Decreasing Unplanned Extubations in the NICU, an Ongoing Quality Improvement Project.

Unplanned extubations (UEs) can have devastating effects on neonates. The purpose of this quality improvement project is to decrease the number of UEs in Lankenau Medical Center's 22-bed Level III NICU. The UE rate had risen to 4.6 UEs per 100 ventilator days in 2016. Transitioning to a standardized bundle for intubated infants has decreased the UE rate to less than 2 per 100 ventilator days since 2018. The UE rate continues to be monitored for ongoing accountability and further staff education when rates increase.

Nasal cannula, CPAP, and high-flow nasal cannula: effect of flow on temperature, humidity, pressure, and resistance.

BACKGROUND: Delivery of warm, humidified, supplemental oxygen via high-flow nasal cannula has several potential benefits; however, the high-flow range may not maintain humidification and temperature and in some cases may cause excessive expiratory pressure loading. OBJECTIVE: To compare the effect of flow on temperature, humidity, pressure, and resistance in nasal cannula (NC), continuous positive airway pressure (CPAP), and high-flow nasal cannula (HFNC) in a clinical setting. METHODS: The three delivery systems were tested in the nursery using each instrument's recommended specifications and flow ranges (0-3 L/min and 0-8 L/min). Flow, pressure, temperature, and humidity were measured, and resistance was calculated. RESULTS: For all devices at 0-3 L/min, there was a difference (p<0.01) in temperature (NC 35.9°C > CPAP 34.5°C > HFNC 34.0°C), humidity (HFNC 82% > CPAP 77% > NC 57%), pressure (HFNC 22 cmH(2)O > NC 4 cmH(2)O > CPAP 3 cmH(2)O), and resistance (HFNC 636 cmH(2)O/L/sec > NC 270 cmH(2)O/L/sec > CPAP 93 cmH(2)O/L/sec) as a function of flow. For HFNC and CPAP at 0-8 L/min, there was a difference (p<0.01) in temperature (CPAP 34.5°C > HFNC 34.0°C) in humidity (HFNC 83 % > CPAP 76 %), pressure (HFNC 56 cmH(2)O > CPAP 14 cmH(2)O) and resistance (HFNC 783 cmH(2)O/L/sec > CPAP 280 cmH(2)O/L/sec) as a function of flow. CONCLUSIONS: Gas delivered by HFNC was more humid than NC and CPAP. However, the higher pressure and resistance delivered by the HFNC system may have clinical relevance, such as increased work of breathing, and warrants further in vivo studies.