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Late Permissive Hypercapnia for Mechanically Ventilated Preterm Infants: A Randomized Trial.

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Targeting higher levels of permissive hypercapnia (pH-controlled) in preterm infants after 7-14 days of mechanical ventilation increased ventilator-free days. This approach may offer lung protection compared to lower permissive hypercapnia levels.

Keywords:
artificialbronchopulmonary dysplasiahypercapniainfantnewbornprematurerespirationrespiratory distress syndrome

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Area of Science:

  • Neonatalogy
  • Pediatric critical care
  • Respiratory physiology

Background:

  • Permissive hypercapnia is used in mechanical ventilation for preterm infants with respiratory distress syndrome.
  • Optimal target levels for permissive hypercapnia beyond the initial postnatal period are not well-established.
  • This study investigated higher vs. lower pH-controlled permissive hypercapnia targets.

Purpose of the Study:

  • To determine if targeting higher levels of pH-controlled permissive hypercapnia beyond postnatal day 7-14 reduces mechanical ventilation duration in preterm infants.
  • To assess the impact of higher permissive hypercapnia levels on ventilator-free days and bronchopulmonary dysplasia.
  • To evaluate the potential lung-protective effects of higher permissive hypercapnia targets.

Main Methods:

  • Single-center randomized clinical trial (NCT02799875) with 130 preterm infants (22-36 weeks' gestation).
  • Infants received either higher (PaCO2 60-75 mmHg, pH ≥ 7.20) or lower (PaCO2 40-55 mmHg, pH ≥ 7.25) pH-controlled permissive hypercapnia for 28 days.
  • Primary outcome: days alive and ventilator-free within 28 days post-randomization.

Main Results:

  • Infants in the higher permissive hypercapnia group had significantly more alive ventilator-free days (11 ± 10 vs. 6 ± 8; P = 0.009).
  • No significant difference in grade 2-3 bronchopulmonary dysplasia or death before discharge between groups (44% vs. 59%; aOR 0.54).
  • Grade 2-3 bronchopulmonary dysplasia among survivors at 36 weeks' postmenstrual age did not differ significantly between groups (35% vs. 50%; aOR 0.56).

Conclusions:

  • Targeting higher levels of permissive hypercapnia from postnatal day 7-14 increased ventilator-free days in preterm infants.
  • This strategy may offer lung protection compared to lower permissive hypercapnia levels.
  • Further research is needed to fully elucidate the long-term effects and optimal management strategies.