Biomedical subjects

Wade Rich

Publications and source records attributed to Wade Rich.

10 recordsLinked to original sources

PubMed2006

Disposable colorimetric carbon dioxide detector use as an indicator of a patent airway during noninvasive mask ventilation.

Colorimetric carbon dioxide detectors are useful indicators of proper endotracheal tube placement. We have found that they also are helpful during bag and mask ventilation as an indicator of a patent airway. In this report, we describe our experience with these devices for use during preintubation airway stabilization as observed during videotaped performances from a prospective, randomized trial of intubation premedication.

Airway Obstruction↗

PubMed2006

A survey of delivery room resuscitation practices in the United States.

OBJECTIVE: To determine current resuscitation practices of neonatologists in the United States. METHODS: A 15-question survey was developed and mailed to neonatal directors in May 2004. RESULTS: Of the total of 797 surveys mailed, 84 were returned undeliverable or unanswered and 450 were returned completed (63% response rate). Respondents were mainly (70%) from level III NICUs. Most programs resuscitate newborns in the delivery room (83%), rather than in a separate room. The number and background of individuals attending deliveries vary greatly, with 31% of programs having <3 individuals attending deliveries. Flow-inflating bags are most commonly used (51%), followed by self-inflating bags (40%) and T-piece resuscitators (14%). Pulse oximeters are used during resuscitation by 52% of programs, and 23% of respondents indicated that there was a useful signal within 1 minute after application. Blenders are available for 42% of programs, of which 77% use pure oxygen for the initial resuscitation and 68% use oximeters to alter the fraction of inspired oxygen. Thirty-two percent of programs use carbon dioxide detectors to confirm intubation, 48% routinely and 43% when there is difficulty confirming intubation. Preterm infants are wrapped with plastic wrap to prevent heat loss in 29% of programs, of which 77% dry the infant before wrap application. A majority of programs (76%) attempt to provide continuous positive airway pressure or positive end expiratory pressure (PEEP) during resuscitation, most commonly with a flow-inflating bag (58%), followed by a self-inflating bag with PEEP valve (19%) and T-piece resuscitator (16%). A level of 5 cm H2O is used by 55% of programs. CONCLUSIONS: Substantial variations exist in neonatal resuscitation practices, some of which are not addressed in standard guidelines. Future guidelines should include recommendations regarding the use of blenders, oximeters, continuous positive airway pressure/PEEP, and plastic wrap during resuscitation.

Data Collection↗

PubMed2005

Neonatal intubation: success of pediatric trainees.

OBJECTIVES: To review the success of pediatric trainees for neonatal intubation over a 10-year interval at a single academic center. STUDY DESIGN: We reviewed a database of all neonatal intubations designed as a quality assurance process at our institution. Respiratory care practitioners recorded the number of attempts at the time of each procedure. Attempts were defined as each time a laryngoscope was placed in the baby's mouth. Success rates were calculated as the number of successful intubations divided by the attempts. RESULTS: From January 1992 through September 2002, 5051 successful intubations with 9190 attempts were performed by all practitioners. Pediatric residents intubated neonates successfully on 1676 occasions requiring 3719 attempts. The median success rates were 33% for pediatric level (PL)1 residents; 40% for PL2 and PL3 residents, and 68% for neonatal fellows ( P < .001). The success rates for residents who had more than 20 total attempts versus those who had fewer than 20 attempts were 49% versus 37% ( P < .001). CONCLUSIONS: Developing proficiency at intubation requires a significant amount of experience. Current pediatric residents at our institution have inadequate opportunity to achieve consistent success.

California↗

PubMed2005

A comparison of three neonatal resuscitation devices.

