1
|
de Carvalho Nunes G, Barbosa de Oliveira C, Zeid M, Leone M, Mardakis S, Remmer E, Boyer J, Hailu E, Altit G, Beltempo M, Shalish W, Sant'Anna G. Early Bubble CPAP Protocol Implementation and Rates of Death or Severe BPD. Pediatrics 2024; 154:e2023065373. [PMID: 38887808 DOI: 10.1542/peds.2023-065373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND A multidisciplinary comprehensive protocol to use bubble continuous positive airway pressure (bCPAP) as the primary respiratory support in the delivery room (DR) and the NICU was introduced. With this study, we aimed to assess the association of this change with respiratory outcomes over time. METHODS Infants with gestational age <32 weeks and birth weight <1250 g admitted between January 2012 and June 2020 were included and categorized into 4 periods, including pre-implementation (P0: 2012-2014), and post-implementation (P1: 2014-2016, P2: 2016-2018, P3: 2018-2020). The primary outcome was the rates of death and severe bronchopulmonary dysplasia (BPD), and the secondary outcomes included the rates of DR and NICU intubation ≤7 days of age, need of surfactant, and pneumothorax. Multivariate logistic regression models accounting for relevant risk factors were used to calculate adjusted odds ratios (ORs). RESULTS The study included 440 infants (P0 = 90, P1 = 91, P2 = 128, P3 = 131). Over time, more infants were free of BPD (P < .001), and the rates of death and severe BPD decreased significantly: P1 = OR 1.21 (95% confidence interval [CI] 0.56-2.67), P2 = OR 0.45 (95% CI 0.20-0.99), and P3 = OR 0.37 (95% CI 0.15-0.84). DR intubation decreased from 66% (P0) to 24% (P3) in the entire cohort (P < .001) and from 96% (P0) to 40% (P3) in infants <26 weeks of age (P < .001). The need for NICU intubation was similar (P = .98), with a decreased need for surfactant (P = .001) occurring at higher FiO2 (P0 = 0.35 vs P3 = 0.55, P < .001). Pneumothorax rates were unchanged. CONCLUSIONS In very preterm infants, the implementation of a comprehensive bCPAP protocol led to a significant and consistent improvement in respiratory practices and the rates of death and severe BPD.
Collapse
Affiliation(s)
| | | | - Marco Zeid
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
| | | | - Stephanie Mardakis
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
| | - Elissa Remmer
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
| | | | - Elizabeth Hailu
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
| | - Gabriel Altit
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
| | - Marc Beltempo
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
| | - Wissam Shalish
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
- Experimental Medicine Department
| | - Guilherme Sant'Anna
- Division of Neonatology, Department of Pediatrics
- Montreal Children's Hospital
- Experimental Medicine Department
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
2
|
Mende S, Ahmed S, DeShea L, Szyld E, Shah BA. Electronic Heart (ECG) Monitoring at Birth and Newborn Resuscitation. CHILDREN (BASEL, SWITZERLAND) 2024; 11:685. [PMID: 38929264 PMCID: PMC11202155 DOI: 10.3390/children11060685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/27/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Approximately 10% of newborns require assistance at delivery, and heart rate (HR) is the primary vital sign providers use to guide resuscitation methods. In 2016, the American Heart Association (AHA) suggested electrocardiogram in the delivery room (DR-ECG) to measure heart rate during resuscitation. This study aimed to compare the frequency of resuscitation methods used before and after implementation of the AHA recommendations. METHODS This longitudinal retrospective cohort study compared a pre-implementation (2015) cohort with two post-implementation cohorts (2017, 2021) at our Level IV neonatal intensive care unit. RESULTS An initial increase in chest compressions at birth associated with the introduction of DR-ECG monitoring was mitigated by focused educational interventions on effective ventilation. Implementation was accompanied by no changes in neonatal mortality. CONCLUSIONS Investigation of neonatal outcomes during the ongoing incorporation of DR-ECG may help our understanding of human and system factors, identify ways to optimize resuscitation team performance, and assess the impact of targeted training initiatives on clinical outcomes.
Collapse
Affiliation(s)
- Sarah Mende
- Department of Pediatrics, College of Medicine, University of Oklahoma (OU), Oklahoma City, OK 73104, USA
| | - Syed Ahmed
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lise DeShea
- Department of Pediatrics, College of Medicine, University of Oklahoma (OU), Oklahoma City, OK 73104, USA
| | - Edgardo Szyld
- Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Birju A. Shah
- Department of Pediatrics, College of Medicine, University of Oklahoma (OU), Oklahoma City, OK 73104, USA
- Neonatal-Perinatal Medicine, Oklahoma Children’s Hospital at OU Health, 1200 North Everett Drive, 7th Floor North Pavilion ETNP #7504, Oklahoma City, OK 73104, USA
| |
Collapse
|
3
|
Chan CS, Chiu M, Ariyapadi S, Brown LS, Burchfield P, Simcik V, Garcia K, Mazioniene K, Jaleel MA, Wyckoff MH, Kapadia VS, Kakkilaya V. Evaluation of a respiratory care protocol including less invasive surfactant administration in preterm infants. Pediatr Res 2024; 95:1603-1610. [PMID: 38097721 DOI: 10.1038/s41390-023-02963-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND Respiratory care protocol including less invasive śsurfactant administration (LISA) in ≤29 weeks' gestational age (GA) infants introduced in October 2018. METHODS Retrospective study of infants admitted on continuous positive airway pressure (CPAP) October 2018 to December 2021. Maternal and neonatal variables were compared between infants managed on CPAP with and without LISA. Infants who received LISA and subsequently required mechanical ventilation (MV) within 72 h of life (HOL) [LISA failure (LF)] were compared with those who required no MV [LISA success (LS)]. RESULTS 249 infants were admitted on CPAP, 5 were intubated prior to LISA, 143 required LISA and 101 remained on CPAP without surfactant. Of those receiving LISA, 108 were LS and 35 were LF. Compared to LS, LF infants were of lower GA and birth weight, required higher fractional inspired oxygen (FiO2), and CPAP level at birth, admission, one HOL, and an hour after LISA. Moreover, LF infants had higher mortality and morbidity. Together GA ≤ 25 weeks' and FiO2 ≥ 0.3 an hour after LISA best predicted LF. CONCLUSIONS Over 80% of infants admitted on CPAP avoided MV within 72 HOL. Early predictors of LF provide targets for future interventions to decrease need for MV in preterm infants. IMPACT Less invasive surfactant administration (LISA) decreases the need for mechanical ventilation (MV) and improves outcomes. However, some infants require MV within 72 h of life (HOL) despite LISA (LISA failure). Over 80% of ≤29 weeks' gestational age (GA) infants can be successfully managed on CPAP with or without surfactant in the first 72 HOL. A combination of factors including ≤25 weeks' GA and fraction of inspired oxygen ≥0.3 an hour after LISA predict LISA failure. Evaluation of a noninvasive respiratory support strategy including LISA provides targets for intervention to decrease need for MV in preterm infants.
Collapse
Affiliation(s)
- Christina S Chan
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Melody Chiu
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Swathi Ariyapadi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Patti Burchfield
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - Kristi Garcia
- Parkland Health and Hospital System, Dallas, TX, USA
| | | | | | - Myra H Wyckoff
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vishal S Kapadia
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | |
Collapse
|
4
|
Legge N, Popat H, Fitzgerald D. Improved survival at the cost of more chronic lung disease? Current management and outcomes in extremely preterm infants born in New South Wales and the Australian Capital Territory: 2010-2020. World J Pediatr 2024; 20:230-238. [PMID: 37902946 PMCID: PMC10957579 DOI: 10.1007/s12519-023-00761-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/10/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Since 2010, most tertiary care hospitals in Australia have changed how they care for extremely premature infants. However, in-hospital and longer-term outcome data have suggested unchanged or even worse health outcomes in later epochs, especially respiratory outcomes. This study examined the trend in outcomes since these changes were introduced, particularly the prevalence of chronic neonatal lung disease (CLD). METHODS This is a retrospective cross-sectional analysis of data from the Neonatal Intensive Care Units' (NICUS) database of all perinatal intensive care units in New South Wales and the Australian Capital Territory, including infants born at ≥ 24 and ≤ 28 weeks of gestational age in tertiary perinatal units between January 1, 2010, and December 31, 2020. Temporal trends and changes in primary outcome were examined by linear and adjusted multivariable logistic regression models. RESULTS This study included 3258 infants. We saw significant changes in antenatal magnesium sulfate (75% increase), delayed cord clamping (66% increase), delivery room intubations (30% decrease), any time (20% decrease), duration on mechanical ventilation (100-hour decrease), and hours on noninvasive ventilation (200-hour increase). Mortality decreased from 17% to 6%. The incidence of CLD increased significantly even when adjusted for confounders (15% increase). Any time and mean hours spent on mechanical ventilation significantly increased the odds of CLD. This study could not find a significant association of any of the protective antenatal treatments on CLD. CONCLUSIONS The last decade saw a significant improvement in survival and survival to discharge without major morbidity. There was increased use of magnesium sulfate, delayed cord clamping, and less invasive respiratory management of extremely preterm infants. The avoidance of mechanical ventilation may impact the incidence of CLD.
