Ventilator Management Protocol

Ventilator Management Protocol

Hermeto F, Bottino MN, Vaillancourt K, Sant'anna GM. Implementation of a Respiratory Therapist-Driven Protocol for Neonatal Ventilation: Impact on the Premature Population. Pediatrics. 2009 May: 123 (5): e907-16.[Full text] [PDF]

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 neuro-development.

Comments. The study was designed to evaluate the impact of the implementation of this RRT-driven protocol on respiratory outcomes of premature infants with birth weight (BW) 1250 g and born at our institution. The authors divided their patients into 3 groups according to 3 time periods; “before,” “after 1 year,” and “after 2 years,” of implementing their protocol. They found significant differences among the 3 periods in time of first extubation attempt; duration of mechanical ventilation; and rate of extubation failure, as well a significant decrease in the combined rates of intraventricular hemorrhage grades III to IV and/or periventricular leukomalacia after the protocol implementation. Having a ventilation protocol implemented in the NICU, whether driven by respiratory therapists, nurses or physicians, provides greater consistency of care and optimal ventilatory support utilizing evidence-based practice may result in minimal ventilation-related morbidity, and a decrease in the time spent on the ventilator. I agree with the authors that this study should open eyes for more prospective RCT to confirm their findings and to assess the impact on important outcomes such as BPD and neurodevelopment. SAA

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