Retrospective Analysis of an Interdisciplinary Ventilator Care Program Intervention on Survival of Infants with Ventilator-Dependent Bronchopulmonary Dysplasia

Jason Gien; John Kinsella; Jodi Thrasher; Alicia Grenolds; Steven H. Abman; Christopher D. Baker

doi:10.1055/s-0036-1584897

American Journal of Perinatology, Table of Contents

Am J Perinatol 2017; 34(02): 155-163
DOI: 10.1055/s-0036-1584897

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Retrospective Analysis of an Interdisciplinary Ventilator Care Program Intervention on Survival of Infants with Ventilator-Dependent Bronchopulmonary Dysplasia

Jason Gien

¹Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

²Division of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

,

John Kinsella

¹Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

²Division of Neonatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

,

Jodi Thrasher

³Division of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

,

Alicia Grenolds

¹Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

³Division of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

,

Steven H. Abman

¹Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

³Division of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

,

Christopher D. Baker

¹Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

³Division of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado

› Author Affiliations

Abstract

Background The clinical needs of infants with severe bronchopulmonary dysplasia (BPD) that remain ventilator-dependent are complex, and management strategies that optimize survival and long-term outcomes controversial. We hypothesized that an interdisciplinary ventilator care program (VCP), committed to the care of this population will improve survival through standardized approaches to cardiopulmonary care and related comorbidities, enhanced communication, and continuity of care.

Methods Retrospective chart reviews were performed on patients at Children's Hospital Colorado's neonatal intensive care unit, who underwent tracheostomy placement between 2000 and 2013. Data were collected for two time periods: 2000 to 2005 and 2006 to 2013, before and after initiation of the VCP. Collected data on infants with ventilator-dependent BPD included: gestational age (GA), age at tracheostomy, respiratory severity score (RSS; mean airway pressure [MAP] × fraction of inspired oxygen [FiO₂]), comorbidities, medication use, and the age of death. Tracheostomy patients without severe BPD were excluded.

Results Despite no difference in GA, birth weight, or cardiorespiratory comorbidities, survival to discharge increased from 50 to 85% after implementation of the VCP (p < 0.05). Between period 1 and 2, there were differences in systemic and inhaled steroid use and mucolytic use.

Conclusion These findings suggest an interdisciplinary approach to the care of infants with ventilator-dependent BPD can improve survival.

Keywords

bronchopulmonary dysplasia - tracheostomy - ventilator-dependent - ventilator care program - interdisciplinary care

