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Letter| Volume 128, ISSUE 5, P871-872, November 2000

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Positive end expiratory pressure and response to inhalednitric oxide therapy

      We read with great interest the article by Johannigman et al (Surgery 2000;127:390-4). They conclude that in non-responders to inhaled nitrogen oxide (iNO), alveolar recruitment through the addition of positive end expiratory pressure improved response to iNO therapy. In our lab, we have reached a similar conclusion by using a lamb model of congenital diaphragmatic hernia (CDH). In CDH, the herniated viscera present in crucial stages of lung development results in pulmonary hypoplasia, pulmonary hypertension, and a surfactant deficiency. In CDH-lambs, ventilation with perfluorocarbon-based liquid or treatment with intratracheal exogenous surfactant has been shown to improve pulmonary function, in part, by alveolar recruitment. iNO, on the other hand, has had minimal effect in CDH despite concentrations as high as 80 ppm. However, we have found that strategies that recruit alveoli (ie, liquid ventilation or exogenous surfactant therapy), restore response to nitric oxide.
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      References

        • Karamanoukian HL
        • Glick PL
        • Wilcox DT
        • Rossman JE
        • Holm BA
        • Morin III, FC
        Pathophysiology of congenital diaphragmatic hernia VIII: inhaled nitric oxide requires exogenous surfactant therapy in the lamb model of congenital diaphragmatic hernia.
        J Pediatr Surg. 1995; 30: 1-4
        • Wilcox DT
        • Glick PL
        • Karamanoukian HL
        • Morin III, FC
        • Fuhrman BP
        • Leach C.
        Partial liquid ventilation and nitric oxide in congenital diaphragmatic hernia.
        J Pediatr Surg. 1997; 32: 1211-1215