Sensitivity and specificity of the Neonatal Visual Assessment to predict motor and cognitive outcomes in infants born very preterm.

BACKGROUND: Very preterm infants are at increased risk of neurodevelopmental impairments. The Neonatal Visual Assessment (NVA) assesses visual function and outcomes and has been used to assess early neurodevelopmental outcomes. This study aimed to compare NVA results of very preterm and term-born infants and to calculate the sensitivity and specificity of the NVA at term equivalent age (TEA) and three months corrected age (CA) to predict motor and cognitive outcomes at 12 months CA in very preterm infants. METHODS: This prospective observational cohort study recruited infants born before 31 weeks gestation and a healthy term-born control group. The NVA was assessed at TEA and three months CA, and neurodevelopmental outcomes (Bayley Scales of Infant and Toddler Development, Third Edition; Neurosensory Motor Developmental Assessment; Alberta Infant Motor Scale) were performed at 12 months CA. The sensitivity and specificity of the NVA to predict outcomes were calculated based on a previously published optimality score. RESULTS: 248 preterm (54 % male) and 46 term-born infants (48 % male) were analysed. The mean NVA scores of preterm and term-born infants were significantly different at TEA (preterm 3.1±2.1; term-born 1.2±1.7, p < 0.001). The NVA had moderate sensitivity (59-78 %) and low specificity (25-27 %) at TEA, and low sensitivity (21-28 %) and high specificity (86-87 %) at three months CA for the prediction of preterm infants' outcomes at 12 months CA. CONCLUSION: The NVA at TEA and three months CA was not a strong predictor of motor and cognitive impairments in this contemporary cohort of very preterm infants.

High-flow nasal oxygen for children's airway surgery to reduce hypoxaemic events: a randomised controlled trial.

BACKGROUND: Tubeless upper airway surgery in children is a complex procedure in which surgeons and anaesthetists share the same operating field. These procedures are often interrupted for rescue oxygen therapy. The efficacy of nasal high-flow oxygen to decrease the frequency of rescue interruptions in children undergoing upper airway surgery is unknown. METHODS: In this multicentre randomised trial conducted in five tertiary hospitals in Australia, children aged 0-16 years who required tubeless upper airway surgery were randomised (1:1) by a web-based randomisation tool to either nasal high-flow oxygen delivery or standard oxygen therapy (oxygen flows of up to 6 L/min). Randomisation was stratified by site and age (<1 year, 1-4 years, and 5-16 years). Subsequent tubeless upper airway surgery procedures in the same child could be included if there were more than 2 weeks between the procedures, and repeat surgical procedures meeting this condition were considered to be independent events. The oxygen therapy could not be masked, but the investigators remained blinded until outcome data were locked. The primary outcome was successful anaesthesia without interruption of the surgical procedure for rescue oxygenation. A rescue oxygenation event was defined as an interruption of the surgical procedure to deliver positive pressure ventilation using either bag mask technique, insertion of an endotracheal tube, or laryngeal mask to improve oxygenation. There were ten secondary outcomes, including the proportion of procedures with a hypoxaemic event (SpO2 <90%). Analyses were done on an intention-to-treat (ITT) basis. Safety was assessed in all enrolled participants. This trial is registered in the Australian New Zealand Clinical Trials Registry, ACTRN12618000949280, and is completed. FINDINGS: From Sept 4, 2018, to April 12, 2021, 581 procedures in 487 children were randomly assigned to high-flow oxygen (297 procedures) or standard care (284 procedures); after exclusions, 528 procedures (267 assigned to high-flow oxygen and 261 assigned to standard care) in 483 children (293 male and 190 female) were included in the ITT analysis. The primary outcome of successful anaesthesia without interruption for tubeless airway surgery was achieved in 236 (88%) of 267 procedures on high-flow oxygen and in 229 (88%) of 261 procedures on standard care (adjusted risk ratio [RR] 1·02, 95% CI 0·96-1·08, p=0·82). There were 51 (19%) procedures with a hypoxaemic event in the high-flow oxygen group and 57 (22%) in the standard care group (RR 0·86, 95% CI 0·58-1·24). Of the other prespecified secondary outcomes, none showed a significant difference between groups. Adverse events of epistaxis, laryngospasm, bronchospasm, hypoxaemia, bradycardia, cardiac arrest, hypotension, or death were similar in both study groups. INTERPRETATION: Nasal high-flow oxygen during tubeless upper airway surgery did not reduce the proportion of interruptions of the procedures for rescue oxygenation compared with standard care. There were no differences in adverse events between the intervention groups. These results suggest that both approaches, nasal high-flow or standard oxygen, are suitable alternatives to maintain oxygenation in children undergoing upper airway surgery. FUNDING: Thrasher Research Fund, the Australian and New Zealand College of Anaesthetists, the Society for Paediatric Anaesthesia in New Zealand and Australia.

