Adjusting ventilator settings to avoid air trapping in extremely premature infants reduces the need for tracheostomy and length of stay.

Despite the improving understanding of how lung mechanics and tidal volume requirements evolve during the evolution of bronchopulmonary dysplasia (BPD), clinical management continues to be heterogeneous and inconsistent at many institutions. Recent reports have examined the use of high tidal-volume low respiratory rate strategies in these patients once disease has been well established to help facilitate their eventual extubation and improve their long-term neurodevelopmental outcomes. In this retrospective observational research study, we describe how intentional adjustment of ventilator settings based on patient lung mechanics by an interdisciplinary BPD team improved the care of the at-risk population of infants, reduced the need for tracheostomies, as well as length of stay over a period of over 3 years. The team aimed to establish consistency in the management of these children using a high tidal volume, low-rate approach, and titrating PEEP to address the autoPEEP and bronchomalacia that is frequently observed in this patient population.

Introducing Less-Invasive Surfactant Administration into a Level IV NICU: A Quality Improvement Initiative.

Less-invasive surfactant administration (LISA), a newer technique of delivering surfactant via a thin catheter, avoids mechanical ventilation. LISA has been widely adopted in Europe but less so in the US. Our goal was to increase the percentage of surfactant delivered via LISA from 0% to 51% by 12/2020. Project planning and literature review started 12/2019, and included a standardized equipment kit and simulation training sessions. We began Plan-Do-Study-Act (PDSA) cycles in 6/2020. Initial exclusions for LISA were gestational age (GA) <28 weeks (w) or ≥36 w, intubation in the delivery room, or PCO2 >70 if known; GA exclusion is now <25 w. From 6 to 12/2020, 97 patients received surfactant, 35 (36%) via LISA. When non-LISA-eligible patients were excluded, 35/42 (83%) received LISA successfully. There were only 2/37 patients for whom LISA was not able to be performed. Three LISA infants required mechanical ventilation in the first week of life. Sedation remained an initial challenge but improved when sucrose was used routinely. LISA was safely and successfully introduced in our NICU.

Are we over-treating hypoxic spells in preterm infants?

A frequent challenge in Neonatology is the high frequency of spontaneously occurring hypoxemic events, a majority of which are associated with apnea or hypoventilation. These episodes present a challenge for caregivers and families as they frequently delay discharge of preterm infants. Supplemental oxygen, respiratory support, and caffeine therapy are widely used as therapeutic approaches, but challenges remain regarding their precise indications. Future clinical practice should be directed by an evidence-based approach including automated supplemental oxygen, minimizing the use of medications for gastroesophageal reflux, optimal timing and dosage of caffeine therapy, and standardization of alarm limits and discharge monitoring protocols.

Usefulness of Echocardiography in Children with New-Onset Supraventricular Tachycardia.

BACKGROUND: Supraventricular tachycardia (SVT) is the most common sustained arrhythmia in children. Infants with SVT and ventricular preexcitation (Wolff-Parkinson-White syndrome) are known to have up to 30% prevalence of congenital heart disease (CHD). Infants without ventricular preexcitation who present with SVT at <1 year of age have a similar prevalence of CHD. However, for children without ventricular preexcitation who present with SVT at older ages, the prevalence of CHD is not known. The aim of this study was to determine the prevalence of CHD in older children and adolescents presenting with SVT without ventricular preexcitation, with the goal of providing guidance regarding the usefulness of echocardiography in this patient population. METHODS: Children aged 2 to 18 years presenting with confirmed SVT between January 2011 and December 2015 were included in this retrospective review. Patients with any history of ventricular preexcitation or preexisting heart disease were excluded. Medical records were reviewed, and electrocardiographic and echocardiographic findings were classified as normal, incidental, or abnormal. RESULTS: Two hundred ninety patients met the inclusion criteria. Echocardiographic examinations were completed on 224 patients. Only one patient was found to have CHD, a moderate primum atrial septal defect. This patient was noted to have electrocardiographic abnormalities consistent with primum atrial septal defect. CONCLUSIONS: For older children and adolescents with no known heart disease presenting with SVT without ventricular preexcitation, echocardiography may not be a necessary part of initial evaluation when the results of physical examination and electrocardiography are normal.