Assisted Ventilation of the Neonate

618 Pages·2017·43.358 MB·English

by  Jay P. Goldsmith, Edward Karotkin, Gautham Suresh, Martin Keszler

Assisted Ventilation
NEONAT E
of the

AN EVIDENCE-BASED APPROACH TO
NEWBORN RESPIRATORY CARE
SIXTH EDITION

JAY P. GOLDSMITH, MD, FAAP
Clinical Professor
Department of Pediatrics
Tulane University School of Medicine
New Orleans, Louisiana
EDWARD H. KAROTKIN, MD, FAAP
Professor of Pediatrics
Neonatal/Perinatal Medicine
Eastern Virginia Medical School
Norfolk, Virginia
MARTIN KESZLER, MD, FAAP
Professor of Pediatrics
Warren Alpert Medical School
Brown University
Director of Respiratory Services
Department of Pediatrics
Women and Infants Hospital
Providence, Rhode Island
GAUTHAM K. SURESH, MD, DM, MS, FAAP
Section Head and Service Chief of Neonatology
Baylor College of Medicine
Texas Children’s Hospital
Houston, Texas
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
ASSISTED VENTILATION OF THE NEONATE: AN EVIDENCE-BASED
APPROACH TO NEWBORN RESPIRATORY CARE, SIXTH EDITION ISBN: 978-0-323-39006-4
Copyright © 2017 by Elsevier, Inc. All rights reserved.
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
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to take all appropriate safety precautions.
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material herein.
Previous editions copyrighted 2011, 2003, 1996, 1988, and 1981.
Library of Congress Cataloging-in-Publication Data
Names: Goldsmith, Jay P., editor. | Karotkin, Edward H., editor. | Keszler, Martin, editor. | Suresh, Gautham,
editor.
Title: Assisted ventilation of the neonate : an evidence-based approach to newborn respiratory care / [edited
by] Jay P. Goldsmith, MD, FAAP, Clinical Professor, Department of Pediatrics, Tulane University School
of Medicine, New Orleans, Louisiana, Edward H. Karotkin, MD, FAAP, Professor of Pediatrics, Neonatal/
Perinatal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, Martin Keszler, MD, FAAP,
Professor of Pediatrics, Warren Alpert Medical School, Brown University, Director of Respiratory Services,
Department of Pediatrics, Women and Infants Hospital, Providence, Rhode Island, Gautham K. Suresh,
MD, DM, MS, FAAP, Section Head and Service Chief of Neonatology, Baylor College of Medicine, Texas
Children’s H ospital, Houston, Texas.
Description: Sixth edition. | Philadelphia, PA : Elsevier, [2017]
Identifiers: LCCN 2016029284 | ISBN 9780323390064 (hardback : alk. paper)
Subjects: LCSH: Respiratory therapy for newborn infants. | Artificial respiration.
Classification: LCC RJ312 .A87 2017 | DDC 618.92/2004636--dc23 LC record available at
https://lccn.loc.gov/2016029284
Executive Content Strategist: Kate Dimock
Publishing Services Manager: Hemamalini Rajendrababu
Senior Project Manager: Beula Christopher
Designer: Renee Duenow
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Printed in United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to my wife, Terri, who has supported
me through six editions of this text and my many nights away
from home while caring for sick neonates.
JPG
I would like to dedicate this sixth edition of Assisted Ventilation
of the Neonate to the numerous bedside NICU nurses, neonatal nurse
practitioners, and respiratory therapists, and all of the other ancillary
health care providers I have had the honor of working with over
the past nearly 40 years at the Children’s Hospital of
The King’s Daughters. Without your commitment to providing
the best of care to our patients I could not have done my job.
EHK
I dedicate this book to my wife, Mary Lenore Keszler, MD,
who has been my lifelong companion, inspiration, and best friend.
Without her incredible patience and unwavering support, none of this
work would have been possible. The book is also dedicated to the many tiny
patients and their families who taught me many valuable lessons, and to the
students, residents, and Fellows whose probing questions inspired me to seek
a deeper understanding of the problems that face us every day.
