Mechanical Ventilation In Newborn Infants Research Articles

Mechanical Ventilation Trigger Tool Identify Errors Associated with Mechanical Ventilation in Newborn Infant

BACKGROUND: Patient safety is the core of quality of health care. Newborn infants who are admitted to NICU are liable to adverse events. Medical errors represent a serious public health problem and pose a threat to patient safety. Mechanical ventilation is a complex procedure that exposes newborn infants to adverse events and complications. AIM: The objective of this study was to identify medical errors related to mechanical ventilation (MV) in newborn infants using the newly design MV trigger tool. METHODS: Observational cohort study was conducted for 6-month duration to determine the medical errors related to mechanical ventilation. It was carried out on newborn infants who needed mechanical ventilation and admitted to the NICU. Furthermore, we used the mechanical ventilation trigger tool to estimate number, types, and risk factors for the related errors. RESULTS: There were 142 errors related to mechanical ventilation. Nearly 21.13% of the errors were related to ventilator settings, 38.39% were related to endotracheal intubation, and 40.14% of the errors were due to manipulation of the ventilators. The adverse events were diagnosed in 73.24% of the detected errors. Error of commission was seen in 53.5% of cases, and omission errors were reported in 46.5% of the cases. Mechanical ventilation trigger tool has 95.87% sensitivity and 95.24% specificity with 95.77% accuracy to detect errors. CONCLUSION: The mechanical ventilation trigger tool may be efficient and effective in identifying errors and adverse events related to mechanical ventilation; it has high sensitivity and specificity. It might increase awareness to improve MV-related care.

Lung Ultrasound Monitoring of Legionella Ventilator-Associated Pneumonia in an Extremely Low-Birth-Weight Infant.

Ventilator-associated pneumonia (VAP) is a common complication of different severe lung diseases that need to be treated with mechanical ventilation in newborn infants. However, VAP due to Legionella pneumophila infection is rarely reported in the literature, especially in extremely low-birth-weight (ELBW) infants. Lung ultrasound (LUS) has been used in the diagnosis of neonatal pneumonia, but there is no literature on the ultrasound characteristics of Legionella-VAP in ELBW infants. This paper introduced the typical LUS findings of Legionella-VAP in ELBW infants, which mainly includes severe and large-area lung consolidation and atelectasis in the bilateral lungs; whether there is blood supply in the consolidated area has an important reference value for predicting the prognosis. In addition, the treatment and management experience were also introduced together, thereby helping us to deepen the understanding of the disease and avoid missed diagnoses.

Carbon dioxide monitoring in the newborn infant.

Carbon dioxide (CO2 ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO2 levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO2 (EtCO2 ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO2 measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO2 can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.

Mechanical ventilation in newborn infants: Clinical practice guidelines of the Saudi Neonatology Society

Mechanical ventilation is one of the most common therapies in the neonatal intensive care unit (NICU), it is an area where technical complexity overlap individual preferences due to lack of extensive scientific evidence. Our aim is to provide clinical practice guidelines for conventional mechanical ventilation of newborn infants, utilizing the best available scientific evidence and to address the controversies. These guidelines are meant to help the clinician in managing ventilated newborn infants; it should not replace clinical judgment.

Protocolized versus non-protocolized weaning for reducing the duration of invasive mechanical ventilation in newborn infants.

