Recommendations for respiratory support in the newborn (IV). High frequency ventilation, ex-utero intrapartum treatment (EXIT), extracorporeal membrane oxygenation (ECMO)

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Ventilación de alta frecuencia, ex-utero intrapartum treatment (EXIT), oxigenador de membrana extracorpórea (ECMO)" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "295.e1" "paginaFinal" => "295.e7" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Recommendations for respiratory support in the newborn (IV). High frequency ventilation, ex-utero intrapartum treatment (EXIT), extracorporeal membrane oxygenation (ECMO)" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1926 "Ancho" => 1629 "Tamanyo" => 168644 ] ] "descripcion" => array:1 [ "es" => "Algoritmo para el manejo inicial y el mantenimiento de la ventilación de alta frecuencia. MAP: presión media en la vía aérea; VMC: ventilación mecánica convencional." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Félix Castillo Salinas, Dolores Elorza Fernández, Antonio Gutiérrez Laso, Julio Moreno Hernando, Gerardo Bustos Lozano, Manuel Gresa Muñoz, Xavier Miracle Echegoyen" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Félix" "apellidos" => "Castillo Salinas" ] 1 => array:2 [ "nombre" => "Dolores" "apellidos" => "Elorza Fernández" ] 2 => array:2 [ "nombre" => "Antonio" "apellidos" => "Gutiérrez Laso" ] 3 => array:2 [ "nombre" => "Julio" "apellidos" => "Moreno Hernando" ] 4 => array:2 [ "nombre" => "Gerardo" "apellidos" => "Bustos Lozano" ] 5 => array:2 [ "nombre" => "Manuel" "apellidos" => "Gresa Muñoz" ] 6 => array:2 [ "nombre" => "Xavier" "apellidos" => "Miracle Echegoyen" ] 7 => array:1 [ "colaborador" => "en representación del Grupo Respiratorio y Surfactante (RESPISURF) de la Sociedad Española de Neonatología" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341287917301552" "doi" => "10.1016/j.anpede.2017.04.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287917301552?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403317301777?idApp=UINPBA00005H" "url" => "/16954033/0000008700000005/v1_201710301212/S1695403317301777/v1_201710301212/es/main.assets" ] ] "itemAnterior" => array:19 [ "pii" => "S234128791730162X" "issn" => "23412879" "doi" => "10.1016/j.anpede.2017.03.009" "estado" => "S300" "fechaPublicacion" => "2017-11-01" "aid" => "2238" "copyright" => "Asociación Española de Pediatría" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "An Pediatr (Barc). 2017;87:294.e1-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4471 "formatos" => array:3 [ "EPUB" => 138 "HTML" => 3539 "PDF" => 794 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Spanish Association of Paediatrics" "titulo" => "Guidelines for prevention, detection and management of hyperbilirubinaemia in newborns of 35 or more weeks of gestation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "294.e1" "paginaFinal" => "294.e8" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones para la prevención, la detección y el manejo de la hiperbilirrubinemia en los recién nacidos con 35 o más semanas de edad gestacional" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Adapted from the American Academy of Pediatrics.<a class="elsevierStyleCrossRef" href="#bib0235">7</a>" "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 462 "Ancho" => 1614 "Tamanyo" => 64441 ] ] "descripcion" => array:1 [ "en" => "Indications for PT in newborns of 35 or more weeks’ gestation. These guidelines are based on limited evidence and the levels shown are approximations. Intensive PT should be used when the TBS concentration exceeds the level shown in the corresponding cell (values expressed in mg/dL). Patients at low risk: GA ≥38 weeks and well. Patients at medium risk: GA ≥38 weeks+risk factors for neurotoxicity, or GA of 35–37+6 weeks and well. Patients at high risk: GA of 35–37+6 weeks with risk factors for neurotoxicity. Risk factors for neurotoxicity: isoimmune haemolytic disease, G6PD deficiency, asphyxia, significant lethargy, temperature instability, sepsis, acidosis or albumin <3g/dL. GA, gestational age; G6PD, glucose-6-phosphate dehydrogenase; PT, intensive phototherapy; TSB, total serum bilirubin." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "María Dolores Sánchez-Redondo Sánchez-Gabriel, José Luis Leante Castellanos, Isabel Benavente Fernández, Alejandro Pérez Muñuzuri, Segundo Rite Gracia, Cesar W. Ruiz Campillo, Ester Sanz López, Manuel Sánchez Luna" "autores" => array:9 [ 0 => array:2 [ "nombre" => "María Dolores" "apellidos" => "Sánchez-Redondo Sánchez-Gabriel" ] 1 => array:2 [ "nombre" => "José Luis" "apellidos" => "Leante Castellanos" ] 2 => array:2 [ "nombre" => "Isabel" "apellidos" => "Benavente Fernández" ] 3 => array:2 [ "nombre" => "Alejandro" "apellidos" => "Pérez Muñuzuri" ] 4 => array:2 [ "nombre" => "Segundo" "apellidos" => "Rite Gracia" ] 5 => array:2 [ "nombre" => "Cesar W." "apellidos" => "Ruiz Campillo" ] 6 => array:2 [ "nombre" => "Ester" "apellidos" => "Sanz López" ] 7 => array:2 [ "nombre" => "Manuel" "apellidos" => "Sánchez Luna" ] 8 => array:1 [ "colaborador" => "On behalf of the Comisión de Estándares de la Sociedad Española de Neonatología" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S1695403317301510" "doi" => "10.1016/j.anpedi.2017.03.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1695403317301510?idApp=UINPBA00005H" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234128791730162X?idApp=UINPBA00005H" "url" => "/23412879/0000008700000005/v1_201710301006/S234128791730162X/v1_201710301006/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Spanish Association of Paediatrics" "titulo" => "Recommendations for respiratory support in the newborn (IV). High frequency ventilation, ex-utero intrapartum treatment (EXIT), extracorporeal membrane oxygenation (ECMO)" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "295.e1" "paginaFinal" => "295.e7" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Félix Castillo Salinas, Dolores Elorza Fernández, Antonio Gutiérrez Laso, Julio Moreno Hernando, Gerardo Bustos Lozano, Manuel Gresa Muñoz, Xavier Miracle Echegoyen" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Félix" "apellidos" => "Castillo Salinas" "email" => array:1 [ 0 => "fecastillo@vhebron.net" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Dolores" "apellidos" => "Elorza Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Antonio" "apellidos" => "Gutiérrez Laso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Julio" "apellidos" => "Moreno Hernando" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Gerardo" "apellidos" => "Bustos Lozano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "Manuel" "apellidos" => "Gresa Muñoz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "Xavier" "apellidos" => "Miracle Echegoyen" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 7 => array:2 [ "colaborador" => "in representation of the Grupo Respiratorio y Surfactante (RESPISURF) of the Sociedad Española de Neonatología" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "◊" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Universitario Vall d’Hebrón, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Universitario Sant Joan de Déu, Barcelona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Materno-Insular Las Palmas, Las Palmas, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Neonatología, Hospital Clínic-Maternidad, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Recomendaciones para la asistencia respiratoria en el recién nacido (IV). Ventilación de alta frecuencia, ex-utero intrapartum treatment (EXIT), oxigenador de membrana extracorpórea (ECMO)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1926 "Ancho" => 1629 "Tamanyo" => 155385 ] ] "descripcion" => array:1 [ "en" => "Algorithm for the initial management and maintenance of high-frequency ventilation. MAP, mean airway pressure; CMV, conventional mechanical ventilation." ] ] ] "textoCompleto" => "High-frequency ventilationGeneral principlesConventional mechanical ventilation attempts to imitate spontaneous breathing by administering tidal volumes similar to physiological volumes at normal respiration rates. When tidal volumes need to be increased in order to maintain an adequate gas exchange, this produces increases in pulmonary pressures that may foster the development of bronchopulmonary dysplasia or air leaks.High-frequency ventilation (HFV) attempts to minimise such lung injury. It uses very small tidal volumes (smaller than the anatomical dead space) at supraphysiological frequencies (of more than 150breaths/min), thus maintaining adequate ventilation.High-frequency ventilation was first described in 1969,<a class="elsevierStyleCrossRef" href="#bib0140">1</a> with positive results in the animal model.There are 3 main types of HFV based on the devices used to deliver it<a class="elsevierStyleCrossRef" href="#bib0145">2</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">High-frequency oscillation ventilation (HFOV). Consist in a closed circuit that maintains a continuous positive pressure with an integrated piston pump or oscillating membrane. The movements of the piston displace the air volume within the circuit towards the lung during inspiration, creating a positive pressure, and pull air away during expiration by generating a negative pressure. Thus, expiration in this type of ventilation is active. It is the type of ventilation used most frequently in our hospitals.<a class="elsevierStyleCrossRef" href="#bib0150">3</a></li><li class="elsevierStyleListItem" id="lsti0010">High-frequency jet ventilation (HFJV). It delivers pulses of humidified gas at the level of the endotracheal tube through a jet injector. Expiration is passive.</li><li class="elsevierStyleListItem" id="lsti0015">High-frequency flow interruption ventilation (HFFIV). It is a mixed type of HFV that uses a solenoid valve that functions as a shutter, opening and closing at a high frequency.</li></ul>Different types of ventilators for HFV are available in Spain. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes some of them.