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PubMed2000

Prophylactic methylxanthine for extubation in preterm infants.

BACKGROUND: When preterm infants have been given intermittent positive pressure ventilation (IPPV) for respiratory failure, weaning from support and tracheal extubation may be difficult. A significant contributing factor is thought to be the relatively poor respiratory drive and tendency to develop hypercarbia and apnea, particularly in very preterm infants. Methylxanthine treatment started before extubation might stimulate breathing and increase the chances of successful weaning from IPPV. OBJECTIVES: Main question: in preterm infants being weaned from IPPV and in whom endotracheal extubation is planned, does treatment with methylxanthine reduce the use of intubation and IPPV, without clinically important side effects. SEARCH STRATEGY: The standard search strategy of the Neonatal Review Group, as outlined in the Cochrane Library, was used. SELECTION CRITERIA: All published trials utilising random or quasi-random patient allocation, in which treatment with methylxanthine (theophylline or caffeine) was compared with placebo or no treatment to improve the chances of successful extubation of preterm or low birth weight infants, were included. DATA COLLECTION AND ANALYSIS: The standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. The second author assessed the quality of trials blinded to the authors and extracted data independently. Relative risk and risk difference was used in the meta-analysis. MAIN RESULTS: Overall analysis of the 4 published trials suggests that methylxanthine treatment results in a reduction in the use of mechanical ventilation. Three of the 4 studies are consistent with this overall result while one small trial (Barrington 1993) found no benefit. One study (Durand 1987) found that treatment was effective in those born at less than 1000 grams and who were less than one week old. In the small prespecified subgroups in this trial, infants of less than 1 kg birth weight and older than one week and those of birth weight 1000-1250 grams who had failed extubation once, no significant benefit could be shown. REVIEWER'S CONCLUSIONS: Implications for practice. Methylxanthines might increase the chances of successful extubation of some preterm infants but the results of this meta-analysis do not allow firm recommendations to be made for clinical practice. One trial suggests that this benefit is principally in infants of extremely low birth weight extubated in the first week. There are no trial data to support the routine use of methylxanthines for the extubation of infants with a birth weight over 1000 gms or those that are older than one week. Implications for research. Further trials are required comparing methylxanthines with placebo for extubation of very preterm infants. There is a need to stratify infants by gestational age (a better indicator of immaturity) rather than birth weight in future studies. Caffeine, with its wider therapeutic margin (Blanchard 1992) would be the better treatment to evaluate against placebo. Side effects and neuro-developmental status at follow up should be included in as outcomes.

Caffeine↗
PubMedDate not supplied

Circulatory changes during anesthetic induction: impact of d-tubocurarine pretreatment, thiamylal, succinylcholine, laryngoscopy, and tracheal lidocaine.

Circulatory changes after IV d-tubocurarine (3 mg), thiamylal (4 mg/kg) plus succinylcholine (2 mg/kg) and followed by direct laryngoscopy with or without intratracheal lidocaine spray (2 mg/kg) just before endotracheal intubation (EI), were measured in 40 adult patients. Pretreatment with d-tubocurarine did not alter mean arterial pressure (MAP), heart rate (HR), or central venous pressure (CVP). One minute after thiamylal-succinylcholine and just before laryngoscopy, MAP was 15 torr less than the awake value (p less than 0.05) and HR was 13 beats/min greater than the awake value (p less than 0.05). Laryngoscopy and EI elevated MAP above awake levels and further increased HR in all patients. The magnitude of these responses immediately following EI was not altered by tracheal lidocaine. However, the pressor and HR changes following EI were more transient when tracheal lidocaine was used (20 patients) and these patients were more likely to tolerate the tracheal tube without immediate additional anesthesia. The incidence of ventricular dysrhythmias was not altered by tracheal lidocaine. Compared with awake values, the cardiac index did not change significantly following intubation but stroke volume was decreased (p less than 0.05), with or without tracheal lidocaine.

Adult↗
PubMed1979

Small endotracheal tubes: ventilator and intratracheal pressures during controlled ventilation.

The use of small endotracheal tubes reduces the trauma of intubation. Ventilator and tracheal pressures were measured during controlled ventilation with various tube dimensions and ventilation volumes. Ventilation with large volumes using small tracheal tubes results in high ventilator pressures. However, tracheal pressures are only marginally greater than those obtained with larger tubes. Small endotracheal tubes and high ventilation volumes result in a positive tracheal pressure at the end of expiration. The measured end-expiratory pressures are within the limits which might be used therapeutically (in PEEP). The force required to reshape endotracheal tubes of varvious dimensions to an "anatomical" shape was related to the tube dimensions; the beneficial effects of performed, "anatomically shaped" endotracheal tubes can be achieved by using small tubes of standard design.

Adult↗
PubMed1990

Influence of glottic mechanism on pulmonary function after acute lung injury.

We measured arterial gas tensions, respiratory timing, and intratracheal pressure in 12 rabbits to investigate the consequences of translaryngeal intubation with normal and subsequently injured lungs. Data were collected before, during, and after intubation. Intubation in normal rabbits precipitated no untoward effects on gas exchange or respiratory phase timing. However, there was significant elevation of subglottic pressure during expiration following extubation. Central venous injection of oleic acid (0.08 ml/kg) induced an acute lung injury that after 24 h was characterized by reduced PaO2 and dynamic lung-thorax compliance and tachypnea. Intubation in animals with acute lung injury was associated with a significant decline in arterial oxygenation, tachypnea, and increased PCO2. Expiratory tracheal pressure and expiratory time were greater and PaCO2 and respiratory rate were lower following extubation. We conclude that translaryngeal intubation following acute lung injury exacerbates already compromised pulmonary function by preventing a compensatory expiratory braking maneuver by the glottic apparatus.

Animals↗