IMPLEMENTATION OF BEST PRACTICE STRATEGIES TO DECREASE UNPLANNED - - PDF document

IMPLEMENTATION OF BEST PRACTICE STRATEGIES TO DECREASE UNPLANNED EXTUBATIONS IN THE NEONATE Purpose: Unplanned extubations (UEX) are a serious and potentially life-threatening event for a neonate. UEX leads to emergent, less-controlled endotracheal re- intubations.Repeated intubations increase the risk of ventilator associated pneumonia, tracheal injury, and may prolong length of stay. A number of factors increase the risk of

• UEXs. These include lack of adequate sedation; type of tube stabilization used, and lack
• f vigilance by staff.

Method: A prospective cohort quality study was designed to consider the impact of modifying these factors and implementing a sequence of best practice strategies. Three leading factors were defined: stabilization of endotracheal tube (ETT), sedation for intubated patients, and personnel at the bedside. Strategies were developed to address these factors: 1) A six month trial of three different stabilization techniques; 2) Sedation guideline implemented, for patients who self extubated and required re-intubation within 48hrs ( scheduled sedation, 1mcg/Kg Fentanyl Q4, 1 mcg/kg Fentanyl q2 hrs PRN); 3) Intubated patients required two personnel at the bedside during care or

• procedures. Patients requiring intubation from February 2010 to present were included

in this 5 year quality study. A tracking tool was developed and data collected included: patient data were protocols followed, circumstances and personnel present for UEX and level of sedation. Results: Baseline data indicated an UEX rate of 4.5/100 ventilator days. Following the implementation of three standards of care practice changes we saw the following decrease in the UEX rate: 1) Standardized Taping to 2.4/100 ventilator days; 2) Standard sedation to 1.7/100 ventilator days; 3) Adequate personnel at the bedside to 0.4/100 ventilator days. Conclusion: UEXs continued to occur despite the implementation of standardized

• taping. It was determined that lack of sedation and the absence of adequate number of

personnel at bedside during procedures and care time contributed to UEXs. After the implementation of Sedation Guidelines and standardizing personnel at the bedside during procedures, we experienced additional decrease in the UEXs rate. Care time, procedures, and sedation are coordinated by nursing and respiratory therapy Qshift. We continue to evaluate and track UEXs as part of our ongoing quality initiatives.

Pulmonary Arterioles and Terminal Bronchioles have Persistent Muscularization in the Lung of Former Preterm Lambs

H Emerson*, J Orchard*, MJ Dahl, L Dong, Z Wang, DM Null, BA Yoder, and KH Albertine * Equal first authors (both 2nd-year medical students)

Haleigh Emerson does not have anything to

disclose

Disclosure Statement

 Bronchopulmonary dysplasia (BPD) is a major pediatric public health problem  Cause: Premature birth and respiratory failure

• Requires ventilation with oxygen-rich gas

 Potential life-long consequences

• Pulmonary hypertension
• Hyperreactive airways

Worrisome Long-Term Outcomes

 2-year mortality rate of 33 to 48%  Pathology and pathophysiology

• Lower density of pulmonary microvessels
• Thicker walls of pulmonary arterioles
• Hypoxic vasoconstriction and increased

pulmonary vascular resistance

• Hypertrophy and/or enlargement of the right

atrium and ventricle

Pulmonary Hypertension and BPD

Khemani et al, Pediatrics 120:1260-1269, 2007 Del Cerro et al, Pediatr Pulmonol 49:49-59, 2014 Baker et al, Pediatr Allergy Immunol Pulmonol 27:8-16, 2014

Pulmonary Arteriole (PA) Muscularization in Preterm Lambs

Preterm IMV 21d

PA

Term Reference

PA

Muscularization Persists from Fetal Anatomy

Smooth Muscle Area External Diameter

Bland et al., Pediatr Res 48:64-74, 2000 Mean ± SD; n=4 to 5 per group

Newborn 1d 21d Fetal 128d 20 10 References Pulmonary Arterioles

Muscularization Persists from Fetal Anatomy

Preterm 21d IMV Smooth Muscle Area External Diameter

Bland et al., Pediatr Res 48:64-74, 2000 Mean ± SD; n=4 to 5 per group

Newborn 1d 21d Fetal 128d 20 10 References Pulmonary Arterioles

Bland et al., Pediatr Res 48:64-74, 2000

Pulmonary Vascular Resistance Did Not Decrease Postnatally

Preterm 21d IMV n=10 3 1 Week Pulmonary Vascular Resistance (mmHg/(L/min) 3 1 40 20 Term Reference Not ventilated n=7 Week

Mean ± SD

Hyper-Reactive Airways and BPD

 Recurrent wheezing and asthma

Jaakkola et al., J Allergy Clin Immunol 118:823-830, 2006 Walter et al., Am J Respir Crit Care Med 180:176-180, 2009

 Mechanisms underlying these respiratory morbidities remain poorly understood

• Our previous studies of chronically ventilated

preterm lambs provide mechanistic insights

Terminal Bronchiole (TB) Muscularization in Preterm Lambs

Term Reference Preterm IMV 21d

TB TB

Increased Muscularization of Airways

Bland et al., AJRCCM 172:899-906, 2005

Terminal Bronchioles Term Reference Preterm 21d 0.20 0.10 Smooth Muscle Area External Diameter

Mean ± SD, n=5

 Invasive intermittent mandatory ventilation immediately after preterm birth will lead to

