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Abstrak :
Manuver rekrutmen paru (MRP) adalah strategi mencegah kerusakan paru saat bayi menggunakan ventilator mekanis (VM). Dengan meningkatkan tekanan akhir ekspirasi (TAE) secara bertahap, MRP membuka alveolus, menurunkan kebutuhan oksigen hirup (FiO2) sekaligus meningkatkan ambilan oksigen paru. Hingga kini, belum cukup bukti ilmiah terkait pengaruh MRP menggunakan VM terhadap luaran bayi prematur. Penelitian ini adalah uji klinis tidak tersamar, dilakukan di RS Cipto Mangunkusumo dan RSIA Bunda Menteng, bertujuan mencari hubungan MRP dengan kejadian DBP dan atau kematian, curah jantung, cedera alveolus-endotel, penurunan diameter duktus arteriosus (DA), dan mikrosirkulasi kulit. Penelitian berlangsung Maret 2021–April 2022. Subjek penelitian adalah bayi prematur 24–32 minggu yang menggunakan ventilator mekanis saat usia < 48 jam. Protein surfaktan-D (SP-D) diukur menggunakan metode ELISA, mikropartikel endotel (CD-31+/CD-42–) menggunakan flowsitometri, curah jantung dan diameter DA menggunakan ekokardiografi, TcCO2–PaCO2, TcO2/PaO2 menggunakan monitor gas darah transkutan dan gas darah arteri, strong ion difference (SID) menggunakan elektrolit darah arteri. Pada usia koreksi 36 minggu, tidak terdapat perbedaan bermakna kejadian DBP atau kematian antara kelompok MRP dan tanpa MRP 38 (69,09%) vs. 43 (78,18%), p = 0,216. Pada 72 jam pasca-penggunaan VM, tidak didapati perbedaan kadar SP-D, CD 31+, Diameter DA, curah jantung, TcCO2 gap dan SID antara kelompok MRP dan tanpa MRP . Terdapat perbedaan bermakna TcO2 indeks 1,00 (1,00; 1,02) vs. 1,00 (0,99; 1,00), p = 0,009* antara kelompok MRP dibanding tanpa MRP. Pada bayi penyintas, MRP mempercepat waktu untuk mencapai FiO2 ter-rendah 60,0 (54,00; 75,00) vs. 435,00 (375,00; 495,00) menit, p < 0,0001 dan lama penggunaan alat bantu napas 25,0 (19,00; 37,00) vs. 36,83 (SB 19,11) hari, p = 0,044. Simpulan, MRP bayi prematur tidak terbukti mengurangi kejadian DBP dan atau kematian pada usia 36 minggu. Tidak ada perbedaan cedera alveolar-endotel, curah jantung kiri-kanan, dan diameter DA pada usia 72 jam. Tindakan MRP meningkatkan mikrosirkulasi. Pada kelompok penyintas, MRP mempersingkat waktu mencapai FiO2 terendah dan penggunaan alat bantu napas. ......Lung recruitment maneuver (LRM) is a strategy during mechanical ventilation which aim to open collapsed alveolus in order to increased oxygenation. This maneuver could be done by application of a stepwise increments of positive end expiratory pressure (PEEP) until lowest FiO2 (< 30%) is achieved. There is still lack of evidence regarding relationship between LRM and neonatal outcome. This study aimed to evaluate effectivity of LRM in order to reduce chronic lung disease and it’s influence to neonatal hemodynamic as well. This was unblinded randomized clinical trial which aimed to investigate relationship between LRM and neonatal death, bronchopulmonary dysplasia (BPD), cardiac output, reduction of ductus arteriosus (DA) diameter, skin microcirculations and alveolar-endotel injury. The study was conducted on March 2021 until April 2022 in Cipto Mangunkusumo and Bunda Menteng Hospital. Plasma surfactant protein-D (SP-D) was measured with ELISA, Microparticel endotel (CD-31+) with flowcytometri, left and right cardiac output (LVO and RVO) and DA diameter were measured by echocardiography, TcCO2–PaCO2, tcO2/PaO2 were measured form arterial blood gas and transcutaneous monitor and strong ion difference (SID) from plasma electrolyte. At 36 weeks follow up, there ware no significant difference of incident of DBP and/or death between MRP vs. without MRP groups 38 (69.09%) vs. 43 (78.18%), p = 0.216 (CI 95% 0.141–0.295). There were no difference between MRP and without MRP group at 72 hours, regarding : plasma SP-D, microparticle endotel, cardiac output, DA diameter, tcCO2 gap and SID. At. 72 hours, tcO2 index was better in MRP compared to control group 1.00 (1.00; 1.02) vs. 1.00 (0.99; 1.00), p = 0.009. There were no significant difference regarding other neonatal morbidity between the two group. Among survival subject, LRM reduced time to achieved lowest FiO2 60.00 (54.00; 75.00) vs. 435.00 (375.00; 495.00) hours, p < 0.0001 and length of respiratoy support 25.0 (19.00; 37.00) vs. 36.83 (SD 19.11) days, p=0.044. Conclusion When applied to 24–32 weeks preterm baby with invasive mechanical ventilation, LRM could not reduced DBP or death at 36 weeks of age. There was no any difference at 72 hours regarding alveolar and endothelial injury, left and right cardiac output and diameter DA. LRM was associated with better microcirculation. Among the survivor, LRM reduced high oxygen concentration exposure time and length of respiratory support.