Mechanical ventilation is a life-saving intervention for critically ill newborn infants with respiratory failure admitted to a neonatal intensive care unit (NICU). Ventilating newborn infants can be challenging due to small tidal volumes, high breathing frequencies, and the use of uncuffed endotracheal tubes. Mechanical ventilation has several short-term, as well as long-term complications. To prevent complications, weaning from the ventilator is started as soon as possible. Weaning aims to support the transfer from full mechanical ventilation support to spontaneous breathing activity. To assess the efficacy of protocolized versus non-protocolized ventilator weaning for newborn infants in reducing the duration of invasive mechanical ventilation, the duration of weaning, and shortening the NICU and hospital length of stay. To determine efficacy in predefined subgroups including: gestational age and birth weight; type of protocol; and type of protocol delivery. To establish whether protocolized weaning is safe and clinically effective in reducing the duration of mechanical ventilation without increasing the risk of adverse events. We searched the Cochrane Central Register of Controlled trials (CENTRAL; the Cochrane Library; 2015, Issue 7); MEDLINE In-Process and other Non-Indexed Citations and OVID MEDLINE (1950 to 31 July 2015); CINAHL (1982 to 31 July 2015); EMBASE (1988 to 31 July 2015); and Web of Science (1990 to 15 July 2015). We did not restrict language of publication. We contacted authors of studies with a subgroup of newborn infants in their study, and experts in the field regarding this subject. In addition, we searched abstracts from conference proceedings, theses, dissertations, and reference lists of all identified studies for further relevant studies. Randomized, quasi-randomized or cluster-randomized controlled trials that compared protocolized with non-protocolized ventilator weaning practices in newborn infants with a gestational age of 24 weeks or more, who were enrolled in the study before the postnatal age of 28 completed days after the expected date of birth. Four authors, in pairs, independently reviewed titles and abstracts identified by electronic searches. We retrieved full-text versions of potentially relevant studies. Our search yielded 1752 records. We removed duplicates (1062) and irrelevant studies (843). We did not find any randomized, quasi-randomized or cluster-randomized controlled trials conducted on weaning from mechanical ventilation in newborn infants. Two randomized controlled trials met the inclusion criteria on type of study and type of intervention, but only included a proportion of newborns. The study authors could not provide data needed for subgroup analysis; we excluded both studies. Based on the results of this review, there is no evidence to support or refute the superiority or inferiority of weaning by protocol over non-protocol weaning on duration of invasive mechanical ventilation in newborn infants.

Clinical and diagnostic value of transcranial cerebral oximetry in the optimization of mechanical ventilation in newborn infants

Treatment of ischemic damage to organs and tissues by mechanical ventilation with a high content of oxygen in the inspired mixture (FiO2) can lead to oxidative stress and reperfusion of tissue alteration, which is particularly characteristic of infants with their characteristic low levels of antioxidant protection. From this perspective, there is optimal mode selection in mechanical ventilation and FiO2 of vital organs and tissue, namely in brain tissue, which was made possible through the use of transcranial cerebral oximetry (TCO).

Prophylactic antibiotics to reduce morbidity and mortality in ventilated newborn infants

Intubation is associated with bacterial colonisation of the respiratory tract and, therefore, may increase the risk of acquiring an infection. The infection may prolong the need for mechanical ventilation and increase the risk of chronic lung disease. The use of prophylactic antibiotics has been advocated for all mechanically ventilated newborns in order to reduce the risk of colonisation and the acquisition of infection. However, there is the possibility that the harm this may cause might outweigh the benefit. To assess the effects of prophylactic antibiotics on mortality and morbidity in intubated, ventilated newborn infants who are not known to have infection. In separate comparisons, two different policies regarding the prophylactic use of antibiotics in intubated, ventilated infants were reviewed: 1) among infants who have been intubated for mechanical ventilation, a policy of prophylactic antibiotics for the duration of intubation versus placebo or no treatment 2) among intubated, ventilated infants who have been started on antibiotics at the time of intubation but whose initial cultures to rule out sepsis were negative, a policy of continuing versus discontinuing prophylactic antibiotics. MEDLINE (January 1950 to March 2007), CINAHL (1982 to March 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2007), the Cochrane Neonatal Group Specialised Register and reference lists of articles were searched. Randomised controlled trials of sufficient quality in which mechanically ventilated newborn infants are randomised to receive prophylactic antibiotics versus placebo or no treatment. Two reviewers independently assessed trial quality. Two studies met the criteria for inclusion in this review. One was of insufficient quality to draw any meaningful conclusions. The other was of fair quality and found no significant differences between treatment and control groups in any of the reported outcomes, however, the rates of septicaemia were not reported. There is insufficient evidence from randomised trials to support or refute the use of prophylactic antibiotics when starting mechanical ventilation in newborn infants, or to support or refute continuing antibiotics once initial cultures have ruled out infection in mechanically ventilated newborn infants.

