Objectives: The purpose of this study is to examine the current state of evidence-based practice on ventilatory weaning in the neonatal intensive care units (NICUs).
Design: Ventilatory practices were followed for neonates when they needed to be intubated from birth. Ventilatory weaning protocol was developed from the literature based on arterial blood gas (ABG) tests.
Sample and Setting: Data has been completed on 82 subjects from 3 NICUs, with gestational age ranged from 25 to 40 weeks, and birth weight ranged from 657 to 4,870 grams.
Measurements: ABG parameters including blood oxygen tension (PO2) levels, acid-base (pH), and carbon-dioxide tension (PCO2) levels were used to guide the ventilatory weaning. Normal ranges of ABG parameters were 50-80 mm Hg for PO2, 40 to 55 mm Hg for PCO2, and 7.25-7.4 for pH. Evidence-based ventilatory weaning is determined based on the integration of ABG tests for ventilatory setting changes. Acceptable ventilatory parameter changes were derived on fraction of inspired oxygen (FiO2), ventilatory rate (VR), peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP), and inspiration time (Ti).
Findings: The number of ventilatory setting changes ranged from 1 to 271 attempts and lasted from 4 hours to 51 days for the first intubation course. Fifty-six (68.3%) subjects started with FiO2 > 40%, and fifty-one (62.2%) subjects began with PIP > 20 cmH2O ventilatory pressure. Twenty-four subjects (29.27%) needed to be re-intubated and were put on more than one course of ventilatory support. The total ventilator days ranged from 4 hours to 73 days. Fourteen subjects (17%) needed to be dependent on oxygen for more than 28 days, which constituted the diagnosis of chronic lung disease, bronchopulmonary dysplasia (BPD). Inter-rate agreement on data recording ranged 90-100%, and on data coding approached 100% for 15% randomly selected cases.
Conclusions: Following the ABG test, current practices on ventilatory weaning or adjustments do not necessarily follow the current state of knowledge, for practice guidelines. Particularly, with 223 ABG test results of hypoxemia (PO2 < 50 mm Hg), only 40% time, FiO2 was increased; whereas, with 697 test results of hyperoxemia (PO2 > 80 mm Hg), only 43.8% time, FiO2 was decreased. In addition, with 179 test results of hypercapnia (PCO2 > 55 mm Hg), less than 50% time, the suggested parameters were adjusted accordingly (26.8% PEEP and 31.7% PIP increased); whereas, with 736 test results of hypocapnia (PCO2 < 40 mm Hg), only 38% PEEP and 31.5% PIP were decreased.
Implications: Most ventilatory adjustments were not performed as suggested by the current guidelines to prevent related complications. Further studies are needed to refine ventilatory weaning protocols based on current state of knowledge, and to examine further on ventilatory weaning in neonates for evidence-based practice.
This study is supported in part by an NIH R01-NR grant funded to the first author.
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