Adherence to oxygenation and ventilation targets in mechanically ventilated premature and sick newborns: a retrospective study

Occurrence of hyperoxia during iNO treatment for persistent pulmonary hypertension of the newborn: a cohort study

High concentrations of oxygen are often needed to optimize oxygenation in infants with persistent pulmonary hypertension (PPHN), but this can also increase the risk of hyperoxemia. We determined the occurrence of hyperoxemia in infants treated for PPHN. Medical records of infants ≥ 34 + 0 weeks gestational age (GA) who received inhaled nitric oxide (iNO) were retrospectively reviewed for oxygenation parameters during iNO therapy. Oxygen was manually titrated to target arterial oxygen tension (PaO2) 10-13 kPa and peripheral oxygen saturation (SpO2) 92-98%. The main study outcomes were the incidence and duration of hyperoxemia and hypoxemia and the fraction of inspired oxygen (FiO2). A total of 181 infants were included. The median FiO2 was 0.43 (IQR 0.34-0.56) and the maximum FiO2 was 1.0 in 156/181 (86%) infants, resulting in at least one PaO2 > 13 kPa in 149/181 (82%) infants, of which 46/149 (31%) infants had minimal one PaO2 > 30 kPa. SpO2 was > 98% in 179/181 (99%) infants for 17.7% (8.2-35.6%) of the iNO time. PaO2 < 10 kPa occurred in 160/181 (88%) infants, of which 81/160 (51%) infants had minimal one PaO2 < 6.7 kPa. SpO2 was < 92% in 169/181 (93%) infants for 1.6% (0.5-4.3%) of the iNO time.    Conclusion: While treatment of PPHN is focused on preventing and reversing hypoxemia, hyperoxemia occurs inadvertently in most patients. What is Known: • High concentrations of oxygen are often needed to prevent hypoxemia-induced deterioration of PPHN, but this can also increase the risk of hyperoxemia. • Infants with persistent pulmonary hypertension may be particularly vulnerable to the toxic effects of oxygen, and hyperoxemia could further induce pulmonary vasoconstriction, potentially worsening the condition. What is New: • Hyperoxemia occurs in the majority of infants with PPHN during treatment with iNO. • Infants with PPHN spent a considerably longer period with saturations above the target range compared to saturations below the target range.

Optimal Conventional Mechanical Ventilation in Full-Term Newborns: A Systematic Review

BACKGROUND

Most studies examining the best mechanical ventilation strategies in newborn infants have been performed in premature infants with respiratory distress syndrome.

PURPOSE

To identify and synthesize the evidence regarding optimal mechanical ventilation strategies in full-term newborns.

METHODS

Systematic review carried out according to the methods described in the PRISMA statement.

SEARCH STRATEGY

Searches in MEDLINE, EMBASE, CINAHL, and the Cochrane Library in March 2017, with an updated search and hand searches of reference lists of relevant articles in August 2017.

STUDY SELECTION

Studies were included if they were published between 1996 and 2017, involved newborns with gestational age of 37 to 42 weeks, were randomized controlled trials, intervention or crossover studies, and addressed outcomes affecting oxygenation and/or ventilation, and/or short-term outcomes including duration of mechanical ventilation. Because of the large heterogeneity between the studies, it was not possible to synthesize the results in meta-analyses. The results are presented according to thematic analysis.

RESULTS

No individual study reported research exclusively in newborns 37 to 42 weeks of gestation. Eight studies fulfilled the inclusion criteria, but the population in all these studies included both premature and term newborns. Evidence about mechanical ventilation tailored exclusively to full-term newborns is scarce.

IMPLICATION FOR PRACTICE

Synchronized intermittent mandatory ventilation with a 6 mL/kg tidal volume and a positive end-expiratory pressure of 8 cm H2O may be advantageous in full-term newborns.

IMPLICATION FOR RESEARCH

There is an urgent need for high-quality studies, preferably randomized controlled trials, in full-term newborns requiring mechanical ventilation to optimize oxygenation, ventilation, and short-term outcomes, potentially stratified according to the underlying pathology.

The need for predictability in coordination of ventilator treatment of newborn infants--a qualitative study

OBJECTIVE

New strategies for interprofessional collaboration are needed to achieve best practice in the care of ventilated newborns. This study explores what physicians and nurses believe to be important to improve collaboration during ventilator treatment.

METHODS

Qualitative data collected from one focus group were analysed using Gittell's theory of relational coordination.

RESULTS

To optimise communication about and coordination of ventilator treatment, six strategies were needed: (1) a pathway toward the goal for each newborn, (2) regular meetings, (3) accurate communication following an established pattern in the rounds conference, (4) collaboration to improve interprofessional level of knowledge, (5) courage to communicate one's own point of view, and (6) flexible responsibility in extubation situations.

CONCLUSION

By identifying weak areas in collaboration, nurses and physicians were inspired to suggest and discuss concrete improvements of work practices in the neonatal intensive care unit. Nurses and physicians can coordinate ventilator treatment by using a pathway and at the same time enhance nurses' involvement and responsibility in order to increase the flexibility of job boundaries, allowing the professions to cover for each other's work.