Collapse
Affiliation(s)
- Nele Legge
- Liverpool Hospital, Corner Elizabeth and Goulburn Streets, Liverpool, NSW, Australia.
- University of Sydney, Camperdown, Australia.
| | - Himanshu Popat
- University of Sydney, Camperdown, Australia
- Children's Hospital Westmead, Westmead, Australia
| | - Dominic Fitzgerald
- University of Sydney, Camperdown, Australia
- Children's Hospital Westmead, Westmead, Australia
| |
Collapse
|
5
|
Monnelly V, Josephsen JB, Isayama T, de Almeida MFB, Guinsburg R, Schmölzer GM, Rabi Y, Wyckoff MH, Weiner G, Liley HG, Solevåg AL. Exhaled CO 2 monitoring to guide non-invasive ventilation at birth: a systematic review. Arch Dis Child Fetal Neonatal Ed 2023; 109:74-80. [PMID: 37558397 DOI: 10.1136/archdischild-2023-325698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE Measuring exhaled carbon dioxide (ECO2) during non-invasive ventilation at birth may provide information about lung aeration. However, the International Liaison Committee on Resuscitation (ILCOR) only recommends ECO2 detection for confirming endotracheal tube placement. ILCOR has therefore prioritised a research question that needs to be urgently evaluated: 'In newborn infants receiving intermittent positive pressure ventilation by any non-invasive interface at birth, does the use of an ECO2 monitor in addition to clinical assessment, pulse oximetry and/or ECG, compared with clinical assessment, pulse oximetry and/or ECG only, decrease endotracheal intubation in the delivery room, improve response to resuscitation, improve survival or reduce morbidity?'. DESIGN Systematic review of randomised and non-randomised studies identified by Ovid MEDLINE, Embase and Cochrane CENTRAL search until 1 August 2022. SETTING Delivery room. PATIENTS Newborn infants receiving non-invasive ventilation at birth. INTERVENTION ECO2 measurement plus routine assessment compared with routine assessment alone. MAIN OUTCOME MEASURES Endotracheal intubation in the delivery room, response to resuscitation, survival and morbidity. RESULTS Among 2370 articles, 23 were included; however, none had a relevant control group. Although studies indicated that the absence of ECO2 may signify airway obstruction and ECO2 detection may precede a heart rate increase in adequately ventilated infants, they did not directly address the research question. CONCLUSIONS Evidence to support the use of an ECO2 monitor to guide non-invasive positive pressure ventilation at birth is lacking. More research on the effectiveness of ECO2 measurement in addition to routine assessment during non-invasive ventilation of newborn infants at birth is needed. PROSPERO REGISTRATION NUMBER CRD42022344849.
Collapse
Affiliation(s)
- Vix Monnelly
- Department of Neonatology, Simpson Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Justin B Josephsen
- Department of Pediatrics, Saint Louis University School of Medicine, St Louis, MO, USA
| | - Tetsuya Isayama
- Division of Neonatology, Center of Maternal-Fetal Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Maria Fernanda B de Almeida
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ruth Guinsburg
- Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation and Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Myra H Wyckoff
- Pediatrics, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Gary Weiner
- Department of Pediatrics, Neonatal-Perinatal Medicine, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Helen G Liley
- Mater Research Institute, The University of Queensland, South Brisbane, QLD, Australia
| | - Anne Lee Solevåg
- Department of Neonatal Intensive Care, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| |
Collapse
|
6
|
Yu Z, Wang L, Wang Y, Zhang M, Xu Y, Liu A. Development and Validation of a Risk Scoring Tool for Bronchopulmonary Dysplasia in Preterm Infants Based on a Systematic Review and Meta-Analysis. Healthcare (Basel) 2023; 11:healthcare11050778. [PMID: 36900783 PMCID: PMC10000930 DOI: 10.3390/healthcare11050778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/28/2023] [Accepted: 03/03/2023] [Indexed: 03/09/2023] Open
Abstract
Background: Bronchopulmonary dysplasia (BPD) is the most common serious pulmonary morbidity in preterm infants with high disability and mortality rates. Early identification and treatment of BPD is critical. Objective: This study aimed to develop and validate a risk scoring tool for early identification of preterm infants that are at high-risk for developing BPD. Methods: The derivation cohort was derived from a systematic review and meta-analysis of risk factors for BPD. The statistically significant risk factors with their corresponding odds ratios were utilized to construct a logistic regression risk prediction model. By scoring the weights of each risk factor, a risk scoring tool was established and the risk stratification was divided. External verification was carried out by a validation cohort from China. Results: Approximately 83,034 preterm infants with gestational age < 32 weeks and/or birth weight < 1500 g were screened in this meta-analysis, and the cumulative incidence of BPD was about 30.37%. The nine predictors of this model were Chorioamnionitis, Gestational age, Birth weight, Sex, Small for gestational age, 5 min Apgar score, Delivery room intubation, and Surfactant and Respiratory distress syndrome. Based on the weight of each risk factor, we translated it into a simple clinical scoring tool with a total score ranging from 0 to 64. External validation showed that the tool had good discrimination, the area under the curve was 0.907, and that the Hosmer-Lemeshow test showed a good fit (p = 0.3572). In addition, the results of the calibration curve and decision curve analysis suggested that the tool showed significant conformity and net benefit. When the optimal cut-off value was 25.5, the sensitivity and specificity were 0.897 and 0.873, respectively. The resulting risk scoring tool classified the population of preterm infants into low-risk, low-intermediate, high-intermediate, and high-risk groups. This BPD risk scoring tool is suitable for preterm infants with gestational age < 32 weeks and/or birth weight < 1500 g. Conclusions: An effective risk prediction scoring tool based on a systematic review and meta-analysis was developed and validated. This simple tool may play an important role in establishing a screening strategy for BPD in preterm infants and potentially guide early intervention.
Collapse
Affiliation(s)
- Zhumei Yu
- Department of Neonatology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
- School of Nursing, Anhui Medical University, Hefei 230032, China
| | - Lili Wang
- Department of Neonatology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Yang Wang
- Department of Neonatology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Min Zhang
- Department of Neonatology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Yanqin Xu
- Department of Neonatology, the First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Annuo Liu
- School of Nursing, Anhui Medical University, Hefei 230032, China
- Correspondence:
| |
Collapse
|
7
|
Escrig-Fernández R, Zeballos-Sarrato G, Gormaz-Moreno M, Avila-Alvarez A, Toledo-Parreño JD, Vento M. The Respiratory Management of the Extreme Preterm in the Delivery Room. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020351. [PMID: 36832480 PMCID: PMC9955623 DOI: 10.3390/children10020351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
The fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization.
Collapse
Affiliation(s)
- Raquel Escrig-Fernández
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
- Correspondence:
| | | | - María Gormaz-Moreno
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Alejandro Avila-Alvarez
- Division of Neonatology, Pediatric Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, 15006 A Coruña, Spain
| | - Juan Diego Toledo-Parreño
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Máximo Vento
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| |
Collapse
|
8
|
Advancements in neonatology through quality improvement. J Perinatol 2022; 42:1277-1282. [PMID: 35368024 DOI: 10.1038/s41372-022-01383-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 11/09/2022]
Abstract
In the past 3 decades, quality improvement methodology has often been employed in medicine to improve patient outcomes. Neonatal medicine has seen an increase in publications using improvement science to ensure the application of potentially better practices to decrease complications and increase survival without major disability. This article reviews quality improvement studies that have impacted neonatal mortality and morbidity, as well as specific disease processes including bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and retinopathy of prematurity. Using improvement science, studies have substantially reduced neonatal mortality and the major complications of preterm birth.