Lung-protective ventilation strategies in neonatology: What do we know—What do we need to know?

Randomized controlled trials (RCTs) investigating various lung-protective ventilation modes or strategies in newborn infants have failed to show clear differences in mortality or bronchopulmonary dysplasia. This review tries to identify possible reasons for this observation, applying modern concepts on ventilator-induced lung injury and lung-protective ventilation. Published RCTs and systematic reviews on mechanical ventilation in newborn infants were identified by searching PubMed and the Cochrane Library. A total of 16 RCTs and four systematic reviews comparing high-frequency ventilation with conventional mechanical ventilation (CMV) failed to show consistent differences in mortality and bronchopulmonary dysplasia. Unfortunately, clear information or data on ventilation and oxygenation targets in the search for optimal lung volumes during high-frequency ventilation or CMV is lacking in many RCTs, questioning the validity of the results and the meta-analytic subgroup analysis. Based on improvement in oxygenation, only three RCTs successfully applied the optimal lung volume strategy during high-frequency ventilation. A total of 24 RCTs and three systematic reviews comparing various CMV modes and settings and two RCTs investigating permissive hypercapnia reported no differences in mortality or bronchopulmonary dysplasia. However, the intervention arms in these RCTs did not differ in tidal volume or positive end-expiratory pressures, variables that are considered important determinants in ventilator-induced lung injury. In fact, no RCT in newborn infants has substantiated so far the experimental finding that avoiding large tidal volumes and low positive end-expiratory pressure during CMV is lung protective in newborn infants. RCTs investigating lung-protective ventilation in neonates have mainly focused on comparing high-frequency ventilation with CMV. Most of these RCTs show weaknesses in the design, which may explain the inconsistent effect of high-frequency ventilation on bronchopulmonary dysplasia. RCTs on CMV only focused on comparing various modes and settings, leaving the important question whether reducing tidal volume or increasing positive end-expiratory pressure is also lung protective in newborn infants unanswered.

Velocity and attenuation of sound in the isolated fetal lung as it is expanded with air

We measured the velocity and attenuation of audible sound in the isolated lung of the near-term fetal sheep to test the hypothesis that the acoustic properties of the lung provide a measure of the volume of gas it contains. We introduced pseudorandom noise (bandwidth 70 Hz-7 kHz) to one side of the lung and recorded the noise transmitted to the surface immediately opposite, starting with the lung containing only fetal lung liquid and making measurements after stepwise inflation with air until a leak developed. The velocity of sound in the lung fell rapidly from 187 +/- 28.2 to 87 +/- 3.7 m/s as lung density fell from 0.93 +/- 0.01 to 0.75 +/- 0.01 g/ml (lung density = lung weight/gas volume plus lung tissue volume). For technical reasons, no estimate of velocity could be made before the first air injection. Thereafter, as lung density fell to 0.35 +/- 0.01 g/ml, there was a further decline in velocity to 69.6 +/- 4.6 m/s. High-frequency sound was attenuated as lung density decreased from 1.0 to 0.5 g/ml, with little change thereafter down to a density of 0.35 +/- 0.01 g/ml. We conclude that both the velocity of audible sound through the lung and the degree to which high-frequency sound is attenuated in the lung provide information on the degree of inflation of the isolated fetal lung, particularly at high lung densities. If studies of sound transmission through the lung in the intact organism were to confirm these findings, the acoustic properties of the lung could provide a means for monitoring lung aeration during mechanical ventilation of newborn infants.

Nasal versus oral intubation for mechanical ventilation of newborn infants.

