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Pulmonary function testing and monitoring plays an important role in the respiratory management of neonates. A noninvasive and complete bedside evaluation of the respiratory status is especially useful in critically ill neonates to assess disease severity and resolution and the response to pharmacological interventions as well as to guide mechanical respiratory support. Besides traditional tools to assess pulmonary gas exchage such as arterial or transcutaenous blood gas analysis, pulse oximetry, and capnography, additional valuable information about global lung function is provided through measurement of pulmonary mechanics and volumes. This has now been aided by commercially available computerized pulmonary function testing systems, respiratory monitors, and modern ventilators with integrated pulmonary function readouts. In an attempt to apply easy-to-use pulmonary function testing methods which do not interfere with the infants airflow, other tools have been developed such as respiratory inductance plethysmography, and more recently, electromagnetic and optoelectronic plethysmography, electrical impedance tomography, and electrical impedance segmentography. These alternative technologies allow not only global, but also regional and dynamic evaluations of lung ventilation. Although these methods have proven their usefulness for research applications, they are not yet broadly used in a routine clinical setting. This review will give a historical and clinical overview of different bedside methods to assess and monitor pulmonary function and evaluate the potential clinical usefulness of such methods with an outlook into future directions in neonatal respiratory diagnostics.

Neonatal abstinence syndrome (NAS) is usually treated with opiate derivatives and supported with nonpharmacological treatment. This prospective, randomized, controlled, blinded, single-center study was carried out between March 2009 and November 2014. Newborn infants diagnosed with NAS after maternal opioid substitution therapy were eligible for inclusion. Infants were randomly allocated to the acupuncture group (combining laser acupuncture and pharmacological therapy of morphine and phenobarbital) or control group (pharmacological therapy alone). Laser acupuncture was performed with a LABpen MED 10 (675 nm/10 mW) at 5 ear and 4 body acupuncture points, bilaterally, and sessions were repeated every day. The primary outcome measure was duration of oral morphine therapy for NAS. Secondary outcomes included highest single Finnegan score, time to highest single Finnegan score, maximum amount of oral morphine solution (in milliliters per kilogram and milligrams per kilogram), time to maximum amount of oral morphine solution, and length of hospital stay. Twenty-eight newborns (14 in each group) were eligible for analysis. Duration of oral morphine therapy was significantly reduced in the acupuncture group compared with the control group (28 vs 39 days, respectively, P = .019). In addition, we observed a significantly reduced length of hospital stay in the acupuncture group compared with the control group (35 days [interquartile range 25 to 47] vs 50 days [36 to 66], P = .048). Adjunctive laser acupuncture significantly reduced the duration of morphine therapy in newborns with NAS.

A pneumothorax (PTX) is a potentially life threatening event during mechanical ventilation. Aim of this study was to analyse 3 different ways of management: expectant treatment, once-only pleural puncture and thoracic drainage.Retrospective data analysis in term and preterm neonates admitted to the NICU of the Medical University of Graz (between 2000-2010) and Innsbruck (2002-2010) who suffered from a PTX during continuous positive airway pressure (CPAP) or conventional mechanical ventilation (CMV).104 neonates, 33 term and 71 preterm neonates with PTX were included. 33 term neonates: 52% were treated expectantly, 36% with thoracic drainage and 12% with once-only pleural puncture (100% thoracic drainage after pleural puncture). 71 preterm neonates: 25% were treated expectantly, 52% with thoracic drainage and 23% with pleural puncture (63% thoracic drainage after pleural puncture). In CPAP-subgroup (n=64), term neonates were treated in 60% expectantly and in 40% with thoracic drain-age, preterm neonates in 33% expectantly, in 47% with thoracic drainage and in 20% with pleural puncture (50% thoracic drainage after pleural puncture). In CMV-subgroup (n=40), term neonates were treated in 44% expectantly, in 33% with thoracic drainage and in 22% with pleural puncture (100% thoracic drainage after pleural puncture), preterm neonates in 9% expectantly, in 64% with thoracic drainage and in 27% with pleural puncture (83% thoracic drain-age after pleural puncture).Present data show that expectant treatment is feasible. If invasive intervention is needed, once-only pleural puncture was not successful, as often thoracic drainage was necessary in addition.

This article provides a narrative review of lung-protective ventilatory strategies (LPVS) in intubated preterm infants with RDS. A description of strategies is followed by results on short-and long-term respiratory and neurodevelopmental outcomes. Strategies will include patient-triggered or synchronized ventilation, volume targeted ventilation, the technique of intubation, surfactant administration and rapid extubation to NCPAP (INSURE), the open lung concept, strategies of high-frequency ventilation, and permissive hypercapnia. Based on this review single recommendations on optimal LPVS cannot be made. Combinations of several strategies, individually applied, most probably minimize or avoid potential serious respiratory and cerebral complications like bronchopulmonary dysplasia and cerebral palsy.

