Ineffective aeration during the first inflations at birth creates regional aeration and ventilation defects, initiating injurious pathways. This study aimed to compare a sustained first inflation at birth or dynamic end-expiratory supported recruitment during tidal inflations against ventilation without intentional recruitment on gas exchange, lung mechanics, spatiotemporal regional aeration and tidal ventilation, and regional lung injury in preterm lambs. Lambs (127 ± 2 d gestation), instrumented at birth, were ventilated for 60 minutes from birth with either lung-protective positive pressure ventilation (control) or as per control after either an initial 30 seconds of 40 cm H2O sustained inflation (SI) or an initial stepwise end-expiratory pressure recruitment maneuver during tidal inflations (duration 180 s; open lung ventilation [OLV]). At study completion, molecular markers of lung injury were analyzed. The initial use of an OLV maneuver, but not SI, at birth resulted in improved lung compliance, oxygenation, end-expiratory lung volume, and reduced ventilatory needs compared with control, persisting throughout the study. These changes were due to more uniform inter- and intrasubject gravity-dependent spatiotemporal patterns of aeration (measured using electrical impedance tomography). Spatial distribution of tidal ventilation was more stable after either recruitment maneuver. All strategies caused regional lung injury patterns that mirrored associated regional volume states. Irrespective of strategy, spatiotemporal volume loss was consistently associated with up-regulation of early growth response-1 expression. Our results show that mechanical and molecular consequences of lung aeration at birth are not simply related to rapidity of fluid clearance; they are also related to spatiotemporal pressure-volume interactions within the lung during inflation and deflation.

A sustained first inflation (SI) at birth may aid lung liquid clearance and aeration, but the impact of SI duration relative to the volume-response of the lung is poorly understood. We compared three SI strategies: 1) variable duration defined by attaining volume equilibrium using real-time electrical impedance tomography (EIT; SI plat); 2) 30 s beyond equilibrium (SI long); 3) short 30-s SI (SI30); and 4) positive pressure ventilation without SI (no-SI) on spatiotemporal aeration and ventilation (EIT), gas exchange, lung mechanics, and regional early markers of injury in preterm lambs. Fifty-nine fetal-instrumented lambs were ventilated for 60 min after applying the allocated first inflation strategy. At study completion molecular and histological markers of lung injury were analyzed. The time to SI volume equilibrium, and resultant volume, were highly variable; mean (SD) 55 (34) s, coefficient of variability 59%. SI plat and SIlong resulted in better lung mechanics, gas exchange and lower ventilator settings than both no-SI and SI30. At 60 min, alveolar-arterial difference in oxygen was a mean (95% confidence interval) 130 (13, 249) higher in SI30 vs. SIlong group (two-way ANOVA). These differences were due to better spatiotemporal aeration and tidal ventilation, although all groups showed redistribution of aeration towards the nondependent lung by 60 min. Histological lung injury scores mirrored spatiotemporal change in aeration and were greatest in SI 30 group (P Ͻ 0.01, Kruskal-Wallis test). An individualized volume-response approach to SI was effective in optimizing aeration, homogeneous tidal ventilation, and respiratory outcomes, while an inadequate SI duration had no benefit over positive pressure ventilation alone. sustained inflation; neonatal resuscitation; lung mechanics; lung volume; variability; electrical impedance tomography; lung injury THE MAJORITY OF EXTREMELY preterm infants require respiratory assistance in the delivery room (41). In part this is because many of these infants do not have the ability to generate the initial prolonged high transpulmonary pressures required to drive lung fluid from the main airways, allow alveolar aeration, establish functional residual capacity (FRC), and then maintain it during tidal ventilation, essential processes for efficient gas exchange and lung protection (19,31). Recently, applying an initial sustained inflation (SI) at birth, consisting of an elevated pressure applied for longer than needed for usual tidal inflation, followed by sufficient positive end-expiratory pressure (PEEP), has been proposed as a method of generating the initial transpulmonary pressure needed at birth (10,18,20). SI has been extensively investigated in preterm animals (15,26,29,32,33,(35)(36)(37)(38) and humans (10, 18, 34) with conflicting results. Some studies suggested SI improved aeration, FRC, and cerebral oxygen delivery (29,32,33), while others failed to demonstrate any benefit over standard respiratory support with sufficient PEEP (26,(35)(36)(37). SI was associated wi...