MK
I dedicate this book to my teachers and mentors over the years,
who taught me and guided me. I also thank my wife, Viju Padmanabhan,
and my daughters, Diksha and Ila, for their support and patience
with me over the years.
GKS
C O N T R I B U TO R S
Kabir Abubakar, MD Laura D. Brown, MD
Professor of Clinical Pediatrics Associate Professor
Neonatology/Pediatrics Pediatrics
Medstar Georgetown University Hospital University of Colorado School of Medicine
Washington, DC Aurora, CO
Namasivayam Ambalavanan, MBBS, MD Jessica Brunkhorst, MD
Professor, Pediatrics Assistant Professor of Pediatrics
University of Alabama at Birmingham Children’s Mercy Hospital
Birmingham, AL University of Missouri - Kansas City
Kansas City, Missouri
Robert M. Arensman, BS, MD
Head, Division of Pediatric Surgery Waldemar A. Carlo, MD
Department of Surgery Edwin M. Dixon Professor of Pediatrics
University of Illinois at Chicago University of Alabama at Birmingham,
Chicago, IL Director, Division of Neonatology
University of Alabama at Birmingham
Eduardo Bancalari, MD Birmingham, AL
Professor of Pediatrics, Obstetrics, and Gynecology,
Director, Division of Neonatology, Robert L. Chatburn, MHHS, RRT-NPS, FAARC
Chief, Newborn Service Clinical Research Manager
Department of Pediatrics, Division of Neonatology Respiratory Institute, Cleveland Clinic,
University of Miami School of Medicine Director, Simulation Fellowship
Miami, FL Education Institute, Cleveland Clinic,
Adjunct Professor of Medicine
Keith J. Barrington, MB, ChB Lerner College of Medicine of Case Western Reserve
Neonatologist and Clinical Researcher University
Sainte Justine University Health Center, Cleveland, OH
Professor of Paediatrics
University of Montréal Nelson Claure, MSc, PhD
Montréal, Canada Research Associate Professor of Pediatrics,
Director, Neonatal Pulmonary Research Laboratory
Jonathan F. Bean, MD Department of Pediatrics, Division of Neonatology
Chief Resident University of Miami School of Medicine
Department of General Surgery Miami, FL
University of Illinois Hospital and Health Sciences Center
Chicago, IL Clarice Clemmens, MD
Assistant Professor of Pediatric Otolaryngology
Edward F. Bell, MD Medical University of South Carolina
Professor of Pediatrics Charleston, SC
Department of Pediatrics
University of Iowa Christopher E. Colby, MD
Iowa City, IA Associate Professor of Pediatrics
Mayo Clinic
David M. Biko, MD Rochester, MN
Assistant Professor
The Children’s Hospital of Philadelphia, Sherry E. Courtney, MD, MS
Pediatric Radiologist Professor of Pediatrics
Pennsylvania Hospital Department of Pediatrics
The University of Pennsylvania Health System University of Arkansas for Medical Sciences
Philadelphia, PA Little Rock, AR
Peter G. Davis, MBBS, MD, FRACP
Professor/Director of Neonatal Medicine
The University of Melbourne and The Royal Women’s
Hospital
Melbourne, Victoria, Australia
vi
CONTRIBUTORS vii
Eugene M. Dempsey, MBBCH BAO, FRCPI, MD, MSc William W. Hay, Jr., MD
Clinical Professor Professor
Paediatrics and Child Health Pediatrics
University College Cork, University of Colorado School of Medicine
Department of Neonatology Aurora, CO
Cork University Maternity Hospital
Wilton, Cork, Ireland Robert M. Insoft, MD
Chief Medical Officer and Attending Neonatologist
Robert Diblasi, RRT-NPS, FAARC Women and Infants Hospital
Seattle Children’s Research Institute - Respiratory Care Alpert Medical School of Brown University
Center for Developmental Therapeutics Providence, RI
Seattle, WA
Erik A. Jensen, MD
Jennifer Duchon, MDCM, MPH Instructor of Pediatrics
Clinical Fellow The University of Pennsylvania,
Pediatric Infectious Disease Attending Neonatologist
Columbia-Presbyterian Medical Center The Children’s Hospital of Philadelphia
New York, NY Philadelphia, PA
