1. The Prevalence and Outcome of Chronic Lung Disease Babies in a Tertiary Neonatal Unit QUAD NETWORK RESEARCH STUDY DAY Anju Singh Amy Walker Shree Vishna Rasiah

2. Background Chronic lung disease – major morbidity among preterm babies especially those extremely low birth babies (<1000grams) – prolonged hospital stays – discharge from the hospital with oxygen therapy – frequent readmission to the hospital in the first year of life – risk of neurodevelopmental delays

3. Chronic lung disease – morbidity and mortality more so in those with evidence of pulmonary hypertension – need for additional ongoing medical support whilst on the neonatal unit and at home

4. Early CPAP Vs Intubation SUPPORT NEJM (1316 infants, 24 weeks- 27+6) VON, 2010(648 infants, 26 – 29 +6) COIN, NEJM (610 infants, 25-28+6), Morley 2008 CURPAP Paeds ( 208 infants, 25-28+6), Sandri et al No difference in the primary outcome of Death or BPD

5. Stevens T.P., Blennow M., Myers E.H. et al. (2007) Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003063. DOI: 10.1002/14651858. CD003063.pub3 6 RCT’s Lower incidence – mechanical ventilation [typical RR 0.67, 95% CI 0.57, 0.79], – air leak syndromes [typical RR 0.52, 95% CI 0.28, 0.96] – BPD [typical RR 0.51, 95% CI 0.26, 0.99] Lower treatment threshold (FIO2 < 0.45) reduced incidences of airleak syndromes and BPD Higher treatment threshold (FIO2 at study > 0.45) was associated with increased risk of PDA

6. Wheeler K, Klingenberg C, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database of Systematic Reviews 2010, Issue 11. Art. No.: CD003666. DOI: 10.1002/14651858.CD003666.pub3 12 RCT’s Use of VTV modes – reduction in the combined outcome of death or bronchopulmonary dysplasia [typical RR 0.73 (95% CI 0.57 to 0.93), NNT8 – Reductions in pneumothorax – days of ventilation – hypocarbia – combined outcome of PVL or grade 3-4 intraventricular haemorrhage

7. Aims To understand the prevalence and outcomes of CLD cases in a tertiary neonatal unit

8. Methods Badger database for all cases of CLD (defined by oxygen requirement at 36 weeks corrected gestational age) Outcomes Impact on the neonatal services in the last 3 years.

9. Results Admissions: 3860 CLD: 97

10. Results: demographics Inborn babiesOutborn babies n5047 Mean Gestational Age in weeks (range) 26 (24-30)25 (23-31) Mean Birth Weight in grams (range) 820 (470- 1610)830 (480-1430) Male/ Female27/2327/20

11. Results: Plurality and Ethinicity InbornOutborn Singletons3639 Twins147 Triplet1 Ethinicity British/ White other3432 Black Carebean23 Asian83 Mixed28 Black african/ other14

12. Results: steroids & delivery Antenatal Steroids InbornOutborn Complete3721 Incomplete615 None39 Not known33 Delivery SVD2126 LSCS2921

13. Results: Ventilation days Inborn BabiesOutborn babies Mean Ventilation Days21.9 (0-60)27.3 (3-93) Mean CPAP days35.6 (1-82)39.8 (6-93)

14. Results: Co-morbidities InbornOutborn ROP Laser28 NEC Surgery814 Grade 3-4 IVH19 Cystic PVL45 PDA3436 Ligation613 Ibuprofen/ Indomethacin1314

15. Results InbornOutboen ECHO at 36 weeks2012 Evidence of Pulmonary Hypertension (PHN) 42 Medication for PHN32 Postnatal Steroids1510 Diuretics3439 Synergis1314

16. Results Inborn babiesOutborn Babies Total Deaths62 Death secondary to Pulmonary Hypertension 31 Home 4445 Home oxygen1917 Average length of stay (days) 106119

17. Conclusion Outborns – Less antenatal steroids – More ventilation and CPAP days – More co-morbidities: NEC requiring surgery, ROP requiring laser, significant PDA, grade 3-4 IVH, PVL – More average length of stay Inborns More postnatal steroids More Pulmonary hypertension More deaths

18. Implications in practice Compare time epochs with change in practices Compare units within regions Compare national outcomes Find ways to improve CLD outcomes

19. Implication for paediatric community services British Thoracic Society guidelines: – infants with chronic lung disease (CLD) oxygen saturations < 90% : increased risk of ALTE – Saturations below 92% : suboptimal growth Recommendation: – Oxygen saturations should be maintained at 93% or above – Assess for the suitability of long term oxygen therapy (LTOT) LE Pritchard. Audit of National Compliance with British Thoracic Society Guidelines for Neonatal Chronic Lung Disease. Arch Dis Child 2012;97:Suppl 1 A28. 65 units – Only 4% units carried out suitability for LTOT – Only 8% units used the BTS target saturations

20. Conclusion CLD is a major morbidity among preterm babies Cases are increasing with increasing survival of extremely preterm babies Babies with pulmonary hypertension have significantly increased risk of mortality Implications for community services

21. Questions?