Published online April 20, 2009
PEDIATRICS Vol. 123 No. 5 May 2009, pp. e907-e916 (doi:10.1542/peds.2008-1647)
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ARTICLE

Implementation of a Respiratory Therapist-Driven Protocol for Neonatal Ventilation: Impact on the Premature Population

Fernanda Hermeto, MD, Marcela Nosralla Bottino, MD, Kelly Vaillancourt, RRT and Guilherme Mendes Sant'Anna, MD, PhD, FRCPC

Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada

OBJECTIVE. The purpose of this work was to evaluate the impact of the implementation of a ventilation protocol driven by registered respiratory therapists on respiratory outcomes of premature infants with birth weight ≤1250 g.

METHODS. A ventilation protocol driven by a registered respiratory therapist was developed by a multidisciplinary group and implemented in our unit in July 2004. A retrospective review of 301 inborn infants with birth weight ≤1250 g who were mechanically ventilated was performed. Ninety-three infants were ventilated before the ventilation protocol (before), 109 in the first year (after 1) and 99 during the second year (after 2) after the ventilation protocol implementation. Data were collected with a predefined form.

RESULTS. The baseline characteristics of the population were similar among the 3 groups, except for a significant smaller number of male infants in the first year after the protocol implementation. The significant differences among the 3 periods were as follows: (1) time of first extubation attempt; (2) duration of mechanical ventilation; and (3) rate of extubation failure (40%, 26%, and 20%). There was no difference in the rate of air leaks, patent ductus arteriosus ligation, necrotizing enterocolitis, bronchopulmonary dysplasia, or death. There was a significant decrease in the combined rates of intraventricular hemorrhage grades III to IV and/or periventricular leukomalacia (31%, 18%, and 4%) after the protocol implementation.

CONCLUSIONS. 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.

Key Words: mechanical ventilation • extubation failure • lung injury • ventilation protocols

Abbreviations: RCT—randomized, controlled trial • RRT—registered respiratory therapist • BW—birth weight • MV—mechanical ventilation • VP—ventilation protocol • Ti—inspiratory time • MAP—mean airway pressure • FIO2—fraction of inspired oxygen • BPD—bronchopulmonary dysplasia • ROP—retinopathy of prematurity • PVL—periventricular leukomalacia • PCA—postconception age • IVH—intraventricular hemorrhage • CPAP—continuous positive airway pressure

Accepted Jan 12, 2009.


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