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BACKGROUND: Nasal CPAP is widely used in neonatal ICUs. Aerosolized medications such as inhaled steroids and ␤ agonists are commonly administered in-line through nasal CPAP, especially to infants with bronchopulmonary dysplasia. We hypothesized that aerosol delivery to the lungs via variable-flow nasal CPAP in an in vitro model would be unreliable, and that the delivery would depend on the position of the aerosol generator within the nasal CPAP circuit. METHODS: We used a system that employed a test lung placed in a plastic jar and subjected to negative pressure. Simulated inspiration effort was measured with a heated-wire anemometer. We used technetium99m-labeled diethylene triamine penta-acetic acid as our aerosol. The nebulizer was placed either close to the humidifier or close to the nasal prongs in the circuit, and patient effort was simulated with a minute ventilation of 0.4 L/min. RESULTS: Relative aerosol delivery to the infant test lung with the nebulizer close to the humidifier was extremely low (0.3 ؎ 0.4%), whereas placing the nebulizer close to the nasal prongs resulted in significantly (P < .001) improved delivery (21 ؎ 11%). Major areas of aerosol deposition with the nebulizer close to the humidifier versus close to the nasal prongs were: nebulizer (10 ؎ 4% vs 33 ؎ 13%, P < .001), exhalation limb (9 ؎ 17% vs 26 ؎ 30%, P ‫؍‬ .23), and generator tubing (21 ؎ 11% vs 19 ؎ 20%, P ‫؍‬ .86). Placing the nebulizer close to the humidifier resulted in 59 ؎ 8% of the aerosol being deposited in the inhalation tubing along the heater wire. CONCLUSIONS: Isotope delivery from an aerosol generator placed near the humidifier on variable-flow nasal CPAP was negligible in this in vitro setup; however, such delivery was significantly improved by locating the aerosol generator closer to the nasal CPAP interface.

Early extubation may be beneficial in preventing or attenuating the development of bronchopulmonary dysplasia (BPD). We tested the hypothesis that patients extubated from higher ventilator pressures would be more likely to fail extubation. To determine the relationship between peak inspiratory pressure (PIP), positive end expiratory pressure (PEEP), and fraction of inspired oxygen (FiO 2 ) at the time of extubation and success of extubation, we reviewed the charts of all patients extubated in our neonatal intensive care unit (NICU) over two time periods; . Successful extubation was defined as not requiring re-intubation within 36 hours of extubation. There were 67 patients extubated during the study periods, and 58 patients (88%) were successfully extubated. There was no difference in the ventilator settings (PIP, PEEP, mean airway pressure, ventilator rate, or inspiratory time) between the patients with successful vs unsuccessful extubations. However, the FiO 2 was significantly (P = 0.011) lower in the successful extubations (median 24, intraquartile range 21-31) than in the unsuccessful extubations (median 33, intraquartile range 28-43). The median PIP was 22 cm H 2 O (intraquartile range 20-24) in the patients successfully extubated. Our data suggest that the FiO 2 may be the only ventilator setting associated with successful extubations in this patient population. Randomized control trials are needed to determine if extubating neonatal patients from relatively high PIP using FiO 2 will shorten the duration of mechanical ventilation.

BackgroundThe incidence of “any” and “severe” BPD in our all-referral unit was higher than comparison NICUs, even when controlling for NICU type, gestational age, and age at admission. Therefore, we initiated a QI project to improve adherence to best practices to reduce our iatrogenic contribution to the development of BPD.ObjectivesIn infants born before 30 weeks admitted to main campus before 29 days of life, to decrease the incidence of any BPD in survivors at DOL 28 from 78% to 62%, and of severe BPD in survivors at 36 weeks CGA from 62% to 48%, by 12/31/2015 and sustain indefinitely.MethodsOur multidisciplinary team identified a number of practice/system drivers (shown in attached key driver diagram). Upon these we layered a frame addressing the three physiologic drivers of BPD: barotrauma, atelecto-trauma, and oxygen toxicity. We developed protocols to address these three drivers (one shown in attachment). After multiple PDSAs, a marketing blitz (“stand-down”), emphasizing a wingman approach, was necessary before change started to occur.ResultsShortly after the stand-down “any” BPD, and a few months later “severe” BPD, each showed statistical improvement. Time to first extubation attempt declined as well. We continue to work on PDSAs to reduce hyperoxia. (all shown in attachment)ConclusionsMultiple contextual factors were leading to our high BPD rate, including lack of a burning platform and a sense of “it is someone else's problem”. Reducing BPD required addressing the physiologic causes of disease as well as these cultural factors.Figure 1Key driver diagram.Figure 2Protocol for ventilation weaning.Figure 3Days until first extubation attempt.Figure 4Percent of sat alarms properly set.Figure 5Rate of “Any BPD” for main campus NICUs.Figure 6Rate of “Severe BPD” for main campus NICUs.