The single most important cause of mortality and morbidity in preterm infants Bianca Marie Moses

…a premature baby’s alveolus

O2 X Not getting much if any O 2 in …a premature baby’s alveolus

CO2 X …or CO 2 out …a premature baby’s alveolus

CO2 X  ↓ Gas exchange …a premature baby’s alveolus

CO2 X  ↓ Gas exchange …a premature baby’s alveolus X

 ↓ Gas exchange  ↓ Alveolar expansion …a premature baby’s alveolus CO2 XX

 ↓ Gas exchange  ↓ Alveolar expansion  Alveolar collapse …a premature baby’s alveolus CO2

 ↓ Gas exchange  ↓ Alveolar expansion  Alveolar collapse …a premature baby’s alveolus CO2 XX X

 ↓ Gas exchange  ↓ Alveolar expansion  Alveolar collapse ↓ ↓ ↓ Lung Compliance! …a premature baby’s alveolus CO2 XX X

 ↓ Gas exchange  ↓ Alveolar expansion  Alveolar collapse Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema  Alveolar, endothelial and epithelial damage Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema  Alveolar, endothelial and epithelial damage  Pulmonary vasoconstriction Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema  Alveolar, endothelial and epithelial damage  Pulmonary vasoconstriction  Atelectasis Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema  Alveolar, endothelial and epithelial damage  Pulmonary vasoconstriction  Atelectasis  Respiratory Acidosis Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema  Alveolar, endothelial and epithelial damage  Pulmonary vasoconstriction  Atelectasis  Respiratory Acidosis  Metabolic Acidosis Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema  Alveolar, endothelial and epithelial damage  Pulmonary vasoconstriction  Atelectasis  Respiratory Acidosis  Metabolic Acidosis  Hypoxia Respiratory Distress Syndrome: RDS …a premature baby’s alveolus CO2 XX X

 Respiratory failure  Edema  Alveolar, endothelial and epithelial damage  Pulmonary vasoconstriction  Atelectasis  Respiratory Acidosis  Metabolic Acidosis  Hypoxia Respiratory Distress Syndrome: RDS What a nurse looks for…

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Grunting respirations

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Grunting respirations  Nasal flaring

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Grunting respirations  Nasal flaring  Apnea

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Grunting respirations  Nasal flaring  Apnea  “Ground Glass” pattern on x-ray Reticulogranular Pattern

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Grunting respirations  Nasal flaring  Apnea  Significant retractions

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Grunting respirations  Nasal flaring  Bradycardia  Significant retractions

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Grunting respirations  Lethargy  Bradycardia  Significant retractions

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Tachypnea >60b/min  Weak cry  Lethargy  Bradycardia  Significant retractions

Respiratory Distress Syndrome: RDS What a nurse looks for…  Increasing cyanosis or acrocyanosis  Hypotonia  Weak cry  Lethargy  Bradycardia  Significant retractions

Respiratory Distress Syndrome: RDS What a nurse looks for…  Pulse Ox 88%-93%  Hypotonia  Weak cry  Lethargy  Bradycardia  Significant retractions

Increased Urination What a nurse looks for…  Pulse Ox 88%-93%  Hypotonia  Weak cry  Lethargy  Bradycardia  Significant retractions

Increased Urination = ↑ respiratory status What a nurse looks for…  Pulse Ox 88%-93%  Hypotonia  Weak cry  Lethargy  Bradycardia  Significant retractions

Respiratory Distress Syndrome (RDS) Caucausian

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often than females

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often than females Risk Factors include:

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often than females Risk Factors include:  Prematurity

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often than females Risk Factors include:  Prematurity AGA, SGA, LGA

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often than females Risk Factors include:  Prematurity AGA, SGA, LGA  Born to diabetic mom

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often than females Risk Factors include:  Prematurity AGA, SGA, LGA  Born to diabetic mom  Surfactant deficiency disease

Respiratory Distress Syndrome (RDS) Caucausian > Hispanic or African American babies Affects males 2x more often than females Risk Factors include:  Prematurity AGA, SGA, LGA  Born to diabetic mom  Surfactant deficiency disease  Genetics

A little background first

Foggy Bathroom Mirror

Water sticks to the glass surface

Foggy Bathroom Mirror Adhesive property of water Water sticks to the glass surface

Foggy Bathroom Mirror Adhesive property of water Water sticks to the glass surface