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Important conceptsContinuous distending pressure of the lung (cmH2O) (CDP). It is the pressure maintained in the ventilator circuit and applied to the alveoli. It is used for alveolar recruitment and therefore for oxygenation.Amplitude (ΔP). Difference in pressure above and below the CDP expressed in cmH2O (expressed as a percentage in some ventilators). It is responsible for alveolar ventilation.Respiratory rate in hertz (Hz) (RR). Frequency of oscillations at the given amplitude; 1Hz=60cycles/min.Ventilation and oxygenationVentilation. The elimination of CO2 is determined by the square of the tidal volume multiplied by the RR (a concept known as DCO2). Tidal volume is the greatest determinant of CO2 clearance.Tidal volume is influenced by amplitude. Small changes in amplitude or lung compliance (and thus in tidal volume) have significant effects on ventilation. The RR is inversely correlated to tidal volume. Tidal volume increases as RR decreases.The precise mechanism by which gas exchange takes place has yet to be elucidated. Different hypotheses have been proposed: direct alveolar ventilation, the pendelluft effect, and facilitated diffusion (convection).<a class="elsevierStyleCrossRef" href="#bib0155">4</a>Oxygenation. The greatest determinant of oxygenation is the maintenance of functional residual capacity (FRC) through the CDP.IndicationsPreterm newborn with respiratory distress syndromeThe various controlled trials that have compared HFV with conventional ventilation have not had the encouraging results obtained in animal experiments. They have failed to demonstrate significant improvements in the variables under study. These discrepancies in the results are most likely due to the different therapeutic strategies used, variability in clinical practices between centres, variability in the included patients, and advances in conventional mechanical ventilation.<a class="elsevierStyleCrossRefs" href="#bib0160">5,6</a>The outcomes observed in the more than 4000 infants studied in the various clinical trials comparing HFV, with a high volume strategy, and conventional mechanical ventilation, with respiratory rates of more than 60cycles per minute and minimal tidal volumes, were similar.With the high lung volume strategy, there was a higher incidence of air leak syndrome and there was not an increased incidence of grade III or IV intraventricular haemorrhage or periventricular leukomalacia, so HFV with high lung volume does not increase the risk of neurologic morbidity.There is no clear evidence that HFV offers any advantages compared to conventional ventilation when used as the initial ventilation strategy in preterm infants with respiratory distress syndrome.<a class="elsevierStyleCrossRefs" href="#bib0170">7,8</a> However, 1 out of 5 very low birth weight newborns may receive HFV at some point during their stay in the intensive care unit.The long-term followup of adolescents aged 11–14 years born before 29 weeks of gestation that had been included in a randomised trial comparing the use of HFOV versus conventional ventilation immediately after birth found that those who had received HFOV had superior lung function with no evidence of poorer functional outcomes.<a class="elsevierStyleCrossRef" href="#bib0180">9</a>When it comes to rescue therapy, few clinical trials have studied the use of HFV as rescue therapy in preterm patients with severe respiratory distress syndrome and interstitial emphysema. The results of most favour HFV when it comes to the resolution of the respiratory problem, but have not shown differences in mortality or the incidence of bronchopulmonary dysplasia.<a class="elsevierStyleCrossRefs" href="#bib0165">6,9</a>Air leak syndrome: pulmonary interstitial emphysema, pneumothorax and bronchopleural fistulaThe studies that compared HFV and conventional ventilation when the use of surfactant was not yet widespread found that in preterm newborns with air leak syndrome, the use of HFV improved gas exchange with lower peak and mean pressures and was associated with a quicker resolution of pulmonary interstitial emphysema and decreased mortality, which suggests that this ventilation modality is an efficient tool in the management of air leak syndromes.<a class="elsevierStyleCrossRef" href="#bib0185">10</a>Diaphragmatic herniaEvidence from retrospective and observational studies suggests that the use of HFOV could improve the incidence of bronchopulmonary dysplasia and mortality, and reduce the need for extracorporeal membrane oxygenation (ECMO) in newborns with isolated congenital diaphragmatic hernia.<a class="elsevierStyleCrossRefs" href="#bib0190">11,12</a>The first clinical trial that compared HFOV with conventional mechanical ventilation in infants with a prenatal diagnosis of congenital diaphragmatic hernia did not find a statistically significant difference in mortality or the incidence of bronchopulmonary dysplasia between the two groups. The study found a shorter duration of ventilation and a less frequent need for ECMO in the conventional ventilation group.<a class="elsevierStyleCrossRef" href="#bib0200">13</a>Acute pulmonary disease refractory to conventional mechanical ventilation and eligible for extracorporeal membrane oxygenation (ECMO)High-frequency oscillatory ventilation is a more effective rescue therapy compared to conventional ventilation in newborns with severe and reversible pulmonary disease eligible for ECMO. It improves gas exchange in term or near-term newborns with severe respiratory failure with no apparent increase in morbidity. It has been associated with a reduced incidence of chronic lung disease and intracranial haemorrhage in infants treated successfully with HFOV compared to newborns that were refractory to it and required ECMO.The effectiveness of HFOV in improving gas exchange depends on the underlying disease, and is greater in cases of pneumonia, meconium aspiration and surfactant deficit.<a class="elsevierStyleCrossRef" href="#bib0205">14</a>The combined use of inhaled nitric oxide and HFOV may be more effective than therapy alone in the management of newborns with reversible severe pulmonary disease and pulmonary hypertension, reducing the use of ECMO. This improvement has been observed especially in newborns with meconium aspiration.<a class="elsevierStyleCrossRef" href="#bib0210">15</a>Other diseasesSmall studies support the use of HFV in patients with increased intra-abdominal pressure that hinders conventional mechanical ventilation (omphalocoele, gastroschisis or necrotising enterocolitis) and pulmonary haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0215">16</a>Practical managementAs we have seen, the main indication for HFV is the need for lung recruitment. We propose the open lung strategy, that is, the use of a mean airway pressure (MAP) that maximises alveolar recruitment while avoiding atelectasis.No objective data are available for the purpose of establishing criteria for the use of HFV. The clinical consensus is to consider the use of this modality in the following situations<a class="elsevierStyleCrossRef" href="#bib0185">10</a>:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">1.When peak inspiratory pressures of more than 25cmH2O are required in conventional mechanical ventilation to achieve adequate ventilation.</li><li class="elsevierStyleListItem" id="lsti0025">2.When a FiO2 of more than 0.6 is needed after optimising conventional mechanical ventilation and there are signs of overdistension (pressure–volume loop, C20/C<0.8).</li><li class="elsevierStyleListItem" id="lsti0030">3.Air leak.</li></ul>Initiation and maintenanceOxygenation. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> proposes an algorithm to guide the initiation and maintenance of HFV with the aim of maximising lung volume while avoiding hyperinflation:<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In cases of air leak, HFV will be initiated with the same CDP applied in conventional mechanical ventilation with a conservative approach, tolerating higher FiO2 and pCO2 values.Different high-frequency ventilators may not produce the same degree of hyperinflation at the same MAP. Furthermore, other signs of hyperinflation should be taken into account, such as a flattened diaphragm or compressed heart contours.Ventilation. The initial amplitude should be of 40–50% (depends on the type of ventilator used) and adjusted in 10% increments to maintain a tidal volume between 1.5 and 2cc/kg and/or a pCO2 adequate for the individual patient. The RR will be determined based on the weight of the patient: rates of 12–15Hz can be used in patients with weights of less than 1500g, while approximately 10Hz can be applied to late preterm or term newborns. Lower rates may be needed in cases of severe lung disease.There are ventilators that offer a volume guarantee option for HFOV. The hypothetical benefit of this option compared to maintaining the pCO2 levels within an optimal range remains to be demonstrated.<a class="elsevierStyleCrossRef" href="#bib0220">17</a><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> proposes an oxygenation and ventilation protocol for HFV.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Weaning and special careWeaning. Once lung recruitment has been achieved and oxygen requirements have dropped to approximately 0.3–0.35, progressive decreases in MAP will be attempted every 12h, maintaining the FiO2 within the desired threshold. The speed of weaning will depend on the disease and developmental stage of the patient.Once the MAP reaches values of 10–12cmH2O, extubation will be contemplated. Extubation can be performed following a switch to conventional mechanical ventilation or directly from HFV (with MAP values of 8–10cmH2O).Special care. The following recommendations constitute a general guideline for the optimal management of patients receiving HFV:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">•The tidal volume delivered to the patient varies with changes in pulmonary conditions, so close monitoring of pO2 and pCO2 by means of transcutaneous sensors is recommended.</li><li class="elsevierStyleListItem" id="lsti0040">•Lung expansion should be assessed by chest radiography whenever substantial changes in MAP are made.