• Persistent muscularization of pulmonary

arterial vessels

• Increased muscularization of airways
• later in life

Hypothesis

Study Groups

 Former preterm ventilated lambs

• 3 months (2 months corrected postnatal age)
• 6 months (5 months corrected postnatal age)

 Term, age-matched, unventilated control lambs

• 2 months
• 5 months
• Pair-fed, based on milk volume taken by the

former preterm lambs

Modified Our Preterm Lamb Model

 Wean preterm lambs from ventilation support

• Based on clinical assessment of

neurodevelopmental outcomes at 2 and 6 years corrected postnatal age

• Recovered preterm lambs for 2 or 5 months,

respectively, after term gestation, based on anthropomorphic characteristic

Postnatal Age Equivalence

Characteristic Humans Sheep Weaning 2 years 2 months

Postnatal Age Equivalence

Characteristic Humans Sheep Weaning 2 years 2 months Interpolated * 6 years 5 months * Puberty onset in sheep occurs at ~8 months of age

Former Preterm Protocol

Delivered at ~128 days (Term is ~150 days) Antenatal Steroids Intubated and treated with surfactant and caffeine citrate Intermittent mandatory ventilation (IMV) 3 days Extubated Less-invasive HFNV for 3 days Removed from ventilation support Fostered for 3 months or 6 months

Management of Preterm Lambs

 Physiologic targets for oxygenation and ventilation

• PaO2 60 to 80 mmHg
• PaCO2 45 to 60 mmHg (pH 7.25 to 7.45)

 Antibiotics  Sedation  Glucose: 60-80 mg/dL  Enteral feeding, using ewe’s colostrum and milk

• Term control lambs were pair-fed

Structural Analyses

 Formalin-fixed, paraffin-embedded lung tissue sections

• Alpha smooth muscle actin localization

 Quantitative histology

• Measure calibrated area of smooth muscle
• Pulmonary arterioles (PA)
• Independent landmark for same

generation (~16th)

• Terminal bronchioles (TB)

Other Analyses

 Heart

• Weight
• Ventricular free wall thickness

 Airway resistance and hyper-reactivity

Persistent Muscularization of PAs

2 months 5 months Term Control Former Preterm

2000 4000 Smooth Muscle Area (μm2)

Mean ± SD, n=5

Term Control 5 mo

*

Former PT 5 mo Term Control 2 mo Former PT 2 mo

* p<0.05 compared to the

matched term control

*

Persistent Muscularization of PAs

3 6

Increased Heart-to-Body Weight Ratio

Heart Weight Body Weight Former PT 2 mo Term Control 2 mo

*

Former PT 5 mo Term Control 5 mo

Mean ± SD, n=5

* p<0.05 compared to matched

term control

3 6 Free Wall Thickness (mm)

Thicker Right Ventricular (RV) Free Wall

*

RV Former PT 2 mo Term Control 2 mo

Mean ± SD, n=5

* p<0.05 compared to matched

term control

3 6 Free Wall Thickness (mm)

Thicker Right Ventricular (RV) Free Wall

RV Former PT 2 mo Term Control 2 mo LV

Mean ± SD, n=5

* p<0.05 compared to matched

term control

Former PT 2 mo Term Control 2 mo

*

1.5 3.0 Airway Resistance (cmH2O/Liter/sec/Kg)

Increased Airway Resistance

Mean ± SD, n=5

* Different from matched term

control, p<0.05

Former PT 5 mo Term Control 5 mo

*

Former PT 2 mo Term Control 2 mo

(n=2)

Increased Muscularization of TBs

2 months 5 months Term Control Former Preterm

4000 8000 Terminal Bronchiole Smooth Muscle Area (μm2) Former PT 2 mo Term Control 2 mo

Increased Muscularization of TBs

Mean ± SD, n=5 * Different from matched term control, p<0.05

Former PT 5 mo Term Control 5 mo

* *

Average (n=3) Former PT 3d IMV lambs, DOL 119 (~6 yr of age in humans) 50 150 100 10 min Baseline Baseline 10 min Methacholine (30 mg/Kg) 100 min Methacholine (15 mg/Kg) 100 min Airway Resistance cmH2O LPS

T Control Former PT Weaned

Long-Term Airways Hyperreactivity, 5 mo

Pulmonary Arterioles (PAs) Former Preterm Lambs Smooth Muscle Thickness Heart-to-Body Wt Ratio RV Free Wall Thickness 2 months* Not Different 5 months* Not done

* Corrected postnatal age Summary for PAs

Pulmonary Arterioles (PAs) Former Preterm Lambs Smooth Muscle Thickness Heart-to-Body Wt Ratio RV Free Wall Thickness 2 months* Not Different 5 months* Not done

* Corrected postnatal age Summary for PAs

Summary for TBs

Terminal Bronchioles (TBs) Former Preterm Lambs Airway Resistance Smooth Muscle Thickness 2 months* ( ) (n=2) 5 months*

* Corrected postnatal age

Conclusion

 Invasive intermittent mandatory ventilation immediately after preterm birth leads to

• Persistent muscularization of pulmonary

arterial vessels and enlargement of the right side of the heart

• Increased airway resistance, muscularization,

and hyperreactivity

• later in life

Speculation

 Persistent muscularization of pulmonary arterial vessels and enlargement of the right ventricle  Consistent with persistent pulmonary hypertension  Next steps: ultrasound and vascular measurements  Potential molecular player and mechanism

• Insulin-like growth factor-1
• Epigenetics

Thank You

Supported by NIH grants HL062875 HL110002 HL007744 (T35 training grant for medical students) Division of Neonatology