In this study, we were able to demonstrate for the first time a significant improvement on the weaning time and duration of mechanical ventilation with the implementation of a ventilation protocol driven by a registered respiratory therapist in the premature population. Based on our experience, other institutions can customize ventilation protocols to their local practice. However, a prospective, randomized, controlled study should be planned to evaluate long-term outcomes such as BPD and neurodevelopment.
Glucose infusion rate: There is insufficient evidence from trials comparing lower with higher glucose infusion rates to inform clinical practice. Large randomized trials are needed, powered on clinical outcomes including death, major morbidities and adverse neurodevelopment.Insulin infusion: The evidence reviewed does not support the routine use of insulin infusions to prevent hyperglycemia in VLBW neonates. Further randomized trials of insulin infusion may be justified. They should enrol extremely low birth weight neonates at very high risk for hyperglycemia and neonatal death. They might use real time glucose monitors if these are validated for clinical use. Refinement of algorithms to guide insulin infusion is needed to enable tight control of glucose concentrations within the target range.
Evidence from randomized trials in hyperglycemic VLBW neonates is insufficient to determine the effects of treatment on death or major morbidities. It remains uncertain whether the hyperglycemia per se is a cause of adverse clinical outcomes or how the hyperglycemia should be treated. Much larger randomized trials in hyperglycemic VLBW neonates that are powered on clinical outcomes are needed in order to determine whether, and how, the hyperglycemia should be treated.
Pneumothorax is a common complication in infants receiving assisted ventilation. The appropriate management of this condition is not always clearly defined, especially when a large air leak and mediastinal shift are present but the infant is hemodynamically stable. Despite the complications associated with chest tube placement, this remains the most common approach in such cases. We report 4 cases of preterm infants who developed large pneumothoraces with mediastinal shift while on assisted ventilation and were managed conservatively, with substantial improvement within 12-96 hours. In this report we also review the literature on pneumothorax in preterm infants.
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