Collapse
|
9
|
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
Collapse
Affiliation(s)
- Emily Whitesel
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States; Division of Newborn Medicine, Harvard Medical School, Boston MA, United States.
| | - Justin Goldstein
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States
| | - Henry C. Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford CA, United States
| | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston MA, United States,Division of Newborn Medicine, Harvard Medical School, Boston MA, United States
| |
Collapse
|
10
|
Should less invasive surfactant administration (LISA) become routine practice in US neonatal units? Pediatr Res 2022; 93:1188-1198. [PMID: 35986148 PMCID: PMC9389478 DOI: 10.1038/s41390-022-02265-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
The harmful effects of mechanical ventilation (MV) on the preterm lung are well established. Avoiding MV at birth and stabilization on continuous positive airway pressure (CPAP) decreases the composite outcome of death or bronchopulmonary dysplasia. Although preterm infants are increasingly being admitted to the neonatal intensive care unit on CPAP, centers differ in the ability to manage infants primarily on CPAP. Over the last decade, less invasive surfactant administration (LISA), a method of administering surfactant with a thin catheter, has been devised and has been shown to decrease the need for MV and improve outcomes compared to surfactant administration via an endotracheal tube following intubation. While LISA has been widely adopted in Europe and other countries, its use is not widespread in the United States. This article provides a summary of the existing evidence on LISA, and practical guidance for US units choosing to implement a change of practice incorporating optimization of CPAP and LISA. IMPACT: The accumulated body of evidence for less invasive surfactant administration (LISA), a widespread practice in other countries, justifies its use as an alternative to intubation and surfactant administration in US neonatal units. This article summarizes the current evidence for LISA, identifies gaps in knowledge, and offers practical tips for the implementation of LISA as part of a comprehensive non-invasive respiratory support strategy. This article will help neonatal units in the US develop guidelines for LISA, provide optimal respiratory support for infants with respiratory distress syndrome, improve short- and long-term outcomes of preterm infants, and potentially decrease costs of NICU care.
Collapse
|
11
|
Decreasing Intubation for Ineffective Ventilation after Birth for Very Low Birth Weight Neonates. Pediatr Qual Saf 2022; 7:e580. [PMID: 35928022 PMCID: PMC9345641 DOI: 10.1097/pq9.0000000000000580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 06/25/2022] [Indexed: 11/18/2022] Open
Abstract
Despite recommendations promoting noninvasive delivery room (DR) ventilation, local historical preterm DR noninvasive ventilation rates were low (50%−64%). Project aims were to improve DR noninvasive ventilation rate in very low birth weight (VLBW) neonates (<1500 g) with a focus on decreasing DR intubations for ineffective positive pressure ventilation (PPV).
Collapse
|
12
|
Whitesel E, Goldstein J, Lee HC, GuptaMMSc M. Quality Improvement for Neonatal Resuscitation and Delivery Room Care. SEMINARS IN SPINE SURGERY 2022:100961. [PMID: 35574250 PMCID: PMC9080026 DOI: 10.1016/j.semss.2022.100961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Quality improvement has become a foundation of neonatal care. Structured approaches to improvement can standardize practices, improve teamwork, engage families, and improve outcomes. The delivery room presents a unique environment for quality improvement; optimal delivery room care requires advanced preparation, adequately trained providers, and carefully coordinated team dynamics. In this article, we examine quality improvement for neonatal resuscitation. We review the published literature, focusing on reports targeting admission hypothermia, delayed cord clamping, and initial respiratory support. We discuss specific challenges related to delivery room quality improvement, including small numbers, data collection, and lack of benchmarking, and potential strategies to address them including simulation, checklists, and state and national collaboratives. We examine how quality improvement can target equity in delivery room outcomes, and explore the impact of the COVID-19 pandemic on delivery room quality of care.
Collapse
Affiliation(s)
- Emily Whitesel
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Henry C Lee
- Stanford University School of Medicine, Stanford, CA
| | - Munish GuptaMMSc
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| |
Collapse
|
13
|
Debay A, Patel S, Wintermark P, Claveau M, Olivier F, Beltempo M. Association of Delivery Room and Neonatal Intensive Care Unit Intubation, and Number of Tracheal Intubation Attempts with Death or Severe Neurological Injury among Preterm Infants. Am J Perinatol 2022; 39:776-785. [PMID: 33075843 DOI: 10.1055/s-0040-1718577] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The study aimed to assess the association of tracheal intubation (TI) and where it is performed, and the number of TI attempts with death and/or severe neurological injury (SNI) among preterm infants. STUDY DESIGN Retrospective cohort study of infants born 23 to 32 weeks, admitted to a single level-3 neonatal intensive care unit (NICU) between 2015 and 2018. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. >1). Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3-4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess association between exposures and outcomes and to adjust for confounders. RESULTS Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with one TI attempt and 23% (27/117) among infants with >1 TI attempt. Overall, median number of TI attempts was 1 (interquartile range [IQR]: 1-2). Compared with no TI, DR TI (adjusted odds ratio [AOR]: 9.04, 95% confidence interval [CI]: 3.21-28.84) and NICU TI (AOR: 3.42, 95% CI: 1.21-10.61) were associated with higher odds of death and/or SNI. The DR TI was associated with higher odds of death and/or SNI compared with NICU TI (AOR: 2.64, 95% CI: 1.17-6.22). The number of intubation attempts (1 vs. >1) was not associated with death and/or SNI (AOR: 0.95, 95% CI: 0.47-2.03). CONCLUSION The DR TI is associated with higher odds of death and/or SNI compared with NICU TI, and may help identify higher risk infants. There was no association between the number of TI attempts and death and/or SNI. KEY POINTS · Delivery room intubation correlates with morbidity.. · Less than 2 intubation attempts are not associated with IVH.. · Provider training reduces intubation attempts..
Collapse
Affiliation(s)
- Anthony Debay
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Sharina Patel
- McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | - Pia Wintermark
- McGill University Health Center Research Institute, Montreal, Quebec, Canada.,Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Martine Claveau
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - François Olivier
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital - McGill University Health Centre, Montreal, Quebec, Canada
| |
Collapse
|
14
|
Fernandez-Gonzalez SM, Sucasas Alonso A, Ogando Martinez A, Avila-Alvarez A. Incidence, Predictors and Outcomes of Noninvasive Ventilation Failure in Very Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2022; 9:426. [PMID: 35327798 PMCID: PMC8947251 DOI: 10.3390/children9030426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/11/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
Non-invasive ventilation (NIV) is now considered the first-line treatment for respiratory distress syndrome in preterm infants. We aimed to evaluate the rates of non-invasive ventilation failure rate in very preterm infants, as well as to identify its predictors and associated outcomes. We designed a single-center retrospective cohort study including infants ≤32 weeks gestational age and ≤1500 g. The NIV failure was defined as the need for intubation at <72 h of life. After applying inclusion and exclusion criteria, 154 patients were included in the study, with a mean GA of 29.7 ± two weeks. The NIV failure rate was 16.2% (n = 25) and it was associated with lower bronchopulmonary dysplasia (BPD)-free survival (OR 0.08; 95% CI 0.02−0.32) and higher incidence of intraventricular hemorrhage > II (OR 6.22; 95% CI 1.36−28.3). These infants were significantly smaller in GA and weight. Higher FiO2 during resuscitation (OR 1.14; 95% CI 1.06−1.22) and after surfactant administration (OR 1.17; 95% CI 1.05−1.31) represented independent risk factors for NIV failure. In conclusion, NIV failure is frequent and it could be predicted by a higher oxygen requirement during resuscitation and a modest response to surfactant therapy. Importantly, this NIV failure is associated with worse clinical outcomes.
Collapse
Affiliation(s)
- Sara M. Fernandez-Gonzalez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Andrea Sucasas Alonso
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Alicia Ogando Martinez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
| | - Alejandro Avila-Alvarez
- Neonatology Department, Complexo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain; (S.M.F.-G.); (A.S.A.); (A.O.M.)
