Early Bubble CPAP Protocol Implementation and Rates of Death or Severe BPD.

BACKGROUND: A multidisciplinary comprehensive protocol to use bubble continuous positive airway pressure (bCPAP) as the primary respiratory support in the delivery room (DR) and the NICU was introduced. With this study, we aimed to assess the association of this change with respiratory outcomes over time. METHODS: Infants with gestational age <32 weeks and birth weight <1250 g admitted between January 2012 and June 2020 were included and categorized into 4 periods, including pre-implementation (P0: 2012-2014), and post-implementation (P1: 2014-2016, P2: 2016-2018, P3: 2018-2020). The primary outcome was the rates of death and severe bronchopulmonary dysplasia (BPD), and the secondary outcomes included the rates of DR and NICU intubation ≤7 days of age, need of surfactant, and pneumothorax. Multivariate logistic regression models accounting for relevant risk factors were used to calculate adjusted odds ratios (ORs). RESULTS: The study included 440 infants (P0 = 90, P1 = 91, P2 = 128, P3 = 131). Over time, more infants were free of BPD (P < .001), and the rates of death and severe BPD decreased significantly: P1 = OR 1.21 (95% confidence interval [CI] 0.56-2.67), P2 = OR 0.45 (95% CI 0.20-0.99), and P3 = OR 0.37 (95% CI 0.15-0.84). DR intubation decreased from 66% (P0) to 24% (P3) in the entire cohort (P < .001) and from 96% (P0) to 40% (P3) in infants <26 weeks of age (P < .001). The need for NICU intubation was similar (P = .98), with a decreased need for surfactant (P = .001) occurring at higher FiO2 (P0 = 0.35 vs P3 = 0.55, P < .001). Pneumothorax rates were unchanged. CONCLUSIONS: In very preterm infants, the implementation of a comprehensive bCPAP protocol led to a significant and consistent improvement in respiratory practices and the rates of death and severe BPD.

"Optimal surfactant delivery protocol using the bovine lipid extract surfactant: a quality improvement study".

IMPORTANCE: Episodes of severe airway obstruction (SAO) are reported during surfactant administration. OBJECTIVE: To evaluate adherence to and impact of a surfactant protocol on adverse events. METHODS: An evidence-based protocol for surfactant administration was developed (2011), implemented (2012) and re-implemented (2014), including three major steps: lung recruitment, manual bagging, and bolus instillation. Three epochs were evaluated: E0 (2010), E1 (2015) and E2 (2018). Adherence was defined as compliance with all steps. Adverse events such as hypoxia (<80%) and severe airway obstruction (SAO) were investigated. RESULTS: 197 infants (246 administrations) were included: E0 81 (110), E1 52 (63), and E2 64 (73). Adherence improved from 49% (E1) to 67% (E2). Full adherence to protocol significantly decreased SAO from 26% to 1.25% (E2; p < 0.005) and hypoxia/bradycardia events (5 to 0% E2; p < 0.005), without any side effects. CONCLUSIONS: Adherence to a surfactant administration protocol improved over time and significantly decreased important adverse events.

Surfactant administration in neonates: A review of delivery methods.

Surfactant has revolutionized the treatment of respiratory distress syndrome and some other respiratory conditions that affect the fragile neonatal lung. Despite its widespread use, the optimal method of surfactant administration in preterm infants has yet to be clearly determined. The present article reviews several aspects of administration techniques that can influence surfactant delivery into the pulmonary airways: the bolus volume, injection rate, gravity and orientation, ventilation strategies, alveolar recruitment, and viscosity and surface tension of the fluid instilled. Based on the present review, knowledge gaps regarding the best way to administer surfactant to neonates remain. From the available evidence, however, the most effective way to optimize surfactant delivery and obtain a more homogeneous distribution of the drug is by using rapid bolus instillation in combination with appropriate alveolar recruitment techniques.

Le surfactant a révolutionné le traitement du syndrome de détresse respiratoire et d'autres troubles respiratoires qui endommagent le fragile poumon néonatal. Malgré l'utilisation généralisée du surfactant son mode optimal d'administration n'est pas clairement établi chez les nourrissons prématurés. Le présent article traite de divers aspects des techniques d'administration, qui peuvent influer sur la libération du surfactant dans les voies respiratoires : le volume du bolus, le rythme d'injection, la gravité et l'orientation, les stratégies de ventilation, le recrutement alvéolaire, ainsi que la viscosité et la tension de surface du liquide instillé. D'après la présente revue, il reste des lacunes quant au meilleur moyen d'administrer le surfactant aux nouveau-nés. Cependant, selon les données probantes, pour en optimiser l'administration et obtenir une distribution plus homogène, il est préférable de procéder à un bolus rapide, combiné à des techniques pertinentes de recrutement alvéolaire.

Home noninvasive ventilation: what does the anesthesiologist need to know?

Treatment of chronic respiratory failure with noninvasive ventilation (NIV) is standard pediatric practice, and NIV systems are commonly used in the home setting. Although practice guidelines on the perioperative management of children supported with home NIV systems have yet to be published, increasingly these patients are referred for consultation regarding perioperative management. Just as knowledge of pharmacology underlies the safe prescription of medication, so too knowledge of biomedical design is necessary for the safe prescription of NIV therapy. The medical device design requirements developed by the Organization for International Standardization provide a framework to rationalize the safe prescription of NIV for hospitalized patients supported at home with NIV systems. This review article provides an overview of the indications for home NIV therapy, an overview of the medical devices currently available to deliver it, and a specific discussion of the management conundrums confronting anesthesiologists.