High flow nasal cannula for respiratory support in term infants.

BACKGROUND: Respiratory failure or respiratory distress in infants is the most common reason for non-elective admission to hospitals and neonatal intensive care units. Non-invasive methods of respiratory support have become the preferred mode of treating respiratory problems as they avoid some of the complications associated with intubation and mechanical ventilation. High flow nasal cannula (HFNC) therapy is increasingly being used as a method of non-invasive respiratory support. However, the evidence pertaining to its use in term infants (defined as infants ≥ 37 weeks gestational age to the end of the neonatal period (up to one month postnatal age)) is limited and there is no consensus of opinion regarding the safety and efficacy HFNC in this population. OBJECTIVES: To assess the safety and efficacy of high flow nasal cannula oxygen therapy for respiratory support in term infants when compared with other forms of non-invasive respiratory support. SEARCH METHODS: We searched the following databases in December 2022: Cochrane CENTRAL; PubMed; Embase; CINAHL; LILACS; Web of Science; Scopus. We also searched the reference lists of retrieved studies and performed a supplementary search of Google Scholar. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that investigated the use of high flow nasal cannula oxygen therapy in infants ≥ 37 weeks gestational age up to one month postnatal age (the end of the neonatal period). DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility, performed data extraction, and assessed risk of bias in the included studies. Where studies were sufficiently similar, we performed a meta-analysis using mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). For statistically significant RRs, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to evaluate the certainty of the evidence for clinically important outcomes. MAIN RESULTS: We included eight studies (654 participants) in this review. Six of these studies (625 participants) contributed data to our primary analyses. Four studies contributed to our comparison of high flow nasal cannula (HFNC) oxygen therapy versus continuous positive airway pressure (CPAP) for respiratory support in term infants. The outcome of death was reported in two studies (439 infants) but there were no events in either group. HFNC may have little to no effect on treatment failure, but the evidence is very uncertain (RR 0.98, 95% CI 0.47 to 2.04; 3 trials, 452 infants; very low-certainty evidence). The outcome of chronic lung disease (need for supplemental oxygen at 28 days of life) was reported in one study (375 participants) but there were no events in either group. HFNC may have little to no effect on the duration of respiratory support (any form of non-invasive respiratory support with or without supplemental oxygen), but the evidence is very uncertain (MD 0.17 days, 95% CI -0.28 to 0.61; 4 trials, 530 infants; very low-certainty evidence). HFNC likely results in little to no difference in the length of stay at the intensive care unit (ICU) (MD 0.90 days, 95% CI -0.31 to 2.12; 3 trials, 452 infants; moderate-certainty evidence). HFNC may reduce the incidence of nasal trauma (RR 0.16, 95% CI 0.04 to 0.66; 1 trial, 78 infants; very low-certainty evidence) and abdominal overdistension (RR 0.22, 95% CI 0.07 to 0.71; 1 trial, 78 infants; very low-certainty evidence), but the evidence is very uncertain. Two studies contributed to our analysis of HFNC versus low flow nasal cannula oxygen therapy (LFNC) (supplemental oxygen up to a maximum flow rate of 2 L/min). The outcome of death was reported in both studies (95 infants) but there were no events in either group. The evidence suggests that HFNC may reduce treatment failure slightly (RR 0.44, 95% CI 0.21 to 0.92; 2 trials, 95 infants; low-certainty evidence). Neither study reported results for the outcome of chronic lung disease (need for supplemental oxygen at 28 days of life). HFNC may have little to no effect on the duration of respiratory support (MD -0.07 days, 95% CI -0.83 to 0.69; 1 trial, 74 infants; very low-certainty evidence), length of stay at the ICU (MD 0.49 days, 95% CI -0.83 to 1.81; 1 trial, 74 infants; very low-certainty evidence), or hospital length of stay (MD -0.60 days, 95% CI -2.07 to 0.86; 2 trials, 95 infants; very low-certainty evidence), but the evidence is very uncertain. Adverse events was an outcome reported in both studies (95 infants) but there were no events in either group. The risk of bias across outcomes was generally low, although there were some concerns of bias. The certainty of evidence across outcomes ranged from moderate to very low, downgraded due to risk of bias, imprecision, indirectness, and inconsistency. AUTHORS' CONCLUSIONS: When compared with CPAP, HFNC may result in little to no difference in treatment failure. HFNC may have little to no effect on the duration of respiratory support, but the evidence is very uncertain. HFNC likely results in little to no difference in the length of stay at the intensive care unit. HFNC may reduce the incidence of nasal trauma and abdominal overdistension, but the evidence is very uncertain. When compared with LFNC, HFNC may reduce treatment failure slightly. HFNC may have little to no effect on the duration of respiratory support, length of stay at the ICU, or hospital length of stay, but the evidence is very uncertain. There is insufficient evidence to enable the formulation of evidence-based guidelines on the use of HFNC for respiratory support in term infants. Larger, methodologically robust trials are required to further evaluate the possible health benefits or harms of HFNC in this patient population.

