Management of Infants With Severe Respiratory Failure and Persistence of the Fetal Circulation, Without Hyperventilation

TLDR

The treatment minimized barotrauma by using nasotracheal intubation with intermittent mandatory ventilation, setting peak inspiratory pressures based on chest excursion, targeting PaO₂ of 50–70 mm Hg while permitting PaCO₂ up to 60 mm Hg, and avoiding hyperventilation and muscle relaxants. In 15 infants, the regimen led to 100 % survival, with only one developing chronic lung disease; high ventilator rates improved chest excursion in half of the infants requiring high pressures, tolazoline improved oxygenation in most of the 14 treated, and dopamine helped the three oliguric patients.

Abstract

The successful management of 15 infants suffering from persistence of fetal pulmonary circulation and in severe respiratory failure is presented. The treatment regimen focused on minimizing barotrauma. Infants were intubated nasotracheally and ventilated with intermittent mandatory ventilation. Peak inspiratory pressures were determined by the clinical assessment of chest excursion. Ventilator settings and fractional inspiratory oxygen (FiO2) were selected to maintain a PaO2 between 50 and 70 mm Hg; PaCO2 was not a controlling parameter and was allowed to increase as high as 60 mm Hg. Hyperventilation and muscle relaxants were not used. High ventilator rate was used in ten infants who required high inspiratory pressure to maintain chest excursion, with a favorable response in five. Tolazoline was given to 14 infants of whom ten showed an improvement in oxygenation; dopamine was given to three infants who were oliguric. All infants survived, and only one infant developed chronic lung disease which was defined by the infant's need for supplemental oxygen beyond 30 days of life.