</li><li class="elsevierStyleListItem" id="lsti0045">•Arterial blood pressure and cardiac output should be optimised, including their exhaustive monitoring and contemplating the administration of fluids and/or inotropic support for their management.</li><li class="elsevierStyleListItem" id="lsti0050">•Sedoanalgesia with or without muscle relaxants may be needed in some occasions when the respiratory efforts of the patient interfere with ventilation.</li><li class="elsevierStyleListItem" id="lsti0055">•Endotracheal suctioning is indicated in case of decreased tactile fremitus, CO2 levels increase or oxygenation decreases with no other apparent cause. The use of closed suction systems is recommended to prevent lung derecruitment during disconnection from the ventilator.</li></ul>ComplicationsHaemodynamic complications. When a high MAP is needed to achieve lung recruitment, certain complications may result from the increased intrathoracic pressure, such as increased central venous pressure or decreased venous return or cardiac output.Air trapping.Recommendations<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0060">1.HFV is used as rescue therapy in patients with severe lung disease in whom treatment with conventional mechanical ventilation has failed (B).</li><li class="elsevierStyleListItem" id="lsti0065">2.HFV is more effective in combination with inhaled nitric oxide (B).</li><li class="elsevierStyleListItem" id="lsti0070">3.HFV offers no advantages compared to conventional ventilation in the initial respiratory management of respiratory distress syndrome in preterm newborns (A).</li><li class="elsevierStyleListItem" id="lsti0075">4.The MAP optimisation strategy may be most appropriate (B).</li></ul>Ex-utero intrapartum treatment (EXIT)Introduction and definitionEx-utero intrapartum treatment (EXIT) is a procedure that allows the establishment of a patent foetal airway before the delivery is complete, while the newborn is still supported by the uteroplacental circulation. It offers a safe time interval to access the foetal airway in cases of severe extrinsic compression.<a class="elsevierStyleCrossRefs" href="#bib0225">18,19</a>ProcedurePerformance of EXIT requires a multidisciplinary team comprising obstetricians, neonatologists, anaesthesiologists, paediatric surgeons and nurses. The procedure is conducted in the operating theatre. The mother is placed supine on the operating table, with slight left lateral decubitus positioning. Tocolytics are administered to the mother before the intervention. An epidural catheter is placed on the mother for intraoperative and postoperative pain relief. Induction of anaesthesia is followed by rapid-sequence intubation and assisted ventilation. Maternal arterial blood pressure must be maintained at adequate levels to ensure placental perfusion. Maternal oxygenation is optimised to avoid foetal hypoxia. A muscle relaxant and fentanyl are delivered directly to the foetus with a transuterine intramuscular injection. Hysterotomy is subsequently performed. Once the uterus is open, the head and arms of the foetus are exposed, and intubation of the airway can be attempted.Foetal monitoring includes continuous pulse oximetry with placement of a sensor in the exposed arm, and ultrasound examination of umbilical cord blood flow and heart rate.Once the procedure has finished (it can take up to 150min), the umbilical cord is clamped and the newborn is placed in the resuscitation crib for neonatal care and treatment.<a class="elsevierStyleCrossRefs" href="#bib0230">19,20</a>IndicationsLarge cervical or pharyngeal masses such as teratomas, cystic hygromas, haemangiomas or lymphangiomas. Although these lesions are rare, they can cause compression of the foetal upper airway and substantially complicate resuscitation in the delivery room. If airway patency cannot be achieved, the newborn may develop acidosis or hypoxia and, as a consequence, suffer irreversible brain damage or death.This complication is all the more tragic if we consider that many of these patients develop normally if the isolated malformation can be overcome.<a class="elsevierStyleCrossRef" href="#bib0240">21</a> This requires a prior accurate and detailed prenatal diagnosis, evaluating the degree of airway compression and the complexity of neonatal resuscitation.Ultrasound can be used to detect indirect signs of secondary airway and oesophageal obstruction, such as polyhydramnios, increased lung volume, inversion of the diaphragm, ascites and foetal hydrops (CHAOS). Magnetic resonance imaging allows a more detailed evaluation, facilitating the planning of EXIT and other necessary interventions (intubation, tracheotomy, puncture of the mass in cases of lymphangioma or resection).<a class="elsevierStyleCrossRef" href="#bib0245">22</a>Other indications for EXIT are<a class="elsevierStyleCrossRefs" href="#bib0245">22,23</a>:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080">1.Ultrasound-guided percutaneous puncture during the EXIT procedure in cases of giant cervical lymphangioma.</li><li class="elsevierStyleListItem" id="lsti0085">2.Reversion of foetal tracheal obstruction in congenital diaphragmatic hernia.</li><li class="elsevierStyleListItem" id="lsti0090">3.Thoracic abnormalities: massive pleural effusion and large congenital cystic adenoid malformation.</li><li class="elsevierStyleListItem" id="lsti0095">4.Closure of thoracoamniotic shunts. Thoracotomy and lobectomy of the lung.</li><li class="elsevierStyleListItem" id="lsti0100">5.Central access line placement prior to ECMO.</li></ul>RecommendationsPlanning performance of EXIT is indicated in cases of severe foetal airway obstruction (A).Extracorporeal membrane oxygenation (ECMO)Extracorporeal membrane oxygenation is a technique that can sustain vital functions by the artificial replacement of the heart, lungs or both for a period of time until the recovery of native cardiac and/or respiratory function.This technique must be used in patients with reversible conditions.<a class="elsevierStyleCrossRef" href="#bib0255">24</a>Components of the ECMO circuitThe main components of the circuit are a venous drainage cannula, venous access line, pump, oxygenator, arterial access line and arterial or venous return cannula, depending on the type of support.PhysiologyExtracorporeal membrane oxygenation is achieved by drainage of venous blood followed by the exchange of CO2 and O2 through an artificial membrane (oxygenator), with a pump pushing the blood through and returning it to the systemic circulation, either venous (venovenous ECMO) or arterial (venoarterial ECMO).Venovenous ECMO provides respiratory support, and venoarterial ECMO respiratory as well as cardiac support. The support can be partial or total, depending on the needs of the patient.Indications and contraindicationsMost newborns who need ECMO are patients with pulmonary hypertension that experience respiratory failure, leading to sustained hypoxaemia.<a class="elsevierStyleCrossRef" href="#bib0260">25</a>The primary cause varies and has an impact on the final efficacy of ECMO. Congenital diaphragmatic hernia, meconium aspiration syndrome, persistent pulmonary hypertension and respiratory distress syndrome are the respiratory diseases for which ECMO is used most frequently.<a class="elsevierStyleCrossRef" href="#bib0265">26</a>Indications<a class="elsevierStyleCrossRefs" href="#bib0260">25,27</a>Oxygenation index (OI)=mean airway pressure×FiO2×100Oxygenation index ≥40: indicated.Oxygenation index ≥20: consider use.ContraindicationsAbsolute<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0105">1.Lethal chromosomal disorders</li><li class="elsevierStyleListItem" id="lsti0110">2.Severe irreversible brain damage</li><li class="elsevierStyleListItem" id="lsti0115">3.Grade III or greater intraventricular haemorrhage</li></ul>Relative<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0120">1.Irreversible organ damage (possibility of transplantation)</li><li class="elsevierStyleListItem" id="lsti0125">2.Body weight<2kg</li><li class="elsevierStyleListItem" id="lsti0130">3.Postmenstrual age<34 weeks</li><li class="elsevierStyleListItem" id="lsti0135">4.Disease with a high probability of poor prognosis</li></ul>The efficacy of ECMO is based on the ability of the patient to recover from lung disease in a short period of time (14–21 days).From the second week of ECMO, the risks and complications associated with the technique (clot formation, nosocomial infection, mechanical problems in the circuit, etc.) increase. Most facilities accept a maximum duration of ECMO of 20–30 days, although improvements in the use of this technique have resulted in increases in this time interval.Discontinuation of ECMOThe main indication for discontinuation is the recovery of adequate pulmonary and cardiac function. As oxygenation improves, the patient is progressively weaned off support until it is fully withdrawn.Complications<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> enumerates potential complications of ECMO.<a class="elsevierStyleCrossRef" href="#bib0270">27</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>RecommendationsExtracorporeal membrane oxygenation is indicated in severe neonatal pulmonary disease that can be reversed with a short period of use (B).Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres932720" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec907150" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres932721" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec907151" "titulo" => "Palabras clave" ] 4 => array:3 [ "identificador" => "sec0005" "titulo" => "High-frequency ventilation" "secciones" => array:1 [ 0 => array:3 [ "identificador" => "sec0010" "titulo" => "General principles" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Important concepts" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Ventilation and oxygenation" ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Indications" "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Preterm newborn with respiratory distress syndrome" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Air leak syndrome: pulmonary interstitial emphysema, pneumothorax and bronchopleural fistula" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Diaphragmatic hernia" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Acute pulmonary disease refractory to conventional mechanical ventilation and eligible for extracorporeal membrane oxygenation (ECMO)" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Other diseases" ] 5 => array:2 [ "identificador" => "sec0055" "titulo" => "Practical management" ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Initiation and maintenance" ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Weaning and special care" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Complications" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Recommendations" ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "sec0080" "titulo" => "Ex-utero intrapartum treatment (EXIT)" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Introduction and definition" ] 1 => array:3 [ "identificador" => "sec0090" "titulo" => "Procedure" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Indications" ] ] ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Recommendations" ] ] ] 6 => array:3 [ "identificador" => "sec0105" "titulo" => "Extracorporeal membrane oxygenation (ECMO)" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Components of the ECMO circuit" ] 1 => array:3 [ "identificador" => "sec0115" "titulo" => "Physiology" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0120" "titulo" => "Indications and contraindications" ] 1 => array:2 [ "identificador" => "sec0125" "titulo" => "Indications" ] 2 => array:3 [ "identificador" => "sec0130" "titulo" => "Contraindications" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0135" "titulo" => "Absolute" ] 1 => array:2 [ "identificador" => "sec0140" "titulo" => "Relative" ] ] ] ] ] 2 => array:2 [ "identificador" => "sec0145" "titulo" => "Discontinuation of ECMO" ] 3 => array:2 [ "identificador" => "sec0150" "titulo" => "Complications" ] 4 => array:2 [ "identificador" => "sec0155" "titulo" => "Recommendations" ] ] ] 7 => array:2 [ "identificador" => "sec0160" "titulo" => "Conflict of interests" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-03-21" "fechaAceptado" => "2017-04-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec907150" "palabras" => array:4 [ 0 => "High frequency ventilation" 1 => "Ex-utero intrapartum treatment (EXIT)" 2 => "Extracorporeal membrane oxygenation (ECMO)" 3 => "Newborn" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec907151" "palabras" => array:4 [ 0 => "Ventilación de alta frecuencia" 1 => "Ex útero intrapartum treatment (EXIT)" 2 => "Oxigenador de membrana extracorpórea (ECMO)" 3 => "Recién nacido" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The recommendations included in this document will be part a series of updated reviews of the literature on respiratory support in the newborn infant. These recommendations are structured into 12 modules, and in this work module 8 is presented. Each module is the result of a consensus process amongst all members of the Surfactant and Respiratory Group of the Spanish Society of Neonatology. They represent a summary of the published papers on each specific topic, as well as the clinical experience of each one of the members of the group." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las recomendaciones incluidas en este documento forman parte de una revisión actualizada de la asistencia respiratoria en el recién nacido. Están estructuradas en 12 módulos, y en este trabajo se presenta el módulo 8. El contenido de cada módulo es el resultado del consenso de los miembros del Grupo Respiratorio y Surfactante de la Sociedad Española de Neonatología. Representan una síntesis de los trabajos publicados y de la experiencia clínica de cada uno de los miembros del grupo." ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "Los miembros del Grupo Respiratorio y Surfactante (RESPISURF) de la Sociedad Española de Neonatología se presentan en <a class="elsevierStyleCrossRef" href="#sec0165">anexo</a>." "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Castillo Salinas F, Elorza Fernández D, Gutiérrez Laso A, Moreno Hernando J, Bustos Lozano G, Gresa Muñoz M, et al. Recomendaciones para la asistencia respiratoria en el recién nacido (IV). Ventilación de alta frecuencia, ex-utero intrapartum treatment (EXIT), oxigenador de membrana extracorpórea (ECMO). An Pediatr (Barc). 2017;87:295.e1–295.e7." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "Dr Félix Castillo Salinas. Department of Neonatology, Hospital Universitario Vall d’Hebrón, Barcelona. Dr Dolores Elorza Fernández. Department of Neonatology, Hospital Universitario La Paz, Madrid. Dr Antonio Gutiérrez Laso. Department of Neonatology, Hospital Universitario La Fe, Valencia. Dr Julio Moreno Hernando. Department of Neonatology, Hospital Universitario Sant Joan de Déu, Barcelona. Dr Gerardo Bustos Lozano. Department of Neonatology, Hospital Universitario 12 de Octubre, Madrid. Dr Manuel Gresa Muñoz. Department of Neonatology, Hospital Materno-Insular Las Palmas, Las Palmas. Dr Xavier Miracle Echegoyen. Department of Neonatology, Hospital Clínic-Maternidad, Barcelona. Dr Jon López de Heredia Goya. Department of Neonatology, Hospital de Cruces, Barakaldo. Dr Marta Aguar Carrascosa. Department of Neonatology, Hospital Universitario La Fe, Valencia. Dr José Ramón Fernández Lorenzo, Department of Neonatology, Complejo Universitario de Vigo. Dr María del Mar Serrano. Hospital Materno-Infantil Carlos Haya, Málaga. Dr Ana Concheiro Guisan. Department of Neonatology, Complejo Hospitalario Universitario de Vigo. Dr Cristina Carrasco Carrasco. Department of Neonatology, Hospital Universitario Sant Joan de Déu, Barcelona. Dr Juan José Comuñas Gómez. Department of Neonatology, Hospital Universitario Vall d’Hebrón, Barcelona. Dr María Teresa Moral Pumarega. Hospital Universitario 12 de Octubre, Madrid. Dr Ana María Sánchez Torres. Department of Neonatology, Hospital Universitario La Paz, Madrid. Dr María Luisa Franco. Department of Neonatology, Hospital Universitario Gregorio Marañón, Madrid." "etiqueta" => "Appendix A" "titulo" => "Group on Respiration and Surfactant (Grupo Respiratorio y Surfactante [RESPISURF]) of the Sociedad Española de Neonatología (Spanish Society of Neonatology)." "identificador" => "sec0165" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1926 "Ancho" => 1629 "Tamanyo" => 155385 ] ] "descripcion" => array:1 [ "en" => "Algorithm for the initial management and maintenance of high-frequency ventilation. MAP, mean airway pressure; CMV, conventional mechanical ventilation." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HFFIV, high-frequency flow interruption ventilation; HFJV, high-frequency jet ventilation; HFOV, high-frequency oscillation ventilation; HFV, high-frequency ventilation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Type \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">HFOV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">HFJV \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">HFFIV \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ventilator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sensormedics® Fabian® SLE 5000® Babylog® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Life Pulse® (Bunnell) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infant Star® VN500® \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1576346.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Types of high-frequency ventilators." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "HFV, high-frequency ventilation; FiO2, administered fraction of inspired oxygen; MAP, mean airway pressure; RR, respiratory rate; ΔP, amplitude." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Poor oxygenation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Adequate oxygenation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hypoventilation \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hyperventilation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↑ FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↓ FiO2 (up to 0.4–0.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↑ ΔP \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↓ ΔP \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↑ MAP (1–2cmH2O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↓ MAP (1–2cmH2O) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↓ RR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">↑ RR \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1576347.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Oxygenation and ventilation protocol for HFV." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanical complications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient complications \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clots in circuit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Haemolysis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cannula-related \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Dialysis/Haemofiltration \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Air in circuit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intracranial haemorrhage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygenator failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Seizures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pump failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heater failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infection \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Circuit break \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Arrhythmia \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1576345.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Mechanical and patient-related complications in extracorporeal membrane oxygenation (ECMO)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Studies of blood pressure regulation: common carotid artery clamping in studies of the carotid-sinus baroreceptor control of the systemic blood pressure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. 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Recommendations for respiratory support in the newborn (IV). High frequency ventilation, ex-utero intrapartum treatment (EXIT), extracorporeal membrane oxygenation (ECMO)