Jonathan M. Fanaroff, MD, JD Jegen Kandasamy, MBBS, MD
Associate Professor of Pediatrics Assistant Professor
Case Western Reserve University School of Medicine, Pediatrics
Co-Director, Neonatal Intensive Care Unit, University of Alabama at Birmingham
Director, Rainbow Center for Pediatric Ethics Birmingham, AL
Rainbow Babies and Children’s Hospital
Cleveland, OH Edward H. Karotkin, MD, FAAP
Professor of Pediatrics
William W. Fox, MD Neonatal/Perinatal Medicine
Attending Neonatologist The Eastern Virginia Medical School
Division of Neonatology Norfolk, VA
Medical Director
Infant Breathing Disorder Center Martin Keszler, MD, FAAP
Children’s Hospital of Philadelphia, Professor of Pediatrics
Professor of Pediatrics Alpert Medical School of Brown University,
University of Pennsylvania Perelman School of Medicine Director of Respiratory Services, Pediatrics
Philadelphia, PA Women and Infants Hospital
Providence, RI
Debbie Fraser, MN, RNC-NIC
Associate Professor John P. Kinsella, MD
Faculty of Health Disciplines Professor of Pediatrics
Athabasca University Department of Pediatrics
Athabasca, Alberta, Canada, Section of Neonatology
Advanced Practice Nurse University of Colorado School of Medicine and Children’s
NICU Hospital Colorado
St Boniface Hospital Aurora, CO
Winnipeg, Manitoba, Canada
Haresh Kirpalani, BM, MRCP, FRCP, MSc
John T. Gallagher, MPH, RRT-NPS, FAARC Professor
Critical Care Coordinator The University of Pennsylvania,
Pediatric Respiratory Care Attending Neonatologist and Director
University Hospitals, Rainbow Babies and Children’s Hospital Newborn and Infant Chronic Lung Disease Program
Cleveland, OH The Children’s Hospital of Philadelphia
Philadelphia, PA;
Jay P. Goldsmith, MD, FAAP Emeritus Professor
Clinical Professor Clinical Epidemiology
Pediatrics McMaster University
Tulane University Hamilton, Ontario, Canada
New Orleans, LA
Derek Kowal, RRT
Malinda N. Harris, MD Supervisor NICU, Respiratory Services
Assistant Professor of Pediatrics Foothills Medical Centre
Mayo Clinic Alberta Health Services
Rochester, MN Calgary, Alberta, Canada
viii CONTRIBUTORS
Satyan Lakshminrusimha, MBBS, MD Bobby Mathew, MD
Professor of Pediatrics Associate Program Director
Director, Center for Developmental Biology of the Lung Assistant Professor of Pediatrics
University at Buffalo, University at Buffalo
Chief of Neonatology Women and Children’s Hospital of Buffalo
Women and Children’s Hospital of Buffalo Buffalo, NY
Buffalo, NY
Patrick Joseph McNamara, MD, MRCPCH, MSc
John D. Lantos, MD Associate Professor
Director of Bioethics Pediatrics and Physiology
Children’s Mercy Hospital Professor University of Toronto,
Pediatrics University of Missouri - Kansas City Staff Neonatologist
Kansas City, MO Pediatrics
Hospital for Sick Children
Krithika Lingappan, MD, MS, FAAP Toronto, Ontario, Canada
Assistant Professor
Section of Neonatology D. Andrew Mong, MD
Department of Pediatrics Assistant Professor
Texas Children’s Hospital The University of Pennsylvania,
Baylor College of Medicine Pediatric Radiologist
Houston, TX The Children’s Hospital of Philadelphia
Philadelphia, PA
Akhil Maheshwari, MD
Professor of Pediatrics and Molecular Medicine Colin J. Morley, DCH, MD, FRCPCH
Pamela and Leslie Muma Endowed Chair in Neonatology, Professor
Chief, Division of Neonatology, Neonatal Research
Assistant Dean, Graduate Medical Education Pediatrics Royal Women’s Hospital
University of South Florida Melbourne, Cambridge, Great Britain
Tampa, FL
Leif D. Nelin, MD
Mark C. Mammel, MD Dean W. Jeffers Chair in Neonatology
Professor of Pediatrics Nationwide Children’s Hospital,
Department of Pediatrics Professor and Chief,
University of Minnesota Division of Neonatology
Minneapolis, MN The Ohio State University and Nationwide Children’s Hospital
