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Martin.Keszler last won the day on January 20 2020

Martin.Keszler had the most liked content!

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About Martin.Keszler

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    Women and Infants Hospital of Rhode Island
    Alpert Medical School of Brown University
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    Providence, RI

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  1. There are indeed many limitations to this study, as mentioned already. For one, it would take >10 years to get 71 cases of real MAS that required mechanical ventilation in my 89 bed 9000 annual delivery unit. So I wonder about the enrollment issues. Heliox of course can only be effective at low FiO2, so only mild cases would stand to benefit, and they probably would do fine anyway. The graphs show almost parallel improvement in both groups and the SD in most of their data look unusually tight. I would love to see this reproduced somewhere else, because this looks too god to be true....
  2. Be careful when using large filters, as this adds very large dead space to the system whey using the T-piece resuscitator (e.g. NeoPuff - see first pic). Exhalation occurs via the opening of the PEEP valve at the top, so the filter is in-line. With mask ventilation, there is probably enough leak around the mask to wash out the dead space, but if used in an intubated baby, you would likely have significant dead space gas rebreathing with hypercapnia. With most self-inflating bags the filter can be placed on the expiratory limb as shown in the second picture, therefore there is no added dead spa
  3. I have observed this repeatedly in babies whose mothers were taking SSRI antidepressants, specifically Zoloft. Happy baby who does not cry. Cheers, MK
  4. Great question, Juan Carlos. I am partial to the VN500, but I'm sure both devices can deliver VG quite well. The problem is that babies don't like to be acidotic. Consequently, there is a problem with permissive hypercapnea in the first days of life in small preemies, because their kidneys are not able to compensate for respiratory acidosis. Therefore, the baby will try to generate a tidal volume sufficient to bring the PCO2 down and normalize the pH. As you know when the tidal volume exceeds the target value, PIP will come down and pretty soon, your baby may be on endotracheal CPAP with
  5. Effect of instrumental dead space.pdfEffect of instrumental dead space.pdfYour first option is the correct one (I assume that though you asked about a 400g baby you used 0.5 kg in your calculations, so we really are dealing with a 500g baby). In any case, the effect of the added dead space is already figured into the approx. 6ml/kg. The concept of dead space is a bit relative. It has an effect, but not as large as you would think if conventional physiology strictly applied. There clearly is some admixture of fresh gas and dead space gas so adding the entire dead space to the calculation w
  6. @spartacus007: Sorry for slow response. Yes we would use AC and avoid heavy sedation. Only use paralysis if despite good NG tube placement we are unable to keep gut decompressed, meaning we use it rarely. Evidence-free zone, for the most part, but muscle relaxation has many downsides and I am a believer in making the baby breathe as much as they can, which minimizes intrathoracic pressure and adverse hemodynamic consequences of PPV. As for SPO2 target, the goal is NOT 100%. Gentle support with minimal PIP needed to get the heart rate up and SPO2 into the low 90s. Generally start wit
  7. "We also start on AC-VG. We bring the ventilator into the delivery room and once intubated, get them on to volume ventilation and avoid as much t-piece or bag ventilation as possible. Initial settings are PEEP 5-6, 4-5mL/kg tidal volume, back up rate of 40, and iTime 0.3" Nathan's approach above is a lot more evidence-based than the earlier post from Winnipeg. There is good evidence that relatively low PEEP should be used to avoid over-expansion of the hypoplastic lungs, which contributes to PPHN (Guevorkian, et al, J Pediatrics 2018). The results of the VICI trial also strongly indicate
  8. I think they work, but at least here in the USA they are not available in small enough size to be useful for small preemies. Are smaller LMs available in Europe? Thanks, Martin Keszler MD Professor of Pediatrics Brown University
  9. John, I have collected some data on this subject with colleagues from Japan and Poland, who have been using HFOV with VG on the VN 500. We have two abstracts at the PAS meeting in Vancouver on this very subject, so please come to Vancouver and find out. Or read the abstracts when they come out. The data are focusing on what VT is needed for normocapnia, not specifically on safety, because using VG should increase safety of HFOV by avoiding inadvertent hyperventilation. Stay tuned, Martin Martin Keszler, Brown University, Providence, RI
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