Beim Ubergang vom intrauterinen zum neonatalen Leben mussen 3–6% aller Neugeborenen unterstutzt werden. Damit stellt die neonatale Erstversorgung eine der haufigsten medizinischen Interventionen dar. Mittels eines Fragebogens wurden das verwendete Equipment und das dazugehorige Verwendungsprotokoll bei der Erstversorgung von Neugeborenen in Osterreich erhoben und mit den im Jahr 2005 publizierten Richtlinien des European Resuscitation Council verglichen. Alle 20 kontaktierten Abteilungen beantworteten den Fragebogen. Erfragt wurden die Verwendung von Pulsoxymetrie, Beatmungsbeutel („self-inflating“/“flow-inflating“/“T-piece device“), CO2-Detektor zur Tubuslagekontrolle, Sauerstoffblender, Larynxmaske, oralem Airway, Klarsichtfolie zur Verhinderung des Warmeverlusts bei der Erstversorgung von Fruhgeborenen unter 28 Schwangerschaftswochen sowie die initiale Sauerstoffkonzentration bei der Erstversorgung von Reifgeborenen. Letztere variierte zwischen 21% und 100%. Bei 17 Abteilungen (85%) kamen Sauerstoffblender, bei den ubrigen Flowmeter zur Anwendung. Alle 20 Abteilungen (100%) verwendeten Pulsoxymetrie, 9 (45%) „self-inflating-bags“, 9 (45%) „T-piece devices“ und 2 beide Beatmungshilfen. Einen oralen Airway bei schwieriger Maskenbeatmung nutzten 10 Abteilungen (50%), eine Larynxmaske als Alternative zur Intubation 8 (40%) und einen CO2-Detektor zur Tubuslagekontrolle 6 (30%). Klarsichtfolien zur Verhinderung des Warmeverlusts wurden in 11 Abteilungen (55%) eingesetzt. Dem internationalen Trend entsprechend zeigte sich auch in Osterreich eine grose Variationsbreite des verwendeten Equipments. Dies reflektiert die allgemein ungenugende Datenlage zur Erstversorgung von Neugeborenen.

Eine Analyse der Frage, wer in einer Gesellschaft wen heiratet, gibt Aufschluss uber die Durchlassigkeit bzw. Geschlossenheit sozialer Klassen und uber Egalitat bzw. Hierarchien in Paarbeziehungen. Dem Zusammenleben von Paaren in Ehe und Lebensgemeinschaften liegen zwar individuelle Entscheidungen zu Grunde; diese sind jedoch als Entscheidungsmuster Ausdruck gesellschaftlicher Strukturen. Bildungshomogamie kann in einer modernen Gesellschaft als Indikator der Geschlossenheit sozialer Schichten, Heterogamie als Hinweis auf soziale Mobilitat interpretiert werden.

