Download PDF
Am J Perinatol 2017; 34(08): 759-764
DOI: 10.1055/s-0037-1598106
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

A Quality Improvement Initiative to Reduce the Need for Mechanical Ventilation in Extremely Low Gestational Age Neonates

Ludivine Templin
1   Department of Neonatology, University Hospital La Conception, Aix-Marseille University, Marseille, France
,
Camille Grosse
1   Department of Neonatology, University Hospital La Conception, Aix-Marseille University, Marseille, France
,
Virginie Andres
1   Department of Neonatology, University Hospital La Conception, Aix-Marseille University, Marseille, France
,
Clotilde Des Robert
1   Department of Neonatology, University Hospital La Conception, Aix-Marseille University, Marseille, France
,
Laurence Fayol
1   Department of Neonatology, University Hospital La Conception, Aix-Marseille University, Marseille, France
,
Umberto Simeoni
2   Division of Pediatrics, Lausanne University Hospital, University of Lausanne, Switzerland
,
Farid Boubred
1   Department of Neonatology, University Hospital La Conception, Aix-Marseille University, Marseille, France
› Author Affiliations
Further Information

Publication History

28 June 2016

21 December 2016

Publication Date:
31 January 2017 (online)

    Permissions and Reprints

Abstract

Objective Limiting early intubation and mechanical ventilation in extremely low gestational age neonates (ELGAN) may decrease neonatal morbidity and mortality. The aim of our study was to demonstrate the feasibility, efficacy, and tolerability of a delivery room respiratory management protocol, including delayed umbilical cord clamping (DUCC) in combination with optimized nCPAP with high PEEP levels and less invasive surfactant administration (LISA).

Study Design This cohort quality improvement study analyzed the respiratory and neonatal outcomes of all consecutive infants born between 24+0 and 26+6 weeks' gestation before (period 1, n = 40) and after (period 2, n = 52) implementing the new protocol.

Results Compared with the period 1 infants, the period 2 infants had a lower rate of intubation in the delivery room (31 vs. 90%, p = 0.001) and were less likely to need mechanical ventilation on day 3 (28 vs. 62%, p = 0.002) and during the hospital stay (75 vs. 92.5%, p < 0.05). The two groups did not differ in terms of mortality or neonatal morbidity.

Conclusion A delivery room respiratory management protocol based on DUCC, optimized nCPAP with high PEEP levels, and LISA procedure is both feasible and safe, and improved ELGAN respiratory outcomes.

Keywords

extremely low gestational age neonates - respiratory distress syndrome - nasal continuous positive airway pressure - surfactant - less invasive surfactant administration - bronchopulmonary dysplasia - delayed umbilical cord clamping
 

