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

2. …a premature baby’s alveolus

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

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

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

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

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

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

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

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

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

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

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

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

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

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

18.  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

19.  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

20.  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

21.  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…

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

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

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

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

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

27. 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

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

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

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

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

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

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

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

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

36. Respiratory Distress Syndrome (RDS) Caucausian

37. Respiratory Distress Syndrome (RDS) Caucausian > Hispanic

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

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

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

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

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

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

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

45. 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

46. 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

47. 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

48. A little background first

49. Foggy Bathroom Mirror

50. Water sticks to the glass surface

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

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

53. Rain Drops

54. Water drops bead up

55. Rain Drops Water drops bead up Cohesive property of water

56. Rain Drops Water drops bead up Cohesive property of water

57. Rain Drops Water drops bead up Cohesive property of water

58. Rain Drops Water drops bead up Cohesive property of water

61. Caught in the rain…

63. Skin Shirt

64. Caught in the rain… Skin Shirt

65. Caught in the rain… Adhesion Skin Shirt

66. Caught in the rain… Skin Shirt Water

67. Caught in the rain… Skin Shirt Water

68. Caught in the rain… Skin Shirt Water

69. Caught in the rain… Skin Shirt Cohesion Water

70. + AdhesionCohesion

71. Surface Tension… + AdhesionCohesion

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

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

74. 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

75. 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

76. Surface Tension…

82. Amniotic fluid

83. Birth canal squeezes amniotic fluid out of alveoli

84. Amniotic fluid Birth canal squeezes amniotic fluid out of alveoli

85. Amniotic fluid Birth canal squeezes amniotic fluid out of alveoli

86. Air Ideally

87. Air Ideally

88. We’ll realign the alveolus for better visualization Air Ideally

91. Alveolar Wall

99. Pull In Alveolar Wall

100. Collapse

102. Surfactant

105. Open

106. O2 Open

107. O2 Open

108. O2 Open

109. O2 Open

110. O2 Open

111. CO2 Open

112. CO2 Open

113. CO2 Open

114. CO2 Open

115. CO2 Open

116. A closer look at surfactant

117. Surfactant

118. Two components in human surfactant

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

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

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

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

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

124. Surfactant 20 Lecithin:Sphingomyelin (L:S) ratio

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

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

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

128. Surfactant 35 Lecithin:Sphingomyelin (L:S) ratio

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

130. 35 Lecithin:Sphingomyelin (L:S) ratio 2:1

131. 35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35

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

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

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

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

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

137. 35 Lecithin:Sphingomyelin (L:S) ratio 2:1 35 X X X X X L:S ratio is < 2:1

138. 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

139. 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

140. 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

141. 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

142. Are baby’s lungs ready?

144.  L:S Ratio Are baby’s lungs ready?

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

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

147.  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

148.  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

149.  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

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

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

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

153.  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?

154.  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?

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

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

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

158.  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?

159.  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?

160.  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?

161. Medications to “make” lungs ready

162.  Surfactants

163. Medications to “make” lungs ready  Surfactants  Steroids

164. Surfactant

165. Within 2 hrs after birth

166. Surfactant Administer Intratracheally Within 2 hrs after birth

167. Surfactant Administer Intratracheally Within 2 hrs after birth

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

169. 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

170. Steroids

171.  Given antenatally X X X X X

172. Steroids  Given antenatally L:S ratio is < 2:1 X X X X X Improve survivability of the 24-34 week gestation and babies <1250g

173. Steroids  Given antenatally Speed up lung development L:S ratio is < 2:1 X X X X X Improve survivability of the 24-34 week gestation and babies <1250g

174. 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 24-34 week gestation and babies <1250g

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

176. Improve survivability of the 24-34 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

177. 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

178. 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

179. 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

180. 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

181. Nursing Diagnoses for RDS

182. 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

183. 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

184. 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

185. 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

186. 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

187. 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

188. 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

189. Study to: Standardize practices for RDS intervention

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

191. 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

192. 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

193. 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

194. 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

195. 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

196. 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

197. 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

198. 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

199. 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

200. 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

201. 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

202. 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

203. 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

204. 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

205. 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

206. 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

207. 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

208. 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

209. 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

210. 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

211. 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