Background: Inhaled nitric oxide (iNO) is used as a vasodilator in pulmonary hypertension (PH) of the newborn infant. Patients and Methods: Retrospective analysis of patients, who were treated at our department with iNO in the period from 1994-2001. Response was defined as an increase of the paO2/FiO2 Ratio ≥ 20 % and/or a decrease of the oxygenation index (OI) ≥ 20 % after 2 h (early response), and consecutively after 24 h (late response). The patients were divided into a) primary persistent pulmonary hypertension of the newbom (PPHN), or b) pulmonary hypertension secondary to meconium aspiration syndrome (MAS), sepsis or congenital diaphragmatic hernia (CDH). Results: Between 1994 and 2001 we treated 47 patients with iNO at our neonatal intensive care unit. We included 16 (35 %) preterm infants (GA 34,5 [25 - 37] weeks, GG 2061 [680 - 3410] g) (Median/Range) and 31 (65 %) newbom (GA 40 [38 - 42] weeks, GG 3510 [2550 - 4560] g). 18 (38 %) patients suffered from primary PPHN, 29 (62 %) from secondary PPHN (14 MAS [30 %], 8 sepsis [17 %], 4 CDH [8 %]). 8 (50 %) preterm and 20 (64 %) term infants showed a positive iNO response after 2 h, again 8 (50 %) preterm and 20 (64%) term infants showed a positive iNO response after 24 h. There was neither a significant difference between term and preterm infants at 2 h, nor at 24 h. Between 2 h and 24 h 10 patients changed in their response to iNO. 5 (18 %) patients with early response showed a significant degradation after 24 h, whereas 5 (26 %) of the patients without early response showed a significant improvement of the oxygenation alter 24 h. Alltogether 13 (72 %) patients with PPHN, 8 (57 %) with MAS, 2 (50 %) with CDH, 4 (50 %) with sepsis showed a positive iNO response after 24 h. In regard to the oxygenation parameters at start of iNO-therapy, the patients with early response did not differ from the patient without response (median OI: 20,0 versus 21,8, median paO2/FiO2 Ratio: 59,3 versus 55,0 mmHg at the start of the iNO therapy). Conclusion: In regard to iNO response, there was no significant difference between term and preterm infants. Due to the changing response, a positive iNO-response after 2 h had no predictive value for the further prognosis of the oxygenation situation under iNO therapy. Hintergrund: Inhalatives Stickstoffmonoxid (iNO) wird als Vasodilatator bei pulmonaler Hypertonie (PH) des Neugeborenen eingesetzt. Patienten und Methodik: Retrospektive Analyse von Patienten, welche im Zeitraum 1994 - 2001 an unserer Abteilung mit iNO betreut wurden. Ein Ansprechen wurde als Zunahme der paO2/FiO2 Ratio ≥ 20 % und/oder Abfall des Oxygenierungsindexes (OI) ≥ 20 % nach 2 h (positiver 2 h-Effekt) und nach 24 h (positiver 24 h Effekt) definiert. Die Patienten wurden anhand ihrer Grunderkrankungen in a) primaren pulmonalen Hochdruck (PPHN) oder b) sekundaren pulmonalen Hochdruck (PH bei Mekonium-Aspirations-Syndrom [MAS], Sepsis und Zwerchfellhernie [CDH]) unterteilt. Ergebnisse: Zwischen 1994 und 2001 wurden auf unserer neonatologischen Intensivstation 47 Kinder mit iNO behandelt. Davon waren 16 (35 %) Fruhgeborene (GA 34,5 [25 - 37] Wochen, GG 2061 [680 - 3410] g) (Median/Range) und 31 (65 %) Neugeborene (GA 40 [38 - 42] Wochen, GG 3510 [2550 - 4560] g). 18 (38 %) Patienten litten an einem primaren PPHN, 29 (62 %) an einem sekundaren pulmonalen Hochdruck (14 MAS [30 %], 8 an einer Sepsis [17 %], 4 CDH [8 %]). Insgesamt reagierten 8 (50 %) Fruh- und 20 (64 %) Neugeborene nach 2 Stunden, beziehungsweise 8 (50 %) Fruh- und 20 (64 %) Neugeborene nach 24 Stunden positiv auf die iNO-Therapie. Es zeigte sich kein Unterschied im Ansprechen auf iNO zwischen Fruh- und Neugeborenen. Zwischen den Analysezeitpunkten 2 h und 24 h wechselten jedoch 10 Patienten den Reaktionstyp. 5 (18 %) Patienten mit positivem 2 h-Effekt zeigten nach 24 h eine signifikante Verschlechterung, wohingegen 5 (26 %) der Patienten ohne 2 h-Effekt nach 24 h eine signifikante Verbesserung der Oxygenierung zeigten. Nach der Grunderkrankung aufgegliedert, zeigten insgesamt 13 (72 %) Patienten mit PPHN, 8 (57 %) mit MAS, 2 (50 %) mit CDH, 4 (50 %) mit Sepsis einen positiven 24 h-Effekt. In Bezug auf die Oxygenierungsparameter am Start der iNO-Therapie unterschieden sich die Patienten mit positiven 2 h-Effekt nicht von den Patienten ohne 2 h-Effekt (medianer OI: 20,0 versus 21,8, medianer paO2/FiO2O Ratio: 59,3 versus 55,0 mmHg). Schlussfolgerung: Im Ansprechen auf iNO zeigte sich kein Unterschied zwischen Fruh- und Neugeborenen. Aufgrund des wechselnden iNO-Effektes war ein positiver 2 h-Effekt kein sicherer Ausgangspunkt fur die weitere Prognose der Oxygenierungssituation unter iNO-Therapie.

In this study, a critical assessment of the single-occlusion technique as a means of measuring passive respiratory mechanics and respiratory drive (P0.1) was performed in nonintubated spontaneously breathing healthy term neonates using commercially available computerized equipment (PEDS system). In general, we found that quality parameters only partially conformed to the international established standards for measuring passive respiratory mechanics. There was a failure rate of technically acceptable occlusions of about 50% for respiratory mechanics measurements and 20% for P0.1 measurements. Intersubject variability of the data was between 10 and 40%. After studying different lengths of occlusion times (Tocc; 0.2, 0.3, 0.4 and 0.5 s), it was found that acceptable occlusions for passive respiratory mechanics were obtained only if the expiratory Tocc exceeded 0.2 s. Increasing the Tocc had no effect on the absolute values of respiratory mechanics but showed a significant trend towards more technically acceptable occlusions. We speculate that a Tocc of at least 0.4 s may be a prerequisite for obtaining reliable results for respiratory mechanics in healthy term neonates.

Two neonates exhibited the clinical picture of the "blueberry muffin baby" at delivery. The integument manifested petechiae and purpuric magenta-colored macules, papules, and plaques, as well as blueberry-colored ecchymoses. These findings led to the diagnosis of a connatal cytomegalovirus infection and fetal erythroblastosis, respectively. The hemorrhagic-purpuric looking skin lesions reflected extramedullary hematopoiesis with ultrastructural study disclosing evidence of both erythro- and granulopoietic lineage. For the first time, we were able to demonstrate that complexes of red cells in various stages of maturation can occur in the skin, similarly to the erythroblastic islands of the bone marrow. In the pathogenesis of extramedullary hematopoiesis, mechanisms underlying the reconstitution of blood cells must be considered. These may reactivate hematopoiesis in organs where it previously occurred in embryonic and fetal life. Possible causative factors may be great compensatory demand, deficient replacement, or loss or dysfunction of corpuscular blood elements. This would explain the occurrence of this disease entity in conjunction with etiologically completely heterogeneous systemic diseases.