Rain Drops

Water drops bead up

Rain Drops Water drops bead up Cohesive property of water

Rain Drops Water drops bead up Cohesive property of water

Rain Drops Water drops bead up Cohesive property of water

Rain Drops Water drops bead up Cohesive property of water

Caught in the rain…

Skin Shirt

Caught in the rain… Skin Shirt

Caught in the rain… Adhesion Skin Shirt

Caught in the rain… Skin Shirt Water

Caught in the rain… Skin Shirt Water

Caught in the rain… Skin Shirt Water

Caught in the rain… Skin Shirt Cohesion Water

+ AdhesionCohesion

Surface Tension… + AdhesionCohesion

Surface Tension… …the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken

Surface Tension… …the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken

Skin Shirt Water Surface Tension… …the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken

Skin Shirt Surface Tension… …the tendency of molecules in a fluid to be pulled toward the center of the fluid, and reduce being stretched or broken Shirt is stuck to his skin

Surface Tension…

Amniotic fluid

Birth canal squeezes amniotic fluid out of alveoli

Amniotic fluid Birth canal squeezes amniotic fluid out of alveoli

Amniotic fluid Birth canal squeezes amniotic fluid out of alveoli

Air Ideally

Air Ideally

We’ll realign the alveolus for better visualization Air Ideally

Alveolar Wall

Pull In Alveolar Wall

Collapse

Surfactant

Open

O2 Open

O2 Open

O2 Open

O2 Open

O2 Open

CO2 Open

CO2 Open

CO2 Open

CO2 Open

CO2 Open

A closer look at surfactant

Surfactant

Two components in human surfactant

Surfactant Lecithin/Sphingomyelin (L/S) ratio Two components in human surfactant

Surfactant Lecithin:Sphingomyelin (L/S) ratio Two components in human surfactant

Surfactant Lecithin:Sphingomyelin (L:S) ratio Two components in human surfactant

Surfactant Lecithin:Sphingomyelin (L:S) ratio Produced by baby Two components in human surfactant

Surfactant Lecithin:Sphingomyelin (L:S) ratio Produced by baby

Surfactant 20 Lecithin:Sphingomyelin (L:S) ratio

Surfactant 20 Lecithin:Sphingomyelin (L:S) ratio 0.5:1

Surfactant 30 Lecithin:Sphingomyelin (L:S) ratio 32

Surfactant 30 Lecithin:Sphingomyelin (L:S) ratio 1:1 32

Surfactant 35 Lecithin:Sphingomyelin (L:S) ratio

Surfactant 35 Lecithin:Sphingomyelin (L:S) ratio 2:1

35 Lecithin:Sphingomyelin (L:S) ratio 2:1

35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35

Lecithin:Sphingomyelin (L:S) ratio 2:1 RDS is unlikely 35

Lecithin:Sphingomyelin (L:S) ratio 2:1 RDS is unlikely 35

Lecithin:Sphingomyelin (L:S) ratio 2:1 35

Lecithin:Sphingomyelin (L:S) ratio 2:1 35 X X X X X

Lecithin:Sphingomyelin (L:S) ratio 2:1 35 X X X X X L:S ratio is < 2:1

35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35 X X X X X L:S ratio is < 2:1

35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35 L:S ratio is < 2:1 X X X X X 50% chance of RDS if < 30 weeks

35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35 L:S ratio is < 2:1 X X X X X Limit of Viability 50% chance of RDS if < 30 weeks

35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35 L:S ratio is < 2:1 X X X X X Limit of Viability ~23-24w 50% chance of RDS if < 30 weeks

35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35 L:S ratio is < 2:1 X X X X X XX X X X X X 50% chance of RDS if < 30 weeks Limit of Viability ~23-24w

Are baby’s lungs ready?

 L:S Ratio Are baby’s lungs ready?

 L:S Ratio Ratio closer to 2 is better Are baby’s lungs ready?

 L:S Ratio Ratio closer to 2 is better May require ratio of 3:1 or 3.5:1 Are baby’s lungs ready?

 L:S Ratio Ratio closer to 2 is better May require ratio of 3:1 or 3.5:1 Are baby’s lungs ready? Insulin antagonizes the cortisol induced stimulation of lecithin in babies of DIABETIC MOMS

 L:S Ratio Ratio closer to 2 is better May require ratio of 3:1 or 3.5:1 Meconium and blood invalidate results Are baby’s lungs ready? Insulin antagonizes the cortisol induced stimulation of lecithin in babies of DIABETIC MOMS

 L:S Ratio Ratio closer to 2 is better May require ratio of 3:1 or 3.5:1 Meconium and blood invalidate results Some conditions accelerate lung maturity Are baby’s lungs ready? Insulin antagonizes the cortisol induced stimulation of lecithin in babies of DIABETIC MOMS