- A Coruña Biomedical Research Institute (INIBIC), 15006 A Coruña, Spain
| |
Collapse
|
15
|
Abstract
BACKGROUND Endotracheal intubation is a commonly performed procedure in neonates, the risks of which are well-described. Some endotracheal tubes (ETT) are equipped with a cuff that can be inflated after insertion of the ETT in the airway to limit leak or aspiration. Cuffed ETTs have been shown in larger children and adults to reduce gas leak around the ETT, ETT exchange, accidental extubation, and exposure of healthcare workers to anesthetic gas during surgery. With improved understanding of neonatal airway anatomy and the widespread use of cuffed ETTs by anesthesiologists, the use of cuffed tubes is increasing in neonates. OBJECTIVES To assess the benefits and harms of cuffed ETTs (inflated or non-inflated) compared to uncuffed ETTs for respiratory support in neonates. SEARCH METHODS We searched CENTRAL, PubMed, and CINAHL on 20 August 2021; we also searched trial registers and checked reference lists to identify additional studies. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs, and cluster-randomized trials comparing cuffed (inflated and non-inflated) versus uncuffed ETTs in newborns. We sought to compare 1. inflated, cuffed versus uncuffed ETT; 2. non-inflated, cuffed versus uncuffed ETT; and 3. inflated, cuffed versus non-inflated, cuffed ETT. DATA COLLECTION AND ANALYSIS We used the standard methods of Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion, extracted data, and assessed risk of bias. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We identified one eligible RCT for inclusion that compared the use of cuffed (inflated if ETT leak greater than 20% with cuff pressure 20 cm H2O or less) versus uncuffed ETT. The author provided a spreadsheet with individual data. Among 76 infants in the original manuscript, 69 met the inclusion and exclusion criteria for this Cochrane Review. We found possible bias due to lack of blinding and other bias. We are very uncertain about frequency of postextubation stridor, because the confidence intervals (CI) of the risk ratio (RR) were very wide (RR 1.36, 95% CI 0.35 to 5.25; risk difference (RD) 0.03, -0.11 to 0.18; 1 study, 69 participants; very low-certainty evidence). No neonate was diagnosed with postextubation subglottic stenosis; however, endoscopy was not available to confirm the clinical diagnosis. We are very uncertain about reintubation for stridor or subglottic stenosis because the CIs of the RR were very wide (RR 0.27, 95% CI 0.01 to 6.49; RD -0.03, 95% CI -0.11 to 0.05; 1 study, 69 participants; very low-certainty evidence). No neonate had surgical intervention (e.g. endoscopic balloon dilation, cricoid split, tracheostomy) for stridor or subglottic stenosis (1 study, 69 participants). Neonates randomized to cuffed ETT may be less likely to have a reintubation for any reason (RR 0.06, 95% CI 0.01 to 0.45; RD -0.39, 95% CI -0.57 to -0.21; number needed to treat for an additional beneficial outcome 3, 95% CI 2 to 5; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about accidental extubation because the CIs of the RR were wide (RR 0.82, 95% CI 0.12 to 5.46; RD -0.01, 95% CI -0.12 to 0.10; 1 study, 69 participants; very low-certainty evidence). We are very uncertain about all-cause mortality during initial hospitalization because the CIs of the RR were extremely wide (RR 2.46, 95% CI 0.10 to 58.39; RD 0.03, 95% CI -0.05 to 0.10; 1 study, 69 participants; very low-certainty evidence). There is one ongoing trial. We classified two studies as awaiting classification because outcome data were not reported separately for newborns and older infants. AUTHORS' CONCLUSIONS Evidence for comparing cuffed versus uncuffed ETTs in neonates is limited by a small number of babies in a single RCT with possible bias. There is very low certainty evidence for all outcomes of this review. CIs of the estimate for postextubation stridor were wide. No neonate had clinical evidence for subglottic stenosis; however, endoscopy results were not available to assess the anatomy. Additional RCTs are necessary to evaluate the benefits and harms of cuffed ETTs (inflated and non-inflated) in the neonatal population. These studies must include neonates and be conducted both for short-term use (in the setting of the operating room) and chronic use (in the setting of chronic lung disease) of cuffed ETTs.
Collapse
Affiliation(s)
- Vedanta Dariya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Luca Moresco
- Pediatric and Neonatology Unit, Ospedale San Paolo, Savona, Italy
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics, Lund University, Skåne University Hospital, Lund, Sweden
- Cochrane Sweden, Lund University, Skåne University Hospital, Lund, Sweden
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern at Dallas, Dallas, Texas, USA
| |
Collapse
|
16
|
Jardine L, Bates K, Bates A, Muirhead R, Bischoff E, Sly A, Cross T, Barrett J, Newman T, Birch P, Woodgate P, Mausling R, Roberts T, Dixon K, Hutchinson F, Beker F, Gately C, Domingo-Bates J. Decreasing delivery room intubations: A quality improvement project. J Paediatr Child Health 2022; 58:163-169. [PMID: 34448317 DOI: 10.1111/jpc.15687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/15/2021] [Accepted: 07/27/2021] [Indexed: 11/27/2022]
Abstract
AIM The delivery room intubation rate for babies born less than 32 weeks postmenstrual age (PMA) at the Mater Mothers' Hospital in 2017 was 51%. Delivery room intubation of preterm infants may be associated with an increased risk of developing bronchopulmonary dysplasia. This quality improvement project aimed to decrease the rate of delivery room intubation for infants born less than 32 weeks PMA. METHODS A quality improvement process using the evidence-based practice for improving quality framework and Plan-Do-Study-Act cycles was undertaken from October 2018 to December 2019. Commencing bubble continuous positive airway pressure for initial resuscitation in the delivery room was the principal change idea. RESULTS The delivery room intubation rate for infants born less than 32 weeks PMA before the commencement of this project was 48% (cohort 1, n = 221). There was a significant decrease in the rate to 37.2% while the project was being conducted (cohort 2, n = 277) and a further significant reduction to 28.2% after introducing bubble continuous positive airway pressure in the delivery room (cohort 3, n = 202). There was a significant improvement in admission temperatures and a significant decrease in mortality rate between cohort 1 and cohort 2 but not between cohort 2 and cohort 3. There was no change in the rate of discharge home on oxygen between cohorts. CONCLUSIONS This quality improvement project led to a significantly decreased delivery room intubation rate in infants born less than 32 weeks PMA. There was no evidence of any adverse outcomes with this approach.
Collapse
Affiliation(s)
- Luke Jardine
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Karina Bates
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Amanda Bates
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Renee Muirhead
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Elise Bischoff
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Angela Sly
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Tenille Cross
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Jade Barrett
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Tracey Newman
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Pita Birch
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Paul Woodgate
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Richard Mausling
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Tamsin Roberts
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Kelly Dixon
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Fiona Hutchinson
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Friederike Beker
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Callum Gately
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| | - Joy Domingo-Bates
- Neonatal Critical Care Unit, Mater Mothers Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
17
|
Association of antenatal steroids with surfactant administration in moderate preterm infants born to women with diabetes mellitus and/or hypertension. J Perinatol 2022; 42:993-1000. [PMID: 34802046 PMCID: PMC8605443 DOI: 10.1038/s41372-021-01273-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/07/2021] [Accepted: 11/05/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Randomized trials of antenatal steroid administration (ANS) for extreme or moderate preterm pregnancies excluded women with diabetes mellitus (DM) and included few with preeclampsia. METHODS Cohort study (n = 1,813) including moderate preterm births [290/7-336/7wks' gestational age GA)] before (Epoch-1) and after (Epoch-2) expansion of ANS administration to women with hypertensive disorders (HTN) and/or DM. We compared surfactant administration in Group-1 (neither HTN nor DM), Group-2a (HTN not DM), Group-2b (DM not HTN) and Group-2c (DM and HTN). RESULTS Surfactant administration was less frequent after ANS in Group-1 [adjusted odds ratio (aOR) 0.54, 95% confidence interval (CI) 0.31, 0.93, P = 0.03], Group-2a (aOR 0.36, CI 0.22, 0.58, P < 0.001) and Group-2c (aOR 0.29, CI 0.12, 0.71, P = 0.007) but not Group-2b (P = 0.64). CONCLUSIONS ANS administration was independently associated with less surfactant administration in moderately preterm neonates whose mothers had neither HTN nor DM, and those with HTN, but not those with DM without HTN.