Physiotherapy practices when treating patients with COVID-19 during a pandemic: A survey study.

Background Specific details pertaining to the clinical and other challenges faced by physiotherapists managing patients with COVID-19 during the pandemic are still largely unknown. Objectives To determine how physiotherapists clinically managed patients with COVID-19 in a hospital-based setting during the pandemic and to identify the personal and professional effects of working as a physiotherapist at this time. Methods Self-administered electronic cross-sectional survey. Participants included physiotherapists from around the world involved in the clinical management of patients with COVID-19. Results Of the 204 participants who returned the questionnaire, 39% worked as senior physiotherapists, 29% as consultant or specialist physiotherapists, 23% as general physiotherapists and 4% as graduate physiotherapists. Seventy-two percent of participants worked in the intensive care unit. The largest barrier to treating patients with COVID-19 was a lack of intensive care trained physiotherapists (70%). Eighty-three percent of participants reported performing activities outside of their typical work duties, including proning patients (55%), tutoring and advising other staff in the intensive care unit (55%) and adjusting or changing ventilator settings (52%). Almost all participants (90%) reported being aware of physiotherapy specific guidelines for treating patients with COVID-19, yet most participants performed techniques that were not recommended. Conclusions The experience of the pandemic highlighted the need for specialist training and availability of experienced cardiorespiratory physiotherapists to manage patients with COVID-19, specifically in intensive care. Furthermore, clear guidelines on the management of patients with COVID-19 should be established to ensure optimal management of patients and ensure the safety of physiotherapy staff.

Measuring the effects of airway clearance in mechanically ventilated infants and children: A systematic review.

BACKGROUND: Robust measurement tools are essential in guiding physiotherapy-delivered airway clearance techniques to ventilated infants and children. OBJECTIVE: To identify measurement tools used to evaluate effects of airway clearance techniques in ventilated infants and children and to determine the clinimetric properties of these tools. DATA SOURCES: Pubmed, CINAHL, Embase, The Cochrane Library, Physiotherapy Evidence Database and Web of Science, up to November 2020. STUDY SELECTION: Randomized and non-randomized clinical trials measuring any aspect of lung function during and/or after airway clearance techniques in mechanically ventilated infants and children from birth to sixteen years. DATA EXTRACTION AND DATA SYNTHESIS: Two independent reviewers identified tools measuring effects of airway clearance techniques including secretion clearance, respiratory mechanics, gas exchange and changes on lung imaging. Extracted data included details of the tool, airway clearance intervention being evaluated and aspects of lung function being measured. Assessment of quality and clinimetric properties, including validity, reliability and responsiveness, were evaluated for each tool using the COnsensus-based Standards for the selection of health status Measurement INstruments methodology. RESULTS: Nine measurement tools measured the effects of airway clearance techniques on secretion clearance, respiratory mechanics, gas exchange and lung imaging. Five tools reported clinimetric properties although the yield and overall quality of studies was low. Tools measured many different aspects of lung function. The CO2SMO Plus respiratory mechanics monitor reported the most clinimetric data. LIMITATIONS: Unpublished or in-progress studies were not included to ensure all data collected were peer-reviewed, therefore additional or novel tools may not have been identified. Included age ranges and definition of airway clearance techiques were kept broad to optimise study identification which may limit generalisability of results. CONCLUSION: Measurement tools used by physiotherapists to enhance airway clearance in ventilated infants and children lack high quality evidence of validity, reliability and responsiveness. Measurements gained through these tools should therefore be interpreted with careful consideration until further climimetric evidence is available. CONTRIBUTION OF PAPER.