Abstrak :
Minum merupakan tantangan bagi bayi prematur karena imaturitas dan penyakit yang menyertainya. Bayi prematur yang dinyatakan siap minum seringkali tidak mampu minum. Saat ini belum terdapat tata laksana yang konsisten dan mempertimbangkan kompleksitas proses minum secara komprehensif. Tujuan penelitian ini adalah menentukan berbagai faktor yang memengaruhi ketidakmampuan minum dan membuktikan efektivitas tata laksana metode baru terhadap kemampuan minum bayi prematur. Penelitian dilakukan di lima rumah sakit di Jakarta pada bulan Agustus–November 2021. Studi potong lintang meneliti faktor yang memengaruhi ketidakmampuan minum 120 bayi prematur siap minum usia kehamilan 28–34 minggu, yaitu tonus postural fleksi fisiologis, stabilitas fisiologis, refleks rooting, kemampuan regulasi diri, morbiditas, dan behavioral state. Selanjutnya dilakukan randomized controlled trial (RCT) membandingkan tata laksana metode baru dan konvensional 70 bayi prematur belum mampu minum dari studi potong lintang. Metode baru mencakup therapeutic positioning fleksi fisiologis melalui pembedongan dan intervensi oromotor berupa stimulasi oral, gerakan sinergis three finger jaw control, dan isapan non-nutritif menggunakan empeng khusus. Metode konvensional mencakup pembedongan tradisional, stimulasi oral, dan isapan non-nutritif menggunakan empeng yang biasa digunakan di ruang perawatan. Analisis data studi potong lintang dilakukan dengan uji bivariat menghitung prevalence ratio (PR) dan nilai p; uji multivariat, penentuan titik potong skor faktor risiko ketidakmampuan minum melalui kurva Receiving Operating Characteristic (ROC), serta penentuan sensitivitas dan spesifisitasnya. Uji klinis membandingkan rentang waktu tercapainya kemampuan minum bayi yang diberikan kedua jenis metode. Data dianalisis dengan program STATA versi 14.2 (tingkat kemaknaan p < 0,05). Hasil studi potong lintang menunjukkan regulasi diri sebagai faktor utama yang memengaruhi ketidakmampuan minum bayi prematur dengan PR 1,96 (1,61–3,34; IK 95%) dan p = 0,012, diikuti tonus postural, behavioral state, dan morbiditas (PR 1,91; 1,59; 1,56). Skor faktor risiko ketidakmampuan minum memiliki area under the curve (AUC) sebesar 0,698, titik potong optimal pada skor ≥ 7 dengan sensitivitas 71,4% dan spesifisitas 54%. Hasil uji klinis membuktikan metode baru lebih efektif dibandingkan metode konvensional (4 vs. 7 hari; p = 0,02). Berbagai faktor yang memengaruhi ketidakmampuan minum bayi prematur siap minum adalah regulasi diri, tonus postural, behavioral state, dan morbiditas. Metode baru lebih efektif dibandingkan metode konvensional. ......Feeding for premature infants is a challenge because of their immaturity and comorbidities. Premature infants who are ready to feed are often not able to feed. Current managements have not been consistent and consider the complexity of the feeding process comprehensively. The purpose of this study was to determine various factors influencing feeding inability of premature infants and to verify the effectiveness of a new method management on the premature infants’ feeding ability. The study was conducted in five hospitals in Jakarta in August–November 2021. A cross-sectional study examined factors influencing the oral feeding inability on 120 ready to feed premature infants born at 28–34 weeks of gestation. Evaluation of feeding inability risk factors included physiological flexion postural tone, physiological stability, rooting reflex, self-regulation ability, morbidity, and behavioral state. Subsequently, a randomized controlled trial (RCT) comparing the new and conventional method was conducted in 70 premature infants who were not able to feed from the cross-sectional study participants. The new method encompasses physiological flexion therapeutic positioning swaddling, and oromotor intervention consisting of oral stimulation, synergic three finger jaw control, and non-nutritive sucking by using a specific pacifier. The conventional method consists of traditional swaddling, oral stimulation, and non-nutritive sucking using the usual pacifier in the nursery room. In the cross-sectional study, bivariate analysis was done to determine the prevalence ratio (PR) and p value; multivariate analysis, Receiving Operating Characteristic (ROC) curve to determine the scoring system cut-off point, as well as its sensitivity and specificity. Clinical trial data analysis compared the new and conventional method effectivity in terms of duration needed to achieve feeding ability in premature infants. STATA version 14.2 was used for data analysis (level of significance p < 0,05). The results from the cross-sectional study showed that self-regulation had the highest influence of feeding inability with PR 1,96 (1,61–3,34; IK 95%) and p = 0,012, followed by postural tone, behavioral state, and morbidity (PR 1,91; 1,59; 1,56). The feeding inability risk score had an area under the curve (AUC) of 0.698, an optimal cut–off point of ≥ 7, as well as sensitivity of 71,4%, and specificity of 54%. In clinical trials, it was proven that the new method was more effective than the conventional method (4 vs. 7 days; p = 0,02). Factors influencing feeding inability in premature infants were self-regulation, postural tone, behavioral state, and morbidity. The new method management was more effective than the conventional method.