Katie Hunt

Changes in the use of humidified high flow nasal cannula oxygen

Humidified high flow nasal cannula (HHFNC) has gained popularity in neonatal care. A systematic review1 of the results of nine trials, which included a total of 1112 infants, however, demonstrated that HHFNC was not superior to other modes of non-invasive ventilation in infants of >28 weeks gestational age. We, therefore, sought to determine whether clinical practice regarding HHFNC had changed since 2012 when all UK units were surveyed2 and also to identify why practitioners preferred HHFNC or continuous positive airway pressure (CPAP). In 2015, lead clinicians of all 194 UK neonatal units were identified from the National Neonatal Audit …

High-flow nasal cannula oxygen and nasal continuous positive airway pressure and full oral feeding in infants with bronchopulmonary dysplasia

Objective To determine whether the time to achieve full oral feeding differed between infants with bronchopulmonary dysplasia (BPD) supported by nasal continuous positive airway pressure (nCPAP) compared with those supported by nCPAP and subsequently transferred to heated, humidified, high-flow nasal cannula oxygen (HHFNC). Design Two-cohort comparison. Setting Tertiary neonatal unit. Patients –72 infants, median gestational age 27 (range 24–32) weeks in the nCPAP group, and 44 infants, median gestational age 27 (range 24–31) weeks in the nCPAP/HHFNC group. Interventions Between 2011 and 2013, infants post extubation were supported by nCPAP and from 2013 infants were supported by nCPAP and then HHFNC. Main outcome measures The postnatal age at which oral feeds were first trialled and full oral feeds established. The length of respiratory support as either nCPAP or nCPAP/HHFNC and the total length of respiratory support and hospital stay were also determined. Subanalysis was undertaken of infants requiring respiratory support beyond 34 weeks postmenstrual age (PMA). Results The postnatal age at trial of first oral feeds was earlier in the nCPAP/HHFNC group (p=0.012), but infants were a shorter time on nCPAP compared with nCPAP/HHFNC (p=0.003). On subgroup analysis, the age to achieve full oral feeds was earlier in the nCPAP/HHFNC group (p<0.001). Conclusions In infants with BPD who required respiratory support beyond 34 weeks PMA, use of nCPAP then HHFNC was associated with earlier establishment of full oral feeds. Consideration should be given to assessing stable BPD infants with regard to oral feeding while on CPAP.

Pulmonary Complications of Haematologic Disorders

Sickle cell disease (SCD), a haemolytic anaemia, is the most common inherited disorder affecting African and Caribbean populations. In young children obstructive lung function abnormalities are common, but restrictive lung function abnormalities become more prominent with increasing age. The rate of decline in lung function is related to age, being commoner in younger children in whom acute chest syndrome episodes are more common. Iron overload, due to a variety of conditions including thalassaemia, can cause damage to the lungs resulting in lung function abnormalities and respiratory morbidity. Approximately 40% of survivors of childhood leukaemia have some degree of abnormality on pulmonary function testing, but only 10–25% of children are symptomatic reporting cough or mild dyspnea; this is as a consequence of chemotherapy and irradiation. Children who are anaemic have a reduction in the amount of haemoglobin in the blood which reduces their oxygen-carrying capacity. Iron deficiency may also reduce the deformability of red blood cells, compromising passage through capillary beds and therefore reducing oxygen delivery. Inherited bleeding disorders, such as haemophilia and von Willebrand’s disease, rarely cause alveolar haemorrhage, but patients may experience bleeding into the pleural cavity or mediastinum with consequent respiratory distress and hypoxaemia. Pulmonary embolism is a rare event in children. Risk factors include congenital cardiac disease, presence of an indwelling central venous catheter and systemic infection. Oral contraceptive use is increasingly recognised as an important risk factor in adolescent girls.

Small for gestational age and extremely low birth weight infant outcomes

Abstract Background Small for gestational age (SGA) infants are less likely to develop respiratory distress syndrome (RDS), but more likely to develop bronchopulmonary dysplasia (BPD) and have a higher mortality. Our aim was to focus on outcomes of those with a birth weight less than or equal to 750 g. Methods The mortality, BPD severity, necrotising enterocolitis (NEC), home oxygen requirement and length of hospital stay were determined according to SGA status of all eligible infants in a 5-year period admitted within the first 24 h after birth. Results The outcomes of 84 infants were assessed, and 35 (42%) were SGA. The SGA infants were more mature (P<0.001), had a lower birth weight centile (P<0.001) and a greater proportion exposed to antenatal corticosteroids (P=0.022). Adjusted for gestational age (GA), there was no significant difference in mortality between the two groups (P=0.242), but a greater proportion of the SGA infants developed severe BPD (P=0.025). The SGA infants had a lower weight z-score at discharge (−3.64 vs. −1.66) (P=0.001), but a decrease in z-score from birth to discharge was observed in both groups (median −1.53 vs. −1.07, P=0.256). Conclusion Despite being more mature, the SGA infants had a similar mortality rate and a greater proportion developed severe BPD.