Aim of this study was to describe the course of perinatal factors in neonates with meconium aspiration syndrome (MAS) from 1990 to 2010 and to determine risk factors for a severe course of the disease.All neonates with MAS hospitalized in our level III neonatal intensive care unit from 1990 to 2010.Retrospective analysis of trends of perinatal factors in neonates with MAS over time and of the association of these factors with severe MAS (need for invasive mechanical ventilation for ≥7 days, or need for high frequency oscillation or need for extracorporeal membrane oxygenation).We included 205 neonates with MAS, 55 had severe MAS (27%). MAS incidence and absolute number of MAS cases per year decreased during the observation period (p=0.003 and 0.005, respectively) as well as rates of outborn deliveries (p=0.004), duration of invasive mechanical ventilation (p=0.004), and hospital stay (p=0.036). Incidence and absolute number of severe MAS cases per year decreased (p=0.008 and 0.006, respectively), though the percentage of severe MAS among all neonates with MAS did not change. Risk factors for severe MAS were acute tocolysis (odds ratio 18.2 (95% confidence interval 2.1-155.3), p

In his famous essay, “On Perpetual Peace” (1795/1987), Kant argued that peace, freedom, and human progress were dependent on the existence of a plurality of politically competing units of independe...

Bei wie vielen Frühgeborenen ≤1250 g und bei wie vielen Neugeborenen >1250 g mit klinischer Symptomatik Ureaplasma urealyticum im Tubussekret nachweisbar war und bei wie vielen eine Pneumonie auftrat. Methodik: Die Patienten wurden in zwei Gruppen unterteilt (Gruppe 1: Geburtsgewicht ≤1250 g, n = 25; Gruppe 2: Geburtsgewicht >1250 g, n = 45) und diese wiederum in zwei Subgruppen (Subgruppe a: U. urealyticum im Tubussekret ohne Pneumonie; Subgruppe b: U. urealyticum im Tubussekret mit Pneumonie). Ergebnisse: Bei 9 Patienten der Gruppe 1 (36%) konnte U. urealyticum nachgewiesen werden, und 5 dieser Patienten (20%) hatten eine Pneumonie (Gruppe 1b). Frühgeborene mit einer Ureaplasmapneumonie hatten im Vergleich zu jenen mit einer blossen Ureaplasmabesiedelung signifikant höhere Beatmungsparameter, eine längere Beatmungsdauer und einen grösseren Sauerstoffbedarf. Bei 6 Patienten der Gruppe 2 (13%) konnte U. urealyticum nachgewiesen werden, und 2 von ihnen (4,4%) hatten eine Pneumonie. Schlussfolgerungen: Bei neonatalen Pneumonien bei sehr kleinen Frühgeborenen, aber auch bei reifen Neugeborenen, sollte stets U. urealyticum in die Differentialdiagnose miteinbezogen werden.

Summary After a spontaneous delivery, a healthy female newborn showed a cyanotic spell. The medical inspection shows a healthy newborn, only the nose was difficult to probe with the smallest tube. This leads to the diagnosis nasal obstruction. The nasal-endoscopy shows cystic malformations which restrict the inferior nasal meatus totally on both sides and the common nasal meatus on the right side [2]. With ultrasound and magnetic resonance imaging these malformations were identified as a mucocele caused by a blocked nasolacrimal duct. By a following nasal-endoscopy the blocked duct was resected. After that the baby could breathe without any symptoms of airway obstruction.

This study was a prospective, randomized, controlled design to evaluate gas exchange, lung mechanics, and pulmonary hemodynamics during partial liquid ventilation (PLV) combined with inhaled nitric oxide (NO) in acute respiratory failure (ARF) with pulmonary hypertension (PH). ARF with PH was induced in 12 piglets weighing 9.7-13.7 kg by repeated lung lavages and the continuous infusion of the stable endoperoxane analog of thromboxane. Thereafter the animals were randomly assigned either for PLV or conventional mechanical ventilation (CMV) at a fractional concentration of inspired O2 (Fio2) of 1.0. Perfluorocarbon (PFC) liquid (30 mL kg-1) was instilled into the endotracheal tube over 5 min followed by 5 mL kg-1h-1. All animals were treated with different concentrations of NO (1-10-20 ppm) inhaled in random order. Continuous monitoring included ECG, right atrial (Pra), mean pulmonary artery (Ppa), pulmonary capillary (Ppc'), and mean arterial (Pa) pressures, arteria oxygen saturation, and mixed venous oxygen saturation measurements. During PLV Pao2/Fio2 increased significantly from 8.2 +/- 0.4 kPa to 34.8 +/- 5.1 kPa (p0.01), whereas Pao2/FiO2 remained constant at 9.5 +/- 0.4 kPa during CMV. The infusion of the endoperoxane analog resulted in a sudden decrease of Pao2/Fio2 from 34.8 +/- 5.1 kPa to 14.1 +/- 0.4 kPa (p0.01) in the PLV group and from 9.5 +/- 0.4 kPa to 6.9 +/- 0.2 kPa (p0.05) in the control group. Inhaled NO significantly improved oxygenation in both groups (Pao2/Fio2: 45.7 +/- 5.3 kPa during PLV and 25.9 +/- 4.7 kPa during CMV). During inhalation of NO mean Ppa decreased significantly from 7.8 +/- 0.26 kPa to 4.2 +/- 0.26 kPa (p0.01) in the PLV group and from 7.4 +/- 0.26 kPa to 5.1 +/- 0.13 kPa (p0.01) in the control group. As documented in the literature PLV significantly improves oxygenation and lung mechanics in severe ARF. In addition, when ARF is associated with severe PH, the combined treatment of PLV and inhaled NO improves pulmonary hemodynamics resulting in better oxygenation.