Columbus, OH
George T. Mandy, MD
Associate Professor of Pediatrics Donald Morley Null Jr., MD
Baylor College of Medicine Professor of Pediatrics
Houston, TX Department of Pediatrics
University of California Davis
Richard J. Martin, MBBS Sacramento, CA
Professor
Pediatrics, Reproductive Biology, and Physiology and Louise S. Owen, MBChB, MRCPCH, FRACP, MD
Biophysics Neonatologist
Case Western Reserve University School of Medicine, Newborn Research
Drusinsky/Fanaroff Professor Royal Women’s Hospital,
Pediatrics Honorary Fellow
Rainbow Babies and Children’s Hospital Murdoch Childrens Research Institute
Cleveland, OH Melbourne, Victoria, Australia
Kathryn L. Maschhoff, MD, PhD Allison H. Payne, MD, MSCR
Assistant Professor of Clinical Pediatrics Assistant Professor
The University of Pennsylvania, Pediatrics
Attending Neonatologist Division of Neonatology
The Children’s Hospital of Philadelphia UH Rainbow Babies and Children’s Hospital
Philadelphia, PA Case Western Reserve University
Cleveland, OH
CONTRIBUTORS ix
Jeffrey M. Perlman, MBChB Guilherme Sant’Anna, MD, PhD, FRCPC
Professor of Pediatrics Associate Professor of Pediatrics
Weill Cornell Medicine, Department of Pediatrics, Neonatal Division,
Division Chief Associate Member of the Division of Experimental Medicine
Newborn Medicine McGill University
New York Presbyterian Hospital Montreal, Quebec, Canada
Komansky Center for Children’s Health
New York, NY Edward G. Shepherd, MD
Chief, Section of Neonatology
Joseph Piccione, DO, MS Nationwide Children’s Hospital
Pulmonary Director Associate Professor of Pediatrics
Center for Pediatric Airway Disorders The Ohio State University
The Children’s Hospital of Philadelphia, Columbus, OH
Assistant Professor of Clinical Pediatrics
Division of Pediatric Pulmonary Medicine Billie Lou Short, MD
University of Pennsylvania School of Medicine Chief, Neonatology
Philadelphia, PA Children’s National Health System,
Professor of Pediatrics
Richard Alan Polin, BA, MD The George Washington University School of Medicine
Director Division of Neonatology Washington, DC
Department of Pediatrics
Morgan Stanley Children’s Hospital, Nalini Singhal, MBBS, MD, FRCPC
William T Speck Professor of Pediatrics Professor of Pediatrics
Columbia University College of Physicians and Surgeons Department of Pediatrics
New York, NY Cumming School of Medicine
University of Calgary
Yacov Rabi, MD, FRCPC Calgary, Alberta, Canada
Assistant Professor
Department of Pediatrics Roger F. Soll, MD
University of Calgary Neonatologist
Calgary, Alberta, Canada Wallace Professor of Neonatology
University of Vermont College of Medicine
Aarti Raghavan, MD, FAAP Burlington, VT
Assistant Professor Clinical Pediatrics
Attending Neonatologist Amuchou S. Soraisham, MBBS, MD, DM, MS, FRCPC, FAAP
Director Quality Improvement, Department of Pediatrics Associate Professor of Pediatrics
Program Director, Neonatology Fellowship Program Department of Pediatrics
Department of Pediatrics Cumming School of Medicine
University of Illinois Hospital and Health Sciences System University of Calgary
Chicago, Illinois Calgary, Alberta, Canada
Matthew A. Rainaldi, MD Nishant Srinivasan, MD
Assistant Professor of Pediatrics Division of Pediatric Surgery, Department of Surgery
Weill Cornell Medicine Division of Neonatology, Department of Pediatrics
New York Presbyterian Hospital University of Illinois Hospital and Health Sciences Center
Komansky Center for Children’s Health Chicago, IL
New York, NY
Daniel Stephens, MD
Tara M. Randis, MD, MS General Surgery Chief Resident
Assistant Professor of Pediatrics Department of Surgery
Division of Neonatology University of Minnesota
New York University School of Medicine Minneapolis, MN
New York, NY
Gautham K. Suresh, MD, DM, MS, FAAP
