failure
A trial of NIPPV should be considered in case of CPAP
failure to reduce the need for re-intubation
37. Recommendations:
1. CPAP should be started from birth in all babies at risk of
RDS, such as those <30 weeks’ gestation who do not need
MV, until their clinical status can be assessed ( A) .
2. Any system of delivering CPAP can be used; however, the
interface should be short binasal prongs or mask and a
starting pressure of at least 6 cm H 2 O should be applied
(A). CPAP level should then be
individualized depending on clinical
condition, oxygenation and perfusion (D).
38. Recommendations:
3. Early rescue surfactant should be considered for babies <
30 weeks with RDS with increasing oxygen requirement
despite optimal CPAP ( A).
4. A trial of NIPPV can be considered to reduce the risk of
extubation failure in babies failing on CPAP; before re-
intubation is considered ( A).
5. Please note that high flow nasal cannulae is a special device
different from the ordinary nasal prongs.
39. The aim of MV is to provide acceptable blood gases with
minimum risk of lung injury, haemodynamic impairment
and other adverse events such as hypocarbia, which is
associated with neurological impairment. This is indicated
for apneic preterm babies, or those failing CPAP.
Criteria of CPAP failure include: If on a CPAP pressure of
8 cms H2O
◦ PaO2 < 60 mmHg on FiO2 > 50%
◦ Saturation <90% on FiO2 > 50%
◦ Respiratory acidosis with PH < 7.22 +/- PCO2 >60
mmHg
◦ Recurrent apnea on CPAP
40. MV can be provided by conventional intermittent positive
pressure ventilation (IPPV) or high-frequency oscillatory
ventilation (HFOV). Both conventional or HFOV are
equally effective depending on the availability of the
equipment and the experience of the available staff in the
unit.
PEEP should be adjusted above the closing pressure
(where progressive collapse of the alveoli will occur)
41. To find the optimum PEEP on conventional ventilation
each significant incremental change of PEEP should be
reflected by reduction in FiO2 and CO2 levels. Close
observation of pulmonary mechanics is essential.
Over-distension should be considered if a baby is
deteriorating on MV following surfactant administration
or any time when an increase of mean airway pressure is
followed by increasing oxygen requirement.
42. Hypocarbia <30 mmHg should always be avoided as this is
associated with increased risks of BPD and periventricular
leukomalacia.
A strategy of providing synchronized MV with targeted
tidal volume appears best at preventing mortality and
BPD in mechanically ventilated newborns (If available).
An initial set tidal volume of 4–5 ml/kg should be adjusted
according to the measured PaCO2 level and the baby’s own
respiratory drive.
43. Babies with RDS should be aggressively weaned towards
extubation to CPAP if they are spontaneously breathing and
have acceptable blood gases. Extubation may be successful
from 6 to 7 cm H2O mean airway pressure on conventional
modes and from 8 to 9 cm H2O of continuous distending
pressure on HFOV, even in the most immature babies.
Do not keep the preterm babies stable on low-rate MV for
longer periods as it does not improve the chance of successful
extubation
Extubate to nasal CPAP to avoid extubation failure.
44. Caffeine Therapy :
◦ Caffeine should be part of routine care for very preterm
babies with RDS to facilitate extubation and reduce
BPD.
◦ Caffeine should be used in babies with apnea and to
facilitate weaning from MV .
◦ Caffeine should also be considered for babies at high risk
of needing MV, such as those <1,250 g birth weight who
are managing on non-invasive respiratory support
45. Permissive Hypercarbia:
◦ During weaning, tolerating higher PaCO2 levels can lead
to reduced time on MV. Acceptable pH levels are 7.22 in
the first 5 days and 7.20 thereafter provided that PaCO2
is less than 70 mmHg.
◦ Permissive Hypercarbia should never be considered in
intubation or initial ventilation.
Postnatal Steroids:
◦ Low dose dexamethasone (<0.2 mg/kg per day) should be
considered in RDS babies who remain ventilator
dependent after the first week of life. (10 day course
should be initiated within the first 1-2 weeks of life and
not be postponed. Start by 0.15 mg/ kg /day for 3 days,
0.1 mg/kg/day for 3 days, 0.05 mg/kg/day for 2 days then
0.02 mg/kg/day for 2 days )
46. Postnatal Steroids:
◦ Much lower doses of dexamethasone (0.05 mg/kg/day)
are effective in facilitating extubation.
47. Recommendations
1. MV should be used to support babies when other methods of
respiratory support have failed. Duration of MV should be
minimized to reduce its injurious effect on the lung (B).
2.Targeted tidal volume ventilation should be employed as this
shortens duration of ventilation and reduces BPD (A).
3. HFOV may be useful as a rescue therapy (B).
48. Recommendations
4.When weaning from MV it is reasonable to tolerate a
moderate degree of hypercarbia,(<70mmHg) provided the
pH remains above 7.22 (B).
