A Consistent Approach to Noninvasive Ventilation

Respiratory distress continues to be the most common causes for admission to a neonatal intensive care unit (NICU) for term and preterm infants. The severity of symptoms and need for intervention increases the earlier the infant is born. The rate of premature delivery continues to increase in the United States, placing these infants at higher risk of respiratory morbidity and mortality. As new therapies have emerged, such as exogenous surfactant, improved mechanical ventilators, and new ventilation strategies, neonatal survival and outcomes have improved. There are wide variations in management, provider availability, and resources among different hospitals. The American Academy of Pediatrics has designated four levels of neonatal care that include; well newborn nursery (level I), special care nursery (level II), NICU (level III), and regional NICU (level IV). Special care nurseries are authorized to care for infants born at 32 weeks gestation or greater who weigh at least 1500 grams. Medical providers in level II nurseries can provide care to moderately ill infants who require mechanical ventilation or continuous positive airway pressure on an interim basis. If the infant does not improve within 24-48 hours, transfer to a tertiary NICU becomes necessary. This separation of mothers from their infants leads to significant financial and emotional burden. Resources in level II nurseries are limited in comparison with a regional NICU. Twenty four hour in-house provider coverage is often not available and infants are cared for by nurses and respiratory therapists with oversight by licensed independent practitioners. An algorithm to guide decision-making that identifies criteria for treatment failure is needed to provide consistency in managing respiratory support and improving patient outcomes. The overall aim of this project was to develop an evidence-based guideline to manage noninvasive ventilation in a level II nursery. The intent was to minimize lung injury, improve patient safety, and potentially reduce the need for transfer to an NICU. Evidence indicates that early intervention with noninvasive ventilation improves functional residual capacity and may prevent the need for more invasive respiratory support. Project objectives included providing education to clinicians in a special care nursery regarding lung protective strategies and establishing a decision-making algorithm to guide noninvasive ventilation. Secondarily, written failure criteria were established to identify infants who may benefit from neonatology consult, invasive mechanical ventilation, or transfer to a higher level of care. In collaboration with neonatal content experts and stakeholders at the implementation site, the guideline and lung protective strategy instruction were presented to clinical staff in a 19 bed, level II nursery in northern Utah. Clinical guidelines have been demonstrated to reduce variations in patient management, improve consistency in treatment approaches, and have been associated with improved patient outcomes.