Recomendaciones para la asistencia respiratoria en el recién nacido (IV). Ventilación de alta frecuencia, ex-utero intrapartum treatment (EXIT), oxigenador de membrana extracorpórea (ECMO)

Félix Castillo Salinasa,

Corresponding author

fecastillo@vhebron.net

Corresponding author.

, Dolores Elorza Fernándezb, Antonio Gutiérrez Lasoc, Julio Moreno Hernandod, Gerardo Bustos Lozanoe, Manuel Gresa Muñozf, Xavier Miracle Echegoyeng, in representation of the Grupo Respiratorio y Surfactante (RESPISURF) of the Sociedad Española de Neonatología ◊

a Servicio de Neonatología, Hospital Universitario Vall d’Hebrón, Barcelona, Spain

b Servicio de Neonatología, Hospital Universitario La Paz, Madrid, Spain

c Servicio de Neonatología, Hospital Universitario La Fe, Valencia, Spain

d Servicio de Neonatología, Hospital Universitario Sant Joan de Déu, Barcelona, Spain

e Servicio de Neonatología, Hospital Universitario 12 de Octubre, Madrid, Spain

f Servicio de Neonatología, Hospital Materno-Insular Las Palmas, Las Palmas, Spain

g Servicio de Neonatología, Hospital Clínic-Maternidad, Barcelona, Spain

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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the initial management and maintenance of high-frequency ventilation&#46; MAP&#44; mean airway pressure&#59; CMV&#44; conventional mechanical ventilation&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">High-frequency ventilation</span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">General principles</span><p id="par0005" class="elsevierStylePara elsevierViewall">Conventional mechanical ventilation attempts to imitate spontaneous breathing by administering tidal volumes similar to physiological volumes at normal respiration rates&#46; When tidal volumes need to be increased in order to maintain an adequate gas exchange&#44; this produces increases in pulmonary pressures that may foster the development of bronchopulmonary dysplasia or air leaks&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">High-frequency ventilation &#40;HFV&#41; attempts to minimise such lung injury&#46; It uses very small tidal volumes &#40;smaller than the anatomical dead space&#41; at supraphysiological frequencies &#40;of more than 150<span class="elsevierStyleHsp" style=""></span>breaths&#47;min&#41;&#44; thus maintaining adequate ventilation&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">High-frequency ventilation was first described in 1969&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> with positive results in the animal model&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">There are 3 main types of HFV based on the devices used to deliver it<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">High-frequency oscillation ventilation</span> &#40;HFOV&#41;&#46; Consist in a closed circuit that maintains a continuous positive pressure with an integrated piston pump or oscillating membrane&#46; The movements of the piston displace the air volume within the circuit towards the lung during inspiration&#44; creating a positive pressure&#44; and pull air away during expiration by generating a negative pressure&#46; Thus&#44; expiration in this type of ventilation is active&#46; It is the type of ventilation used most frequently in our hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">High-frequency jet ventilation</span> &#40;HFJV&#41;&#46; It delivers pulses of humidified gas at the level of the endotracheal tube through a jet injector&#46; Expiration is passive&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">High-frequency flow interruption ventilation</span> &#40;HFFIV&#41;&#46; It is a mixed type of HFV that uses a solenoid valve that functions as a shutter&#44; opening and closing at a high frequency&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall">Different types of ventilators for HFV are available in Spain&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes some of them&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Important concepts</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Continuous distending pressure of the lung &#40;cmH</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">O&#41;</span> &#40;CDP&#41;&#46; It is the pressure maintained in the ventilator circuit and applied to the alveoli&#46; It is used for alveolar recruitment and therefore for oxygenation&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Amplitude</span> &#40;&#916;<span class="elsevierStyleItalic">P</span>&#41;&#46; Difference in pressure above and below the CDP expressed in cmH<span class="elsevierStyleInf">2</span>O &#40;expressed as a percentage in some ventilators&#41;&#46; It is responsible for alveolar ventilation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Respiratory rate in hertz &#40;Hz&#41;</span> &#40;RR&#41;&#46; Frequency of oscillations at the given amplitude&#59; 1<span class="elsevierStyleHsp" style=""></span>Hz<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>60<span class="elsevierStyleHsp" style=""></span>cycles&#47;min&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ventilation and oxygenation</span><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ventilation</span>&#46; The elimination of CO<span class="elsevierStyleInf">2</span> is determined by the square of the tidal volume multiplied by the RR &#40;a concept known as DCO<span class="elsevierStyleInf">2</span>&#41;&#46; Tidal volume is the greatest determinant of CO<span class="elsevierStyleInf">2</span> clearance&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Tidal volume is influenced by amplitude&#46; Small changes in amplitude or lung compliance &#40;and thus in tidal volume&#41; have significant effects on ventilation&#46; The RR is inversely correlated to tidal volume&#46; Tidal volume increases as RR decreases&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The precise mechanism by which gas exchange takes place has yet to be elucidated&#46; Different hypotheses have been proposed&#58; direct alveolar ventilation&#44; the pendelluft effect&#44; and facilitated diffusion &#40;convection&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oxygenation</span>&#46; The greatest determinant of oxygenation is the maintenance of functional residual capacity &#40;FRC&#41; through the CDP&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Indications</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Preterm newborn with respiratory distress syndrome</span><p id="par0080" class="elsevierStylePara elsevierViewall">The various controlled trials that have compared HFV with conventional ventilation have not had the encouraging results obtained in animal experiments&#46; They have failed to demonstrate significant improvements in the variables under study&#46; These discrepancies in the results are most likely due to the different therapeutic strategies used&#44; variability in clinical practices between centres&#44; variability in the included patients&#44; and advances in conventional mechanical ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">The outcomes observed in the more than 4000 infants studied in the various clinical trials comparing HFV&#44; with a high volume strategy&#44; and conventional mechanical ventilation&#44; with respiratory rates of more than 60<span class="elsevierStyleHsp" style=""></span>cycles per minute and minimal tidal volumes&#44; were similar&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">With the high lung volume strategy&#44; there was a higher incidence of air leak syndrome and there was not an increased incidence of grade III or IV intraventricular haemorrhage or periventricular leukomalacia&#44; so HFV with high lung volume does not increase the risk of neurologic morbidity&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">There is no clear evidence that HFV offers any advantages compared to conventional ventilation when used as the initial ventilation strategy in preterm infants with respiratory distress syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7&#44;8</span></a> However&#44; 1 out of 5 very low birth weight newborns may receive HFV at some point during their stay in the intensive care unit&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The long-term followup of adolescents aged 11&#8211;14 years born before 29 weeks of gestation that had been included in a randomised trial comparing the use of HFOV versus conventional ventilation immediately after birth found that those who had received HFOV had superior lung function with no evidence of poorer functional outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">When it comes to rescue therapy&#44; few clinical trials have studied the use of HFV as rescue therapy in preterm patients with severe respiratory distress syndrome and interstitial emphysema&#46; The results of most favour HFV when it comes to the resolution of the respiratory problem&#44; but have not shown differences in mortality or the incidence of bronchopulmonary dysplasia&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;9</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Air leak syndrome&#58; pulmonary interstitial emphysema&#44; pneumothorax and bronchopleural fistula</span><p id="par0110" class="elsevierStylePara elsevierViewall">The studies that compared HFV and conventional ventilation when the use of surfactant was not yet widespread found that in preterm newborns with air leak syndrome&#44; the use of HFV improved gas exchange with lower peak and mean pressures and was associated with a quicker resolution of pulmonary interstitial emphysema and decreased mortality&#44; which suggests that this ventilation modality is an efficient tool in the management of air leak syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diaphragmatic hernia</span><p id="par0115" class="elsevierStylePara elsevierViewall">Evidence from retrospective and observational studies suggests that the use of HFOV could improve the incidence of bronchopulmonary dysplasia and mortality&#44; and reduce the need for extracorporeal membrane oxygenation &#40;ECMO&#41; in newborns with isolated congenital diaphragmatic hernia&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The first clinical trial that compared HFOV with conventional mechanical ventilation in infants with a prenatal diagnosis of congenital diaphragmatic hernia did not find a statistically significant difference in mortality or the incidence of bronchopulmonary dysplasia between the two groups&#46; The study found a shorter duration of ventilation and a less frequent need for ECMO in the conventional ventilation group&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Acute pulmonary disease refractory to conventional mechanical ventilation and eligible for extracorporeal membrane oxygenation &#40;ECMO&#41;</span><p id="par0125" class="elsevierStylePara elsevierViewall">High-frequency oscillatory ventilation is a more effective rescue therapy compared to conventional ventilation in newborns with severe and reversible pulmonary disease eligible for ECMO&#46; It improves gas exchange in term or near-term newborns with severe respiratory failure with no apparent increase in morbidity&#46; It has been associated with a reduced incidence of chronic lung disease and intracranial haemorrhage in infants treated successfully with HFOV compared to newborns that were refractory to it and required ECMO&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The effectiveness of HFOV in improving gas exchange depends on the underlying disease&#44; and is greater in cases of pneumonia&#44; meconium aspiration and surfactant deficit&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The combined use of inhaled nitric oxide and HFOV may be more effective than therapy alone in the management of newborns with reversible severe pulmonary disease and pulmonary hypertension&#44; reducing the use of ECMO&#46; This improvement has been observed especially in newborns with meconium aspiration&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Other diseases</span><p id="par0140" class="elsevierStylePara elsevierViewall">Small studies support the use of HFV in patients with increased intra-abdominal pressure that hinders conventional mechanical ventilation &#40;omphalocoele&#44; gastroschisis or necrotising enterocolitis&#41; and pulmonary haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Practical management</span><p id="par0145" class="elsevierStylePara elsevierViewall">As we have seen&#44; the main indication for HFV is the need for lung recruitment&#46; We propose the <span class="elsevierStyleItalic">open lung</span> strategy&#44; that is&#44; the use of a mean airway pressure &#40;MAP&#41; that maximises alveolar recruitment while avoiding atelectasis&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">No objective data are available for the purpose of establishing criteria for the use of HFV&#46; The clinical consensus is to consider the use of this modality in the following situations<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a>&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">When peak inspiratory pressures of more than 25<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O are required in conventional mechanical ventilation to achieve adequate ventilation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">When a FiO<span class="elsevierStyleInf">2</span> of more than 0&#46;6 is needed after optimising conventional mechanical ventilation and there are signs of overdistension &#40;pressure&#8211;volume loop&#44; C<span