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ARTICLES: John Kattwinkel, Corrine Stewart, Brian Walsh, Matthew Gurka, and Alix Paget-Brown Responding to Compliance Changes in a Lung Model During Manual Ventilation: Perhaps Volume, Rather Than Pressure, Should be Displayed Pediatrics 2009; 123: e465-e470 [Abstract] [Full text] [PDF]

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Circulation is as Important as Ventilation

Eileen Nicole Simon   (21 March 2009)

Circulation is as Important as Ventilation 21 March 2009
Eileen Nicole Simon, Nurse conradsimon.org Send letter to journal: Re: Circulation is as Important as Ventilation eileen{at}conradsimon.org Eileen Nicole Simon	Resuscitation of the newborn should focus on reestablishment of circulation, as is now the goal for resuscitation of adults. Ventilation may not be the optimal way to effect lung inflation. Evidence from more than 50 years ago should be considered by Kattwinkel et al. (2009) and other childbirth care givers [1]. Jäykkä (1958) demonstrated that inflation of lungs from fetuses that died before birth could be accomplished by infusing liquid into the pulmonary artery [2, 3]. The liquid filled the capillaries that supply the alveoli, and lungs expanded in this way resembled normally inflated lungs. Jäykkä described inflation by filling of the capillaries as “erectile expansion,” as distinct from inflation brought about by introducing air through the bronchus. Filling of capillaries that supply the alveoli is not a passive process that follows ventilation. On the contrary, Jäykkä found that ventilation led to over-inflation of lung areas proximal to the bronchi, leaving distal areas unexpanded. Filling of the capillaries that supply the alveoli produced uniform expansion throughout the lungs. Jäykkä urged greater attention to resuscitation procedures that promote filling of the capillaries, and he stressed that forceful introduction of air into atelectatic (fetal state) lungs results in abnormal and incomplete expansion. By nature’s plan and in the past, filling of the capillary bed would take place by gradual transfer of placental blood to the lungs. Gunther (1957), among others, measured this transfer, and documented that some infants did not begin breathing for several minutes after birth, but because the umbilical cord remained intact, placental respiration obviously kept the baby well oxygenated [4]. Mahaffey and Rossdale (1957) wrote a letter in response to the article by Gunther, and described a convulsive syndrome in thoroughbred foals that they attributed to human intervention at birth, and in which the lungs failed to expand normally [5, 6]. Recent rediscovery that maintaining placental circulation is helpful, until pulmonary respiration is established, should hopefully reduce the percentage of infants requiring resuscitation [7, 8, 9]. Hutchon and Thakur (2007, 2008) have devised a “Resuscitaire” table that can be rolled over to the delivery table so that ventilation can be done without clamping off ongoing blood flow from the placenta [10, 11]. Eileen Nicole Simon, PhD, RN References 1. Kattwinkel J, Stewart C, Walsh B, Gurka M, Paget-Brown A. Responding to compliance changes in a lung model during manual ventilation: perhaps volume, rather than pressure, should be displayed. Pediatrics. 2009 Mar;123(3):e465-70. 2. Jäykkä S. Capillary erection and the structural appearance of fetal and neonatal lungs. Acta Paediatr. 1958 Sep;47(5):484-500. 3. Jäykkä S. Capillary erection and lung expansion; an experimental study of the effect of liquid pressure applied to the capillary network of excised fetal lungs. Acta Paediatr Suppl. 1957 Jan;46(suppl 112):1-91. 4. Gunther M. The transfer of blood between baby and placenta in the minutes after birth. Lancet. 1957 Jun 22;272(6982):1277-80. 5. Mahaffey LW, Rossdale PD (1957) On the newborn infant's oxygen supply. Lancet 1957 Jul 13, ii:95. 6. Mahaffey LW, Rossdale PD. A convulsive syndrome in newborn foals resembling pulmonary syndrome in the newborn infant. Lancet. 1959 Jun 13; 1(7085):1223-5. 7. Mercer JS, Skovgaard RL. Neonatal transitional physiology: A new paradigm. J Perinat Neonatal Nurs. 2002 Mar;15(4):56-75. 8. Mercer J, Erickson-Owens D, Skovgaard R. Cardiac asystole at birth: Is hypovolemic shock the cause? Med Hypotheses. 2009 Apr;72(4):458- 63. 9. Wyllie J, Niermeyer S. The role of resuscitation drugs and placental transfusion in the delivery room management of newborn infants. Semin Fetal Neonatal Med. 2008 Dec;13(6):416-23. 10. Hutchon DJ, Thakur I. Resuscitate with the placental circulation intact. Arch Dis Child. 2008 May;93(5):451. 11. Hutchon DJ, Thakur I. How to (allow the paediatrician to) Resuscitate the Neonate with the Cord Intact at Caesarean Section. PowerPoint presentation at the 31st British Congress of Obstetrics and Gynaecology, London, 6 July 2007. Obtained from David Hutchon <djrhutchon@hotmail.co.uk> Conflict of Interest: None declared