A pneumothorax (PTX) is a potentially life threatening event during mechanical ventilation. Aim of this study was to analyse 3 different ways of management: expectant treatment, once-only pleural puncture and thoracic drainage.Retrospective data analysis in term and preterm neonates admitted to the NICU of the Medical University of Graz (between 2000-2010) and Innsbruck (2002-2010) who suffered from a PTX during continuous positive airway pressure (CPAP) or conventional mechanical ventilation (CMV).104 neonates, 33 term and 71 preterm neonates with PTX were included. 33 term neonates: 52% were treated expectantly, 36% with thoracic drainage and 12% with once-only pleural puncture (100% thoracic drainage after pleural puncture). 71 preterm neonates: 25% were treated expectantly, 52% with thoracic drainage and 23% with pleural puncture (63% thoracic drainage after pleural puncture). In CPAP-subgroup (n=64), term neonates were treated in 60% expectantly and in 40% with thoracic drain-age, preterm neonates in 33% expectantly, in 47% with thoracic drainage and in 20% with pleural puncture (50% thoracic drainage after pleural puncture). In CMV-subgroup (n=40), term neonates were treated in 44% expectantly, in 33% with thoracic drainage and in 22% with pleural puncture (100% thoracic drainage after pleural puncture), preterm neonates in 9% expectantly, in 64% with thoracic drainage and in 27% with pleural puncture (83% thoracic drain-age after pleural puncture).Present data show that expectant treatment is feasible. If invasive intervention is needed, once-only pleural puncture was not successful, as often thoracic drainage was necessary in addition.

OBJECTIVE: To determine the degree of clotting activation that occurs with the usual anticoagulation regimen with systemic heparinization. METHODS: To allow a standardized comparison of the patients, this study focused on the first 48 hours of extracorporeal membrane oxygenation (ECMO) in term newborn infants. The ECMO perfusion circuit consisted of a roller pump, silicone membrane lungs, and silicone rubber tubing. Coagulation was controlled routinely by measuring prothrombin time, fibrinogen, antithrombin III, and reptilase time. Platelet counts, activated clotting time, and heparin concentration were controlled regularly. The following specific activation markers of the clotting system were measured: prothrombin activation fragment 1 + 2 (F 1 + 2 ), thrombin-antithrombin III complexes, and D -dimer. Measurements were done before the start of ECMO, after 5 minutes, and at hours 1, 2, 3, 4, 6, 12, 24 and 48. RESULTS: All seven term infants had excessively high levels of clotting activation markers within the first 2 hours of ECMO: F l + 2 , 11.6 (±0.9) nmol/L (mean ± SEM); thrombin-antithrombin, 920 (±2.2) μg/L; D -dimer, 15.522 (±3.689) ng/L. During the next 46 hours of ECMO, F l + 2 and thrombin-antithrombin III complexes decreased from those high values, whereas D -dimer did not. The increase of activation markers was accompanied by low fibrinogen, low platelet counts. and prolongation of reptilase time. CONCLUSIONS: These findings fit the pattern of consumptive coagulopathy during neonatal ECMO, especially in the first 24 hours. (J P EDIATR 1996;129:264-8)

The influence of head-neck posture (neutral, 15 degrees, 30 degrees, and 45 degrees extension and flexion) on airflow and pulmonary mechanics was evaluated in 10 spontaneously breathing healthy preterm neonates (mean +/- SD; birth weight, 1.32 +/- 0.23 kg; gestational age, 29.4 +/- 2.4 weeks; study age, 36.6 +/- 1.6 weeks) who had had respiratory distress syndrome. Head-neck postures were quantified using specially constructed wooden wedges. Airflow was measured by a pneumotachometer via face mask. Lung compliance (CL) and resistance (RL) were measured using an esophageal balloon. Airflow interruption was designated as mild (10-40%), moderate (40-80%), and severe (> 80-100%) decrease of airflow. At neutral head-neck posture, 42.8 +/- 7.5% SEM of breaths had airflow interruption (71.4% mild, 19.9% moderate, 8.7% severe). There was no significant change with 15 degrees and 30 degrees head-neck flexion and extension. However, at 45 degrees flexion the overall incidence of airflow interruption (77.3 +/- 4.8%, P < 0.05) and RL (86.6 +/- 6.7 vs. 64.2 +/- 3.9 cmH2O/L/s, mean +/- SEM; P < 0.05) significantly increased. Extension to 45 degrees caused severe airflow interruption and increased RL in some infants, but no statistically significant change for the whole group. The incidence of severe airflow interruption significantly increased (P < 0.05) from 8.7% at neutral head-neck posture to 26.3% at hyperflexion (45 degrees). No changes in CL were observed. We conclude that minor (15-30 degrees) deviations from neutral neck posture are insignificant, whereas hyperflexion, and in some infants, hyperextension, can significantly affect airflow and pulmonary mechanics.