BACKGROUND: Ventilation during neonatal resuscitation involves the use of self-inflating bags, flow-inflating bags, and T-piece resuscitators. The ability of operators to deliver desired peak inspiratory pressures (PIP), positive end expiratory pressures (PEEP), prolonged inflations and the length of time to transition between different pressures has not been compared for all three of these devices. OBJECTIVE: To compare the ability of neonatal resuscitation personnel to deliver predetermined ventilation interventions using these devices in advance of a clinical trial of neonatal resuscitation. DESIGN/METHODS: We studied 31 operators (neomatologists, neonatal respiratory therapists, neonatal fellows, a pediatrician, pediatric residents, neonatal nurse practitioners, and neonatal nurses) using a T-piece resuscitator (Neopuff), Fisher and Paykel Healthcare, Auckland, New Zealand), a self-inflating bag (Baby Blue II, Vital Signs, Totowa, NJ), and a flow-inflating bag (Model E191 Anesthesia Associates, San Marcos, CA). The self-inflating bag was tested with and without the manufacturer's PEEP valve. Using a continuous pressure recording system and a neonatal manikin, we evaluated the ability to deliver a consistent PIP of 20 or 40 cmH2O and a PEEP of 5 cmH2O during 30 s of ventilation, the ability to maintain a 5 s inflation at a PIP of 20 cmH2O and the time to transition from a PIP of 20 to 40 cmH2O. Each device was evaluated with and without a qualitative CO2 detector (Pedicap) Nellcor Pleasanton, CA). RESULTS: The T-piece resuscitator delivered the desired PIP more precisely and consistently compared with the self-inflating bag at a target of 20 cmH2O (maximum PIP 20.7 cmH2O, S.D.=0.8 versus 24.7 cmH2O, S.D.=2.8; p<0.001). At a target of 40 cmH2O, the maximum pressure delivered with the T-piece resuscitator was significantly less than both the flow-inflating bag and the self-inflating bag (39.7 cmH2O, S.D.=2.1 versus 44 cmH2O, S.D.=3.3 versus 45.3 cmH2O, S.D.=4.7; p<0.001). It took significantly longer to increase the PIP from 20 to 40 cmH2O using the T-piece resuscitator compared to the self-inflating bag or the flow-inflating bag (5.7 s versus 2.2 s versus 1.8 s; p<0.001), and three operators could not make the transition in the allotted 15 s time limit. During the 5 s prolonged inflation, the T-piece resuscitator and the flow-inflating bag maintained a pressure greater than 18 cmH2O for a longer time than the self-inflating bag (4 s versus 3.7 s versus 2.2 s; p<0.001). The self-inflating bag with the PEEP valve in place provided significantly less PEEP than both the T-piece resuscitator and the flow-inflating bag (3.6 cmH2O versus 4.4 cmH2O versus 4.4 cmH2O; p<0.005). The Pedicap did not significantly affect any of the observed results, and there were no consistent operator differences between different disciplines or years of experience. CONCLUSIONS: The T-piece resuscitator delivered the desired pressures more accurately, but required greater time to increase the PIP from 20 to 40 cmH2O. It was difficult to maintain a prolonged inflation and deliver the desired PEEP with the self-inflating bag even with the PEEP valve in place. There is a need for improvement in the design and function of current manual resuscitation devices and for prospective trials to evaluate the optimal method of bag and mask ventilation during resuscitation of the newborn infant.

Adult↗

PubMed2004

Duration of intubation attempts during neonatal resuscitation.

OBJECTIVE: Since the American Academy of Pediatrics Neonatal Resuscitation Program recommends that intubation should be completed in approximately 20 seconds, we measured the duration of neonatal intubation attempts by different operators, using video recordings of neonatal resuscitations. STUDY DESIGN: We used an ongoing quality improvement program to measure the duration of intubation attempts. RESULTS: The mean duration for the 50 successful intubations, including 6 for meconium, was 27.3 seconds compared with 29.8 seconds for unsuccessful attempts (not significant). Fifteen infants were successfully intubated on each of the first and second attempts, 10 on the third attempt, and 10 required more than 3 attempts. The mean duration of successful intubation was 31.9 seconds for PL-1's, 27.5 seconds for PL-2/3's, and 23.6 seconds for fellows. Overall intubations were more successful for a duration of 30 seconds or less compared with 20 seconds or less (72% vs 38%; chi(2)=10.3, P=.001). No infant decompensated between 20 and 30 seconds. Ten successful and 12 failed attempts took longer than 40 seconds. CONCLUSIONS: We recommend that a duration of 30 seconds is a reasonable guideline for neonatal intubation during resuscitation.