class="elsevierStyleInf">20</span>&#47;C<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;8&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Air leak&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Initiation and maintenance</span><p id="par0170" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Oxygenation</span>&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> proposes an algorithm to guide the initiation and maintenance of HFV with the aim of maximising lung volume while avoiding hyperinflation&#58;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">In cases of air leak&#44; HFV will be initiated with the same CDP applied in conventional mechanical ventilation with a conservative approach&#44; tolerating higher FiO<span class="elsevierStyleInf">2</span> and pCO<span class="elsevierStyleInf">2</span> values&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Different high-frequency ventilators may not produce the same degree of hyperinflation at the same MAP&#46; Furthermore&#44; other signs of hyperinflation should be taken into account&#44; such as a flattened diaphragm or compressed heart contours&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ventilation</span>&#46; The initial amplitude should be of 40&#8211;50&#37; &#40;depends on the type of ventilator used&#41; and adjusted in 10&#37; increments to maintain a tidal volume between 1&#46;5 and 2<span class="elsevierStyleHsp" style=""></span>cc&#47;kg and&#47;or a pCO<span class="elsevierStyleInf">2</span> adequate for the individual patient&#46; The RR will be determined based on the weight of the patient&#58; rates of 12&#8211;15<span class="elsevierStyleHsp" style=""></span>Hz can be used in patients with weights of less than 1500<span class="elsevierStyleHsp" style=""></span>g&#44; while approximately 10<span class="elsevierStyleHsp" style=""></span>Hz can be applied to late preterm or term newborns&#46; Lower rates may be needed in cases of severe lung disease&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">There are ventilators that offer a volume guarantee option for HFOV&#46; The hypothetical benefit of this option compared to maintaining the pCO<span class="elsevierStyleInf">2</span> levels within an optimal range remains to be demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> proposes an oxygenation and ventilation protocol for HFV&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Weaning and special care</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Weaning</span>&#46; Once lung recruitment has been achieved and oxygen requirements have dropped to approximately 0&#46;3&#8211;0&#46;35&#44; progressive decreases in MAP will be attempted every 12<span class="elsevierStyleHsp" style=""></span>h&#44; maintaining the FiO<span class="elsevierStyleInf">2</span> within the desired threshold&#46; The speed of weaning will depend on the disease and developmental stage of the patient&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Once the MAP reaches values of 10&#8211;12<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; extubation will be contemplated&#46; Extubation can be performed following a switch to conventional mechanical ventilation or directly from HFV &#40;with MAP values of 8&#8211;10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Special care</span>&#46; The following recommendations constitute a general guideline for the optimal management of patients receiving HFV&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">The tidal volume delivered to the patient varies with changes in pulmonary conditions&#44; so close monitoring of pO<span class="elsevierStyleInf">2</span> and pCO<span class="elsevierStyleInf">2</span> by means of transcutaneous sensors is recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Lung expansion should be assessed by chest radiography whenever substantial changes in MAP are made&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Arterial blood pressure and cardiac output should be optimised&#44; including their exhaustive monitoring and contemplating the administration of fluids and&#47;or inotropic support for their management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Sedoanalgesia with or without muscle relaxants may be needed in some occasions when the respiratory efforts of the patient interfere with ventilation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Endotracheal suctioning is indicated in case of decreased tactile fremitus&#44; CO<span class="elsevierStyleInf">2</span> levels increase or oxygenation decreases with no other apparent cause&#46; The use of closed suction systems is recommended to prevent lung derecruitment during disconnection from the ventilator&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Complications</span><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Haemodynamic complications</span>&#46; When a high MAP is needed to achieve lung recruitment&#44; certain complications may result from the increased intrathoracic pressure&#44; such as increased central venous pressure or decreased venous return or cardiac output&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Air trapping&#46;</span><span class="elsevierStyleVsp" style="height:0.5px"></span></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Recommendations</span><p id="par0250" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">1&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">HFV is used as rescue therapy in patients with severe lung disease in whom treatment with conventional mechanical ventilation has failed &#40;B&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">2&#46;</span><p id="par0260" class="elsevierStylePara elsevierViewall">HFV is more effective in combination with inhaled nitric oxide &#40;B&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">3&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">HFV offers no advantages compared to conventional ventilation in the initial respiratory management of respiratory distress syndrome in preterm newborns &#40;A&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">4&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">The MAP optimisation strategy may be most appropriate &#40;B&#41;&#46;</p></li></ul></p></span></span></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100"><span class="elsevierStyleItalic">Ex-utero intrapartum treatment</span> &#40;EXIT&#41;</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Introduction and definition</span><p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ex-utero intrapartum treatment</span> &#40;EXIT&#41; is a procedure that allows the establishment of a patent foetal airway before the delivery is complete&#44; while the newborn is still supported by the uteroplacental circulation&#46; It offers a safe time interval to access the foetal airway in cases of severe extrinsic compression&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">18&#44;19</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Procedure</span><p id="par0280" class="elsevierStylePara elsevierViewall">Performance of EXIT requires a multidisciplinary team comprising obstetricians&#44; neonatologists&#44; anaesthesiologists&#44; paediatric surgeons and nurses&#46; The procedure is conducted in the operating theatre&#46; The mother is placed supine on the operating table&#44; with slight left lateral decubitus positioning&#46; Tocolytics are administered to the mother before the intervention&#46; An epidural catheter is placed on the mother for intraoperative and postoperative pain relief&#46; Induction of anaesthesia is followed by rapid-sequence intubation and assisted ventilation&#46; Maternal arterial blood pressure must be maintained at adequate levels to ensure placental perfusion&#46; Maternal oxygenation is optimised to avoid foetal hypoxia&#46; A muscle relaxant and fentanyl are delivered directly to the foetus with a transuterine intramuscular injection&#46; Hysterotomy is subsequently performed&#46; Once the uterus is open&#44; the head and arms of the foetus are exposed&#44; and intubation of the airway can be attempted&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Foetal monitoring includes continuous pulse oximetry with placement of a sensor in the exposed arm&#44; and ultrasound examination of umbilical cord blood flow and heart rate&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Once the procedure has finished &#40;it can take up to 150<span class="elsevierStyleHsp" style=""></span>min&#41;&#44; the umbilical cord is clamped and the newborn is placed in the resuscitation crib for neonatal care and treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">19&#44;20</span></a></p><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Indications</span><p id="par0295" class="elsevierStylePara elsevierViewall">Large cervical or pharyngeal masses such as teratomas&#44; cystic hygromas&#44; haemangiomas or lymphangiomas&#46; Although these lesions are rare&#44; they can cause compression of the foetal upper airway and substantially complicate resuscitation in the delivery room&#46; If airway patency cannot be achieved&#44; the newborn may develop acidosis or hypoxia and&#44; as a consequence&#44; suffer irreversible brain damage or death&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">This complication is all the more tragic if we consider that many of these patients develop normally if the isolated malformation can be overcome&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> This requires a prior accurate and detailed prenatal diagnosis&#44; evaluating the degree of airway compression and the complexity of neonatal resuscitation&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Ultrasound can be used to detect indirect signs of secondary airway and oesophageal obstruction&#44; such as polyhydramnios&#44; increased lung volume&#44; inversion of the diaphragm&#44; ascites and foetal hydrops &#40;CHAOS&#41;&#46; Magnetic resonance imaging allows a more detailed evaluation&#44; facilitating the planning of EXIT and other necessary interventions &#40;intubation&#44; tracheotomy&#44; puncture of the mass in cases of lymphangioma or resection&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Other indications for EXIT are<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">22&#44;23</span></a>&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">1&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Ultrasound-guided percutaneous puncture during the EXIT procedure in cases of giant cervical lymphangioma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">2&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Reversion of foetal tracheal obstruction in congenital diaphragmatic hernia&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">3&#46;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Thoracic abnormalities&#58; massive pleural effusion and large congenital cystic adenoid malformation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">4&#46;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Closure of thoracoamniotic shunts&#46; Thoracotomy and lobectomy of the lung&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">5&#46;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Central access line placement prior to ECMO&#46;</p></li></ul></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Recommendations</span><p id="par0340" class="elsevierStylePara elsevierViewall">Planning performance of EXIT is indicated in cases of severe foetal airway obstruction &#40;A&#41;&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Extracorporeal membrane oxygenation &#40;ECMO&#41;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation is a technique that can sustain vital functions by the artificial replacement of the heart&#44; lungs or both for a period of time until the recovery of native cardiac and&#47;or respiratory function&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">This technique must be used in patients with reversible conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a></p><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Components of the ECMO circuit</span><p id="par0355" class="elsevierStylePara elsevierViewall">The main components of the circuit are a venous drainage cannula&#44; venous access line&#44; pump&#44; oxygenator&#44; arterial access line and arterial or venous return cannula&#44; depending on the type of support&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Physiology</span><p id="par0360" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation is achieved by drainage of venous blood followed by the exchange of CO<span class="elsevierStyleInf">2</span> and O<span class="elsevierStyleInf">2</span> through an artificial membrane &#40;oxygenator&#41;&#44; with a pump pushing the blood through and returning it to the systemic circulation&#44; either venous &#40;venovenous ECMO&#41; or arterial &#40;venoarterial ECMO&#41;&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Venovenous ECMO provides respiratory support&#44; and venoarterial ECMO respiratory as well as cardiac support&#46; The support can be partial or total&#44; depending on the needs of the patient&#46;</p><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Indications and contraindications</span><p id="par0370" class="elsevierStylePara elsevierViewall">Most newborns who need ECMO are patients with pulmonary hypertension that experience respiratory failure&#44; leading to sustained hypoxaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">The primary cause varies and has an impact on the final efficacy of ECMO&#46; Congenital diaphragmatic hernia&#44; meconium aspiration syndrome&#44; persistent