This section is under preparation and will be included in the next issue. The purpose of the review was to compare the complications associated with intubation by the nasal route with those associated with intubation by the oral route for mechanical ventilation in newborn infants. The standard search strategy of the Neonatal Review Group as outlined in the Cochrane Library was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Register of Controlled Trials, MEDLINE and CINAHL. A call was placed on the list servers, NICU-NET and Neonatal Talk for unpublished trials, conference presentations and current trials. All trials using random or quasi-random allocation of patients to either the nasal or oral route of intubation were included. Study quality and eligibility were assessed independently by each author. The standard method of the Cochrane Collaboration and the Neonatal Review Group was used to assess the methodological quality of the included studies. The methodological quality of each study was reviewed by the second author blinded to study authors and institutions. Each reviewer extracted data separately before comparison and resolution of differences. The standard method of the Neonatal Review Group was used to measure the effect of the different routes of intubation, using Relative Risk (RR) and 95% Confidence Intervals (CI). Only two eligible randomized trials were found. Data from these two trials failed to show significant differences between the oral and nasal route of intubation for mechanically ventilated neonates. The rate of failure to intubate using the nasal route was higher in one study. One study found post extubation atelectasis occurred more frequently in nasally intubated infants who weighed less than 1500 grams. The rates of malposition of the tube at the initial intubation, accidental extubation, tube blockage, re-intubation after extubation, septicaemia, clinical infection and local trauma (nasal erosion or palatal groove) were not significantly different for the two groups. Post extubation atelectasis may be more frequent after nasal intubation, particularly in very low birth weight infants. One route of intubation does not seem to be preferable to the other. There is a need for further randomized controlled trials containing larger numbers of infants.

Ultrasonic measurement of tidal gas flow in mechanical ventilation of newborn infants: Simon Bignall a, Keith Lawes b, aDepartment of Paediatrics, St. Mary's Hospital Medical School, London W2 1NY, UK, bGill Electronic Research and Development, Lymington, Hants, UK

Ultrasonic measurement of tidal gas flow in mechanical ventilation of newborn infants: Simon Bignall a, Keith Lawes b, aDepartment of Paediatrics, St. Mary's Hospital Medical School, London W2 1NY, UK, bGill Electronic Research and Development, Lymington, Hants, UK

Multicenter controlled trial comparing high-frequency jet ventilation and conventional mechanical ventilation in newborn infants with pulmonary interstitial emphysema

One hundred forty-four newborn infants with pulmonary interstitial emphysema were stratified by weight and severity of illness, and randomly assigned to receive treatment with high-frequency jet ventilation (HFJV) or rapid-rate conventional mechanical ventilation (CV) with short inspiratory time. If criteria for treatment failure were met, crossover to the alternate ventilatory mode was permitted. Overall, 45 (61%) of 74 infants met treatment success criteria with HFJV compared with 26 (37%) of 70 treated with CV (p less than 0.01). Eighty-four percent of patients who crossed over from CV to HFJV initially responded to the new treatment, and 45% ultimately met success criteria on HFJV. In contrast, only 9% of those who crossed over from HFJV to CV responded well to CV (p less than 0.01), and the same 9% ultimately met success criteria (p less than 0.05). Therapy with HFJV resulted in improved ventilation at lower peak and mean airway pressures, as well as more rapid radiographic improvement of pulmonary interstitial emphysema, in comparison with rapid-rate CV. Survival by original assignment was identical. When survival resulting from rescue by the alternate therapy in crossover patients was excluded, the survival rate was 64.9% for HFJV, compared with 47.1% for CV (p less than 0.05). The incidence of chronic lung disease, intraventricular hemorrhage, patent ductus arteriosus, airway obstruction, and new air leak was similar in both groups. We conclude that HFJV, as used in this study, is safe and is more effective than rapid-rate CV in the treatment of newborn infants with pulmonary interstitial emphysema.

