Neil L. McNinch

Evaluating the Effect of Flow and Interface Type on Pressures Delivered With Bubble CPAP in a Simulated Model

BACKGROUND: Bubble CPAP, used for spontaneously breathing infants to avoid intubation or postextubation support, can be delivered with different interface types. This study compared the effect that interfaces had on CPAP delivery. We hypothesized that there would be no difference between set and measured levels between interface types. METHODS: A validated preterm infant nasal airway model was attached to the ASL 5000 breathing simulator. The simulator was programmed to deliver active breathing of a surfactant-deficient premature infant with breathing frequency at 70 breaths/min inspiratory time of 0.30 s, resistance of 150 cm H2O/L/s, compliance of 0.5 mL/cm H2O, tidal volume of 5 mL, and esophageal pressure of −10 cm H2O. Nasal CPAP prongs, size 4030, newborn and infant RAM cannulas were connected to a nasal airway model and a bubble CPAP system. CPAP levels were set at 4, 5, 6, 7, 8, and 9 cm H2O with flows of 6, 8, and 10 L/min each. Measurements were recorded after 1 min of stabilization. The analysis was performed using SAS 9.4. The Kolmogorov-Smirnov test assessed normality of the data. The Friedman test was used to compare non-normally distributed repeated measures. The Wilcoxon signed-rank test was used to conduct post hoc analysis. All tests were 2-sided, and P values of <.05 were considered as indicating significant differences unless otherwise indicated. RESULTS: At lower set CPAP levels, 4–6 cm H2O, measured CPAP dropped precipitously with the nasal prongs with the highest flow setting. At higher CPAP levels, 7–9 cm H2O measured CPAP concomitantly increased as the flow setting increased. Statistically significant differences in set and measured CPAP occurred for all devices across all CPAP levels, with the measured CPAP less than set for all conditions, P < .001. CONCLUSIONS: Set flow had a profound effect on measured CPAP. The concomitant drop in measured pressure with high and low flows could be attributed to increased resistance to spontaneous breathing or insufficient flow to meet inspiratory demand. Clinicians should be aware of the effect that the interface and flow have on CPAP delivery.

Assessment of adherence to guidelines for using progesterone to prevent recurrent preterm birth

Abstract Objective: To assess if women with recurrent preterm birth had been offered, received, and adhered to progesterone supplementation guidelines and to ascertain reasons for failure to follow guidelines. Methods: Charts of infants who were products of recurrent spontaneous preterm birth were reviewed at four neonatal intensive care units of Akron Children’s Hospital. Mothers of identified infants were interviewed and charts abstracted to determine: if progesterone was offered; acceptance of progesterone; compliance with progesterone; and reasons why progesterone was declined. Results: One hundred twenty-eight mothers with a recurrent spontaneous preterm birth were identified and 98 consented to participate. 62.2% (61/98) of the interviewed mothers reported that they were offered progesterone. Of the women offered progesterone, 82% (50/61) accepted treatment and 18.0% (11/61) declined. One woman who accepted progesterone did not receive it. Of the women who received progesterone, 18.4% (9/49) reported compliance failure. Of the women who did not receive progesterone, 75.5% (37/49) reported that they were not offered progesterone and 89.2% (33/37) of the women not offered progesterone reported that their care providers were aware of their prior preterm delivery. Conclusions: Only 50% (49/98) of women who were candidates for progesterone received treatment. The main reason for women not receiving treatment was not being offered progesterone by their caregiver.

Accuracy and Precision of an Optoacoustic Prototype in Determining Endotracheal Tube Position in Children

BACKGROUND: Confirmation of endotracheal tube (ETT) tip position and timely identification and correction of malposition is an essential component of care for endotracheally intubated and mechanically ventilated children. We evaluated the ability of a prototype optoacoustic medical device to determine ETT tip position. We hypothesized that the precision of optoacoustic assessment of ETT tip position would be comparable to chest radiography. METHODS: We recruited children aged newborn to 16 y who were admitted to the pediatric ICU requiring tracheal intubation and undergoing a chest radiograph for clinical purposes. After positioning each child on a chest radiograph plate, a sterile optical fiber, temporarily inserted through the ETT, emitted laser pulses perpendicular to the fiber and to the ETT, generating acoustic (ultrasound) waves in overlying tissue when the tip of the fiber passed beneath an acoustic sensor in the sternal notch. The distance from the ETT tip to the peak acoustic signal was used to calculate the distance from the ETT tip to the carina, which was compared with the same distance calculated by the radiologist reading the chest radiograph. Pearsons correlation coefficient, paired t tests, a Bland-Altman plot were used to compare the measures (P < .05 was considered statistically significant). RESULTS: Twenty-six subjects were enrolled: 15 (57.7%) were male, median (interquartile range) age, weight, and height were 9 months (4–24), 9.6 kg (5.7–13.0), and 75 cm (62–90), respectively. All ETTs were cuffed (internal diameter range 3.0–5.0 mm). The relationship between optoacoustic and chest radiograph measurements was strong (r = 0.91, P < .001). Bias was 0.1 cm with narrow limits of agreement between measures (0.58 cm and 0.76 cm). CONCLUSIONS: The optoacoustic prototype accurately determined ETT tip position and was comparable in precision to chest radiograph.

