January 2009

Section Congratulates 2008 Specialty Practitioner of the Year
The Neonatal-Pediatrics Section was proud to bestow its 2008 Specialty Practitioner of the Year award on Dave Crotwell, RRT-NPS. Look for an article on Dave and his accomplishments in the Winter issue of the Bulletin, which will be published next month.

Evidence Lacking on Weaning, Extubation in Kids
Minimizing time on the ventilator is considered paramount to improving patient outcomes, but when it comes to children, the medical literature is lacking on when to wean or how to assess readiness for extubation. Researchers from several major U.S facilities reached that conclusion after reviewing studies conducted between 1972 and 2008. While little evidence was found to guide clinicians on weaning and extubation in the pediatric population, results did show a significant proportion of patients being evaluated for weaning were actually ready for extubation, leading the researchers to conclude weaning is not being considered early enough in the course of ventilation. At the same time, indications for extubation have yet to be clearly defined, though the review did suggest the value of a spontaneous breathing trial. The authors note several indices to predict weaning and extubation success have been developed, but results show they offer little advantage over clinical judgment alone. Extubation failure rates in the review ranged from 2-20% and bore little relationship to time on the ventilator. The most common cause of extubation failure was upper airway obstruction. The investigators published their findings in the December 2 Epub edition of Pediatric Critical Care Medicine. READ ABSTRACT

Quality Improvement Effort Leads to Reduction in Chronic Lung Disease
A new study out of the Greater Baltimore Medical Center finds a quality improvement process aimed at avoiding intubation, adoption of new pulse oximeter limits, and early use of nasal continuous positive airway pressure therapy can significantly reduce the incidence of chronic lung disease in infants with birth weights between 501-1500 grams. The researchers compared outcomes for infants born in their facility in 2002, before the changes were implemented, with those born in 2005, after the changes were put into place. Results showed:

• The incidence of chronic lung disease fell from 46.5% to 20.5%.
• The number of infants discharged from the hospital with oxygen therapy decreased from 16.4% to 4.1%.
• The overall relative risk reduction for chronic lung disease in 2005, compared with 2002, was 55.8%.

The study appears in this month’s Pediatrics. READ ABSTRACT

Instrumental Dead Space in Volume-targeted Ventilation of the ELBW Infant
Noting a lack of normative data for appropriate tidal volume settings in extremely low birth weight (ELBW) infants receiving volume-targeted ventilation, researchers from Georgetown University conducted a chart review among infants born at their facility between 2003 and 2005 with a birth weight of less than 800 g. The investigators were most interested in assessing the role played by the added dead space of the flow sensor in these patients. Their results suggest effective alveolar ventilation occurs with tidal volumes at or below the calculated dead space. “This can be explained by the fact that at the high flow rates seen in these tiny infants who have extremely short inspiratory times, fresh gas penetrates through the dead space gas, rather than pushing it ahead,” they write. “Therefore there is no need to forego synchronized and volume targeted ventilation because of dead space concerns.” The report appeared in the December 5 Epub edition of Pediatric Pulmonology. READ ABSTRACT

HFV Weaning and Extubation in Preterm Infants
Dutch investigators who set out to determine the feasibility of weaning the continuous distending pressure (CDP) below 8 cm H2O and the Fio2 below 0.30 in preterm infants on open lung high-frequency ventilation (HFV)—and whether these settings would result in successful extubation—found positive results on both accounts. In a study conducted among 215 infants, they noted a significant decrease in the CDP, but not the Fio2, in the 24 hours before extubation, resulting in a mean CDP of 6.8 +/- 1.6 cm H2O and a mean Fio2 of 0.25 at the time of extubation. Successful extubation occurred in 193 of the infants, or 90%, at these settings. They conclude, “The value of this approach should be prospectively compared with conventional weaning and extubation strategies”. The study was published in the December 2 Epub edition of Pediatric Critical Care Medicine. READ ABSTRACT