pulmonary hypertension and respiratory distress syndrome are the respiratory diseases for which ECMO is used most frequently&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Indications<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">25&#44;27</span></a></span><p id="par0380" class="elsevierStylePara elsevierViewall">Oxygenation index &#40;OI&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>mean airway pressure<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>100</p><p id="par0385" class="elsevierStylePara elsevierViewall">Oxygenation index &#8805;<span class="elsevierStyleHsp" style=""></span>40&#58; indicated&#46;</p><p id="par0390" class="elsevierStylePara elsevierViewall">Oxygenation index &#8805;<span class="elsevierStyleHsp" style=""></span>20&#58; consider use&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Contraindications</span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Absolute</span><p id="par0395" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">1&#46;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Lethal chromosomal disorders</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">2&#46;</span><p id="par0405" class="elsevierStylePara elsevierViewall">Severe irreversible brain damage</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">3&#46;</span><p id="par0410" class="elsevierStylePara elsevierViewall">Grade III or greater intraventricular haemorrhage</p></li></ul></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Relative</span><p id="par0415" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">1&#46;</span><p id="par0420" class="elsevierStylePara elsevierViewall">Irreversible organ damage &#40;possibility of transplantation&#41;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">2&#46;</span><p id="par0425" class="elsevierStylePara elsevierViewall">Body weight<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>kg</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">3&#46;</span><p id="par0430" class="elsevierStylePara elsevierViewall">Postmenstrual age<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>34 weeks</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">4&#46;</span><p id="par0435" class="elsevierStylePara elsevierViewall">Disease with a high probability of poor prognosis</p></li></ul></p><p id="par0440" class="elsevierStylePara elsevierViewall">The efficacy of ECMO is based on the ability of the patient to recover from lung disease in a short period of time &#40;14&#8211;21 days&#41;&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">From the second week of ECMO&#44; the risks and complications associated with the technique &#40;clot formation&#44; nosocomial infection&#44; mechanical problems in the circuit&#44; etc&#46;&#41; increase&#46; Most facilities accept a maximum duration of ECMO of 20&#8211;30 days&#44; although improvements in the use of this technique have resulted in increases in this time interval&#46;</p></span></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Discontinuation of ECMO</span><p id="par0450" class="elsevierStylePara elsevierViewall">The main indication for discontinuation is the recovery of adequate pulmonary and cardiac function&#46; As oxygenation improves&#44; the patient is progressively weaned off support until it is fully withdrawn&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Complications</span><p id="par0455" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> enumerates potential complications of ECMO&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Recommendations</span><p id="par0460" class="elsevierStylePara elsevierViewall">Extracorporeal membrane oxygenation is indicated in severe neonatal pulmonary disease that can be reversed with a short period of use &#40;B&#41;&#46;</p></span></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Conflict of interests</span><p id="par0465" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The recommendations included in this document will be part a series of updated reviews of the literature on respiratory support in the newborn infant&#46; These recommendations are structured into 12 modules&#44; and in this work module 8 is presented&#46; Each module is the result of a consensus process amongst all members of the Surfactant and Respiratory Group of the Spanish Society of Neonatology&#46; They represent a summary of the published papers on each specific topic&#44; as well as the clinical experience of each one of the members of the group&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las recomendaciones incluidas en este documento forman parte de una revisi&#243;n actualizada de la asistencia respiratoria en el reci&#233;n nacido&#46; Est&#225;n estructuradas en 12 m&#243;dulos&#44; y en este trabajo se presenta el m&#243;dulo 8&#46; El contenido de cada m&#243;dulo es el resultado del consenso de los miembros del Grupo Respiratorio y Surfactante de la Sociedad Espa&#241;ola de Neonatolog&#237;a&#46; Representan una s&#237;ntesis de los trabajos publicados y de la experiencia cl&#237;nica de cada uno de los miembros del grupo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Castillo Salinas F&#44; Elorza Fern&#225;ndez D&#44; Guti&#233;rrez Laso A&#44; Moreno Hernando J&#44; Bustos Lozano G&#44; Gresa Mu&#241;oz M&#44; et al&#46; Recomendaciones para la asistencia respiratoria en el reci&#233;n nacido &#40;<span class="elsevierStyleSmallCaps">IV</span>&#41;&#46; Ventilaci&#243;n de alta frecuencia&#44; <span class="elsevierStyleItalic">ex-utero intrapartum treatment</span> &#40;EXIT&#41;&#44; oxigenador de membrana extracorp&#243;rea &#40;ECMO&#41;&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;87&#58;295&#46;e1&#8211;295&#46;e7&#46;</p>"
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            "apendice" => "<p id="par0470" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dr F&#233;lix Castillo Salinas</span>&#46; Department of Neonatology&#44; Hospital Universitario Vall d&#8217;Hebr&#243;n&#44; Barcelona&#46; <span class="elsevierStyleItalic">Dr Dolores Elorza Fern&#225;ndez</span>&#46; Department of Neonatology&#44; Hospital Universitario La Paz&#44; Madrid&#46; <span class="elsevierStyleItalic">Dr Antonio Guti&#233;rrez Laso</span>&#46; Department of Neonatology&#44; Hospital Universitario La Fe&#44; Valencia&#46; <span class="elsevierStyleItalic">Dr Julio Moreno Hernando</span>&#46; Department of Neonatology&#44; Hospital Universitario Sant Joan de D&#233;u&#44; Barcelona&#46; <span class="elsevierStyleItalic">Dr Gerardo Bustos Lozano</span>&#46; Department of Neonatology&#44; Hospital Universitario 12 de Octubre&#44; Madrid&#46; <span class="elsevierStyleItalic">Dr Manuel Gresa Mu&#241;oz</span>&#46; Department of Neonatology&#44; Hospital Materno-Insular Las Palmas&#44; Las Palmas&#46; <span class="elsevierStyleItalic">Dr Xavier Miracle Echegoyen&#46;</span> Department of Neonatology&#44; Hospital Cl&#237;nic-Maternidad&#44; Barcelona&#46; <span class="elsevierStyleItalic">Dr Jon L&#243;pez de Heredia Goya</span>&#46; Department of Neonatology&#44; Hospital de Cruces&#44; Barakaldo&#46; <span class="elsevierStyleItalic">Dr Marta Aguar Carrascosa</span>&#46; Department of Neonatology&#44; Hospital Universitario La Fe&#44; Valencia&#46; <span class="elsevierStyleItalic">Dr Jos&#233; Ram&#243;n Fern&#225;ndez Lorenzo</span>&#44; Department of Neonatology&#44; Complejo Universitario de Vigo&#46; <span class="elsevierStyleItalic">Dr Mar&#237;a del Mar Serrano&#46;</span> Hospital Materno-Infantil Carlos Haya&#44; M&#225;laga&#46; <span class="elsevierStyleItalic">Dr Ana Concheiro Guisan&#46;</span> Department of Neonatology&#44; Complejo Hospitalario Universitario de Vigo&#46; <span class="elsevierStyleItalic">Dr Cristina Carrasco Carrasco&#46;</span> Department of Neonatology&#44; Hospital Universitario Sant Joan de D&#233;u&#44; Barcelona&#46; <span class="elsevierStyleItalic">Dr Juan Jos&#233; Comu&#241;as G&#243;mez&#46;</span> Department of Neonatology&#44; Hospital Universitario Vall d&#8217;Hebr&#243;n&#44; Barcelona&#46; <span class="elsevierStyleItalic">Dr Mar&#237;a Teresa Moral Pumarega&#46;</span> Hospital Universitario 12 de Octubre&#44; Madrid&#46; <span class="elsevierStyleItalic">Dr Ana Mar&#237;a S&#225;nchez Torres&#46;</span> Department of Neonatology&#44; Hospital Universitario La Paz&#44; Madrid&#46; <span class="elsevierStyleItalic">Dr Mar&#237;a Luisa Franco&#46;</span> Department of Neonatology&#44; Hospital Universitario Gregorio Mara&#241;&#243;n&#44; Madrid&#46;</p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Group on Respiration and Surfactant &#40;Grupo Respiratorio y Surfactante &#91;RESPISURF&#93;&#41; of the Sociedad Espa&#241;ola de Neonatolog&#237;a &#40;Spanish Society of Neonatology&#41;&#46;"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Oberg"
                            1 => "U&#46; Sjostrand"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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                        "fecha" => "1969"
                        "volumen" => "75"
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                      ]
                    ]
                  ]
                ]
              ]
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            1 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recomendaciones sobre la ventilaci&#243;n de alta frecuencia en el reci&#233;n nacidos"
                      "autores" => array:1 [
                        0 => array:2 [
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                          "etal" => false
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
                        "fecha" => "2002"
                        "volumen" => "57"
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                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Ventilaci&#243;n de alta frecuencia oscilatoria como estrategia de rescate en el reci&#233;n nacido&#46; Estudio multic&#233;ntrico espa&#241;ol"
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "Grupo Colaborativo Espa&#241;ol sobre la Ventilaci&#243;n Oscilatoria de Alta Frecuencia de la Sociedad Espa&#241;ola de Neonatolog&#237;a"
                          "etal" => false
                          "autores" => array:6 [
                            0 => "F&#46; Morcillo"
                            1 => "A&#46; Guti&#233;rrez"
                            2 => "J&#46; P&#233;rez"
                            3 => "J&#46; Quero"
                            4 => "S&#46; Salcedo"
                            5 => "F&#46; Castillo"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
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                        "volumen" => "50"
                        "paginaInicial" => "269"
                        "paginaFinal" => "274"
                      ]
                    ]
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            3 => array:3 [
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Effective pulmonary ventilation with small-volume oscillations at high frequency"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Slutsky"
                            1 => "J&#46; Drazen"
                            2 => "R&#46; Ingram"
                            3 => "R&#46; Kamm"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Science"
                        "fecha" => "1980"
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                        "paginaFinal" => "611"
                        "link" => array:1 [
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                0 => array:3 [
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                      "titulo" => "Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Cools"
                            1 => "D&#46;J&#46; Henderson-Smart"
                            2 => "M&#46; Offringa"
                            3 => "L&#46;M&#46; Askie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:3 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2009"
                        "volumen" => "8"
                      ]
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                  ]
                ]
              ]
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            5 => array:3 [
              "identificador" => "bib0165"
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                    0 => array:2 [
                      "titulo" => "Elective high frequency oscillatory ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm infants"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Cools"
                            1 => "M&#46; Offringa"
                            2 => "L&#46;M&#46; Askie"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:2 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High-frequency oscillatory ventilation for the prevention of chronic lung disease of prematurity"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46; Johnson"
                            1 => "A&#46; Greenough"
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                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa020432"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2001"
                        "volumen" => "347"
                        "paginaInicial" => "633"
                        "paginaFinal" => "642"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12200550"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
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                0 => array:2 [
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2017.04.003

