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Do Clinical Markers of Barotrauma and Oxygen Toxicity Explain Interhospital Variation in Rates of Chronic Lung Disease? Van Marter LJ, Allred EN, Pagano M, et al. Pediatrics 2000; 105:1194-1201.
This case-cohort study was designed to explore the hypothesis that variations in respiratory management among NICUs explains differences in chronic lung disease (CLD) rates. The NICUs studied were Babies’ and Children’s Hospital in New York [Babies’] and Beth Israel and Brigham and Women’s Hopsitals in Boston. 452 infants born at 500 - 1500 gram birth weight in 1991 - 1993 were included. The prevalence of CLD (defined at oxygen requirement at 36 weeks postmenstrual age) differed substantially between the centers: 4% at Babies’ and 22% at the 2 Boston Hospitals despite similar mortality rates. Initial respiratory management at Boston was more likely to include mechanical ventilation (79% vs 29%) and surfactant treatment (45% vs 10%). Case and control infants at Babies’ were more likely than those at Boston to have higher Pco2 and lower pH values on arterial blood gases. In multivariate logistic regression analysis, the initiation of mechanical ventilation was associate with increased risk of CLD: after adjusting for confounding factors, the odds ratios for mechanical ventilation were 13.4 on day of birth, 9.6 on days 1-3, and 6.3 on days 4-7. Among ventilated infants, CLD risk was elevated for maximum PIP > 25, and maximum FIO2 = 1.0 on the day of birth, lowest PIP > 20 and maximum Pco2 > 50 on days 1-3, and WBC < 8K on days 4-7.
Comment. Back in 1987, Mary Ellen Avery published a multicenter comparison of the incidence of CLD in 8 NICUs. Even back then, the Babies and Children’s NICU was credited with having the lowest CLD rate. It was suggested that this was because of their unique respiratory management strategy for VLBW babies which emphasizes early and routine use of CPAP, and more limited use of intubation and mechanical ventilation. Despite all the advances in NICU care in the 13 years since that report, the incidence of CLD remains essentially unchanged, and the disparity in CLD rates between NICUs remains large. Now the present study re-emphasizes that the use of mechanical ventilation was the single most important risk factor for the development of CLD in VLBW babies. Unless there are other centers out there who can claim a similar incidence of CLD in babies < 1500 gms (4% at Babies’) using a different respiratory management strategy, then I’d suggest that it’s high time for the rest of us to adopt the Babies’ strategy that includes early and routine CPAP use and avoidance of intubation and mechanical ventilation if possible.
Andrew B. Kairalla MD