Lung recruitment manoeuvres for reducing mortality and respiratory morbidity in mechanically ventilated neonates.

BACKGROUND: Preterm infants and neonates with respiratory conditions commonly require intubation and conventional mechanical ventilation (CMV) to maintain airway patency and support their respiration. Whilst this therapy is often lifesaving, it simultaneously carries the risk of lung injury. The use of lung recruitment manoeuvres (LRMs) has been found to reduce the incidence of lung injury, and improve oxygenation and lung compliance in ventilated adults. However, evidence pertaining to their use in neonates is limited, and there is no consensus of opinion as to whether LRMs are appropriate or effective in this population. OBJECTIVES: To determine the effects of LRMs on mortality and respiratory outcomes in mechanically ventilated neonates, when compared to no recruitment (routine care).  SEARCH METHODS: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2020, Issue 4) in the Cochrane Library, MEDLINE via Ovid (1946 to 13 April 2020), and CINAHL via EBSCOhost (1989 to 13 April 2020). We also handsearched the reference lists of retrieved studies to source additional articles.  SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs and randomised cross-over studies that compared the effect of LRMs to no recruitment (routine care) in mechanically ventilated neonates. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility, extracted data and evaluated risk of bias in the included studies. When studies were sufficiently similar, we performed a meta-analysis using mean difference (MD) for continuous data and risk ratio (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of the evidence for key (clinically important) outcomes. MAIN RESULTS: We included four studies (152 participants in total) in this review. Three of these studies, enrolling 56 participants, contributed data to our prespecified outcomes. Two studies enrolling 44 participants on CMV for respiratory distress syndrome compared a stepwise LRM with positive end-expiratory pressure (PEEP) to routine care. Meta-analysis demonstrated no evidence of a difference between the LRM and routine care on mortality by hospital discharge (RR 1.00, 95% CI 0.17 to 5.77; low-certainty evidence), incidence of bronchopulmonary dysplasia (RR 0.25, 95% CI 0.03 to 2.07; low-certainty evidence), duration of supplemental oxygen (MD -7.52 days, 95% CI -20.83 to 5.78; very low-certainty evidence), and duration of ventilatory support (MD -3.59 days, 95% CI -12.97 to 5.79; very low-certainty evidence). The certainty of the evidence for these outcomes was downgraded due to risk of bias, imprecision, and inconsistency. Whilst these studies contributed data to four of our primary outcomes, we were unable to identify any studies that reported our other primary outcomes: duration of continuous positive airway pressure therapy, duration of neonatal intensive care unit stay, and duration of hospital stay.  The third study that contributed data to the review enrolled 12 participants on CMV for respiratory and non-respiratory causes, and compared two different LRMs applied after endotracheal tube suctioning to routine care. It was determined that both LRMs may slightly improve end-expiratory lung volume at 120 minutes' post-suctioning, when compared to routine care (incremental PEEP LRM versus routine care: MD -0.21, 95% CI -0.37 to -0.06; double PEEP LRM versus routine care: MD -0.18, 95% CI -0.35 to -0.02). It was also demonstrated that a double PEEP LRM may slightly reduce mean arterial pressure at 30 minutes' post-suctioning, when compared with routine care (MD -16.00, 95% CI -29.35 to -2.65).  AUTHORS' CONCLUSIONS: There is insufficient evidence to guide the use of LRMs in mechanically ventilated neonates. Well-designed randomised trials with larger sample sizes are needed to further evaluate the potential benefits and risks of LRM application in this population.

A quality appraisal using the AGREE II instrument of endotracheal tube suction guidelines in neonatal intensive care units.