Reduction of platelet counts induced by mechanical ventilation in newborn infants

The association between platelet counts and mechanical ventilation was assessed in 61 newborn infants with respiratory distress syndrome, 10 infants with congenital diaphragmatic hernia, and 10 infants with tracheoesophageal fistula. A significant decrease in platelet counts was observed during mechanical ventilation: (mean +/- SD) reduction of 39% +/- 5%, 42% +/- 5.6%, and 11.9% +/- 5.4% in the three groups, respectively, independent of other causes. In the group with congenital diaphragmatic hernia, there was a significant correlation between mean airway pressure and the reduction in platelet counts. In a subsequent series of experiments, platelet counts were recorded before and during ventilation in rabbits. A significant mean decrease of 37.3% in platelet counts was associated with ventilation with either air or pure oxygen. Results of these studies indicate that mechanical ventilation itself may cause a major decrease in platelet count in newborn infants.

Inadvertent positive end-expiratory pressure in mechanically ventilated newborn infants: Detection and effect on lung mechanics and gas exchange

During mechanical ventilation, inadvertent positive end-expiratory pressure (PEEP) can have deleterious effects, including decreasing lung compliance and alveolar ventilation. To detect and quantitate inadvertent PEEP in 10 preterm neonates receiving mechanical ventilation, we clamped the connection between the endotracheal tube and the respirator at end-expiration and, after about 5 seconds, measured the airway pressure resulting from the trapped gas that emptied into the airways and the measuring system. To study the effect of decreasing inadvertent PEEP on lung mechanics and gas exchange, we measured the compliance of the respiratory system and blood gases. Inadvertent PEEP >1 cm H 2 O was detected in 19 of 29 measurements. Decreasing inadvertent PEEP by lengthening the expiratory time increased the complicance of the respiratory system (r=−0.74, n=10, P 1 cm H 2 O (mean 2.1±0.8 cm H 2 O) in six newborn infants increased respiratory compliance from 0.57±0.09 to 0.73±0.13 ml/cm H 2 O, or ≈30%, and lowered Pco 2 from 40.6±14.4 to 38.2±14.1 mm Hg despite a reduction in the level of ventilation set on the respirator. Knowing the amount of inadvertent PEEP and its effects can help improve mechanical ventilation in newborn infants.

Inadvertent positive end-expiratory pressure in mechanically ventilated newborn infants: Detection and effect on lung mechanics and gas exchange

During mechanical ventilation, inadvertent positive end-expiratory pressure (PEEP) can have deleterious effects, including decreasing lung compliance and alveolar ventilation. To detect and quantitate inadvertent PEEP in 10 preterm neonates receiving mechanical ventilation, we clamped the connection between the endotracheal tube and the respirator at end-expiration and, after about 5 seconds, measured the airway pressure resulting from the trapped gas that emptied into the airways and the measuring system. To study the effect of decreasing inadvertent PEEP on lung mechanics and gas exchange, we measured the compliance of the respiratory system and blood gases. Inadvertent PEEP greater than 1 cm H2O was detected in 19 of 29 measurements. Decreasing inadvertent PEEP by lengthening the expiratory time increased the compliance of the respiratory system (r = -0.74, n = 10, P less than 0.02). Decreasing inadvertent PEEP by greater than 1 cm H2O (mean 2.1 +/- 0.8 cm H2O) in six newborn infants increased respiratory compliance from 0.57 +/- 0.09 to 0.73 +/- 0.13 ml/cm H2O, or approximately 30%, and lowered Pco2 from 40.6 +/- 14.4 to 38.2 +/- 14.1 mm Hg despite a reduction in the level of ventilation set on the respirator. Knowing the amount of inadvertent PEEP and its effects can help improve mechanical ventilation in newborn infants.