Collapse
|
18
|
Electrocardiogram for heart rate evaluation during preterm resuscitation at birth: a randomized trial. Pediatr Res 2022; 91:1445-1451. [PMID: 34645954 PMCID: PMC8513736 DOI: 10.1038/s41390-021-01731-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Although electrocardiogram (ECG) can detect heart rate (HR) faster compared to pulse oximetry, it remains unknown if routine use of ECG for delivery room (DR) resuscitation reduces the time to stabilization in preterm infants. METHODS Neonates <31 weeks' gestation were randomized to either an ECG-displayed or an ECG-blinded HR assessment in the DR. HR, oxygen saturation, resuscitation interventions, and clinical outcomes were compared. RESULTS During the study period, 51 neonates were enrolled. The mean gestational age in both groups was 28 ± 2 weeks. The time to stabilization, defined as the time from birth to achieve HR ≥100 b.p.m., as well as oxygen saturation within goal range, was not different between the ECG-displayed and the ECG-blinded groups [360 (269, 435) vs 345 (240, 475) s, p = 1.00]. There was also no difference in the time to HR ≥100 b.p.m. [100 (75, 228) vs 138 (88, 220) s, p = 0.40] or duration of positive pressure ventilation (PPV) [345 (120, 558) vs 196 (150, 273) s, p = 0.36]. Clinical outcomes were also similar between groups. CONCLUSIONS Although feasible and safe, the use of ECG in the DR during preterm resuscitation did not reduce time to stabilization. IMPACT Although feasible and apparently safe, routine use of the ECG in the DR did not decrease time to HR >100 b.p.m., time to stabilization, or use of resuscitation interventions such as PPV for preterm infants <31 weeks' gestational age. This article adds to the limited randomized controlled trial evidence regarding the impact of routine use of ECG during preterm resuscitation on DR clinical outcomes. Such evidence is important when considering recommendations for routine use of the ECG in the DR worldwide as such a recommendation comes with a significant cost burden.
Collapse
|
19
|
Kapadia V, Oei JL, Finer N, Rich W, Rabi Y, Wright IM, Rook D, Vermeulen MJ, Tarnow-Mordi WO, Smyth JP, Lui K, Brown S, Saugstad OD, Vento M. Outcomes of delivery room resuscitation of bradycardic preterm infants: A retrospective cohort study of randomised trials of high vs low initial oxygen concentration and an individual patient data analysis. Resuscitation 2021; 167:209-217. [PMID: 34425156 PMCID: PMC8603874 DOI: 10.1016/j.resuscitation.2021.08.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 07/23/2021] [Accepted: 08/09/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To determine whether hospital mortality (primary outcome) is associated with duration of bradycardia without chest compressions during delivery room (DR) resuscitation in a retrospective cohort study of randomized controlled trials (RCTs) in preterm infants assigned low versus high initial oxygen concentration. METHODS Medline and EMBASE were searched from 01/01/1990 to 12/01/2020. RCTs of low vs high initial oxygen concentration which recorded serial heart rate (HR) and oxygen saturation (SpO2) during resuscitation of infants <32 weeks gestational age were eligible. Individual patient level data were requested from the authors. Newborns receiving chest compressions in the DR and those with no recorded HR in the first 2 min after birth were excluded. Prolonged bradycardia (PB) was defined as HR < 100 bpm for ≥2 min. Individual patient data analysis and pooled data analysis were conducted. RESULTS Data were collected from 720 infants in 8 RCTs. Neonates with PB had higher odds of hospital death before [OR 3.8 (95% CI 1.5, 9.3)] and after [OR 1.7 (1.2, 2.5)] adjusting for potential confounders. Bradycardia occurred in 58% infants, while 38% had PB. Infants with bradycardia were more premature and had lower birth weights. The incidence of bradycardia in infants resuscitated with low (≤30%) and high (≥60%) oxygen was similar. Neonates with both, PB and SpO2 < 80% at 5 min after birth had higher odds of hospital mortality. [OR 18.6 (4.3, 79.7)]. CONCLUSION In preterm infants who did not receive chest compressions in the DR, prolonged bradycardia is associated with hospital mortality.
Collapse
Affiliation(s)
- Vishal Kapadia
- Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center at Dallas, TX, USA.
| | - Ju Lee Oei
- Department of Newborn Care, The Royal Hospital for Women, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Neil Finer
- Department of Neonatology, University of California San Diego, San Diego, CA, USA
| | - Wade Rich
- Department of Neonatology, University of California San Diego, San Diego, CA, USA
| | - Yacov Rabi
- University of Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Alberta, Canada
| | - Ian M Wright
- Illawarra Health and Medical Research Institute and Graduate Medicine, The University of Wollongong, Wollongong, NSW, Australia
| | - Denise Rook
- Department of Pediatrics, Division of Neonatology, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marijn J Vermeulen
- Department of Pediatrics, Division of Neonatology, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | | | - John P Smyth
- Department of Newborn Care, The Royal Hospital for Women, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Kei Lui
- Department of Newborn Care, The Royal Hospital for Women, Randwick, NSW, Australia; School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - Steven Brown
- Parkland Health and Hospital System, Dallas, TX, USA
| | - Ola D Saugstad
- Department of Pediatric Research, University of Oslo, Oslo University Hospital, Norway; Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Feinberg School of Medicine, USA
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| |
Collapse
|
20
|
Kakkilaya VB, Weydig HM, Smithhart WE, Renfro SD, Garcia KM, Brown CM, He H, Wagner SA, Metoyer GC, Brown LS, Kapadia VS, Savani RC, Jaleel MA. Decreasing Continuous Positive Airway Pressure Failure in Preterm Infants. Pediatrics 2021; 148:peds.2020-014191. [PMID: 34552000 DOI: 10.1542/peds.2020-014191] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Many preterm infants stabilized on continuous positive airway pressure (CPAP) at birth require mechanical ventilation (MV) during the first 72 hours of life, which is defined as CPAP failure. Our objective was to decrease CPAP failure in infants ≤29 weeks' gestational age (GA). METHODS A quality improvement bundle named OPTISURF was implemented for infants ≤29 weeks' GA admitted on CPAP, consisting of stepwise escalation of CPAP and less invasive surfactant administration guided by fractional inspired oxygen concentration ≥0.3. The CPAP failure rate was tracked by using control charts. We compared practice and outcomes of a pre-OPTISURF cohort (January 2017 to September 2018) to a post-OPTISURF cohort (October 2018 to December 2019). RESULTS Of the 216 infants ≤29 weeks' GA admitted to NICU on CPAP, 125 infants belonged to the pre-OPTISURF cohort (OSC) and 91 to the post-OSC. Compared with the pre-OSC, a higher proportion of infants in the post-OSC received CPAP 7 cm H2O within 4 hours of life (7% vs 32%; P < .01). The post-OSC also had lower rates of CPAP failure (54% vs 11%; P < .01), pneumothoraces (8% vs 1%; P < .03), need for MV (58% vs 31%; P < .01), and patent ductus arteriosus treatment (21% vs 9%; P = .02). Additionally, in a subgroup analysis, CPAP failure was lower in the post-OSC among infants 23 to 26 weeks (79% vs 27%; P < .01) and 27 to 29 weeks' GA (46% vs 3%; P < .01). CONCLUSIONS Implementation of a quality improvement bundle including CPAP optimization and less invasive surfactant administration decreased CPAP failure and need for MV in preterm infants.