BACKGROUND: Endotracheal tube (ETT) suction is among the most common procedures performed in neonatal intensive care units (NICUs). Although necessary, it is associated with significant risks. To mitigate these risks, clinical practice guidelines are developed to provide evidence-based recommendations. OBJECTIVE: The aim of the study was to appraise the quality of neonatal ETT suction guidelines from all NICUs in Australia and New Zealand. METHODS: All level III NICUs in Australia and New Zealand were invited to participate. Three researchers graded the methodological quality of the received guidelines using the AGREE II instrument. Item and domain scores were calculated by scaling as a percentage of the total possible score out of 100%. A threshold score of <50% is considered to be of limited potential use. RESULTS: Twenty-three (79.31%) clinical practice guidelines were received from 29 invited facilities. The scaled results of the AGREE II domains were as follows: Scope and Purpose, mean = 73%, 95% confidence interval (CI) = 63-83%; Stakeholder Involvement, mean = 23%, 95% CI = 15-31%; Rigour of Development, mean = 17%, 95% CI = 12-21%; Clarity of Presentation, mean = 63%, 95% CI = 56-70%; Applicability, mean = 5%, 95% CI = 20-30%; and Editorial Independence, mean = 50%, 95% CI = 50-50%. Overall assessment indicated low methodological quality (31%; 22-39%), with only five clinical practice guidelines scoring >50%, suggesting that they could be recommended for use with modifications. The remaining 18 could not be recommended for use. CONCLUSIONS: Neonatal ETT suction guidelines are of a low methodological quality. All guidelines poorly incorporated latest evidence in guideline development. This appraisal highlights the need to improve the quality of neonatal ETT suction guidelines to promote optimal patient care.

Pediatric hospital in the home: clinical outcomes for treatment of a cystic fibrosis respiratory exacerbation.

Background: Children with cystic fibrosis (CF) have recurrent lung infections and these exacerbation periods have conventionally been treated in hospital. Hospital in the Home (HITH) programs have recently been introduced but equivalence of care has not previously been established.Objectives: To determine if standardization of treatment (application and frequency) for children with CF during a pulmonary exacerbation would produce equivocal clinical outcomes (lung function and weight), regardless of whether treatment was received in hospital or HITH.Design and Participants: A retrospective audit was conducted on electronic medical records from 39 children with CF (6-17 years).Main Outcome measures: Forced expiratory volume in one second (FEV1), forced vital capacity (FVC), weight and length of stay (LOS) were compared between participants treated either in hospital or under the provision of HITH.Results: Care provided by HITH was found to be equivalent to hospital-based care (mean difference; 95% CI) for: FEV1 (0.067; -0.104, 0.238); FVC (0.051; -0.102, 0.204); weight (0.718; -0.251, 1.687); and LOS (-0.781, -2.505, 0.943). All investigated clinical measurements significantly improved (FEV1 p = .001; FVC p < .001; and weight p < .001) from admission to discharge for both hospital and HITH participants.Conclusions: HITH appears comparable to hospital provision of care for children with CF during a pulmonary exacerbation in terms of post-treatment outcomes (FEV1, FVC, weight, and LOS).

Nasal high flow in preterm infants: A dose-finding study.

OBJECTIVE: To investigate the relationship between applied flows of nasal high flow (NHF) and physiological outcomes and work of breathing (WOB), to identify an optimal delivery flow which results in reduced WOB in preterm infants. DESIGN: A prospective observational clinical study with randomly applied NHF rates. PATIENTS AND SETTING: Preterm infants within 72 hours of commencement of NHF respiratory support. INTERVENTIONS: Infants were initially placed on 8 L/min of NHF and flows of 2, 4, and 6 L/min were then applied in random order. MEASUREMENTS AND RESULTS: WOB was measured using transcutaneous electromyography and respiratory inductance plethysmography. Physiological variables were also recorded. Measurements taken 10 minutes after each flow change were compared with 8 L/min. Sixteen infants with a median gestational age of 28 (range 24-31) weeks and postnatal age of 14 (2-55) days were included in the study. The median flow rate before the study was 6 (4-8) L/min and a fraction of inspired oxygen (FiO2 ) was 0.21 (0.21-0.26). Changes in flow resulted in changes in activity in the front diaphragm (P = .027) and intercostals (P = .034). The electrical activity of the front diaphragm at 8 L/min was significantly lower than that at 2 L/min (P = .016). Respiratory rate was lowest at 6 L/min (P = .002) and SpO2 /FiO2 was highest at 8 L/min (P < .04). CONCLUSION: In preterm infants, changes in WOB resulting from randomly applied levels of NHF can be demonstrated by measuring the electrical activity of the diaphragm and intercostal muscles with transcutaneous electromyography. In combination with physiological measurements, the similarities in electrical activity between 4, 6, and 8 L/min suggest that these three flows may be equally as effective.

Simulation-based education improves student self-efficacy in physiotherapy assessment and management of paediatric patients.

