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Chronic Lung DiseaseInterventions

N. SinghalUniversity of Calgary

November 2006

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Outline

• Process

• Interventions proposed– Infection – K. Aziz– CLD – N. Singhal

• Interventions implemented– Infection – K. Aziz– CLD – N. Singhal

• Future directions – K. Aziz

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Review Process

• Cochrane reviews

• Systematic reviews

• Informal reviews

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CLD Group Interventions

• Process– Experts selected topics

– Training provided for literature review

– Each centre given ONE topic to review

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Review Process

• Cochrane reviews

• Systematic reviews

• Informal reviews

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• Meeting of all centre/experts to discuss areas for improvement

• Generated list of interventions

Process cont’d

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Interventions Proposed

• Antenatal

– Treat urea plasma with erythromycin

– Antenatal steroids

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Interventions Proposed

• Resuscitation

– Early within one hour prophylactic surfactant <28 weeks or <1250 g.

– Diminish hand ventilation

– Decrease 100% oxygen exposure

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Interventions Proposed

• CPAP

– Early CPAP for babies in supplemental oxygen

– Long term CPAP

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Interventions Proposed

• Ventilation–Early use of

HFV

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Interventions Proposed

• Normocarbia

• Avoid hypocarbia

• PaC02 40-55 mm of Hg

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Interventions Proposed

• Saturation targets

• Saturation targets

• > 88 to < 94 ? 93

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Interventions Proposed

• Nutrition/Fluids– Calories– Decrease fluid use– High dose Vitamin A

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Interventions Proposed

• Environment– Pain– Massage– Noise– NIDCAP

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CLD Interventions Implemented

• Antenatal:-Antibiotics

-Expectant arrangement of PROM

-Antenatal steroids

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CLD Interventions Implemented

• Resuscitation– Surfactant within 30 minutes– Avoid hand ventilation– Ventilation delivery room– Only Laerdel bags with PEEP– Blended gases

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CLD Interventions Implemented

• Ventilation– Early HVF – not done– Assist control and volume guarantee

–Not done specifically

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CLD Interventions Implemented

• Normocarbia– PaC02 – 45-55 mm of Hg

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CLD Interventions Implemented

• Saturation targets– Sat alarm limits 85-95%– Goal 88-92%

• Physician orders oxygen as drug

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CLD Interventions Implemented

• Nutrition/Fluids– ↓ TFI < 32 weeks first few days– TPN within 24 hours– TPN within 4 hours

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CLD Interventions Implemented

• Environment – Renovations to unit– ↓ sound levels

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CLD Interventions Implemented

• Others:– Comment card for parents– Avoid re-intubation with CPAP– Perinatal referral policies

Early CPAP – EPIC PDSA Cycle # 4

> 27 weeks and < 34 weeks

Respiratory Distress? (based on clinical

judgment)

Intubate, BLES transfer to NICU (*may be given in NICU after

transfer)

Stabilize then transfer to NICU

Extubate to CPAP if FiO2 <.4 at 2 to 4 hours of age and if

clinically stable

Develops respiratory distress?

Intubate, BLES

Extubate to CPAP if FiO2 <.4 (no time frame)

Routine management***

Routine management***

Routine management***

If > 27 weeks, had HMD and on supplemental FiO2 in first 24 hours of life should be on CPAP

*** wean from CPAP as per clinical indications

No

Yes

Yes No

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Thank you