  • References

  • 1 Stoll BJ, Hansen NI, Bell EF. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 2010; 126 (03) 443-456
    CrossrefPubMedGoogle Scholar
  • 2 Venkatesh V, Ponnusamy V, Anandaraj J. , et al. Endotracheal intubation in a neonatal population remains associated with a high risk of adverse events. Eur J Pediatr 2011; 170 (02) 223-227
    CrossrefPubMedGoogle Scholar
  • 3 Baraldi E, Filippone M. Chronic lung disease after premature birth. N Engl J Med 2007; 357 (19) 1946-1955
    CrossrefPubMedGoogle Scholar
  • 4 Polglase GR, Miller SL, Barton SK. , et al. Initiation of resuscitation with high tidal volumes causes cerebral hemodynamic disturbance, brain inflammation and injury in preterm lambs. PLoS One 2012; 7 (06) e39535 . Doi: 10.1371/journal.pone.0039535
    CrossrefPubMedGoogle Scholar
  • 5 Subramaniam P, Ho JJ, Davis PG. Prophylactic nasal continuous positive airway pressure for preventing morbidity and mortality in very preterm infants. Cochrane Database Syst Rev 2016; 6 (06) CD001243 . Doi: 10.1002/14651858.CD001243.pub3
    PubMedGoogle Scholar
  • 6 Stevens TP, Harrington EW, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev 2007; 17 (04) CD003063 . Doi: 10.1002/14651858.CD003063.pub3
    PubMedGoogle Scholar
  • 7 Sweet DG, Carnielli V, Greisen G. , et al; European Association of Perinatal Medicine. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants—2013 update. Neonatology 2013; 103 (04) 353-368
    CrossrefPubMedGoogle Scholar
  • 8 Kribs A, Vierzig A, Hünseler C. , et al. Early surfactant in spontaneously breathing with nCPAP in ELBW infants—a single centre four year experience. Acta Paediatr 2008; 97 (03) 293-298
    CrossrefPubMedGoogle Scholar
  • 9 Göpel W, Kribs A, Ziegler A. , et al; German Neonatal Network. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet 2011; 378 (9803): 1627-1634
    CrossrefPubMedGoogle Scholar
  • 10 Kanmaz HG, Erdeve O, Canpolat FE, Mutlu B, Dilmen U. Surfactant administration via thin catheter during spontaneous breathing: randomized controlled trial. Pediatrics 2013; 131 (02) e502-e509
    CrossrefPubMedGoogle Scholar
  • 11 Kribs A, Roll C, Göpel W. , et al; NINSAPP Trial Investigators. Nonintubated Surfactant Application vs Conventional Therapy in Extremely Preterm Infants: a randomized clinical trial. JAMA Pediatr 2015; 169 (08) 723-730
    CrossrefPubMedGoogle Scholar
  • 12 Klebermass-Schrehof K, Wald M, Schwindt J. , et al. Less invasive surfactant administration in extremely preterm infants: impact on mortality and morbidity. Neonatology 2013; 103 (04) 252-258
    CrossrefPubMedGoogle Scholar
  • 13 Göpel W, Kribs A, Härtel C. , et al; German Neonatal Network (GNN). Less invasive surfactant administration is associated with improved pulmonary outcomes in spontaneously breathing preterm infants. Acta Paediatr 2015; 104 (03) 241-246
    CrossrefPubMedGoogle Scholar
  • 14 Dawson JA, Kamlin COF, Vento M. , et al. Defining the reference range for oxygen saturation for infants after birth. Pediatrics 2010; 125 (06) e1340-e1347
    CrossrefPubMedGoogle Scholar
  • 15 Boumecid H, Rakza T, Abazine A, Klosowski S, Matran R, Storme L. Influence of three nasal continuous positive airway pressure devices on breathing pattern in preterm infants. Arch Dis Child Fetal Neonatal Ed 2007; 92 (04) F298-F300
    CrossrefPubMedGoogle Scholar
  • 16 Elgellab A, Riou Y, Abbazine A. , et al. Effects of nasal continuous positive airway pressure (NCPAP) on breathing pattern in spontaneously breathing premature newborn infants. Intensive Care Med 2001; 27 (11) 1782-1787
    CrossrefPubMedGoogle Scholar
  • 17 Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr 1978; 92 (04) 529-534
    CrossrefPubMedGoogle Scholar
  • 18 Bell MJ, Ternberg JL, Feigin RD. , et al. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 1978; 187 (01) 1-7
    CrossrefPubMedGoogle Scholar
  • 19 International Committee for the Classification of Retinopathy of Prematurity. The International Classification of Retinopathy of Prematurity revisited. Arch Ophthalmol 2005; 123 (07) 991-999
    CrossrefPubMedGoogle Scholar
  • 20 Hooper SB, Siew ML, Kitchen MJ, te Pas AB. Establishing functional residual capacity in the non-breathing infant. Semin Fetal Neonatal Med 2013; 18 (06) 336-343
    CrossrefPubMedGoogle Scholar
  • 21 te Pas AB, Walther FJ. A randomized, controlled trial of delivery-room respiratory management in very preterm infants. Pediatrics 2007; 120 (02) 322-329
    CrossrefPubMedGoogle Scholar
  • 22 Niermeyer S, Velaphi S. Promoting physiologic transition at birth: re-examining resuscitation and the timing of cord clamping. Semin Fetal Neonatal Med 2013; 18 (06) 385-392
    CrossrefPubMedGoogle Scholar
  • 23 Katheria AC, Truong G, Cousins L, Oshiro B, Finer NN. Umbilical cord milking versus delayed cord clamping in preterm infants. Pediatrics 2015; 136 (01) 61-69
    CrossrefPubMedGoogle Scholar
  • 24 Dekker J, Lopriore E, Rijken M, Rijntjes-Jacobs E, Smits-Wintjens V, Te Pas A. Sedation during minimal invasive surfactant therapy in preterm infants. Neonatology 2016; 109 (04) 308-313
    CrossrefPubMedGoogle Scholar