BACKGROUND: The Australian Physiotherapy Council mandates that physiotherapy clinical education be sufficient to produce graduates who are competent to practice across the lifespan. Due to a lack of opportunities for paediatric clinical placements, there is a risk of graduates not having the opportunity to develop competency in paediatric physiotherapy. To address this risk, simulation-based education (SBE) has been proposed as an educational strategy to address the placement shortfall. Despite encouraging evidence for its use in physiotherapy education, there is limited evidence supporting its use specifically in paediatric populations. The aims of this research were to investigate the effect of SBE on student self-efficacy in the physiotherapy assessment and management of paediatric clients, and to determine student satisfaction with SBE as a learning strategy. METHODS: Three interactive SBE sessions were run during the undergraduate paediatric physiotherapy unit at the campus of one Australian university. Self-efficacy was surveyed before and after each session, to determine confidence in clinical skills, clinical decision-making, treatment preparation and planning, communication skills; evaluating and modifying interventions, and interprofessional practice. Student satisfaction with SBE as a learning strategy was surveyed after the final SBE session. RESULTS: For the 164 participants included in this study, self-efficacy survey response rate varied from 77 to 96% for each session. Significant increases in mean student self-efficacy were recorded for all questions (p <  0.001). A total of 139 (85%) responded to the learning reactionnaire with 78.6% indicating they were very satisfied with SBE as a learning strategy. Written comments from 41 participants identified 'experience' as the primary theme. CONCLUSION: SBE had a significant positive effect on student self-efficacy in the physiotherapy assessment and management of paediatric patients. Students also perceived SBE to be a valuable learning experience. Future research is needed to investigate whether the improvement in self-efficacy achieved through SBE translates into improved student performance during workplace-based clinical placements.

Chest wall mesenchymal hamartoma in an infant: Evaluation with electrical impedance tomography.

Mesenchymal hamartoma of the chest wall is a rare benign nonneoplastic lesion of infancy arising from chondro-osseous tissue. Although its natural history suggests spontaneous regression, we describe a fatal case in a neonate with significant respiratory compromise. We explored the use of electrical impedance tomography to evaluate the dynamic impact of such space occupying lesions on a ventilated infant.

Effect of randomization of nasal high flow rate in preterm infants.

OBJECTIVE: To assess the effect of nasal high flow (NHF) cannula on end-expiratory level (EEL), continuous distending pressure (CDP) and regional ventilation distribution in preterm infants. DESIGN: A prospective observational clinical study with randomly applied NHF rates. PATIENTS AND SETTING: Preterm infants requiring continuous positive airway pressure (CPAP) respiratory support in a Neonatal Intensive Care Unit. INTERVENTIONS: Infants were measured on randomly applied flow rates at 2, 4, and 6 L/min of NHF and compared with bubble CPAP. MEASUREMENTS AND RESULTS: Regional ventilation distribution and EEL were measured using electrical impedance tomography (EIT) and respiratory inductance plethysmography (RIP) in 24 preterm infants (31.19 ± 1.17 weeks corrected age). Changes in CDP were measured from the esophagus via the nasogastric tube. Physiological variables were also recorded. There were no differences in ventilation distribution, EEL or CDP between CPAP and NHF (P > .05). However, the physiological variables of FiO2 (P = .01) and SpO2 /FiO2 (P < .01) were improved on CPAP compared with NHF. CONCLUSION: NHF applied in random order with flow rates between 2 to 6 L/min was equally as good as CPAP in maintaining EEL and ventilation distribution in stable preterm infants. Overall oxygenation was better on CPAP compared to NHF.

Prevalence and impact of pelvic floor dysfunction in an adult cystic fibrosis population: a questionnaire survey.

INTRODUCTION AND HYPOTHESIS: Pelvic floor (PF) dysfunction in patients with cystic fibrosis (CF) is poorly understood due to lack of research. The aim of this study was to examine the prevalence, risk factors and bothersomeness of PF dysfunction and its implications for the clinical management of CF. METHODS: Of 64 adults with CF approached at a tertiary hospital, 60 were surveyed. A clinically meaningful score on the Australian Pelvic Floor Questionnaire (APFQ) is ≥1 in each of the bladder, bowel, sexual function and prolapse sections or a global PF score of ≥3. A frequency Likert scale was used to analyse the impact of PF dysfunction on the ability to perform physiotherapy lung management when well and unwell. RESULTS: The prevalence of clinically meaningful bladder dysfunction was 39 % in women and 12 % in men, the prevalence of bowel dysfunction was 54 % in women and 44 % in men, and the prevalence of sexual dysfunction was 43 % in women and 65 % in men. APFQ scores were clinically meaningful only for bowel dysfunction in women (median 1.47, IQR 0.59 - 2.28). PF dysfunction constrains lung management in up to 22 % of patients when well and in 37 % of patients when unwell. CONCLUSIONS: PF dysfunction affects the adult CF population, with PF symptoms limiting the ability of up to one in three patients to participate in physiotherapy management.