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	16	20	36
2024 October	69	47	116
2024 September	86	41	127
2024 August	121	62	183
2024 July	168	53	221
2024 June	145	37	182
2024 May	104	38	142
2024 April	96	29	125
2024 March	89	39	128
2024 February	58	29	87
2024 January	79	29	108
2023 December	90	28	118
2023 November	47	44	91
2023 October	73	36	109
2023 September	60	38	98
2023 August	66	31	97
2023 July	78	30	108
2023 June	86	41	127
2023 May	92	27	119
2023 April	81	26	107
2023 March	108	36	144
2023 February	127	20	147
2023 January	90	37	127
2022 December	138	33	171
2022 November	114	36	150
2022 October	119	47	166
2022 September	106	48	154
2022 August	125	58	183
2022 July	125	55	180
2022 June	102	51	153
2022 May	105	45	150
2022 April	105	42	147
2022 March	116	60	176
2022 February	99	61	160
2022 January	135	88	223
2021 December	100	70	170
2021 November	90	51	141
2021 October	170	93	263
2021 September	90	53	143
2021 August	70	57	127
2021 July	101	35	136
2021 June	80	54	134
2021 May	101	61	162
2021 April	214	109	323
2021 March	122	51	173
2021 February	87	17	104
2021 January	114	31	145
2020 December	97	33	130
2020 November	80	18	98
2020 October	90	25	115
2020 September	81	56	137
2020 August	93	26	119
2020 July	93	32	125
2020 June	89	21	110
2020 May	118	33	151
2020 April	199	36	235
2020 March	244	46	290
2020 February	102	38	140
2020 January	65	36	101
2019 December	83	44	127
2019 November	76	24	100
2019 October	124	34	158
2019 September	108	29	137
2019 August	94	26	120
2019 July	60	31	91
2019 June	63	25	88
2019 May	119	45	164
2019 April	99	41	140
2019 March	58	99	157
2019 February	46	21	67
2019 January	54	33	87
2018 December	54	30	84
2018 November	104	46	150
2018 October	88	21	109
2018 September	50	14	64
2018 August	12	0	12
2018 July	3	0	3
2018 June	4	0	4
2018 May	11	0	11
2018 April	28	0	28
2018 March	37	0	37
2018 February	25	0	25
2018 January	16	0	16
2017 December	16	0	16
2017 October	0	17	17

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