Based on the results from semistructured interviews with parents of fifty SIDS victims and of fifty matched controls we developed a SIDS risk questionnaire, the so-called SRFB Graz. In a retrospective study this questionnaire was applied to 65 SIDS victims and 195 comparable controls. By statistical analysis a cut point was computed, which discriminates SIDS cases from controls with a sensitivity of 86% and a specificity of 95%.

Lung injury caused by intrauterine inflammation has recently been strongly implicated in the pathogenesis of Wilson-Mikity syndrome (WMS). This article supports this theory by suggesting a causative role of intrauterine cytomegalovirus (CMV) infection for the development of WMS. A male premature infant, born at 33 weeks of gestational age, developed chronic lung disease compatible with WMS and diagnostic evaluation was positive for CMV infection. High-resolution computed tomography scan and lung histology revealed typical features of WMS in association with signs of interstitial pneumonia. CMV was found in urine, breastmilk, bronchoalveolar lavage material and lung tissue from open lung biopsy. Follow-up after treatment with ganciclovir and steroids showed resolving lung disease at the age of 6, 10 and 16 months, with lung function signs of mild obstruction. Assuming that a chance coexistence of cytomegalovirus pneumonia and Wilson-Mikity syndrome is rather unlikely, it is possible that intrauterine cytomegalovirus infection caused a pattern of lung injury consistent with Wilson-Mikity syndrome. Further cases of Wilson-Mikity syndrome should be investigated as to a possible role of congenital infection.

In 24 patients at risk for SIDS (12 infants with a near miss event and 12 infants with apnea and perioral cyanosis during sleep) respiratory and esophageal function were investigated by impedance pneumography (IP) and esophageal manometry combined with simultaneous pH-monitoring (EMPH). Both groups had ad early pathologic breathing pattern, but did not show any difference in the recorded parameters (number of apneic spells, longest apneic spell, apneic spells longer than 10 seconds, transcutaneous oxygen pressure, mean apnea time). Near miss infants had about 50% more manometric refluxes (15.4 +/- 1.3) than the apnea/cyanosis group (9.9 +/- 2.2). This difference was mainly caused by a significant rise of reflux episodes without pH-change (near miss 8.5 +/- 3.1 versus 2.9 +/- 1.4 in apnea/cyanosis infants). Furthermore, propulsive peristaltic properties after induced swallows were more disturbed in the near miss group (3.3 +/- 1.0 versus 6.1 +/- 1.9). On the other hand, the apnea cyanosis group showed significantly more pH-drops under 4 (6.8 +/- 2.3 vs 2.4 +/- 0.7), which might be due to a more rapid clearance of neutralising milk from the stomach in these infants. In conclusion the study showed that infants with a near miss event in the anamnesis suffer from a more pathologic esophageal motor function when compared with infants with apneic spells and cyanosis during sleep. Near miss infants are also considered to have a delay of gastric clearance.

Drainage problems due to catheter malpositioning are acutely life-threatening in patients undergoing extracorporeal membrane oxygenation. In order to reduce these complications we introduced sonographically guided catheter positioning. We compare the outcome in a group of patients with blind cannula positioning to that in a group with sonographically guided catheter positioning. Our results show that neonates and young infants especially are at high risk of drainage problems due to catheter malposition and that their outcome could be markedly improved by introducing sonographically guided cannula insertion.