Prediction of bronchopulmonary dysplasia development

The survival of infants born extremely prematurely is increasing, but the incidence of bronchopulmonary dysplasia (BPD) is not diminishing.1 Strategies employed to reduce the incidence of BPD have largely been unsuccessful or have an unacceptably high rate of adverse effects.2 It is, therefore, essential to identify predictors of BPD development and in particular the development of severe BPD so that preventative interventions can be targeted at high-risk infants. We tested the hypothesis that a requirement for invasive mechanical ventilation at 1 week of age would predict development of BPD and severe BPD. Infants <32 weeks of gestational age …

Volume targeting levels and work of breathing in infants with evolving or established bronchopulmonary dysplasia

Objectives To assess the work of breathing at different levels of volume targeting in prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD). Design Randomised crossover study. Setting Tertiary neonatal intensive care unit. Patients Eighteen infants born at <32 weeks gestation who remained ventilated at or beyond 1 week after birth, that is, they had evolving or established BPD. Interventions Infants received ventilation at volume targeting levels of 4, 5, 6 and 7 mL/kg each for 20 minutes, the levels were delivered in random order. Baseline ventilation (without volume targeting) was delivered for 20 minutes between each epoch of volume-targeting. Main outcome measures Pressure-time product of the diaphragm (PTPdi), a measure of the work of breathing, at different levels of volume targeting. Results The 18 infants had a median gestational age of 26 (range 24–30) weeks and were studied at a median of 18 (range 7–60) days. The mean PTPdi was higher at 4 mL/kg than at baseline, 5 mL/kg, 6 mL/kg and 7 mL/kg (all P≤0.001). The mean PTPdi was higher at 5 mL/kg than at 6 mL/kg (P=0.008) and 7 mL/kg (P<0.001) and higher at 6 mL/kg than 7 mL/kg (P=0.003). Only at 7 mL/kg was the PTPdi significantly lower than at baseline (P=0.001). Conclusions Only a tidal volume target of 7 mL/kg reduced the work of breathing below the baseline and may be more appropriate for infants with evolving or established BPD who remained ventilator dependent at or beyond 7 days of age.

Detection of exhaled carbon dioxide following intubation during resuscitation at delivery

Objectives End tidal carbon dioxide (ETCO2) monitoring can facilitate identification of successful intubation. The aims of this study were to determine the time to detect ETCO2 following intubation during resuscitation of infants born prematurely and whether it differed according to maturity at birth or the Apgar scores (as a measure of the infant’s condition after birth). Design Analysis of recordings of respiratory function monitoring. Setting Two tertiary perinatal centres. Patients Sixty-four infants, with median gestational age of 27 (range 23–34)weeks. Interventions Respiratory function monitoring during resuscitation in the delivery suite. Main outcome measures The time following intubation for ETCO2 levels to be initially detected and to reach 4 mm Hg and 15 mm Hg. Results The median time for initial detection of ETCO2 following intubation was 3.7 (range 0–44) s, which was significantly shorter than the median time for ETCO2 to reach 4 mm Hg (5.3 (range 0–727) s) and to reach 15 mm Hg (8.1 (range 0–827) s) (both P<0.001). There were significant correlations between the time for ETCO2 to reach 4 mm Hg (r=−0.44, P>0.001) and 15 mm Hg (r=−0.48, P<0.001) and gestational age but not with the Apgar scores. Conclusions The time for ETCO2 to be detected following intubation in the delivery suite is variable emphasising the importance of using clinical indicators to assess correct endotracheal tube position in addition to ETCO2 monitoring. Capnography is likely to detect ETCO2 faster than colorimetric devices.

