Nasal continuous-positive-airway-pressure (NCPAP) is popular for infant respiratory support. We compared delivered to intended intra-prong, proximal-airway, and distal-airway pressures using ventilator (V-NCPAP) and bubble (B-NCPAP) devices. Measurements were repeated at five flows (4,6,8,10, and 12 L/min) and three NCPAP (4, 6, and 8 cm H 2 O) under no, small, and large nares-prong interface leak conditions. With no-leak, delivered B-NCPAP was systematically greater than intended levels at all pressure sites. The corresponding V-NCPAP flow-dependence was noneto-minimal. Prong and intra-airway B-NCPAP overshoots were also observed with small-leak, while only prong B-NCPAP showed a flow-dependent overshoot for large-leak. Leaks did not affect intraprong V-NCPAP but resulted in progressively lower than desired, flow-independent intra-airway V-NCPAP. We conclude that the selfadjusting capability of ventilators allows closely matched actual versus intended V-NCPAP. Alternatively, for the range of flows used clinically, intra-prong and intra-airway B-NCPAP are systematically higher at increasing flows than operator-intended levels, even when appreciable nares-prong leak is present. Additionally, the oscillations (noise) characterizing B-NCPAP are substantially attenuated between the proximal and distal airways; therefore, it is unlikely that B-NCPAP engenders ventilation or lung recruitment via this phenomenon. Tubing submersion depth for setting the level of B-NCPAP is highly inaccurate, and operators should instead rely on intra-prong pressure measurement. (Pediatr Res 62: [343][344][345][346][347] 2007) N CPAP is an increasingly popular mode of respiratory support in preterm infants with varying pulmonary disorders. The renewed interest in this form of ventilatory support aims at preventing collapse of the alveoli and terminal airways during expiration while relying on the infant's spontaneous respiration, and thereby avoids both the risk of tracheal intubation and concerns about ventilator-induced lung injury (1,2).A variety of devices are currently used for NCPAP delivery in infants. Most commonly, an infant ventilator is used to generate positive pressure. Flow is continuous and NCPAP pressure can be changed as desired by using the ventilator's positive end-expiratory pressure control. Ventilators maintain the delivered NCPAP pressure (V-NCPAP) close to the set pressure by automatic adjustments at the expiratory valve. Another device, B-NCPAP, has become a focus of interest as it is relatively inexpensive, easy to use, and favored by an institution reporting a low incidence of chronic lung disease (3). Warmed, humidified gas flows to the infant via the NCPAP circuit, binasal prongs are used, and the expiratory limb of the NCPAP tubing is submerged underwater to a depth in centimeters equal to the desired NCPAP. Flow rate is adjusted until gas bubbles through the water chamber. A hypothesized benefit to gas exchange and lung recruitment during B-NCPAP, the high-frequency oscillatory content of the b...

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Objectives: To compare rates of narcotic administration for medically treated neonates in different neonatal intensive care units (NICUs) and to compare treated and untreated neonates to assess whether narcotics provided advantages or disadvantages for short-term outcomes, such as cardiovascular stability (ie, blood pressure and heart rate), hyperbilirubinemia, duration of respiratory support, growth, and the incidence of intraventricular hemorrhage. Study Design: The medical charts of neonates weighing less than 1500 g, admitted to 6 NICUs (A-F), were abstracted. Neonates who had a chest tube or who had undergone surgery were excluded from the study, leaving the records of 1171 neonates. We modeled outcomes by linear or logistic regression, controlling for birth weight (Ͻ750, 750-999, and 1000-1499 g) and illness severity (low, 0-9; medium, 10-19; high, Ն20) using the Score for Neonatal Acute Physiology (SNAP), and adjusted for NICU.

Prong pressure during bubble nasal continuous positive airway pressure delivery is highly variable and depends on the interaction of submersion depth and flow amplitudes.

Premature infants with respiratory distress oxygenate better and have improved breathing synchrony when they are nursed in the prone position. We investigated whether work of breathing (WOB) is decreased in the prone position in healthy premature infants nearing discharge from the neonatal intensive care unit. Nineteen convalescing premature infants in room air were studied in both supine and prone position. Positioning order was randomized. Mean birth weight was 1358 +/- 332 (SD) g, gestational age 29.7 +/- 2.1 weeks, weight at study 1757 +/- 248 g, and age at study 33.6 +/- 1.4 days. Calibrated respiratory inductance plethysmography (RIP) was used to measure tidal volume; an esophageal catheter estimated pleural pressure. Inspiratory, elastic, and resistive WOB were calculated and were unaffected by prone versus supine positioning (P = 0.46, 0.36, and 0.87, respectively). Similarly, respiratory rate, tidal volume, minute ventilation, and lung compliance did not differ between positions. These data suggest that sleep position recommendations for healthy premature infants discharged home without oxygen should be no different than for term infants.