Effect of time and body position on ventilation in premature infants.

BACKGROUND: Infants with respiratory dysfunction undergo regular position changes to improve lung function however it is not known how often a position change should occur. This study measured changes in lung function occurring over time after repositioning in preterm infants. METHODS: Changes in end-expiratory level (EEL) and ventilation distribution were measured 30 mins, 2 h, and 4 h after repositioning into either prone, quarter turn from prone, or supine using Electrical Impedance Tomography (EIT). Physiological measurements were also taken. RESULTS: Sixty preterm infants were included in the study. Infants receiving respiratory support (mechanical ventilation or continuous positive airway pressure (CPAP)) had improved ventilation homogeneity after 2 h (P < 0.01), maintained at 4 h. Spontaneously breathing infants had improved homogeneity at 2 h (P < 0.01) and improved global EEL after 4 h (P < 0.01) whereas infants receiving CPAP demonstrated an improved global EEL at 2 h (P < 0.01). CONCLUSION: Regional ventilation distribution is influenced by time independent of changes due to body position. Differences exist between infants on ventilatory support compared with those who are spontaneously breathing. Infants receiving ventilatory support have a physiological peak in lung function after 2 h which remains above baseline at 4 h. A change in body position facilitates an improvement in lung function in infants on ventilatory support.

An Evidence-Based Approach to Influencing Evidence-Based Practice in Allied Health.

BACKGROUND: Factors affecting the evidence-based practice (EBP) capabilities of allied health staff are complex and are linked with institutional barriers, personal self-belief, and individual experience and ability. This study's aim was to measure the effect of training and organisational change on EBP measures among allied health staff. METHODS: Sixty-three percent of allied health hospital staff (201/303) completed an online survey measuring constructs of EBP. Results were compared to those from the same survey conducted in the previous year, with a response rate of 72.2% (182/252). Eighty staff completed the survey at both time points. Independent and repeated measures ANOVAs were used to compare levels of self-efficacy, outcome expectancy, knowledge, and use, according to discipline over time. RESULTS: A significant increase in EBP self-efficacy was observed over time (p=0.03), as well as amongst staff who completed the survey at both time points (p=0.013). Significant differences existed between professions at time 2 in EBP-outcome expectancy (p=0.002) and EBP use (p=0.016). CONCLUSIONS: Targeted within-department and general allied health workplace evidence-based interventions to improve EBP constructs have been effective at improving overall allied health EBP self-efficacy. Different departments have demonstrated individual improvements in EBP scores, potentially reflecting different training and organisational strategies implemented across departments.

Strategies for the discontinuation of humidified high flow nasal cannula (HHFNC) in preterm infants.

BACKGROUND: Humidified high flow nasal cannula (HHFNC) delivers humidified gas at increased flow rates via binasal prongs and is becoming widely accepted as a method of non-invasive respiratory support for preterm infants. While indications for the use of (HHFNC) and its associated risks and benefits are being investigated, the best strategy for the discontinuation of HHFNC remains unknown. At what point an infant is considered stable enough to attempt to start withdrawing their HHFNC is not known. The criteria for a failed attempt at HHFNC discontinuation is also unclear. OBJECTIVES: To determine the risks and benefits of different strategies used for the discontinuation of HHFNC in preterm infants. SEARCH METHODS: We searched the Cochrane Neonatal Review Group Specialized Register, PubMed (1966 to March 2015), CINAHL (1982 to March 2015), EMBASE (1980 to March 2015), and the Cochrane Central Register of Controlled Trials (CENTRAL). Also, we checked previous reviews, including cross references. We searched for following web sites for ongoing trials: ClinicalTrials.gov and controlled-trials.com. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs in which either individual newborn infants or clusters of infants (such as separate neonatal units) were randomised to different HHFNC withdrawal strategies (from the first time they come off HHFNC and any subsequent weaning, or withdrawal attempt, or both). DATA COLLECTION AND ANALYSIS: We used standard methods of Cochrane and the Cochrane Neonatal Review Group. MAIN RESULTS: We identified no eligible studies examining the best strategy to wean or withdraw HHFNC once started as respiratory support in preterm infants AUTHORS' CONCLUSIONS: There is currently no evidence available to suggest the best strategy for weaning and withdrawing HHFNC as a respiratory support in preterm infants. Research is required into the best strategy for withdrawal of HHFNC and to which subgroups this applies. Clear criteria for the definition of stability prior to attempting to withdraw HHFNC needs to be established. Furthermore, clear definitions are needed as to what constitutes failure of HHFNC.