Collapse
Affiliation(s)
- Venkatakrishna B Kakkilaya
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heather M Weydig
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - William E Smithhart
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | - Cari M Brown
- Parkland Hospital and Health System, Dallas, Texas
| | - Henry He
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | - Vishal S Kapadia
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rashmin C Savani
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
21
|
Hatch LD, Clark RH, Carlo WA, Stark AR, Ely EW, Patrick SW. Changes in Use of Respiratory Support for Preterm Infants in the US, 2008-2018. JAMA Pediatr 2021; 175:1017-1024. [PMID: 34228110 PMCID: PMC8261685 DOI: 10.1001/jamapediatrics.2021.1921] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE In preterm infants, mechanical ventilation (MV) is associated with adverse pulmonary and neurodevelopmental outcomes. Multiple randomized clinical trials over the past 2 decades have shown the effectiveness of early noninvasive ventilation (NIV) in decreasing the use of MV in preterm infants. The epidemiologic factors associated with respiratory support in US preterm infants and any temporal changes after these trials is unknown. OBJECTIVE To evaluate temporal changes in MV and noninvasive respiratory support in US preterm infants. DESIGN, SETTING, AND PARTICIPANTS In a cohort design, 2 large national data sets (Pediatrix Clinical Data Warehouse for the clinical cohort and National Inpatient Sample for the national cohort) were used to collect data on preterm infants (<35 weeks' gestation) without congenital anomalies who received active intensive care and were discharged home or died in the birth hospital from January 1, 2008, to December 31, 2018. Data analysis was conducted from December 10, 2019, to December 16, 2020. EXPOSURE Discharge year. MAIN OUTCOME AND MEASURES In the clinical cohort, detailed respiratory support data were generated, including days of MV and NIV modalities, and temporal trends were evaluated using multivariable modified Poisson or negative binomial regression models with discharge year as a continuous variable. In the national cohort, observed and expected national MV use were calculated. RESULTS Among 259 311 infants (47.2% female) in 359 neonatal intensive care units in the clinical cohort, decreases were noted in the use (from 29.4% of infants in 2008 to 18.5% in 2018, relative risk for annual change, 0.96; 95% CI, 0.95-0.96) and duration (mean days, from 10.3 in 2008 to 9.7 in 2018; rate ratio for annual change, 0.98; 95% CI, 0.97-0.98) of MV. Noninvasive ventilation use increased from 57.9% of infants in 2008 to 67.4% in 2018 (adjusted relative risk for annual change, 1.02; 95% CI, 1.02-1.03), and mean NIV duration increased by 3.2 days (95% CI, 2.9-3.6 days). With increased use of continuous positive airway pressure and nasal intermittent positive-pressure ventilation as the main factors in the increase, the mean duration of respiratory support increased from 13.8 to 15.4 days (adjusted rate ratio for annual change, 1.03; 95% CI, 1.02-1.04) from 2008 to 2018. Among 1 169 441 infants in the national cohort, MV use decreased from 22.0% in 2008 to 18.5% in 2018, with an estimated 29 700 fewer ventilated infants and 142 000 fewer days of MV than expected during this period. CONCLUSIONS AND RELEVANCE These findings suggest that preterm respiratory support changed significantly from 2008 to 2018, with decreased use and duration of MV, increased use and duration of NIV, and an overall increase in respiratory support duration.
Collapse
Affiliation(s)
- L. Dupree Hatch
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee,Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Reese H. Clark
- Mednax Center for Research, Education, Quality and Safety, Sunrise, Florida
| | | | - Ann R. Stark
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee,Center for Health Services Research, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee,Veteran’s Affairs Tennessee Valley Geriatric Research Education and Clinical Center, Nashville, Tennessee
| | - Stephen W. Patrick
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee,Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
22
|
Weydig HM, Rosenfeld CR, Jaleel MA, Burchfield PJ, Frost MS, Brion LP. Association of antenatal steroids with neonatal mortality and morbidity in preterm infants born to mothers with diabetes mellitus and hypertension. J Perinatol 2021; 41:1660-1668. [PMID: 34035455 DOI: 10.1038/s41372-021-01090-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/14/2021] [Accepted: 04/29/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Randomized trials of antenatal steroids (ANS) included women at 24-33 weeks gestational age (GA); however, few women had preeclampsia and women with diabetes mellitus (DM) were excluded. METHODS Cohort study including preterm births at 230/7-286/7 weeks GA before (Epoch-1) and after (Epoch-2) expansion of ANS administration to women with DM and hypertensive disorders (HTN). We compared Group-A (neither DM nor HTN) and Group-B (DM and/or HTN). RESULTS Among 747 neonates the adjusted odds ratio (aOR) for surfactant administration, in-hospital mortality, severe intraventricular hemorrhage (IVH) and death or severe IVH were lower in ANS-exposed neonates than unexposed neonates. In Group-B, ANS administration was independently associated with less severe IVH and less death or severe IVH, but not less surfactant use or mortality. CONCLUSIONS Increased ANS administration in women with DM and/or HTN was independently associated with less severe IVH and less death or severe IVH but without decrease in surfactant administration.
Collapse
Affiliation(s)
- Heather M Weydig
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Charles R Rosenfeld
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mambarambath A Jaleel
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patti J Burchfield
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Mackenzie S Frost
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| |
Collapse
|
23
|
Dye ME, Pugh C, Sala C, Scott TA, Wallace T, Grubb PH, Hatch LD. Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU. Jt Comm J Qual Patient Saf 2021; 47:654-662. [PMID: 34284954 DOI: 10.1016/j.jcjq.2021.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/13/2021] [Accepted: 06/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Quality improvement (QI) methods have been widely adopted in health care. Although theoretical frameworks and models for organizing successful QI programs have been described, few reports have provided practical examples to link existing QI theory to building a unit-based QI program. The purpose of this report is to describe the authors' experience in building QI infrastructure in a large neonatal ICU (NICU). METHODS A unit-based QI program was developed with the goal of fostering the growth of high-functioning QI teams. This program was based on six pillars: shared vision for QI, QI team capacity, QI team capability, actionable data for improvement, culture of improvement, and QI team integration with external collaboratives. Multiple interventions were developed, including a QI dashboard to align NICU metrics with unit and hospital quality goals, formal training for QI leaders, QI coaches imbedded in project teams, a day-long QI educational workshop to introduce QI methodology to unit staff, and a secure, Web-based QI data infrastructure. RESULTS Over a five-year period, this QI infrastructure brought organization and support for individual QI project teams and improved patient outcomes in the unit. Two case studies are presented, describing teams that used support from the QI infrastructure. The Infection Prevention team reduced central line-associated bloodstream infections from 0.89 to 0.36 infections per 1,000 central line-days. The Nutrition team decreased the percentage of very low birth weight infants discharged with weights less than the 10th percentile from 51% to 40%. CONCLUSION The clinicians provide a pragmatic example of incorporating QI organizational and contextual theory into practice to support the development of high-functioning QI teams and build a unit-based QI program.
Collapse
|
24
|
Delivery room resuscitation and short-term outcomes of extremely preterm and extremely low birth weight infants: a multicenter survey in North China. Chin Med J (Engl) 2021; 134:1561-1568. [PMID: 34133350 PMCID: PMC8280058 DOI: 10.1097/cm9.0000000000001499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Delivery room resuscitation assists preterm infants, especially extremely preterm infants (EPI) and extremely low birth weight infants (ELBWI), in breathing support, while it potentially exerts a negative impact on the lungs and outcomes of preterm infants. This study aimed to assess delivery room resuscitation and discharge outcomes of EPI and ELBWI in China. Methods: The clinical data of EPI (gestational age [GA] <28 weeks) and ELBWI (birth weight [BW] <1000 g), admitted within 72 h of birth in 33 neonatal intensive care units from five provinces and cities in North China between 2017 and 2018, were analyzed. The primary outcomes were delivery room resuscitation and risk factors for delivery room intubation (DRI). The secondary outcomes were survival rates, incidence of bronchopulmonary dysplasia (BPD), and risk factors for BPD. Results: A cohort of 952 preterm infants were enrolled. The incidence of DRI, chest compressions, and administration of epinephrine was 55.9% (532/952), 12.5% (119/952), and 7.0% (67/952), respectively. Multivariate analysis revealed that the risk factors for DRI were GA <28 weeks (odds ratio [OR], 3.147; 95% confidence interval [CI], 2.082–4.755), BW <1000 g (OR, 2.240; 95% CI, 1.606–3.125), and antepartum infection (OR, 1.429; 95% CI, 1.044–1.956). The survival rate was 65.9% (627/952) and was dependent on GA. The rate of BPD was 29.3% (181/627). Multivariate analysis showed that the risk factors for BPD were male (OR, 1.603; 95% CI, 1.061–2.424), DRI (OR, 2.094; 95% CI, 1.328–3.303), respiratory distress syndrome exposed to ≥2 doses of pulmonary surfactants (PS; OR, 2.700; 95% CI, 1.679–4.343), and mechanical ventilation ≥7 days (OR, 4.358; 95% CI, 2.777–6.837). However, a larger BW (OR, 0.998; 95% CI, 0.996–0.999), antenatal steroid (OR, 0.577; 95% CI, 0.379–0.880), and PS use in the delivery room (OR, 0.273; 95% CI, 0.160–0.467) were preventive factors for BPD (all P < 0.05). Conclusion: Improving delivery room resuscitation and management of respiratory complications are imperative during early management of the health of EPI and ELBWI.
