Improved Outcomes With Standardized Convalescent Preterm Respiratory Care Practices.

BACKGROUND: Chronic lung disease is the most common morbidity affecting very low birthweight (VLBW) infants. Many of these infants are discharged home on oxygen, placing significant emotional and financial burdens on families. We sought to reduce the proportion of VLBW infants requiring discharge home on oxygen by improving convalescent respiratory practices. METHODS: We performed a prospective quality-improvement project for infants with birth weights ≤ 1,500 g in a single neonatal ICU. Using Plan-Do-Study-Act cycles, we developed and implemented a room air challenge, oxygen reference chart, and a standardized oxygen delivery guideline. The primary outcome was the proportion of VLBW infants discharged home on oxygen. Secondary outcomes included rate of chronic lung disease and postmenstrual age when off all respiratory support. Balancing measures were postmenstrual age and weight at discharge, as well as unplanned readmissions. Statistical process control charts were used to monitor outcomes and balancing measures. RESULTS: The proportion of VLBW infants discharged home on oxygen decreased from 34.4% to 18.5% and 21.7% in the following two years (P = .044 and P = .01, respectively). G-Chart analysis showed a higher mean number of successes between failures. The rate of chronic lung disease decreased from 31.2% to 25.4% (P = .03). The mean postmenstrual age at discharge, mean weight at discharge, and readmission rate were unchanged. CONCLUSION: Standardization of convalescent respiratory care practices improved respiratory morbidities in VLBW infants. These interventions could be utilized in other NICUs with high incidence of respiratory morbidities despite improvement in delivery room practices.

Does the RAM Cannula Provide Continuous Positive Airway Pressure as Effectively as the Hudson Prongs in Preterm Neonates?

OBJECTIVE: To compare the level of continuous positive airway pressure (CPAP) delivered by the RAM cannula system (Neotech, Valencia, CA) with that delivered by a traditional CPAP nasal delivery interface (Hudson prongs; Hudson-RCI, Temecula, CA) in preterm infants with respiratory distress. METHODS: This was a crossover intervention study in a convenience sample of preterm infants with respiratory distress requiring treatment with CPAP. We measured the mean intraoral (pharyngeal) pressure, which approximates the applied CPAP level, using both the RAM cannula and Hudson prongs. The primary outcome was a comparison of the differences between the set CPAP levels and the measured intraoral pressures of both delivery systems. RESULTS: We analyzed data from 12 preterm infants with mean (standard deviation) birth weight of 1,225 (405) g and gestational age of 28.4 (2.1) weeks at a median postnatal age of 10 days. The mean difference (95% confidence interval) between the set CPAP level and measured intraoral pressure was -2.45 cm H2O (-3.36, -1.55) with the RAM cannula and +0.40 cm H2O (-0.30, 1.12) with Hudson prongs, p = 0.0002. CONCLUSION: For given set CPAP pressure level in preterm infants, the RAM cannula system consistently delivers lower pharyngeal pressure (effective CPAP) levels than Hudson prongs.

Does Diaphragmatic Electrical Activity in Preterm Infants Predict Extubation Success?

BACKGROUND: Despite many advances in respiratory care and mechanical ventilation, neonatologists lack an objective tool to aid in decision making for timely extubation. Electrical activity of the diaphragm (EAdi), a measure of neural respiratory drive and inspiratory load, may be a useful predictor of extubation success in preterm neonates. The objective of this work was to investigate whether peak EAdi could distinguish successful versus failed extubation in mechanically ventilated preterm infants. METHODS: We examined peak EAdi as a predictor of extubation outcome in a convenience sample of 21 preterm infants with respiratory distress syndrome requiring mechanical ventilation. Infants were ventilated with a VN500 ventilator using volume guarantee mode and extubated per unit protocol. Peak EAdi was continuously measured with an EAdi catheter in the esophagus to obtain data at 1-min intervals for 24 h before extubation. The primary outcome was extubation success, defined as not requiring re-intubation for at least 72 h. RESULTS: Twenty one premature infants with respiratory distress syndrome included in the study had a mean ± SD) gestational age of 28 ± 2.6 weeks and mean birthweight of 1,208 ± 611 g. The first extubation attempt occurred at a median age of 1 d (interquartile range 1-2 d). One third of the infants failed the first extubation attempt. Infants with failed extubations were significantly smaller (mean ± SD birthweight 788 ± 266 g versus 1,417 ± 632 g) and of lower gestational age (mean ± SD 26 ± 1.9 weeks versus 29 ± 2.6 weeks) compared with those with successful extubation. Mean peak EAdi before extubation did not differ between the 2 groups. CONCLUSIONS: This small study suggests that the pre-extubation peak EAdi does not predict extubation success. (ClinicalTrials.gov registration NCT02144363.).