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Chronic Lung Disease Interventions N. Singhal University of Calgary November 2006 1 Outline • Process • Interventions proposed – Infection – K. Aziz – CLD – N. Singhal • Interventions implemented – Infection – K. Aziz – CLD – N. Singhal • Future directions – K. Aziz 2 Review Process • Cochrane reviews • Systematic reviews • Informal reviews 3 CLD Group Interventions • Process – Experts selected topics – Training provided for literature review – Each centre given ONE topic to review 4 Review Process • Cochrane reviews • Systematic reviews • Informal reviews 5 Process cont’d • Meeting of all centre/experts to discuss areas for improvement • Generated list of interventions 6 Interventions Proposed • Antenatal – Treat urea plasma with erythromycin – Antenatal steroids 7 Interventions Proposed • Resuscitation – Early within one hour prophylactic surfactant <28 weeks or <1250 g. – Diminish hand ventilation – Decrease 100% oxygen exposure 8 Interventions Proposed • CPAP – Early CPAP for babies in supplemental oxygen – Long term CPAP 9 Interventions Proposed • Ventilation –Early use of HFV 10 Interventions Proposed • Normocarbia • Avoid hypocarbia • PaC02 40-55 mm of Hg 11 Interventions Proposed • Saturation targets • Saturation targets • > 88 to < 94 ? 93 12 Interventions Proposed • Nutrition/Fluids – Calories – Decrease fluid use – High dose Vitamin A 13 Interventions Proposed • Environment – Pain – Massage – Noise – NIDCAP 14 CLD Interventions Implemented • Antenatal: -Antibiotics -Expectant arrangement of PROM -Antenatal steroids 16 CLD Interventions Implemented • Resuscitation – Surfactant within 30 minutes – Avoid hand ventilation – Ventilation delivery room – Only Laerdel bags with PEEP – Blended gases 17 CLD Interventions Implemented • Ventilation – Early HVF – not done – Assist control and volume guarantee –Not done specifically 18 CLD Interventions Implemented • Normocarbia – PaC02 – 45-55 mm of Hg 19 CLD Interventions Implemented • Saturation targets – Sat alarm limits 85-95% – Goal 88-92% • Physician orders oxygen as drug 20 CLD Interventions Implemented • Nutrition/Fluids – ↓ TFI < 32 weeks first few days – TPN within 24 hours – TPN within 4 hours 21 CLD Interventions Implemented • Environment – Renovations to unit – ↓ sound levels 22 CLD Interventions Implemented • Others: – Comment card for parents – Avoid re-intubation with CPAP – Perinatal referral policies 23 Early CPAP – EPIC PDSA Cycle # 4 > 27 weeks and < 34 weeks Respiratory Distress? (based on clinical judgment) Yes Intubate, BLES transfer to NICU (*may be given in NICU after transfer) Extubate to CPAP if FiO2 <.4 at 2 to 4 hours of age and if clinically stable No Stabilize then transfer to NICU Develops respiratory distress? No Routine management*** Yes Intubate, BLES 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 Extubate to CPAP if FiO2 <.4 (no time frame) Routine management*** Thank you 28