Clinical Competence↗

PubMed2004

A randomized trial of suprasternal palpation to determine endotracheal tube position in neonates.

OBJECTIVE: To compare suprasternal palpation, a previously described bedside technique, with standard chest radiography for correct positioning of the endotracheal tube (ETT) in newborn infants. STUDY DESIGN: A randomized single-blinded study in an academic medical center. Preterm and term newborn infants requiring intubation were eligible, provided that they had not had their initial chest roentgenogram (CXR). Infants were randomized to ETT palpation and non-adjustment (Controls), or to ETT palpation and adjustment (Treatment), following digital palpation of the ETT tip in the suprasternal notch. ETT position was considered correct when only the tip of the ETT was palpable in the suprasternal notch. ETT position by CXR was blindly assessed by an experienced pediatric radiologist. RESULTS: Fifty-five infants were enrolled in the delivery room or neonatal intensive care unit. Correct tube placements improved from 48% pre-study to 85 and 93% in the Control and Treatment arms, respectively. The majority of incorrect estimations were that the ETT position using palpation was judged to be too low when it was, in fact, in correct position, as noted in 11 infants. ETT palpation had a 70% concordance with the position determined by CXR. No difficulties or complications were associated with the use of suprasternal palpation. CONCLUSIONS: Suprasternal palpation is a simple, safe, teachable, method of confirming ETT position in neonates when CXR is unavailable, and may especially helpful during neonatal resuscitation prior to surfactant administration.

Female↗

PubMed2003

Ten-year trends in neonatal assisted ventilation of very low-birthweight infants.

OBJECTIVES: To examine ventilatory support for the VLBW infant over the past 10 years in a single academic NICU and determine factors that predicted length of ventilation, death, and CLD. STUDY DESIGN: A retrospective cohort review of neonatal blood gases, ventilatory support, and clinical outcomes. RESULTS: From 1992 through October 2002, 6254 infants were admitted, of whom 2388 required intubation for mechanical ventilation. Of these, 837 were <1500 g at birth (VLBW) infants and 453 were less than 1000 g (ELBW). Total duration of ventilation decreased in all weight groups. Noninvasive ventilatory support increased from 20 to 55% of total ventilation from 1997 to 2002. During this same period, CLD decreased from 20 to 11% in ventilated VLBW infants. Duration of total ventilation was best predicted by birth weight, with each 100 g increment decreasing the duration of ventilation by 71 hours. Lower birth weight, male sex, and a longer total duration of ventilatory support were significant factors in predicting the occurrence of CLD. Death alone was best predicted by lower birth weight and maximum oxygen index (OI). Transported infants had significantly increased maximal OIs, durations of ventilation, and incidence of death. A total of 48% of infants with a single OI >10 either died or survived with CLD. CONCLUSIONS: Birth weight is the best predictor of duration of ventilation, and CLD is best predicted by birth weight, duration of ventilation and male sex. The increasing use of noninvasive strategies has not been associated with an observable increase in respiratory morbidity. VLBW infants with a single OI>10 may benefit from inclusion in future interventional rescue studies.

Birth Weight↗

PubMed2002

Neonatal resuscitation: toward improved performance.

BACKGROUND: As part of a continuous quality assurance process which we instituted in 1999, we review videotapes of selected high-risk deliveries at our hospital. We utilized our reviews to evaluate the occurrence of errors, and to evaluate team and leader functions during neonatal resuscitation. METHODS: We established accepted behavior for members of resuscitation teams and the team leader. The actual conduct of the resuscitation was judged against the standard of the guidelines of the Neonatal Resuscitations Program of the American Heart Association, and the American Academy of Pediatrics. The videotapes of resuscitations were reviewed, and significant deviations from accepted practices were noted, and discussed by a specifically developed quality assurance committee, including, whenever possible, the actual resuscitators. RESULTS: We were able to detect a number of problems, which included inappropriate leader and team member activities, inappropriate preparation, communication, and coordination, and made a number of changes to our practice. CONCLUSIONS: We believe that neonatal resuscitation may be improved by the provision of teaching about team and leader functions, encouraging debriefing following complicated resuscitations, developing a minimal form to be completed for any patient requiring compressions or epinephrine within the delivery room, and providing more direct observations regarding the actual conduct of resuscitation.