Inhaled nitric oxide (iNO) is used as a vasodilator in pulmonary hypertension (PH) of the newborn infant.Retrospective analysis of patients, who were treated at our department with iNO in the period from 1994-2001. Response was defined as an increase of the paO (2)/FiO (2) Ratioor = 20 % and/or a decrease of the oxygenation index (OI)/= 20 % after 2 h (early response), and consecutively after 24 h (late response). The patients were divided into a) primary persistent pulmonary hypertension of the newbom (PPHN), or b) pulmonary hypertension secondary to meconium aspiration syndrome (MAS), sepsis or congenital diaphragmatic hernia (CDH).Between 1994 and 2001 we treated 47 patients with iNO at our neonatal intensive care unit. We included 16 (35 %) preterm infants (GA 34,5 [25 - 37] weeks, GG 2061 [680 - 3410] g) (Median/Range) and 31 (65 %) newbom (GA 40 [38 - 42] weeks, GG 3510 [2550 - 4560] g). 18 (38 %) patients suffered from primary PPHN, 29 (62 %) from secondary PPHN (14 MAS [30 %], 8 sepsis [17 %], 4 CDH [8 %]). 8 (50 %) preterm and 20 (64 %) term infants showed a positive iNO response after 2 h, again 8 (50 %) preterm and 20 (64%) term infants showed a positive iNO response after 24 h. There was neither a significant difference between term and preterm infants at 2 h, nor at 24 h. Between 2 h and 24 h 10 patients changed in their response to iNO. 5 (18 %) patients with early response showed a significant degradation after 24 h, whereas 5 (26 %) of the patients without early response showed a significant improvement of the oxygenation alter 24 h. Alltogether 13 (72 %) patients with PPHN, 8 (57 %) with MAS, 2 (50 %) with CDH, 4 (50 %) with sepsis showed a positive iNO response after 24 h. In regard to the oxygenation parameters at start of iNO-therapy, the patients with early response did not differ from the patient without response (median OI: 20,0 versus 21,8, median paO (2)/FiO (2) Ratio: 59,3 versus 55,0 mmHg at the start of the iNO therapy).In regard to iNO response, there was no significant difference between term and preterm infants. Due to the changing response, a positive iNO-response after 2 h had no predictive value for the further prognosis of the oxygenation situation under iNO therapy.

A newborn with congenital varicella complicated by varicella pneumonia was transferred to our hospital on day 16 of life for the consideration of extracorporeal membrane oxygenation (ECMO). The newborn received varicella zoster immunoglobulin 13 hours after birth since the mother developed a varicella exanthema two days before delivery. On day 10 of life the newborn became clinically symptomatic with red macules and pustules. The chest roentgenogram revealed reticular pulmonary infiltrates in the right upper lobe. Antibacterial chemotherapy was initiated. In the following days the cutaneous lesions progressed, and respiratory symptoms like tachypnoea and oxygen dependence occurred. Chest roentgenograms revealed diffuse reticular and patchy pulmonary infiltrates. On day 14 of life antiviral chemotherapy with acyclovir was started. ECMO was initiated in the veno-arterial mode on day 17 due to severe respiratory failure despite maximal conventional assisted ventilation and carried out for 14 days. With the age of 10 weeks he was discharged from the hospital with mild chronic lung disease without oxygen requirements and without neurological handicap. ECMO might be considered as life saving support in newborns with severe congenital varicella, considered to have a high mortality risk.

This paper gives an critical overview over different therapies for the management of neonates with respiratory failure. Several, partially revolutionary, new therapies have been introduced in the clinical routine in the last 10 to 15 years like surfactant therapy, inhalation of nitric oxide, extracorporeal membrane oxygenation and high frequency oscillatory ventilation. Furthermore, there are new promising ventilatory techniques like pressure support ventilation, proportional assist ventilation or liquid ventilation in clinical testing.

Two neonates exhibited the clinical picture of the "blueberry muffin baby" at delivery. The integument manifested petechiae and purpuric magenta-colored macules, papules, and plaques, as well as blueberry-colored ecchymoses. These findings led to the diagnosis of a connatal cytomegalovirus infection and fetal erythroblastosis, respectively. The hemorrhagic-purpuric looking skin lesions reflected extramedullary hematopoiesis with ultrastructural study disclosing evidence of both erythro- and granulopoietic lineage. For the first time, we were able to demonstrate that complexes of red cells in various stages of maturation can occur in the skin, similarly to the erythroblastic islands of the bone marrow. In the pathogenesis of extramedullary hematopoiesis, mechanisms underlying the reconstitution of blood cells must be considered. These may reactivate hematopoiesis in organs where it previously occurred in embryonic and fetal life. Possible causative factors may be great compensatory demand, deficient replacement, or loss or dysfunction of corpuscular blood elements. This would explain the occurrence of this disease entity in conjunction with etiologically completely heterogeneous systemic diseases.

Our purpose was to investigate how many preterm infants with a birth weight/=1,250 g and how many newborns with one1,250 g with clinical symptoms had Ureaplasma urealyticum in their endotracheal tube aspirates, and how many of them had pneumonia.The patients were divided into two groups (group 1: birth weight/=1,250 g, n = 25; group 2: birth weight1,250 g, n = 45), and these two groups were subdivided into two subgroups (subgroup a: U. urealyticum in aspirate without pneumonia; subgroup b: U. urealyticum in aspirate with pneumonia).In group 1, there were 25 patients. Nine patients (36%) had U. urealyticum in their aspirates, 5 patients (20%) had pneumonia (group 1b), and 4 patients (16%) did not (group 1a). Infants with pneumonia showed a significant increase in parameters of mechanical ventilation, in the duration of mechanical ventilation, and in the duration of oxygen dependence as compared with subgroup 1a. In group 2, there were 45 patients. Six patients of group 2 (13%) had U. urealyticum in their aspirates, 2 patients (4.4%) had a pneumonia (group 2b), and 4 patients (8.8%) did not (group 2b).In preterm infants as well as in term newborns one should consider U. urealyticum as a potential cause of neonatal pneumonia.

