Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. 240 (doi:10.1542/10.1542/peds.2007-1065)

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LETTER TO THE EDITOR

Ventilatory Pump Failure and Strategies to Prevent Bronchopulmonary Dysplasia

Jon F. Watchko, MD
Division of Newborn Medicine
Department of Pediatrics
University of Pittsburgh School of Medicine
Pittsburgh, PA 15213

To the Editor.—

It was with great interest that I read Dr Aly's commentary regarding strategies for preventing bronchopulmonary dysplasia (BPD).¹ The avoidance of intubation and conventional mechanical ventilation is a commendable goal when clinically feasible, and more widespread effective use of early nasal continuous positive airway pressure (CPAP) holds potential clinical promise to reduce the incidence and severity of BPD. However, the effectiveness of any CPAP strategy will depend on factors that extend beyond operator experience and include, among other physiologic variables, the severity of the infant's underlying parenchymal lung disease and the maturity of the newborn's ventilatory pump. Although the former is widely appreciated as an important respiratory variable in predicting the need for conventional mechanical ventilator support, the latter is often overlooked, to the detriment of establishing clinically effective respiratory support for the extremely low birth weight (ELBW) neonate. This neonatologist's experience suggests that ventilatory pump failure is often an indication for initiation of conventional mechanical ventilator support in early postnatal life and a contributor to the duration of such support as well, especially in the ELBW preterm neonate.² Immaturity of the ventilatory pump in preterm neonates is characterized by diminished central neural respiratory drive, contractile properties of the diaphragm and accessory muscles of respiration that limit force generation, and thoracoabdominal mechanics that place the preterm neonate at a disadvantage when challenged with lung disease.^3,4 These factors individually and collectively predispose to ventilatory pump failure in ELBW neonates.^3,4 Despite knowledge of these deficits, little is known regarding how to enhance the effectiveness of the preterm newborn's ventilatory pump. The use of caffeine to increase central neural respiratory drive is currently the only widely used intervention aimed at enhancing the effectiveness of the preterm neonate's ventilatory pump, and it is of interest that caffeine therapy for apnea of prematurity was shown recently to reduce the rate of BPD in very low birth weight newborns.⁵ Novel noninvasive efforts designed to improve chest wall stability and support lung volume in preterm newborns may prove beneficial but await more widespread application in the clinical arena.⁶ Until additional strategies are developed to enhance central neural respiratory drive and newborn respiratory muscle contractile properties and improve the preterm neonate's chest wall mechanics, success in using CPAP in the respiratory support of the ELBW neonate will be suboptimal and its therapeutic potential to reduce the incidence of BPD not fully realized.

REFERENCES

1. Aly H. Is there a strategy for preventing bronchopulmonary dysplasia? Absence of evidence is not evidence of absence. Pediatrics. 2007;119 :818 –820[Free Full Text]
2. Watchko JF, Balsan MJ. Ventilatory pump failure in premature newborns. Pediatr Pulmonol. 1994;17 :231 –233[CrossRef][Web of Science][Medline]
3. Watchko JF, Mayock DE, Standaert TA, Woodrum DE. The ventilatory pump: neonatal and developmental issues. Adv Pediatr. 1991;38 :109 –134[Medline]
4. Devlieger H. The Chest Wall in the Preterm Infant. Leuven, Belgium: Katholieke Universiteit; 1987
5. Schmidt B, Roberts RS, Davis P, et al. Caffeine therapy for apnea of prematurity. N Engl J Med. 2006;354 :2112 –2121[Abstract/Free Full Text]
6. Miller TL, Palmer C, Shaffer TH, Wolfson MR. Neonatal chest wall suspension splint: a novel and noninvasive method for support of lung volume. Pediatr Pulmonol. 2005;39 :512 –520[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Watchko, J. F. Search for Related Content PubMed Articles by Watchko, J. F. Related Collections Respiratory Tract Social Bookmarking                         What's this?