 L:S Ratio  PG (phosphatidylglycerol) Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol) Appears at 36 weeks or sooner if distressed Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol) Appears at 36 weeks or sooner if distressed Present or Absent Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol) Appears at 36 weeks or sooner if distressed Present or Absent Results are not invalid if contaminated by blood Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol) Appears at 36 weeks or sooner if distressed Present or Absent Results are not invalid if contaminated by blood PG + L:S >2 is good Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol)  Flourescence Polarization Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol)  Flourescence Polarization Uncentrifuged AF Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol)  Flourescence Polarization Uncentrifuged AF Measures ratio of Surfactant:Albumin Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol)  Flourescence Polarization Uncentrifuged AF Measures ratio of Surfactant:Albumin ○ Non diabetic >50mg/g ○ Diabetic >70mg/g Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol)  Flourescence Polarization Uncentrifuged AF Measures ratio of Surfactant:Albumin ○ Non diabetic >50mg/g ○ Diabetic >70mg/g Blood and meconium will not yield a false positive Are baby’s lungs ready?

 L:S Ratio  PG (phosphatidylglycerol)  Flourescence Polarization Uncentrifuged AF Measures ratio of Surfactant:Albumin ○ Non diabetic >50mg/g ○ Diabetic >70mg/g Blood and meconium will not yield a false positive Vaginally collected AF is ok Are baby’s lungs ready?

Medications to “make” lungs ready

 Surfactants

Medications to “make” lungs ready  Surfactants  Steroids

Surfactant

Within 2 hrs after birth

Surfactant Administer Intratracheally Within 2 hrs after birth

Surfactant Administer Intratracheally Within 2 hrs after birth

Surfactant Administer Intratracheally Within 2 hrs after birth  Survanta (bovine)  Infasurf (bovine)  Beractant (bovine)  Calfactant (bovine)  Poractant (porcine)  Curosurf (porcine)

Surfactant Administer Intratracheally Within 2 hrs after birth  Survanta (bovine)  Infasurf (bovine)  Beractant (bovine)  Calfactant (bovine)  Poractant (porcine)  Curosurf (porcine)  Exosurf  Surfaxin  Colfosceril  Lucinactant  Pumactant

Steroids

 Given antenatally X X X X X

Steroids  Given antenatally L:S ratio is < 2:1 X X X X X Improve survivability of the week gestation and babies <1250g

Steroids  Given antenatally Speed up lung development L:S ratio is < 2:1 X X X X X Improve survivability of the week gestation and babies <1250g

L:S ratio is < 2:1 X X X X X Steroids  Given antenatally Speed up lung development Initiate surfactant production Improve survivability of the week gestation and babies <1250g

L:S ratio is < 2:1 X X X X X Steroids  Given antenatally Speed up lung development Initiate surfactant production

Improve survivability of the week gestation and babies <1250g L:S ratio is < 2:1 X X X X X Steroids  Given antenatally Speed up lung development Initiate surfactant production 2 doses

Steroids  Given antenatally Speed up lung development Initiate surfactant production L:S ratio is < 2:1 X X X X X  Bethamethasone (IM) 2 doses

Steroids  Given antenatally Speed up lung development Initiate surfactant production L:S ratio is < 2:1 X X X X X  Bethamethasone (IM) 12mg q24 hrs 2-3 days before delivery 2 doses

Steroids  Given antenatally Speed up lung development Initiate surfactant production L:S ratio is < 2:1 X X X X X  Bethamethasone (IM) 12mg q24 hrs 2-3 days before delivery  Dexamethasone (IM) 2 doses

Steroids  Given antenatally Speed up lung development Initiate surfactant production L:S ratio is < 2:1 X X X X X  Bethamethasone (IM) 12mg q24 hrs 2-3 days before delivery  Dexamethasone (IM) 6mg q12 hrs 2 days before delivery 2 doses

Nursing Diagnoses for RDS

ND#1 Risk for ineffective breathing pattern r/t immature lung development  Review records  Initiate cardiac and respiratory monitoring and calibrate q8 hrs  Monitor infants Respiratory rate and rhythm Pulse Blood pressure Activity

ND#1 Risk for ineffective breathing pattern r/t immature lung development  Assess skin color Cyanosis, duskiness and/or pallor  Administer warmed humidified O2 by oxygen hood Monitor O2 concentration q30 minutes Maintain stable O2 by ↑ or ↓ 5%-10% increments

ND#2 Ineffective thermoregulation r/t increased respiratory effort  Review Records  Assess temperature frequently Place servo probe on skin or over organ  Observe for signs of ↑ O2 consumption and metabolic acidosis  Warm and humidify all inspired gases Record temps for all administered gases