Cyclical fluctuations in cerebral blood flow velocity in Doppler measurements are a well known phenomenon. In 1992 Livera et al have shown in one patient, that cyclical fluctuations of cerebral blood volume could be measured with near infrared spectroscopy (NIRS). The aim of the present study was a quantification of the amplitude of cyclical fluctuations of cerebral blood volume (represented by total haemoglobin [Hbtot]) in a large number of healthy infants. Furthermore changes of oxygenated haemoglobin (HbO(2)) and deoxygenated haemoglobin (Hb) were investigated. Measurements were done during two hours of undisturbed daytime sleep. Fifty-eight infants (30 male, 28 female) were included in the study. All but one infant showed cyclical fluctuations. For quantification of cyclical fluctuations only periods during quiet sleep with excellent tracing quality were used. A number of 7894 cycles was analyzed for each of the three NIRS parameters. The median amplitude of the cycling fluctuations was: Delta Hbtot 1.1 mu mol/l, Delta HbO(2) 1.1 mu mol/l, and Delta Hb 0.2 mu mol/l. The frequency was changing within a range of 3 to 6 cycles/minute. Polynominal regression analysis showed that the relationship of Delta HbO(2) and Delta Hbtot was distinctively stronger compared to the relationship of Delta Hb and Delta Hbtot. In conclusion we think that these data represent "normal ranges" for parameter fluctuations in long-time NIRS tracings.

Over a 6-year period (1989-1995), gastrointestinal (GI) perforation was diagnosed in nine preterm infants (mean gestational age 27 weeks, mean birth weight 872 g). Three presented with necrotizing enterocolitis (NEC), two with indwelling-tube-induced perforation of the stomach, one with small-left-colon syndrome, and another with meconium ileus. Spontaneous intestinal perforation occurred in two similar very-low-birth-weight (VLBW) infants, in the distal ileum, on days 8 and 9 of life, respectively. The only clinical sign was extensive abdominal distension, and abdominal X-ray studies revealed free peritoneal air. All findings were distinct from those associated with NEC. Their further clinical course was complicated by reperforation on day 32 and 39, respectively. They subsequently recovered and presented without GI problems at the corrected ages of 4 and 2 months, respectively. In contrast to high mortality of 57% in the group with non-spontaneous intestinal perforations, spontaneous perforation seems to have a good prognosis even in VLBW infants if diagnosed and treated promptly.

We report our experience with pulmonary function testing in 11 out of 22 full-term neonates with severe respiratory failure, treated at the ECMO center Graz (Austria) during the period from 1990 to 1995. Altogether 17 out of 22 patients survived ECMO and all of them were successfully weaned from ECMO. Pulmonary function was assessed by monitoring expiratory tidal volume on the ventilator and estimating respiratory system compliance from the ratio tidal volume/(PIP-PEEP). In addition, compliance, and functional residual capacity were measured using a computerized pulmonary function system (PEDS). Compliance (mean +/- SD) decreased markedly after 24 hours of ECMO, compared with baseline values (0.20 +/- 0.12 vs 0.12 +/- 0.13 ml/cmH2O/kg) and was significantly higher (0.43 +/- 0.14 ml/cmH2O/kg, p0.01) before ECMO stop. When tidal volumes increased continuously ECMO blood flow could be decreased, indicating lung recovery. Most patients had a tidal volume of7 ml/kg prior to decannulation. Functional residual capacity and corresponding dynamic compliance, measured in 5 patients, ranged from 18.6 to 29.6 ml/kg and 0.49 to 0.57 ml/cmH2O/kg at this time. Functional residual capacity (mean +/- SD) increased significantly when surfactant was administered to promote weaning from ECMO (8.28 +/- 0.9 vs 19.0 +/- 1.0 ml/kg, p0.01). We conclude that the assessment of lung function has improved our understanding of pulmonary recovery during ECMO. Its clinical significance in determining the optimum time of weaning from ECMO needs further evaluation.

Congenital central hypoventilation syndrome (CCHS, Ondine's curse syndrome) is a rare respiratory disorder; less than 100 cases have been reported. Familiality of the disease has been discussed, but only few familial cases have been reported so far. In this report we describe the occurrence of CCHS in two male siblings. Diagnosis was established only at the age of 4 years in the first case, although the patient had disease related symptoms since early infancy. The second patient was one of dizygotic twins, he was diagnosed with CCHS at the age of 8 months. Up to that age only moderate desaturations had been observed. The other twin was unaffected by the disease. Both patients were successfully treated by nocturnal positive-pressure ventilation via a specially adapted face mask. They show satisfactory physical and neurologic development.Our cases support the assumption of familiality in CCHS although the mode of inheritance remains to be clarified. Polygraphic recordings including capnography should be performed in siblings of CCHS patients early in life in order to avoid secondary complications. Noninvasive treatment by ventilation via special face masks is feasible.