Lawrence Rhein, MD Section Head and Service Chief of Neonatology
Assistant Professor of Pediatrics Baylor College of Medicine
Newborn Medicine and Pediatric Pulmonology Texas Children’s Hospital
Boston Children’s Hospital Houston, TX
Boston, MA
x CONTRIBUTORS
Andrea N. Trembath, MD, MPH Gary M. Weiner, MD, FAAP
Assistant Professor, Pediatrics Associate Professor/Director
Division of Neonatology Neonatal-Perinatal Fellowship Training Program
UH Rainbow Babies and Children’s Hospital University of Michigan, C.S. Mott Children’s Hospital
Case Western Reserve University Ann Arbor, MI
Cleveland, OH
Dany E. Weisz, BSc, MD, MSc
Anton H. van Kaam, MD, PhD Assistant Professor of Pediatrics
Professor of Neonatology University of Toronto,
Emma Children’s Hospital Academic Medical Center Staff Neonatologist
Amsterdam, Netherland Newborn and Developmental Paediatrics
Sunnybrook Health Sciences Centre
Maximo Vento, MD, PhD Toronto, Ontario, Canada
Professor
Division of Neonatology Bradley A. Yoder, MD
University and Polytechnic Hospital La Fe, Professor of Pediatrics
Professor Medical Director, NICU
Neonatal Research Group University of Utah School of Medicine
Health Research Institute La Fe, Salt Lake City, UT
Valencia, Spain
Huayan Zhang, MD
Michele C. Walsh, MD, MSEpi Attending Neonatologist, Medical Director
Professor, Pediatrics The Newborn and Infant Chronic Lung Disease Program
Division of Neonatology Division of Neonatology
UH Rainbow Babies and Children’s Hospital Department of Pediatrics
Case Western Reserve University Children’s Hospital of Philadelphia,
Cleveland, OH Associate Professor of Clinical Pediatrics
Department of Pediatrics
Julie Weiner, MD University of Pennsylvania Perelman School of Medicine
Assistant Professor of Pediatrics Philadelphia, PA
Children’s Mercy Hospital
University of Missouri - Kansas City
Kansas City, MO
F O R E WO R D
Learn how to exhale, the inhale will take care of itself. experts in their fields, represents many nationalities and points
of view. Each mode of ventilation is discussed in detail, yet is
—Carla Melucci Ardito
easy to comprehend. There is a great balance between physi-
I congratulate Drs. Goldsmith, Karotkin, Keszler, and Suresh on ology, pathophysiology, diagnostic approaches, pulmonary
the publication of the sixth edition of their classic text, Assisted imaging, and the techniques of mechanical ventilation, as well
Ventilation of the Neonate. The first edition was published in as the short- and long-term outcomes. This edition includes
1981, when neonatal ventilation was in its infancy, and long a thoughtful chapter on respiratory care in resource-limited
before the availability of surfactant, generalized use of antenatal countries and all the latest advances in delivery room manage-
corticosteroids, and various modern modes of assisted ventila- ment and resuscitation. There are also contributions on quality
tion. Indeed, in the 1970s many units did not have the benefit of improvement and ethics and medicolegal aspects of respiratory
neonatal ventilators and were forced to use adult machines that care, in addition to a very informative chapter on pulmonary
delivered far too great a tidal volume, even with a minimal turn imaging. The sections on pharmacologic support provide the
of the knob controlling airflow. Not surprisingly, almost half reader with all of the novel approaches to respiratory insuffi-
the babies receiving mechanical ventilation developed air leaks, ciency and pulmonary hypertension, and the section on neu-
and the mortality was very high. Respiratory failure in preterm rological outcomes and surgical interventions completes a
infants was the leading cause of neonatal mortality. comprehensive, yet easy-to-read textbook.