Background: In translational animal studies both a sustained inflation (SI) and PEEP have been associated with better lung aeration at birth, but the role of each on lung injury is inconclusive. We aimed to determine the effect of different PEEP and SI strategies at birth on early development of lung injury pathways. Method: 70 antenatal-steroid exposed lambs (125d AE 1d) were instrumented during caesarean section. Lambs were randomly assigned to either 1) Positive Pressure Ventilation (PPV; n = 20) using volume targeted ventilation at PEEP 8 cmH 2 O (maximum PIP 35 cmH 2 O, V T 7 ml/kg), 2) Volumetric Sustained Inflation 1 at 35 cmH 2 O until full aeration was visualised using electrical impedance tomography (SI; n = 23), or 3) 3-min Dynamic PEEP strategy 1 guided by breath-to-breath compliance (n = 27). All lambs were treated at 10 min with surfactant 200 mg/kg, and then received PPV for 90 min, with measurement of mechanics and gas exchange throughout. Standardised samples from the gravity-dependent and non-dependent lung were analysed for early injury mRNA markers (EGR1, CYR61, CTGF, IL-6,-8,-1B) and histology. Results: All groups expressed injury in the non-dependent lung compared to unventilated fetal controls across all injury parameters (p < 0.0001 ANOVA). In the dependent lung, only SI resulted in higher EGR1, CYR61, CTGF, IL-6,-1B expression compared to PPV and dynamic PEEP (p < 0.0001 ANOVA), and both were not different from fetal controls. Dynamic PEEP had better oxygenation throughout (p < 0.0001, two-way ANOVA) Conclusions: This large preterm lamb study is the first to show significant injury differences between SI and PEEP starte-gies. Early lung injury was heterogeneous and greater in the dependent lung following a SI. This suggests that achieving aeration slowly using tidal inflations maybe more beneficial than a SI. Reference: 1. Tingay DG et al. Background: Volume targeted ventilation (VTV) is widely used and may reduce lung injury, but this assumes the clinically set V T (V Tset) is accurately delivered. The aims of this prospective observational study were to determine the relationship between V Tset , expiratory V T (V Te) and endotracheal tube leak in a modern neonatal VTV ventilator, and the resultant PaCO 2 relationship with and without VTV. Method: Continuous inflations were recorded for 24 hours in 100 infants receiving synchronised mechanical ventilation (SLE5000, SLE Ltd, UK) with VTV (n = 77 infants) or without, and either the manufacturer's V4 (n = 50) or newer V5 (n = 50) VTV algorithm. For every inflation the set V Tset , V Te and leak were determined (maximum 90000 inflations/infant). If PaCO 2 was sampled (maximum 2/infant), this was compared with the average V T data from the preceeding 15 minutes. Results: A total of 7,917,020 inflations were analysed. Using VTV the V Tset-V Te bias (95% CI) was 0.3 (−0.12, 0.19) mL/kg. Leak influenced V Tset-V Te bias with V4 algorithm (r 2 = −0.64, p < 0.0001; linear regression) but not V5 (r 2 = 0.04, p = 0.21). Overall 80% of V Te were AE...

BackgroundCurrent sustained lung inflation (SI) approaches use uniform pressures and durations. We hypothesized that gestational-age-related mechanical and developmental differences would affect the time required to achieve optimal lung aeration, and resultant lung volumes, during SI delivery at birth in lambs.Methods49 lambs, in five cohorts between 118 and 139 days of gestation (term 142 d), received a standardized 40 cmHO SI, which was delivered until 10 s after lung volume stability (optimal aeration) was visualized on real-time electrical impedance tomography (EIT), or to a maximum duration of 180 s. Time to stable lung aeration (T) within the whole lung, gravity-dependent, and non-gravity-dependent regions, was determined from EIT recordings.ResultsT was inversely related to gestation (P<0.0001, Kruskal-Wallis test), with the median (range) being 229 (85,306) s and 72 (50,162) s in the 118-d and 139-d cohorts, respectively. Lung volume at T increased with gestation from a mean (SD) of 20 (17) ml/kg at 118 d to 56 (13) ml/kg at 139 d (P=0.002, one-way ANOVA). There were no gravity-dependent regional differences in T or aeration.ConclusionsThe trajectory of aeration during an SI at birth is influenced by gestational age in lambs. An understanding of this may assist in developing SI protocols that optimize lung aeration for all infants.

The encapsulation of therapeutic molecules within multiple layers of biocompatible and biodegradable polymeric excipients allows exquisite design of their release profile, to the extent the drug can be selectively delivered to a specific target location in vivo. Here, we develop a novel technique for the assembly of multilayer polyelectrolyte nanocarriers based on surface acoustic wave atomization as a rapid and efficient alternative to conventional layer-by-layer assembly, which requires the use of a sacrificial colloidal template over which consecutive polyelectrolyte layers are deposited. Polymer nanocarriers are synthesized by atomizing a polymer solution and suspending them within a complementary polymer solution of opposite charge subsequent to their solidification in-flight as the solvent evaporates; reatomizing this suspension produces nanocarriers with a layer of the second polymer deposited over the initial polymer core. Successive atomization-suspension layering steps can then be repeated to produce as many additional layers as desired. Specifically, we synthesize nanocarriers comprising two and three, and up to eight, alternating layers of chitosan (or polyethyleneimine) and carboxymethyl cellulose within which plasmid DNA is encapsulated and show in vitro DNA release profiles over several days. Evidence that the plasmid's viability is preserved and hence the potential of the technique for gene delivery is illustrated through efficient in vitro transfection of the encapsulated plasmid in human mesenchymal progenitor and COS-7 cells.