Death or Neurodevelopmental Impairment at 18 to 22 Months Corrected Age in a Randomized Trial of Early Dexamethasone to Prevent Death or Chronic Lung Disease in Extremely Low Birth Weight Infants

The improvement in survival in premature infants associated with the evolution of mechanical ventilation has been accompanied by an increase in ventilator induced lung injury. High frequency ventilation has been shown to reduce the incidence of ventilator induced lung injury and hence chronic lung disease in the very low birth weight infant. The evolution in understanding how to best use high frequency ventilation in this population has prompted us to ask whether similar strategies to optimize lung volumes on conventional mechanical ventilation can minimize chronic lung disease in the neonate. We retrospectively reviewed the medical charts of 51 extremely low birth weight infants born in Kingston, Ontario in two epochs, 1990 to 1991 and 1999 to 2000, for ventilatory strategy and outcome. From our review, it is clear that surfactant therapy rapidly changes lung mechanics by improving pulmonary compliance and that lung damage may result if there are not changes in the ventilatory management to reflect the altered compliance. Early ventilation strategies during the apparently stable "honeymoon period" in a patient with respiratory distress syndrome (RDS) has significant implications on long term morbidity. In the era prior to the use of surfactant, 30% of infants died and 40% developed chronic lung disease (CLD). Immediately following the use of surfactant, mortality was reduced to 18%, however, the incidence of CLD increased to 78%. In the most recent era, following 10 years of experience with surfactant and mechanical ventilation, morbidity was 17% and CLD 21%. This study demonstrates that a particularly crucial time is in the immediate period following surfactant administration. The use of lower peak inspiratory pressure (PIP) and mean airway pressure (MAP) over the first 24 hours and an increase in the use of synchronous intermittent mandatory ventilation (SIMV) was associated with an improved outcome. The challenge remaining is to determine how to best utilize a conventional mode of ventilation to best optimize lung volume and protect the immature lung.

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Replacement doses of hydrocortisone may prevent progressive chronic lung disease in extremely low birth weight infants. 1528

Pediatric Research ◽

10.1203/00006450-199704001-01547 ◽

1997 ◽

Vol 41 ◽

pp. 257-257

Author(s):

Robert E. Kimura ◽

Amy Hennessy

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Lung Disease ◽

Chronic Lung Disease ◽

Extremely Low Birth Weight ◽

Low Birth Weight Infants

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Evaluation and Development of Potentially Better Practices to Prevent Chronic Lung Disease and Reduce Lung Injury in Neonates

PEDIATRICS ◽

10.1542/peds.111.se1.e426 ◽

2003 ◽

Vol 111 (Supplement_E1) ◽

pp. e426-e431

Author(s):

Paul J. Sharek ◽

Robin Baker ◽

Fern Litman ◽

Joseph Kaempf ◽

Kelly Burch ◽

...

Keyword(s):

Quality Improvement ◽

Birth Weight ◽

Focus Group ◽

Low Birth Weight ◽

Lung Disease ◽

Chronic Lung Disease ◽

Extremely Low Birth Weight ◽

Low Birth Weight Infants ◽

Effect Change ◽

Individual Site

Objective. Despite increased knowledge and improving technology, chronic lung disease (CLD) rates in extremely low birth weight infants have remained constant for 20 years. One reason for this is an ineffective translation of research-proven improvements into practice. The Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was created to provide participating nurseries the tools necessary to effect change. The objective of this study was to develop and implement a process that uses quality improvement techniques to collaboratively improve CLD rates. Methods. Nine member hospitals of the NIC/Q 2000 collaborative formed a focus group aiming to decrease CLD rates. The focus group established goals and outcome measures, created a list of potentially better practices (PBPs) based on available literature, benchmarked and performed site visits, encouraged individual site implementation of PBPs, developed a database, and measured outcomes. Results. The goal “decrease CLD rates in extremely low birth weight infants” was established. Nine PBPs were identified, and 57 PBPs were implemented by the 9 participating sites. Twelve site visits were conducted, and a 435-patient database of infants with a mean birth weight of 789 g was established. Conclusions. Collaborative use of quality improvement techniques resulted in creation of a logical, efficient, and effective process to improve CLD rates. Group creation of PBPs, based on literature review and reinforced with site visits, internal data analysis, and improved individual site outcomes, resulted in accelerated and effective change, unlikely to occur if attempted outside of the collaborative.

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