1. 1 Chronic Lung Disease Interventions N. Singhal University of Calgary November 2006

2. 2 Outline Process Interventions proposed –Infection – K. Aziz –CLD – N. Singhal Interventions implemented –Infection – K. Aziz –CLD – N. Singhal Future directions – K. Aziz

3. 3 Review Process Cochrane reviews Systematic reviews Informal reviews

4. 4 CLD Group Interventions Process –Experts selected topics –Training provided for literature review –Each centre given ONE topic to review

5. 5 Review Process Cochrane reviews Systematic reviews Informal reviews

6. 6 Meeting of all centre/experts to discuss areas for improvement Generated list of interventions Process cont’d

7. 7 Interventions Proposed Antenatal –Treat urea plasma with erythromycin –Antenatal steroids

8. 8 Interventions Proposed Resuscitation –Early within one hour prophylactic surfactant <28 weeks or <1250 g. –Diminish hand ventilation –Decrease 100% oxygen exposure

9. 9 Interventions Proposed CPAP –Early CPAP for babies in supplemental oxygen –Long term CPAP

10. 10 Interventions Proposed Ventilation –Early use of HFV

11. 11 Interventions Proposed Normocarbia Avoid hypocarbia PaC0 2 40-55 mm of Hg

12. 12 Interventions Proposed Saturation targets > 88 to < 94 ? 93

13. 13 Interventions Proposed Nutrition/Fluids –Calories –Decrease fluid use –High dose Vitamin A

14. 14 Interventions Proposed Environment –Pain –Massage –Noise –NIDCAP

16. 16 CLD Interventions Implemented Antenatal:-Antibiotics -Expectant arrangement of PROM -Antenatal steroids

17. 17 CLD Interventions Implemented Resuscitation –Surfactant within 30 minutes –Avoid hand ventilation –Ventilation delivery room –Only Laerdel bags with PEEP –Blended gases

18. 18 CLD Interventions Implemented Ventilation –Early HVF – not done –Assist control and volume guarantee –Not done specifically

19. 19 CLD Interventions Implemented Normocarbia –PaC0 2 – 45-55 mm of Hg

20. 20 CLD Interventions Implemented Saturation targets –Sat alarm limits 85-95% –Goal 88-92% Physician orders oxygen as drug

21. 21 CLD Interventions Implemented Nutrition/Fluids –↓ TFI < 32 weeks first few days –TPN within 24 hours –TPN within 4 hours

22. 22 CLD Interventions Implemented Environment –Renovations to unit –↓ sound levels

23. 23 CLD Interventions Implemented Others: –Comment card for parents –Avoid re-intubation with CPAP –Perinatal referral policies

27. Early CPAP – EPIC PDSA Cycle # 4 > 27 weeks and < 34 weeks Respiratory Distress? (based on clinical judgment) Intubate, BLES transfer to NICU (*may be given in NICU after transfer) Stabilize then transfer to NICU Extubate to CPAP if FiO2 <.4 at 2 to 4 hours of age and if clinically stable Develops respiratory distress? Intubate, BLES Extubate to CPAP if FiO2 <.4 (no time frame) Routine management*** If > 27 weeks, had HMD and on supplemental FiO2 in first 24 hours of life should be on CPAP *** wean from CPAP as per clinical indications No Yes No

28. 28 Thank you