UK neonatal resuscitation survey

Background Previous surveys have demonstrated that neonatal resuscitation practices on the delivery suite vary between UK units, particularly according to the hospital’s neonatal unit’s level. Our aim was to determine if recent changes to the Resuscitation Council guidelines had influenced clinical practice. Methods Surveys of resuscitation practices at UK delivery units carried out in 2012 and 2017 were compared. Results Comparing 2017 with 2012, initial resuscitation using air was more commonly used in both term (98% vs 75%, p<0.001) and preterm (84% vs 34%, p<0.001) born infants. Exhaled carbon dioxide monitoring was more frequently employed in 2017 (84% vs 19%, p<0.001). There were no statistically significant differences in practices according to the level of neonatal care provided by the hospital. Conclusion There have been significant changes in neonatal resuscitation practices in the delivery suite since 2012 regardless of the different levels of neonatal care offered.

G199(P) Comparing the acccuracy of delivery of a sustained inflation to inflation breaths on a neonatal mannequin

Aims The Neonatal Life Support (NLS) guidelines currently recommend delivery of five inflation breaths (IB) each lasting two to three seconds.1 In practise, however, doctors often fail to deliver the recommended duration.2 There has been increasing interest in delivery of a sustained inflation (SI=15 s) as initial resuscitation of prematurely-born infants. Our aim was to investigate how accurately neonatal doctors could deliver an SI compared to IB using a resuscitation mannequin. Methods Doctors were invited to deliver five IB (each five seconds in duration) and a fifteen second SI to a neonatal mannequin. A respiratory function monitor was used to assess the duration of the inflations. Recordings were made after the doctors had the opportunity to practise using the equipment and delivering an SI. All were trained in NLS. Results Twenty four doctors took part in the study. Abstract G199(P) Table 1 Median (range) duration of IB (seconds) Median (range) duration of SI (seconds) 2.2 (1.1–3.8) 15.3 (11.5–22.0) The median error for IB was −0.8 s, that is, on average, each inflation was 0.8 s too short and for SI the median error was +0.34 s, that is, on average, each inflation was 0.34 s too long. The magnitude of error was significantly higher for IB than SI (26% versus 5.7% respectively, p=0.001). To further compare the variability in the two techniques the IB results were divided by three and the SI results by 15. The interquartile range for IB was 0.59 s and for SI was 0.25 s, demonstrating much closer clustering of results around the median for the SIs (Table 1). Conclusions A fifteen second SI was delivered more accurately than three second inflation breaths by neonatal doctors using a mannequin. Studies of neonatal resuscitation should examine the accuracy with which the techniques are applied. References . (UK) RC. NLS Guidelines (Resuscitation Council). resus.org.uk . Murthy V, et al. Eur J Pediatr2012;171:843–6.

G203(P) Uk neonatal resuscitation survey

Aim In the UK, neonatal resuscitation practice follows national guidelines set by the UK Resuscitation Council. Two previous surveys, however, found significant differences in practice between units according to the level of care offered.1,2 Since then changes have been made to the guidelines3 and there has been interest in the role of carbon dioxide (CO2) monitoring during neonatal resuscitation.4 Our aim was to determine if these changes had altered resuscitation practice in the delivery suite across the UK. Methods An online questionnaire was sent to the lead consultants of 189 units. If no response was received, a follow up email was sent and further non-response was followed by a telephone call. The results were compared to the 2012 survey.1 Results Over all, there was an 83% response rate per level of unit: (neonatal intensive care unit (NICU) 93%, local neonatal unit (LNU) 83%, special care baby unit (SCBU). Currently all units used an initial inspired oxygen (FiO2) of 0.21 for term born infants, whereas previously it had been used in 84.5% NICUs, 39.5% of LNUs and 31.7% of SCBUs. An initial FiO2 of 0.21 for preterm infants was used in NICUs, LNUs and SCBUs in 2017 in 86%, 93% and 93% respectively and in 2012 in 42%, 22% and 24% respectively. Routine use of oxygen saturation monitoring for preterm infants had increased from 71%, 65% and 42% in 2012 to 94%, 88% and 84% (NICUs, LNUs and SCBUs respectively). CO2 monitoring was also more common, currently used by 88%, 81% and 84% compared to 24%–20% and 10% in 2012 (NICUs, LNUs and SCBUs respectively). Conclusion There have been marked changes in delivery suite resuscitation practices since 2012 and more consistency across levels on units. References . Murthy V, et al. Arch Dis Child Fetal Neonatal Ed2012;97:F154–5. . Mann C, et al. Resuscitation2012;83:607–11. . Wyllie J, et al. European Resuscitation Council Guidelines for Resuscitation2015. . Hawkes G, et al. Resuscitation2014;85:1315–9.