5.Avoid hypocarbia as this is associated with increased risks of
BPD and periventricular leukomalacia (B).
49. Recommendations
7. Caffeine should be used in babies with apnea and in all
preterms on MV to facilitate weaning from MV (A).
Caffeine should also be considered for at high risk of
needing MV, such as those <1,250 g birth weight who are
managing on non-invasive respiratory support (B).
8. A short tapering course of low- or very low-dose
dexamethasone (0.05 mg/kg/day) should be considered to
facilitate extubation in babies who remain on MV after 1–
2 weeks (A).
Low dose dexamethasone (<0.2 mg/kg per day)
should be considered in RDS babies who
remain ventilator dependent after the first week
of life. 10 day course should be initiated within
the first 1-2 weeks of life and not be postponed.
Start by 0.15 mg/ kg /day for 3 days, 0.1
mg/kg/day for 3 days, 0.05 mg/kg/day for 2 days
then 0.02 mg/kg/day for 2 days
50. Although early onset Sepsis is Relatively Rare, it is fatal in
up to third of pre-term babies and the proportion of
adverse neurological sequelae is high. The cause of Early
onset Sepsis is not exclusive to Group B Streptococcus
(GBS), as Escherichia coli and other organisms may also
be responsible for that matter.
Thus, It is considered good practice to screen all babies
with Respiratory Distress Syndrome (RDS) by performing
blood cultures, along with looking for other evidence of
sepsis such as neutropenia or an elevated C-reactive
protein.
51. Empiric routine Antibiotic therapy is initiated while
waiting for lab results. This approach is not preferable
for long period of time in preterm babies since, it is
associated with adverse outcomes including
Necrotizing enterocolitis (NEC).
Furthermore, In women who are known to be
colonized with group B streptococcus, the risk of early
onset sepsis can be reduced by administration of
intrapartum antibiotic prophylaxis.
The shortest possible course should be used while
evidence for absence of sepsis is sought.
52. Moreover, Routine antifungal prophylaxis with
Fluconazole or Nystatin is initiated to reduce the risk of
invasive fungal infection in babies <1,000 g birth weight*
* is not recommended unless there is strong suspicion or proven evidence of invasive fungal infection in babies <1,000 g
53. Recommendations
1. Antibiotics are often started in babies with RDS until sepsis has
been ruled out, but policies should be in place to narrow the
spectrum and minimize unnecessary exposure. A common
regimen includes penicillin or ampicillin in combination with an
aminoglycoside (D). Antibiotics should be stopped as soon as
possible once sepsis has been excluded (C).
2. In units with a high rate of invasive fungal infection prophylaxis
with fluconazole is recommended in babies <1,000 g birth weight
or ≤ 27 weeks’ gestation, starting on day 1 of life with 3 mg/kg
twice weekly for 6 weeks (A).
54. Recommendations
1. Body temperature should be maintained at 36.5–37.5 ° C at
all times (C).
2. Most babies should be started on intravenous fluids of 70–80
ml/kg/day while being kept in a humidified incubator (60-
80%), although some very immature babies may need more
(D).
3. Fluids must be tailored individually according to serum
sodium levels and weight loss (D).
55. Recommendations
(4) Sodium intake should be restricted over the first few days of
life and initiated after the onset of diuresis with careful
monitoring of fluid balance and electrolyte levels (B).
(5) Parenteral nutrition should be started on day 1 to avoid
growth restriction and quickly increased to 3.5 g/kg/day of
protein and 3.0 g/kg/day of lipids as tolerated (C) protein can
be increased up to 4 g/kg/day in extremely premature.
(6) Minimal enteral feeding should also be started from the first
day (B).
56. Recommendations
1. Blood pressure should be monitored regularly aiming to
maintain normal tissue perfusion, if necessary inotropes
can be used.
2. Hb concentration should be maintained within normal
limits (D). A suggested Hb threshold for babies on
respiratory support is 12 g/dl in week 1, 11 g/dl in week 2
and 9 g/dl beyond 2 weeks of age.
57. Recommendations:
3. If a decision is made to attempt
therapeutic closure of the PDA then
indomethacin or oral ibuprofen have
been shown to be equally efficacious,
although there is less evidence of
transient renal failure or NEC with
ibuprofen (A).
58. Recommendations
1. Elective caesarean section in low-risk pregnancies should
not be performed before 39 weeks’ gestation (B).
2. Inhaled nitric oxide therapy is not beneficial in the
management of preterm babies with RDS (A).
59. Recommendations
3. Surfactant therapy can be used to improve oxygenation
following pulmonary hemorrhage but there may be no
long term-benefits (C).
4. Surfactant replacement for evolving BPD leads to only
short-term benefits and cannot be recommended (C).