Objective: During bubble nasal continuous positive airway pressure (B-NCPAP), gas flows through the expiratory limb of CPAP tubing submerged underwater to a depth in centimeters considered equal to the desired end expiratory pressure. Ventilator-derived NCPAP (V-NCPAP) controls the delivered pressure at the expiratory orifice. Limited data exist comparing the two forms of NCPAP on work of breathing (WOB) and other short-term respiratory outcomes. We compared WOB and gas exchange between B-NCPAP and V-NCPAP at equivalent delivered nasal prong pressures among a cohort of preterm infants on NCPAP.Study Design: We performed a randomized crossover study in 18 premature infants <1500 g (BW 1101±254 g, GA 28±2 weeks, study age 13 ± 8 days (means ± s.d.)), who were already on NCPAP for mild respiratory distress, comparing B-NCPAP to V-NCPAP. Each infant was studied at a constant flow rate and varying pressures of 3, 5, 7, 4 and 2 cm H 2 O in that order. Tidal volumes were obtained by calibrated respiratory inductance plethysmography. Intrapleural pressure was estimated by an esophageal catheter. WOB (inspiratory, elastic and resistive) was calculated from pressure volume data. Breathing asynchrony was assessed with phase angle. Comparisons of respiratory rate, heart rate, tidal volume, minute ventilation, breathing asynchrony, lung compliance, oxygen saturation and transcutaneous (Tc) O 2 and CO 2 were also made.Result: WOB and most respiratory parameters were not different between B-NCPAP and V-NCPAP. TcO 2 was higher with B-NCPAP compared to V-NCPAP (P ¼ 0.01). TcCO 2 was not different. None of the other measured parameters was significantly different between the two devices.Conclusion: WOB and ventilation with B-NCPAP and V-NCPAP are similar when equivalent delivered prong pressures are assured. Improved oxygenation with B-NCPAP is intriguing and requires further investigation.

OBJECTIVES:To investigate variation among neonatal intensive care units (NICUs) in prevalence and management of thrombocytopenia in infants <1500 g. STUDY DESIGN:In total 1283 infants <1500 g admitted to six NICUs over 21 months were prospectively analyzed. Illness severity was measured by the Score for Neonatal Acute Physiology (SNAP). Platelet counts in the first 12 hours after birth and on day 3 of life were abstracted from the infants' medical records. Thrombocytopenia was determined from the lowest platelet count in each of these time periods. RESULTS:There was variability in rates of thrombocytopenia among NICUs, even after controlling for risk factors (e.g., SNAP, small for gestational (SGA) age and maternal hypertension). One site had a high prevalence of thrombocytopenia, but the lowest percentage of infants with thrombocytopenia who received platelet transfusions. After controlling for SNAP, GA, SGA, Apgar score and incidence of thrombocytopenia, the odds of receiving platelets at this site, relative to the site with the highest transfusion rate, was 0.10 (95% CI 0.02 to 0.43). CONCLUSIONS:This multicenter study finds a 10-fold variation among NICU in the administration of platelets to their thrombocytopenic infants that cannot be explained by presence of thrombocytopenia or illness severity.

OBJECTIVEThere are only 3 small case series in the literature that report on the management of in-hospital newborn falls (NFs), and recommendations are unclear. The authors performed a retrospective review to determine outcome and differences in management and to understand why management of NFs varies at their institution.METHODSAll NFs occurring within the authors’ institution over a 3.5-year period were reviewed. Post-fall management and outcomes of each incident were compared.RESULTSThere were 24 NFs out of 40,349 deliveries (5.9 NFs/10,000 deliveries). The mechanism of injury was nearly identical in 22 of 24 falls (the newborn fell to the floor from a parent in a bed or chair), and physical examination findings were normal or benign in all cases. Unexplained management variation based solely on clinician preference was noted, including observation only (in 13 cases), skull radiograph (in 7), head CT scan (in 6), bone survey (in 4), and head ultrasound examination (in 1), with some babies having more than 1 study. Two babies had nondepressed linear parietal fractures diagnosed by skull radiograph, and 2 babies had small subdural hemorrhages diagnosed by head CT scan. All 24 babies had normal findings on examination at discharge.CONCLUSIONSThere is a high incidence of nondepressed linear parietal skull fractures associated with NFs. However, since associated intracranial injury is uncommon, imaging studies may not be routinely performed. Neonatal intensive care unit admission, head CT, and neurosurgical evaluation are reserved for the rare baby with abnormal physical examination or neurological findings.