Anemia of Prematurity - Portal Neonatal

• Selective main bronchial intubation and occlusion
o Many case reports exist of successful treatment of severe localized PIE in infants with
selective intubation of the contralateral bronchus to decompress the overdistended lung
tissue and to avoid exposing it to high positive inflationary pressures. Selective bronchial
intubation of the right main bronchus is not a difficult procedure; the left side may be more
difficult. The endotracheal tube of the same diameter as for a regular intubation is inserted
2-4 cm beyond its usual position. It is introduced with the bevel on the end of the tube
positioned so that the long part of the tube is toward the bronchus to be intubated. This
increases the chance of entering the correct bronchus as the tube is advanced into the
airway. Turning the infant's head to the left or right moves the tip of the endotracheal tube
to the contralateral side of the trachea and may help in selective tube placement.
o Weintraub et al have described a method for left selective bronchus intubation using a
regular Portex endotracheal tube in which an elliptical hole 1 cm in length has been cut
through half the circumference 0.5 cm above the tip of the oblique distal end. With the
side with the elliptical hole directed to the left lung, left selective bronchus intubation can
be accomplished easily and repeatedly. Another method of selective intubation is the use
of a small fiberoptic bronchoscope to direct the endotracheal tube tip into the desired
bronchus. Selective intubation under fluoroscopy also can be considered.
o Potential complications of the selective intubation/ventilation are atelectasis in the affected
lung, injury to bronchial mucosa with subsequent scarring and stenosis, acute
hypoventilation or hypoxemia if ventilating one lung is inadequate, excessive secretions,
hyperinflation of the intubated or nonoccluded lung, upper lobe collapse when intubating
the right lung, and bradycardia. Despite potential risks, selective bronchial intubation is a
desirable alternative to lobectomy in a persistent, severe, localized PIE causing
mediastinal shift and compression atelectasis and not responding to conservative
management. This procedure should be attempted before any surgical intervention.
• High-frequency ventilation
o Keszler et al studied use of high-frequency jet ventilation (HFJV) in 144 newborns with
PIE. They concluded that HFJV was safe and more effective than rapid-rate conventional
ventilation in the treatment of newborns with PIE. With HFJV, similar oxygenation and
ventilation was obtained at lower peak and mean airway pressures, suggesting that in
infants with PIE a reduction in the amount of air leaking into the interstitial spaces would
occur.
o Similar effects can be achieved by use of HFOV.
� In a study by Clark et al, 27 low birth weight infants who developed PIE and
respiratory failure while on conventional ventilation were treated with HFOV. Surviving
patients showed continued improvement in oxygenation and ventilation at an
increasingly lower fraction of inspired oxygen (FiO2) and proximal airway pressure
with resolution of PIE, while nonsurvivors progressively developed chronic respiratory
insufficiency with continued PIE from which recovery was not possible. Overall
survival in nonseptic patients was 80%.
� They found HFOV to be effective in the treatment of PIE and hypothesized that
interstitial air leak is decreased during HFOV because adequate ventilation is
provided at lower peak distal airway pressures. Although this mode of ventilation has
inherent risks, it can be a very effective tool in experienced hands for the treatment of
severe diffuse PIE. Care must be taken in smaller infants who require a high
amplitude to ventilate because the active exhalation during HFOV may cause small
airway collapse and exacerbate gas trapping.
• Other treatment modalities
o Case reports and/or case series describe different approaches for the management of
PIE, including 3-day course of dexamethasone (0.5 mg/kg/d), chest physiotherapy with
intermittent 100% oxygen in localized and persistent compressive PIE, artificial
pneumothorax, and multiple pleurotomies.
o Despite success claimed by the authors, the efficacy of these treatment modalities seems
questionable. With advancements in respiratory care, these treatment modalities rarely
are used.