1899 COMPARISON OF RISK FACTORS ASSOCIATED WITH BRONCHOPULMONARY DYSPLASIA

Bronchopulmonary dysplasia (BPD) remains a significant complication associated with positive pressure mechanical ventilation of newborn infants. All NICU admissions during 1982 and 1983 were studied to compare the incidence of BPD and to identify differences with respect to, recognized risk factors. In 1983 an effort was made to use lower peak inflation pressures (PIP) and less IV fluid in initial management. RDS was present in 77/355 infants in 1982 and 71/354 in 1983 with no difference in disease severity. In 1982, 15/77 (19.5%) of infants with RDS developed clinical BPD (requiring supplemental oxygen for >28d) compared with 5/71 (7%) in 1983 (p<.05). In the 20 infants with clinical BPD, there was no significant difference between 1982 and 1983 with respect to gestational age, radiographic severity of initial lung disease, presence of a clinically significant PDA, or maximum FiO2. Mean PIP in 1982 and 28.6±11SM cmH2O vs 17.7±1.9 cmH2O for 1983 (p<.02). Weight loss/birth weight × 100 at days 3 and 10 were 9.19% and 10.02% (1982) vs 16.75% and 18.2% ((p<.03, p<.02). In summary, a lower incidence of BPD was associated with lower peak inflation pressure and greater weight loss in early life suggesting that judicious use of positive pressure ventilation and careful fluid management may reduce the occurrence of BPD.

Respiratory support in the newborn

The prognosis of newborn infants with acute· resplratory failure is much better in recent years, due to changes in the methods of and the indications for mechanical ventilation. Several years ago there has still hesitation to use mechanical ventilation in newborn infants. Stock (1973) for example suggested to reserve mechanical ventilation for patients unlikely to survive without it. It seemed that the uncertainty was due to the lack of an appropriate ventilator for newborn infants.

PANCURONIUM DURING MECHANICAL VENTILATION SPEEDS RECOVERY OF LUNGS OF INFANTS WITH HYALINE MEMBRANE DISEASE

Spontaneous breathing during mechanical ventilation in newborn infants may damage the lung. To find out whether the prevalence of lesions which might be due to trauma was reduced by muscle relaxation, fifty infants who required mechanical ventilation of hyaline membrane disease were randomly assigned to treated and control groups. The treated infants were kept muscle relaxed with pancuronium bromide until they needed a FiO2 of 0·40 or less during ventilation. The mean birthweight, gestational age, age at entry to the trial, duration of intubation and ventilation, FiO2 during the acute phase of the illness, and ventilator pressures were closely comparable in the two groups. Two of twenty-six treated infants and one of twenty-four controls died. Four treated and five control infants acquired pneumothoraces and/or interstitial emphysema. The length of time that the treated infants required added oxygen was significantly less than in the control infants. All treated infants were breathing room air spontaneously by one month of age whereas seven control infants were still dependent on added oxygen, needing an average FiO2 of 0·35 to achieve a mean PaO2 of 6·5 kPa (49 mm Hg). These seven infants required added oxygen until they were 5-18 (mean 10) weeks old. Muscle relaxation during mechanical ventilation for hyaline membrane disease speeds recovery of the lungs, probably owing to a reduction in traumatic damage.

Evaluation of mechanical ventilation in newborn infants. II. Pulmonary and neuro-developmental sequelae in relation to original diagnosis.

The incidence of bronchopulmonary dysplasia (BPD) and neuro-developmental sequelae in 135 infants surviving intermittent positive pressure ventilation (IPPV) in the newborn period were studied in relation to primary disorders requiring IPPV. The rate of BPD increased over the 6-year study period in hyaline membrane disease survivors from 14% to 28%, but decreased in infants with apnoea repetens from 38% to 13%. Immaturity seemed to be one important factor for development of BPD. The incidence of neuro-developmental sequelae in IPPV treated infants fell from 22% to 13% over the years. In infants with birth weight below 1501 g the rate of neurological handicaps was 11%.

Mechanical Ventilation in Newborn Infants With Hyaline Membrane Disease*

Mechanical Ventilation in Newborn Infants With Hyaline Membrane Disease*