The term neonatology was coined in 1960 by Alexander Schaffer Assisted Ventilation of the Neonate, sixth edition, by
to designate the art and science of diagnosis and treatment of disor- Drs. Jay P. Goldsmith, Edward H. Karotkin, Martin Keszler,
ders of the newborn. Neonatal care was largely a necdote-based, and and Gautham K. Suresh, serves as a living, breathing compan-
that era has been designated “the era of benign neglect and disas- ion, which guides you through the latest innovations in venti-
trous interventions.” The all-too-f amiliar stories of oxygen causing latory assistance. It is a must read for neonatologists, neonatal
retrolental fibroplasia, prophylactic antibiotics causing death and fellows, neonatal respiratory therapists, and nurses working in
kernicterus, diethylstilbestrol causing vaginal carcinoma, and the the neonatal intensive care unit.
prolonged starvation of extremely preterm infants contributing to For breath is life, and if you breathe well you will live long
their dismal outcome are well documented. on earth.
Since 1975 we have witnessed dramatic increases in knowl-
edge and the accumulation of evidence in randomized trials –Sanskrit Proverb
resulting in the transition to evidence-based medicine. This has
been progressively documented in each successive edition of
Avroy A. Fanaroff, MD
this text. There is now extensive science to support the various
Emeritus Professor of Pediatrics
modalities of assisted ventilation.
The sixth edition documents the new science and the applica- Case Western Reserve University
tion of translational research from bench to bedside. There have Emeritus Eliza Henry Barnes Professor of Neonatology
been extensive changes in contributors as well as in the orga- Rainbow Babies and Children’s Hospital
nization of the book. The wide array of authors, well-known Cleveland, March 2016
xi
P R E FAC E
Thirty-nine years ago, before there were exogenous surfactants, Specifically, attempts to decrease the incidence of BPD have con-
inhaled nitric oxide, high-frequency ventilators, and other mod- centrated on ventilatory approaches such as noninvasive venti-
ern therapies, two young neonatologists (JPG, EHK) were auda- lation, volume guarantee modes, and adjuncts such as caffeine
cious enough to attempt to edit a primer on newborn assisted and vitamin A. Yet some of these therapies remain unproven in
ventilation for physicians, nurses, and respiratory therapists large clinical trials and the incidence of BPD in national databases
entrusted with treating respiratory failure in fragile neonates. for very low birth-weight infants exceeds 30%. Thus, until there
Because, even in the early days of neonatology, respiratory care are social, pharmacological, and technical solutions to prematu-
was an essential part of neonatal intensive care unit (NICU) rity, neonatal caregivers will continue to be challenged to provide
care, we thought that such a text could fill a void and provide a respiratory support to the smallest premature infants without
reference to the many caretakers in this new and exciting field. causing lifelong pulmonary or central nervous system injury.
We called upon our teachers and mentors to write most of the In this, the sixth edition, two new editors have graciously added
chapters and they exceeded our expectations in producing a their expertise to the task of providing the most up-to-date and
“how to” guide for successful ventilation of the distressed new- evidence-based guidelines on providing ventilatory and support-
born. The first edition, published in 1981, was modeled after ive care to critically ill newborns. Dr. Martin Keszler, Professor of
the iconic text of Marshall Klaus and Avroy Fanaroff, Care of the Pediatrics and Medical Director of Respiratory Care at Brown Uni-
High-Risk Neonate, which was the “go to” reference for prac- versity, is internationally renowned for his work in neonatal ven-
ticing neonatal caregivers at the time. Dr. Klaus wrote the fore- tilation. Dr. Gautham K. Suresh, now the Chief of Neonatology of
word, and Assisted Ventilation of the Neonate was born. the Newborn Center at Texas Children’s Hospital and a professor
The preface to the first edition started with a quotation from at Baylor University, is regarded as one of the foremost authorities
Dr. Sydney S. Gellis, then considered the Dean of Pediatrics in on quality improvement in neonatal care. With an infusion of new
the United States: ideas, the text has been completely rewritten and divided into five
sections. The first section covers general principles and concepts
As far as I am concerned, the whole area of ventilation of
and includes new chapters on respiratory diagnostic tests, medical
infants with respiratory distress syndrome is one of chaos.