Adherence to Endotracheal Tube Depth Guidelines and Incidence of Malposition in Infants and Children

BACKGROUND: Adherence to guidelines for endotracheal tube (ETT) insertion depth may not be sufficient to prevent malposition or harm to the patient. To obtain an estimate of ETT malpositioning, we evaluated initial postintubation chest radiographs and hypothesized that many ETTs in multiple intubation settings would be malpositioned despite adherence to Pediatric Advanced Life Support and Neonatal Resuscitation Program guidelines. METHODS: In a random subset (randomization table) of 2,000 initial chest radiographs obtained from January 1, 2009, to May 5, 2012, we recorded height, weight, age, sex, ETT inner diameter, and cm marking at the lip from the electronic health record. Chest radiographs of poor quality and with spinal or skeletal deformities were excluded. We defined adherence to Pediatric Advanced Life Support or Neonatal Resuscitation Program guidelines as the difference between predicted and actual ETT markings at the lip as ± 0.25, ± 0.50, or ± 1.0 cm for ETTs of 2.5–4, 4.5–6.0, or >6.5 mm inner diameter, respectively. We defined the proper position as the ETT tip being below the thoracic inlet (superior border of the clavicular heads) and ≥1 cm above the carina. Descriptive statistics reported demographics, guideline adherence, and malposition incidence. The chi-square test was used to assess relationships among intubation setting, malposition, and depth guideline adherence (P < .05, significant). RESULTS: We reviewed 507 records, 477 of which met inclusion criteria and had sufficient data for analysis. Fifty-six percent of the subjects were male, with median (interquartile range) age 15.2 (3.4–59.4) months, and 330 ETTs (69%) were malpositioned: 39 above the thoracic inlet, and 291 < 1 cm above the carina. Of 79 ETTS (17%) that adhered to depth guidelines, 56 (74%) were malpositioned. Three-hundred seventy-three ETTs (83%) did not meet guidelines. Two-hundred sixty-four (68%) were malpositioned. The intubation setting did not influence malposition or guideline adherence (P = .54). CONCLUSIONS: In infants and children, a high proportion of ETTs were malpositioned on the first postintubation chest radiograph, with little influence of guideline adherence.

Perceptions of barriers and facilitators to early integration of pediatric palliative care: A national survey of pediatric oncology providers

The goal of this study was to assess pediatric oncology providers’ perceptions of palliative care in order to validate previously identified barriers and facilitators to early integration of a pediatric palliative care team (PCT) in the care of children with cancer.

Procedural outcomes of fluoroless catheter ablation outside the traditional catheterization lab

Aims Non-fluoroscopic catheter ablation is becoming routine. In experienced centres, fluoroscopy is rarely required. The use of a traditional catheterization lab (cath lab) may no longer be necessary. We began performing catheter ablations at a paediatric centre outside the traditional cardiac cath lab in 2013. The purpose of this study was to compare procedural features of paediatric catheter ablation performed outside the cath lab to those performed within a cath lab. Methods and results We prospectively looked at patients presenting to the paediatric centre with supraventricular tachycardia (SVT) undergoing catheter ablation outside the cath lab in a standard operating room (OR group). We compared retrospectively to a control group matched for age, type, and location of arrhythmia who had ablations in a traditional cath lab (CL group). Catheter visualization was exclusively by electro-anatomic mapping. Fifty-nine patients with SVT underwent catheter ablation in the OR from October 2013 to December 2015. Thirty-three patients had accessory pathways, 29 were manifest, and 13 of those were left sided. Twenty-six had atrioventricular nodal re-entrant tachycardia. Transseptal puncture with transoesophageal echocardiography guidance was used for 10 left-sided pathways, whereas the other 3 had patent foramen ovales. Procedure time did not differ significantly between groups (OR group mean 131 min, range 57-408; CL group mean 152 min, range 68-376; P = 0.12). Acute success was similar in both groups [OR group: 58/59 (98.3%) and CL group: 57/59 (96.6%)]. There were no major complications in either group. There was no fluoroscopy used in either group. Conclusion Although performing paediatric catheter ablations outside the traditional cath lab is early in our experience, we produced similar outcomes and results without encountering procedural difficulties of performing ablations in a non-conventional setting. Larger multi-centred trials will be essential to determine the feasibility of this practice.