Collapse
|
25
|
钱 苗, 余 章, 陈 小, 徐 艳, 马 月, 姜 善, 王 淮, 王 增, 韩 良, 李 双, 卢 红, 万 俊, 高 艳, 陈 筱, 赵 莉, 吴 明, 张 红, 薛 梅, 朱 玲, 田 兆, 屠 文, 吴 新, 韩 树, 顾 筱. [Clinical features of preterm infants with a birth weight less than 1 500 g undergoing different intensities of resuscitation: a multicenter retrospective analysis]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23:593-598. [PMID: 34130781 PMCID: PMC8214002 DOI: 10.7499/j.issn.1008-8830.2101142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To evaluate the clinical features of preterm infants with a birth weight less than 1 500 g undergoing different intensities of resuscitation. METHODS A retrospective analysis was performed for the preterm infants with a birth weight less than 1 500 g and a gestational age less than 32 weeks who were treated in the neonatal intensive care unit of 20 hospitals in Jiangsu, China from January 2018 to December 2019. According to the intensity of resuscitation in the delivery room, the infants were divided into three groups:non-tracheal intubation (n=1 184), tracheal intubation (n=166), and extensive cardiopulmonary resuscitation (ECPR; n=116). The three groups were compared in terms of general information and clinical outcomes. RESULTS Compared with the non-tracheal intubation group, the tracheal intubation and ECPR groups had significantly lower rates of cesarean section and use of antenatal corticosteroid (P < 0.05). As the intensity of resuscitation increased, the Apgar scores at 1 minute and 5 minutes gradually decreased (P < 0.05), and the proportion of infants with Apgar scores of 0 to 3 at 1 minute and 5 minutes gradually increased (P < 0.05). Compared with the non-tracheal intubation group, the tracheal intubation and ECPR groups had significantly higher mortality rate and incidence rates of moderate-severe bronchopulmonary dysplasia and serious complications (P < 0.05). The incidence rates of grade Ⅲ-Ⅳ intracranial hemorrhage and retinopathy of prematurity (stage Ⅲ or above) in the tracheal intubation group were significantly higher than those in the non-tracheal intubation group (P < 0.05). CONCLUSIONS For preterm infants with a birth weight less than 1 500 g, the higher intensity of resuscitation in the delivery room is related to lower rate of antenatal corticosteroid therapy, lower gestational age, and lower birth weight. The infants undergoing tracheal intubation or ECRP in the delivery room have an increased incidence rate of adverse clinical outcomes. This suggests that it is important to improve the quality of perinatal management and delivery room resuscitation to improve the prognosis of the infants.
Collapse
Affiliation(s)
- 苗 钱
- 南京医科大学附属妇产医院/南京市妇幼保健院新生儿科, 江苏南京 210004Department of Neonatology, Women's Hospital of Nanjing Medical University/Nanjing Maternity and Child Health Care Hospital, Nanjing 210004, China
| | - 章斌 余
- 南京医科大学附属妇产医院/南京市妇幼保健院新生儿科, 江苏南京 210004Department of Neonatology, Women's Hospital of Nanjing Medical University/Nanjing Maternity and Child Health Care Hospital, Nanjing 210004, China
| | - 小慧 陈
- 南京医科大学附属妇产医院/南京市妇幼保健院新生儿科, 江苏南京 210004Department of Neonatology, Women's Hospital of Nanjing Medical University/Nanjing Maternity and Child Health Care Hospital, Nanjing 210004, China
| | - 艳 徐
- 徐州医科大学附属医院新生儿科, 江苏徐州 221002
| | - 月兰 马
- 南京医科大学附属苏州医院/苏州市立医院新生儿科, 江苏苏州 215002
| | - 善雨 姜
- 无锡市妇幼保健院新生儿科, 江苏无锡 214002
| | - 淮燕 王
- 常州市妇幼保健院新生儿科, 江苏常州 213003
| | - 增芹 王
- 徐州市妇幼保健院新生儿科, 江苏徐州 221009
| | - 良荣 韩
- 淮安市妇幼保健院新生儿科, 江苏淮安 223002
| | - 双双 李
- 南通市妇幼保健院新生儿科, 江苏南通 226001
| | - 红艳 卢
- 江苏大学附属医院新生儿科, 江苏镇江 212001
| | | | - 艳 高
- 连云港市妇幼保健院新生儿科, 江苏连云港 222000
| | - 筱青 陈
- 南京医科大学第一附属医院新生儿科, 江苏南京 210036
| | - 莉 赵
- 南京医科大学附属儿童医院新生儿科, 江苏南京 210008
| | - 明赴 吴
- 扬州大学附属医院新生儿科, 江苏扬州 225001
| | | | | | | | - 兆方 田
- 淮安市第一人民医院新生儿科, 江苏淮安 223002
| | | | - 新萍 吴
- 扬州市妇幼保健院新生儿科, 江苏扬州 225002
| | - 树萍 韩
- 南京医科大学附属妇产医院/南京市妇幼保健院新生儿科, 江苏南京 210004Department of Neonatology, Women's Hospital of Nanjing Medical University/Nanjing Maternity and Child Health Care Hospital, Nanjing 210004, China
| | - 筱琪 顾
- 南京医科大学附属妇产医院/南京市妇幼保健院新生儿科, 江苏南京 210004Department of Neonatology, Women's Hospital of Nanjing Medical University/Nanjing Maternity and Child Health Care Hospital, Nanjing 210004, China
| |
Collapse
|
26
|
[Risk factors for endotracheal intubation during resuscitation in the delivery room among very preterm infants]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021. [PMID: 33840409 PMCID: PMC8050545 DOI: 10.7499/j.issn.1008-8830.2102004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To explore the risk factors for endotracheal intubation during resuscitation in the delivery room among very preterm infants. METHODS A retrospective analysis was performed for 455 very preterm infants who were admitted to the neonatal intensive care unit from January 2017 to December 2019. They were divided into an intubation group (n=79) and a non-intubation group (n=376) according to whether endotracheal intubation was performed during resuscitation. The risk factors for endotracheal intubation during resuscitation were evaluated by multivariate logistic regression analysis. RESULTS The intubation rate was 17.4% (79/455). Compared with the intubation group, the non-intubation group had significantly higher gestational age, birth weight, and rates of caesarean birth, delayed cord clamping (DCC), resuscitation quality improvement, regular use of antenatal glucocorticoids in mothers and premature rupture of membranes > 18 hours (P < 0.05), but significantly lower rates of maternal gestational diabetes mellitus, placental abruption, placenta previa or placenta previa status, and maternal thyroid dysfunction (P < 0.05). Regular use of antenatal glucocorticoids in mothers (OR=0.368, P < 0.05) and DCC (OR=0.222, P < 0.05) were protective factors against intubation during resuscitation, while younger gestational age, birth weight < 750 g, maternal gestational diabetes mellitus, and placenta previa or placenta previa status were risk factors for intubation during resuscitation (P < 0.05). CONCLUSIONS Very preterm infants with younger gestational age, birth weight < 750 g, maternal diabetes mellitus, placenta previa or placenta previa status may have a higher risk for endotracheal intubation after birth. The regular use of antenatal glucocorticoids and DCC can reduce the risk of intubation during resuscitation in very preterm infants.