Asphyxia Neonatorum↗

PubMed2002

Apnea at discharge and gastro-esophageal reflux in the preterm infant.

OBJECTIVE: To determine the relationship between respiratory patterns and acid gastro-esophageal reflux (g-e reflux) prior to discharge of the formerly preterm infant. STUDY DESIGN: Forty-five infants of <32 weeks' gestation were studied at an average postmenstrual age of 37.2 weeks (SD 3.5). Following informed parental consent, a 12-hour multichannel recording including esophageal pH was obtained. Apneas of greater than 10 seconds were recorded, as well as the occurrence of bradycardia or desaturation. RESULTS: Acid g-e reflux (pH <4.0) occurred at least once in all of the infants; prevalence was between <1% and 41% of the 12-hour record (median 4.6%, interquartile range 0.5% to 9%). The number of reflux episodes ranged from 1 to 143 (median 23). The number of apneas (>10 seconds duration) ranged from 0 to 71, median 6. There was no correlation between apnea frequency or severity and reflux frequency or duration. There was no difference in apnea frequencies between the 5 minutes after the start of a reflux episode and the 5 minutes prior to each episode. CONCLUSION: Acid g-e reflux in the formerly preterm infant at discharge is frequent and may be prolonged; there is no association between reflux and apnea.

Apnea↗

PubMed2002

Role of L-carnitine in apnea of prematurity: a randomized, controlled trial.

OBJECTIVE: Carnitine is thought to be a conditionally essential biological cofactor for premature infants. A preliminary study suggested that carnitine could significantly reduce apnea of prematurity. The objective of this study was to evaluate critically the role of carnitine in idiopathic apnea of prematurity and to determine whether the use of carnitine would facilitate discontinuation of mechanical ventilatory support, shorten the duration of ventilatory support, and reduce the amount of time that such infants are exposed to both mechanical ventilation and oxygen. We also wanted to determine the effects of supplemental carnitine on weight gain, time to regain birth weight, time to achieve full enteral feedings, and length of hospital stay. METHODS: A prospective, randomized, blinded trial was conducted on 44 preterm infants who were from the same neonatal intensive care unit and who were < or =32 weeks' gestational age with a postnatal age <48 hours and a birth weight <1500 g and required total parenteral nutrition (TPN). Infants were randomized to receive carnitine supplementation or placebo without crossover. Carnitine-supplemented infants received 30 mg/kg/d carnitine in their TPN until the they were tolerating 120 mL/kg/d enteral feedings, and then they received 30 mg/kg/d oral carnitine. The placebo group received TPN without supplemental carnitine; when they tolerated 120 mL/kg/d enteral feedings, they received an oral placebo. The 2 groups continued on their respective supplemental carnitine or placebo until 34 weeks' adjusted age, at which time the study period was completed. Twelve-hour cardiorespiratorygrams to record heart rate, respiratory impedance, and oxygen saturation, and a nasal thermistor to detect expiratory airflow were performed every 4 days on 3 occasions and at 30 and 34 weeks' adjusted age. Plasma carnitine levels were measured at day 14. RESULTS: There were no significant differences between the 2 groups in the occurrence of apnea as detected by cardiorespiratorygram or nursing observation. There were no significant differences between the groups in regard to total days on ventilator, days of nasal continuous positive airway pressure, time to regain birth weight, time to reach enteral feedings of 120 mL/kg/d, discharge weight, adjusted age at discharge, need for oxygen at 28 days' and 36 weeks' adjusted age, or length of stay. The plasma carnitine level was a median of 15.5 micromol/L (range: 7.6-30.5) for the placebo infants compared with a median of 195.3 micromol/L (range: 71.7-343.6) for the carnitine infants. CONCLUSIONS: In this blinded, randomized, placebo-controlled study, we found that infants who received supplemental carnitine did not demonstrate any reduction in apnea of prematurity, ventilator or nasal continuous positive airway pressure days, or the need for supplemental oxygen therapy. Although carnitine may be of significant nutritional benefit for very low birth weight infants, our study does not support its use to reduce apnea of prematurity or decrease dependence on mechanical ventilation.

Aminophylline↗