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Changes in respiratory mechanics in response to crystalloid infusions in extremely premature infants.

Arvind Sehgal,Bishal Gauli

Published 2023 in American Journal of Physiology - Lung cellular and Molecular Physiology

ABSTRACT

Extremely premature infants are at a higher risk of developing respiratory distress syndrome and circulatory impairments in the first few weeks of life. Administration of normal saline bolus is a common practice to manage hypotension in preterm infants. As a crystalloid, a substantial proportion might leak into the interstitium; most consequently the lungs in the preterm cohorts, putatively affecting ventilation. We downloaded and analysed ventilator mechanics data in infants managed by conventional mechanical ventilation and administered normal saline bolus for clinical reasons. Ventilator mechanics data was downloaded for 30 minutes pre-bolus, 60 minutes during the bolus followed by 30 minutes post-bolus. Sixteen infants (mean gestational age 25.2±1 weeks and birthweight 620±60g) were administered 10ml/kg normal saline over 60 minutes. The most common clinical indication was hypotension. No significant increase was noted in mean blood pressure after the saline bolus. A significant reduction in pulmonary compliance (mL/cmH₂O/kg) was noted (0.43±0.07 vs 0.38±0.07 vs 0.33±0.07, P=0.003 ANOVA). This was accompanied by an elevation in the required peak inspiratory pressure to deliver volume-guarantee (19±2 vs 22±2 vs 22±3 mmHg, P<0.0001, ANOVA), resulting in a higher respiratory severity score. Normal saline infusion therapy was associated with adverse pulmonary mechanics. Relevant pathophysiologic mechanisms might include translocation of fluid across pulmonary capillaries affected by low vascular tone and heightened permeability in extremes of prematurity, back-pressure effects from raised left atrial volume due to immature left-ventricular myocardium; complemented by the effect of cytokine release from positive pressure ventilation.

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