Full Text

References

References
1 Northway Jr WH, Rosan RC, Porter DY. Pulmonary disease following respirator therapy of hyaline-membrane disease. Bronchopulmonary dysplasia. N Engl J Med 1967; 276 (7) 357-368
2 Baraldi E, Filippone M. Chronic lung disease after premature birth. N Engl J Med 2007; 357 (19) 1946-1955
3 Jobe AH. The new bronchopulmonary dysplasia. Curr Opin Pediatr 2011; 23 (2) 167-172
4 Kinsella JP, Greenough A, Abman SH. Bronchopulmonary dysplasia. Lancet 2006; 367 (9520) 1421-1431
5 Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001; 163 (7) 1723-1729
6 Gowans M, Keenan HT, Bratton SL. The population prevalence of children receiving invasive home ventilation in Utah. Pediatr Pulmonol 2007; 42 (3) 231-236
7 Cristea AI, Carroll AE, Davis SD, Swigonski NL, Ackerman VL. Outcomes of children with severe bronchopulmonary dysplasia who were ventilator dependent at home. Pediatrics 2013; 132 (3) e727-e734
8 Mandy G, Malkar M, Welty SE , et al. Tracheostomy placement in infants with bronchopulmonary dysplasia: safety and outcomes. Pediatr Pulmonol 2013; 48 (3) 245-249
9 Khemani E, McElhinney DB, Rhein L , et al. Pulmonary artery hypertension in formerly premature infants with bronchopulmonary dysplasia: clinical features and outcomes in the surfactant era. Pediatrics 2007; 120 (6) 1260-1269
10 Bhat R, Salas AA, Foster C, Carlo WA, Ambalavanan N. Prospective analysis of pulmonary hypertension in extremely low birth weight infants. Pediatrics 2012; 129 (3) e682-e689
11 Mourani PM, Sontag MK, Younoszai A , et al. Early pulmonary vascular disease in preterm infants at risk for bronchopulmonary dysplasia. Am J Respir Crit Care Med 2015; 191 (1) 87-95
12 Edwards JD, Kun SS, Keens TG. Outcomes and causes of death in children on home mechanical ventilation via tracheostomy: an institutional and literature review. J Pediatr 2010; 157 (6) 955-959.e2
13 Rane S, Bathula S, Thomas RL, Natarajan G. Outcomes of tracheostomy in the neonatal intensive care unit: is there an optimal time?. J Matern Fetal Neonatal Med 2014; 27 (12) 1257-1261
14 Overman AE, Liu M, Kurachek SC , et al. Tracheostomy for infants requiring prolonged mechanical ventilation: 10 years' experience. Pediatrics 2013; 131 (5) e1491-e1496
15 Abman SH, Nelin L. Management of severe BPD. In, Bancalari E, ed. The Newborn Lung: Neonatology Questions and Controversies, 2nd Edition. Philadelphia: Elsevier; 2012
16 Allen J, Zwerdling R, Ehrenkranz R , et al; American Thoracic Society. Statement on the care of the child with chronic lung disease of infancy and childhood. Am J Respir Crit Care Med 2003; 168 (3) 356-396
17 Viswanathan S, Mathew A, Worth A, Mhanna MJ. Risk factors associated with the need for a tracheostomy in extremely low birth weight infants. Pediatr Pulmonol 2013; 48 (2) 146-150
18 Ochiai M, Hikino S, Yabuuchi H , et al. A new scoring system for computed tomography of the chest for assessing the clinical status of bronchopulmonary dysplasia. J Pediatr 2008; 152 (1) 90-95 , 95.e1–95.e3
19 Miller RW, Woo P, Kellman RK, Slagle TS. Tracheobronchial abnormalities in infants with bronchopulmonary dysplasia. J Pediatr 1987; 111 (5) 779-782
20 Cohn RC, Kercsmar C, Dearborn D. Safety and efficacy of flexible endoscopy in children with bronchopulmonary dysplasia. Am J Dis Child 1988; 142 (11) 1225-1228
21 Filbrun AG, Popova AP, Linn MJ, McIntosh NA, Hershenson MB. Longitudinal measures of lung function in infants with bronchopulmonary dysplasia. Pediatr Pulmonol 2011; 46 (4) 369-375
22 Baraldi E, Bonetto G, Zacchello F, Filippone M. Low exhaled nitric oxide in school-age children with bronchopulmonary dysplasia and airflow limitation. Am J Respir Crit Care Med 2005; 171 (1) 68-72
23 Farhath S, Aghai ZH, Nakhla T , et al. Pepsin, a reliable marker of gastric aspiration, is frequently detected in tracheal aspirates from premature ventilated neonates: relationship with feeding and methylxanthine therapy. J Pediatr Gastroenterol Nutr 2006; 43 (3) 336-341
24 Demirel G, Yilmaz Y, Uras N , et al. Dramatical recovery of a mechanical ventilatory dependent extremely low birth weight premature infant after Nissen fundoplication. J Trop Pediatr 2011; 57 (6) 484-486
25 Powers CJ, Levitt MA, Tantoco J , et al. The respiratory advantage of laparoscopic Nissen fundoplication. J Pediatr Surg 2003; 38 (6) 886-891
26 Mourani PM, Ivy DD, Rosenberg AA, Fagan TE, Abman SH. Left ventricular diastolic dysfunction in bronchopulmonary dysplasia. J Pediatr 2008; 152 (2) 291-293
27 Drossner DM, Kim DW, Maher KO, Mahle WT. Pulmonary vein stenosis: prematurity and associated conditions. Pediatrics 2008; 122 (3) e656-e661
28 Akinola E, Rosenkrantz TS, Pappagallo M, McKay K, Hussain N. Gastroesophageal reflux in infants < 32 weeks gestational age at birth: lack of relationship to chronic lung disease. Am J Perinatol 2004; 21 (2) 57-62
29 Guaman MC, Gien J, Baker CD, Zhang H, Austin ED, Collaco JM. Point prevalence, clinical characteristics, and treatment variation for infants with severe bronchopulmonary dysplasia. Am J Perinatol 2015; 32 (10) 960-967