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Influence of end expiratory pressure on cerebral blood flow in preterm infants
R A Mullaart1, J C Hopman, J J Rotteveel
1Paediatric Division, University Hospital Nijmegen, The Netherlands.
Insights
Positive End-Expiratory Pressure (PEEP) supports cerebral blood flow (CBF) in neonates with Respiratory Distress Syndrome (RDS). PEEP interruption decreases CBF velocity, but restlessness may lessen this effect, protecting against hypoperfusion.
Area of Science:
- Neonatal Physiology
- Respiratory Medicine
- Cerebrovascular Physiology
Background:
- Mechanical ventilation with Positive End-Expiratory Pressure (PEEP) is crucial for neonates with Respiratory Distress Syndrome (RDS).
- Understanding the impact of PEEP on cerebral blood flow (CBF) is vital for managing potential hypoperfusion in immature brains.
- Cerebral blood flow fluctuations (CBFF) and velocity (CBFV) are key indicators of cerebral perfusion.
Purpose of the Study:
- To investigate the effects of PEEP interruption on CBFV and CBFF in mechanically ventilated neonates with RDS.
- To identify factors influencing CBFV changes during PEEP withdrawal.
- To assess the protective role of PEEP in maintaining cerebral perfusion.
Main Methods:
- Studied 17 mechanically ventilated neonates diagnosed with RDS.
- Monitored cerebral blood flow velocity (CBFV) and fluctuation (CBFF) in internal carotid arteries.
- Analyzed heart rate, restlessness, and wakefulness during PEEP interruption using multiple regression analysis.
Main Results:
- A significant decrease in CBFV was observed upon PEEP interruption, while CBFF remained unchanged.
- Decreased CBFV reduction was associated with increased restlessness during PEEP withdrawal.
- Higher baseline CBFV, patent ductus arteriosus, and complicated RDS course exacerbated CBFV reduction.
Conclusions:
- PEEP appears to support CBF, potentially by reducing ductal shunting away from the brain.
- PEEP may protect against cerebral hypoperfusion, a significant risk in premature infants with RDS.
- Restlessness can moderate, while factors like patent ductus arteriosus and brain injury can accentuate, CBF reduction during PEEP interruption.
Abstract:
The effect of interruption of positive and expiratory pressure (PEEP) on cerebral blood flow velocity (CBFV) and CBF fluctuation (CBFF) in the internal carotid arteries and on heart rate, restlessness and wakefulness has been studied in 17 mechanically ventilated neonates with RDS. A decrease in CBFV was found, but no significant change in CBFF. Multiple regression analysis showed that the decrease in CBFV is less pronounced if the PEEP interruption is accompanied by restlessness. It further appeared that the decrease in CBFV is more pronounced if CBFV is high, the ductus arteriosus is patent, or RDS follows a complicated course. These findings indicate that PEEP supports CBF, probably by a decrease in ductal stealing from the brain. Therewith PEEP protects against cerebral hypoperfusion which is one of the major risks in RDS and immaturity. Furthermore, our findings suggest that the decrease in CBF during PEEP interruption is moderated by restlessness and accentuated by brain damage.