legal aspects of respiratory care, and quality and safety. The second
Claims and counterclaims about the best and least harmful
section reviews assessment, diagnosis, and monitoring methods of
method of ventilating the premature infant make me light-
the newborn in respiratory distress. New chapters include imaging,
headed. I can’t wait for the solution or solutions to prema-
noninvasive monitoring of gas exchange, and airway evaluation.
ture birth, and I look forward to the day when this gadgetry
Therapeutic respiratory interventions are covered in the greatly
will come to an end and the neonatologists will be retired.
expanded third section, with all types of ventilator modalities and
Year Book of Pediatrics (1977) strategies reviewed in detail. Adjunctive interventions such as pul-
monary and nursing care, nutritional support, and pharmacologic
Nearly four decades and five editions of the text later, we are therapies are the subjects of the fourth section. Finally, the fifth
still looking for the solutions to premature birth despite decades section of the text reviews special situations and outcomes, includ-
of research on how to prevent it, and neonatal respiratory sup- ing chapters on transport, BPD care, discharge, and transition to
port is still an important part of everyday practice in the modern home as well as pulmonary and neurologic outcomes.
NICU. No doubt, the practice has changed dramatically. Pharma- During the four-decade and six-edition life of this text, neo-
cological, technological, and philosophical advances in the care natology has grown and evolved in the nearly 1000 NICUs in the
of newborns, especially the extremely premature, have continued United States. The two young neonatologists are now near retire-
to refine the way we manage neonatal respiratory failure. Micro- ment and will be turning over the leadership of future editions
processor-based machinery and information technology, the new of the text to the new editors. We have seen new and unproven
emphasis on safety, quality improvement, and evidence-based therapies come and go, and despite our frustration at not being
medicine have affected our practice as they have all of medical care. able to prevent death or morbidity in all of our patients, we con-
Mere survival is no longer the only focus; the emphasis of neo- tinue to advocate for evidence-based care and good clinical trials
natal critical care has changed to improving functional outcomes before the application of new devices and therapies. We hope
of even the smallest premature infant. While the threshold of this text will stimulate its readers to continue to search for better
viability has not changed significantly in the past decade, there therapies as they use the wisdom of these pages in their clinical
certainly have been decreases in morbidities, even at the smallest practice. We have come full circle, as Dr. Klaus’s coeditor of Care
weights and lowest gestational ages. The large institutional varia- of the High-Risk Neonate, Dr. Avroy Fanaroff, has favored us with
tion in morbidities such as bronchopulmonary dysplasia (BPD) the foreword to this edition. And as we wait for the solution(s) to
can no longer be attributed solely to differences in the popula- prematurity, we should heed the wisdom of the old Lancet edito-
tions being treated. The uniform application of evidence-based rial: “The tedious argument about the virtues of respirators not
therapies and quality improvement programs has shown signifi- invented over those readily available can be ended, now that it is
cant improvements in outcomes, albeit not in all centers. We have abundantly clear that the success of such apparatus depends on
recognized that much of neonatal lung injury is human-made the skill with which it is used” (Lancet 2: 1227, 1965).
and occurs predominantly in the most premature infants. Our
perception of the ventilator has shifted from that of a lifesaving Jay P. Goldsmith, MD, FAAP
machine to a tool that can cause harm while it helps—a dou- Edward H. Karotkin, MD, FAAP
ble-edged sword. However, the causes of this morbidity are mul- Martin Keszler, MD, FAAP
tifactorial and its prevention remains controversial and elusive. Gautham K. Suresh, MD, DM, MS, FAAP
xii