Collapse
|
27
|
Healy H, Croonen LEE, Onland W, van Kaam AH, Gupta M. A systematic review of reports of quality improvement for bronchopulmonary dysplasia. Semin Fetal Neonatal Med 2021; 26:101201. [PMID: 33563565 DOI: 10.1016/j.siny.2021.101201] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common morbidity of preterm infants, and its incidence has not responded to research and intervention efforts to the same degree as other major morbidities associated with prematurity. The complexity of neonatal respiratory care as well as persistent inter-institutional variability in BPD rates suggest that BPD may be amenable to quality improvement (QI) efforts. We present a systematic review of QI for BPD in preterm infants. We identified 22 reports from single centers and seven from collaborative efforts published over the past two decades. In almost all of the reports, respiratory QI interventions successfully reduced BPD or other key respiratory measures, particularly for infants with birth weight over 1000 g. Several themes and lessons from existing reports may help inform future efforts in both research and QI to impact the burden of BPD.
Collapse
Affiliation(s)
- H Healy
- Boston Children's Hospital, Boston, MA, USA; Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - L E E Croonen
- Emma Children's Hospital Amsterdam University Medical Centers, University of Amsterdam, VU University Medical Center, Amsterdam, the Netherlands.
| | - W Onland
- Emma Children's Hospital Amsterdam University Medical Centers, University of Amsterdam, VU University Medical Center, Amsterdam, the Netherlands.
| | - A H van Kaam
- Emma Children's Hospital Amsterdam University Medical Centers, University of Amsterdam, VU University Medical Center, Amsterdam, the Netherlands.
| | - M Gupta
- Beth Israel Deaconess Medical Center, Boston, MA, USA.
| |
Collapse
|
28
|
Lo SCY, Bhatia R, Roberts CT. Introduction of a Quality Improvement Bundle Is Associated with Reduced Exposure to Mechanical Ventilation in Very Preterm Infants. Neonatology 2021; 118:578-585. [PMID: 34515183 DOI: 10.1159/000518392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 07/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Exposure to mechanical ventilation (MV) is a risk factor for bronchopulmonary dysplasia (BPD) in very preterm infants (VPTIs). We assessed the impact of a quality improvement (QI) bundle in VPTIs (<32 week gestation) on exposure to MV. METHODS We introduced a QI bundle consisting of deferred cord clamping (DCC), nasal bubble continuous positive airway pressure (bCPAP) in the delivery room (DR), and minimally invasive surfactant therapy (MIST). We compared respiratory outcomes and neonatal morbidity in historical pre-QI (July-December 2017) and prospective post-QI (February-July 2019) cohorts (QICs) of VPTIs. We pre-specified an adjusted analysis to account for the effects of gestational age, sex, antenatal steroids, and any demographic data that significantly differed between cohorts. RESULTS The pre-QI and post-QICs included 87 and 98 VPTIs, respectively. The post-QIC had decreased rates of MV in the DR (adjusted odds ratio [aOR] 0.26, 95% confidence interval [CI] 0.09-0.71), in the first 72 h of life (aOR 0.27, 95% CI 0.11-0.62) and during admission (aOR 0.28, 95% CI 0.12-0.66). Rates of BPD, combined BPD/death, and BPD severity were similar. The post-QIC was less likely to be discharged with home oxygen (aOR 0.27, 95% CI 0.08-0.91). Necrotising enterocolitis grade ≥2 increased (aOR 19.01, 95% CI 1.93-188.6) in the post-QIC. CONCLUSION In this rapid-cycle QI study, implementation of a QI bundle consisting of DCC, early nasal bCPAP, and MIST in VPTIs was associated with reduced rates of MV in the DR, in the first 72 h of life and during admission, and reduced need for home oxygen.
Collapse
Affiliation(s)
- Stacey Chi-Yan Lo
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Risha Bhatia
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Calum T Roberts
- Department of Paediatrics, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
| |
Collapse
|
29
|
Dariya V, Moresco L, Bruschettini M, Brion LP. Cuffed versus uncuffed endotracheal tubes for neonates. Cochrane Database Syst Rev 2020. [DOI: 10.1002/14651858.cd013736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Vedanta Dariya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine; University of Texas Southwestern Medical Center; Dallas Texas USA
| | - Luca Moresco
- Pediatric and Neonatology Unit; Ospedale San Paolo; Savona Italy
| | - Matteo Bruschettini
- Department of Clinical Sciences Lund, Paediatrics; Lund University, Skåne University Hospital; Lund Sweden
| | - Luc P Brion
- Division of Neonatal-Perinatal Medicine; University of Texas Southwestern at Dallas; Dallas Texas USA
| |
Collapse
|
30
|
Weydig H, Ali N, Kakkilaya V. Noninvasive Ventilation in the Delivery Room for the Preterm Infant. Neoreviews 2020; 20:e489-e499. [PMID: 31477597 DOI: 10.1542/neo.20-9-e489] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A decade ago, preterm infants were prophylactically intubated and mechanically ventilated starting in the delivery room; however, now the shift is toward maintaining even the smallest of neonates on noninvasive respiratory support. The resuscitation of very low gestational age neonates continues to push the boundaries of neonatal care, as the events that transpire during the golden minutes right after birth prove ever more important for determining long-term neurodevelopmental outcomes. Continuous positive airway pressure (CPAP) remains the most important mode of noninvasive respiratory support for the preterm infant to establish and maintain functional residual capacity and decrease ventilation/perfusion mismatch. However, the majority of extremely low gestational age infants require face mask positive pressure ventilation during initial stabilization before receiving CPAP. Effectiveness of face mask positive pressure ventilation depends on the ability to detect and overcome mask leak and airway obstruction. In this review, the current evidence on devices and techniques of noninvasive ventilation in the delivery room are discussed.
Collapse
Affiliation(s)
- Heather Weydig
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Noorjahan Ali
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Venkatakrishna Kakkilaya
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
31
|
Affiliation(s)
- Taylor Sawyer
- Department of Pediatrics, Division of Neonatology, and
| | - Kaalan Johnson
- Department of Otolaryngology, Division of Pediatric Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, WA
| |
Collapse
|
32
|
Eye-tracking during simulation-based neonatal airway management. Pediatr Res 2020; 87:518-522. [PMID: 31499516 DOI: 10.1038/s41390-019-0571-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/02/2019] [Accepted: 08/08/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Eye-tracking devices help to understand provider behavior during medical tasks. The aim of this study was to assess participants' gaze behavior and usability of eye-tracking glasses during airway management in a simulated neonatal resuscitation. METHODS This study was an observational simulation-based study. The team member assigned to airway management wore head-mounted eye-tracking glasses. Main outcome measures were airway providers' gaze, dwell time (total amount of time a participant fixates certain areas of interest), and usability of eye-tracking glasses. RESULTS Data from 13 participants were included. There were significant differences in dwell time during the scenario (p < 0.001), with participants spending twice as much time on the newborn and instruments as on the monitor and other staff. Participants spent about 25% more time focusing on another provider while the provider was inserting the umbilical vein catheter than in all other times of interest (intervals of time with meaningful events) (p = 0.04). The use of the glasses was perceived easy and not disturbing. CONCLUSIONS Eye-tracking glasses enhance our understanding of providers' gaze and perspective during simulated neonatal airway management. Future studies will better characterize the ideal use in real situations.
Collapse
|
33
|
Early predictors of continuous positive airway pressure failure in preterm neonates. J Perinatol 2019; 39:1081-1088. [PMID: 31089256 DOI: 10.1038/s41372-019-0392-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To develop a prediction model to identify infants admitted on continuous positive airway pressure (CPAP) requiring intubation within seventy-two hours of life (HOL). STUDY DESIGN Infants born ≤29 weeks' gestational age between 2013 and April 2018 were randomly assigned to either a modeling cohort (MC) or a validation cohort (VC) in a 2:1 ratio. Variables available within two HOL were compared between the CPAP failure group (CFG) and the CPAP success group (CSG). RESULTS Of the 189 infants in the MC, 50% failed CPAP. Compared to CSG, infants in the CFG had lower antenatal steroid exposure, birth weight, higher radiographic severe respiratory distress syndrome (RDS) and fraction of inspired oxygen (FiO2). A forward stepwise logistic regression modeling in both MC and VC showed that FiO2 >0.3 and radiographic severe RDS predicted CPAP failure. CONCLUSION FiO2 >0.3 within two HOL and radiographic severe RDS predicts CPAP failure in preterm infants.
Collapse
|