The effectiveness of quarter turn from prone in maintaining respiratory function in premature infants.

AIM: The aim of this study was to determine the effectiveness of quarter turn from prone compared with supine and prone positioning in maintaining respiratory function in premature infants managed in a neonatal intensive care unit. METHODS: The study was a prospective, randomised, cross-over trial with concealed allocation and intention to treat analysis. Fifty-four infants ≤32 weeks gestation were randomly allocated to the order of the positions supine, prone and quarter turn from prone. Distribution of ventilation was assessed by measurement of regional impedance amplitude, global inhomogeneity index and phase angle analysis using electrical impedance tomography 30 min after each position change. Physiological characteristics of heart rate, respiratory rate (RR), oxygen saturation and inspired oxygen were also measured. RESULTS: There was a significant difference between positions for RR with the RR in quarter turn from prone significantly lower than for supine (mean difference 6.53 breaths/min; 2.04-11.02), but not compared with the prone position. No significant differences between positions were found for any of the other outcomes measured. CONCLUSION: This study demonstrated that quarter turn from prone had an immediate positive positional effect on the RR of premature infants. The position of quarter turn from prone was comparable with prone in the maintenance of lung function and had a superior effect over supine on RR. These findings support the view that a quarter turn from prone can be confidently used in neonatal nurseries to manage premature infants.

Lung recruitment and endotracheal suction in ventilated preterm infants measured with electrical impedance tomography.

AIMS: Although suctioning is a standard airway maintenance procedure, there are significant associated risks, such as loss of lung volume due to high negative suction pressures. This study aims to assess the extent and duration of change in end-expiratory level (EEL) resulting from endotracheal tube (ETT) suction and to examine the relationship between EEL and regional lung ventilation in ventilated preterm infants with respiratory distress syndrome. METHODS: A prospective observational clinical study of the effect of ETT suction on 20 non-muscle-relaxed preterm infants with respiratory distress syndrome (RDS) on conventional mechanical ventilation was conducted in a neonatal intensive care unit. Ventilation distribution was measured with regional impedance amplitudes and EEL using electrical impedance tomography. RESULTS: ETT suction resulted in a significant increase in EEL post-suction (P < 0.01). Regionally, anterior EEL decreased and posterior EEL increased post-suction, suggesting heterogeneity. Tidal volume was significantly lower in volume-guarantee ventilation compared with pressure-controlled ventilation (P = 0.04). CONCLUSIONS: ETT suction in non-muscle-relaxed and ventilated preterm infants with RDS results in significant lung volume increase that is maintained for at least 90 min. Regional differences in distribution of ventilation with ETT suction suggest that the behaviour of the lung is heterogeneous in nature.

Physiologic effect of high-flow nasal cannula in infants with bronchiolitis.

OBJECTIVE: To assess the effect of delivering high-flow nasal cannula flow on end-expiratory lung volume, continuous distending pressure, and regional ventilation distribution in infants less than 12 months old with bronchiolitis. DESIGN: Prospective observational clinical study. SETTING: Nineteen bed medical and surgical PICU. PATIENTS: Thirteen infants with bronchiolitis on high-flow nasal therapy. INTERVENTIONS: The study infants were measured on a flow rate applied at 2 and 8 L/min through the high-flow nasal cannula system. MEASUREMENTS AND RESULTS: Ventilation distribution was measured with regional electrical impedance amplitudes and end-expiratory lung volume using electrical impedance tomography. Changes in continuous distending pressure were measured from the esophagus via the nasogastric tube. Physiological variables were also recorded. High-flow nasal cannula delivered at 8 L/min resulted in significant increases in global and anterior end-expiratory lung volume (p < 0.01) and improvements in the physiological variables of respiratory rate, SpO2, and FIO2 when compared with flows of 2 L/min. CONCLUSION: In infants with bronchiolitis, high-flow nasal cannula oxygen/air delivered at 8 L/min resulted in increases in end-expiratory lung volume and improved respiratory rate, FIO2, and SpO2.