ND#2 Ineffective thermoregulation r/t increased respiratory effort  Use radiant warmers or incubators with servo controls and open cribs with appropriate clothing  Note s/sx of respiratory distress Tachypnea Apnea Cyanosis Acrocyanosis Bradycardia Lethargy Weak cry Hypotonia

ND#3 Imbalanced Nutrition: Less than body requirements r/t increased metabolic needs of infant  Assess suck, swallow, gag and cough reflexes  Assess respiratory status of infant  Monitor IV rates per infusion pump Start at 80 mL/kg/day  Record hourly I/O and daily weights  Provide TPN when indicated

ND#3 Imbalanced Nutrition: Less than body requirements r/t increased metabolic needs of infant  Advance from IV to GI tube feedings Based on tolerance Gavage or nipple feedings are used IV is used as supplement ○ Discontinue when oral intake is sufficient  Provide adequate caloric intake  Assesss infusion site for s/sx of infection Erythema, edema, drainage w/ foul odor

ND#4 Risk for deficient fluid volume r/t increased insensible water loss  Observe for weight fluctuations  Document cumulative I/O  Obtain urinalysis Closely monitor nitrates and specific gravity  Monitors vitals BP, pulse, temp, MAP  Assess for s/sx dehydration Poor skin turgor, pale mucous membranes, sunken fontanels  Assess IV site for s/sx of infection

Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Study to: Standardize practices for RDS intervention

Study by Howell, Holzman, Kleinman, Wang and Chassin in 2010… Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” “We found significant discordance from those recommendations: substantial delays in surfactant use for a majority of infants and racial disparities regarding who receives surfactant at all” ”More than a decade ago, as surfactant therapy was still diffusing into practice, such disparities were not found” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “Our findings of racial/ethnic disparities in this potentially life-saving treatment highlight the critical need to understand, improve, and deliver high-quality care to all. The inadequate delivery of surfactant to 63% of infants within 2h of delivery and the failure to deliver surfactant at all to infants within 4h emphasizes why we need to re-design health care such that delivery of treatment, such as surfactant, is a function of clinical characteristics and of the health care delivery system and less dependent on the individuals who are functioning within it.” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “Our findings of racial/ethnic disparities in this potentially life-saving treatment highlight the critical need to understand, improve, and deliver high-quality care to all. The inadequate delivery of surfactant to 63% of infants within 2h of delivery and the failure to deliver surfactant at all to infants within 4h emphasizes why we need to re-design health care such that delivery of treatment, such as surfactant, is a function of clinical characteristics and of the health care delivery system and less dependent on the individuals who are functioning within it.” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “Our findings of racial/ethnic disparities in this potentially life-saving treatment highlight the critical need to understand, improve, and deliver high-quality care to all. The inadequate delivery of surfactant to 63% of infants within 2h of delivery and the failure to deliver surfactant at all to infants within 4h emphasizes why we need to re-design health care such that delivery of treatment, such as surfactant, is a function of clinical characteristics and of the health care delivery system and less dependent on the individuals who are functioning within it.” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “Our findings of racial/ethnic disparities in this potentially life-saving treatment highlight the critical need to understand, improve, and deliver high-quality care to all. The inadequate delivery of surfactant to 63% of infants within 2h of delivery and the failure to deliver surfactant at all to infants within 4h emphasizes why we need to re-design health care such that delivery of treatment, such as surfactant, is a function of clinical characteristics and of the health care delivery system and less dependent on the individuals who are functioning within it.” Study to: Standardize practices for RDS intervention

Surfactant use for premature infants with respiratory distress syndrome in three new york city hospitals: Discordance of practice from a community clinician consensus standard Operational definition of RDS to distinguish babies who would get treatment from those who would not Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h Panel decided to administer surfactant in ≤2hr based on strict guidelines which assessed: Chest x-rays readings Diagnosis of another respiratory disorder (ie. pneumothorax or diaphragmatic hernia) Distress w/o identifiable mechanical stressors …surfactant use would be assessed at 2h and 4h n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children n=773 Clinical judgment superseded the standards agreed upon for treating ARDS children “Our findings of racial/ethnic disparities in this potentially life-saving treatment highlight the critical need to understand, improve, and deliver high-quality care to all. The inadequate delivery of surfactant to 63% of infants within 2h of delivery and the failure to deliver surfactant at all to infants within 4h emphasizes why we need to re-design health care such that delivery of treatment, such as surfactant, is a function of clinical characteristics and of the health care delivery system and less dependent on the individuals who are functioning within it.” Study to: Standardize practices for RDS intervention