NeoReviews 2014_06

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This program is accredited for 1.00 NAPNAP CE contact hour; pharmacology (Rx) and psychopharmacology contact hours to be determined per the National Association of Pediatric Nurse Practitioners (NAPNAP) Continuing Education Guidelines. It has been established that each CME activity will take the learner approximately 1 hour to complete.

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How to complete this activity

NeoReviews can be accessed and reviewed in print or online at http://neoreviews.aappublications.org. Learn ers can claim credit monthly online upon completion of each CME article. The deadline for completing this activity is December 31, 2016. Credit will be Jane McGowan, Philadelphia, PA

Karen M. Puopolo, Boston, MA Renate Savich, Albuquerque, NM Karen Shattuck, Galveston, TX Michael P. Sherman, Columbia, MO

Founding Editor: William W. Hay Jr, Denver, CO

International Advisory Board:

Malcolm Battin, Auckland, New Zealand Matts Blennow, Stockholm, Sweden Jose Diaz Rossello, Montevideo, Uruguay Janusz Gadzinowski, Poznan, Poland Gorm Greisen, Copenhagen, Denmark Kazushige Ikeda, Tokyo, Japan Ian Laing, Edinburgh, Scotland Frank Pohlandt, Ulm, Germany

Jorge César Martinez, Buenos Aires, Argentina J. Jane Pillow, Subiaco, Western Australia Siddarth Ramji, New Delhi, India Francesco Raimondi, Naples, Italy Eric Shinwell, Jerusalem, Israel Umberto Simeoni, Marseille, France Bo Sun, Shanghai, China Cleide Trindade, Sao Paolo, Brazil Maximo Vento, Valencia, Spain Andrew Whitelaw, Bristol, United Kingdom David Woods, Cape Town, South Africa Khalid Yunis, Beirut, Lebanon Tsu-Fuy Yeh, Taichung, Taiwan

Liaison, Council on International Neonatal Nurses:

Carole Kenner, Boston, MA

Liaison, National Association for Neonatal Nurses:

Susan Reinarz, PhD, DNP, ARNP, NNP-BC, Grand Prairie, TX

Managing Editor: Luann Zanzola

Editorial Associate: Sara Strand

Publisher: American Academy of Pediatrics

Associate Executive Director for Education: Robert Perelman

Division of Scholarly Journals Director: Michael Held

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(ISSN 1526-9906) is owned and controlled by the American Academy of Pediatrics. It is published monthly by the American Academy of Pediatrics, 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098. Statements and opinions expressed in NeoReviews™ are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees. Recommendations included in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Subscription price for NeoReviews™ for 2014: AAP Member $118; AAP National Affiliate Member $89; Nonmember $134; Allied Health/In-training $104; AAP Perinatal Section Member $104. Institutions call for pricing (866-843-2271).

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The American Academy of Pediatrics (AAP) Policy on Disclosure of Financial Relationships and Resolution of Conflicts of Interest for AAP CME Activities is designed to ensure quality, objective, balanced, and scientifically rigorous AAP CME activities by identifying and resolving all potential conflicts of interest before the confirmation of service of those in a position to influence and/or control CME content. All individuals in a position to influence and/or control the content of AAP CME activities are required to disclose to the AAP and subsequently to learners that the individual either has no relevant financial relationships or any financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in CME activities. Commercial interest is defined as any entity producing, marketing, reselling or distributing health-care goods or services consumed by, or used on, patients. Each of the editorial board members, reviewers, question writers, and staff has disclosed, if applicable, that the CME content he/she edits/ writes/reviews may include discussion/reference to generic pharmaceuticals, off-label pharmaceutical use, investigational therapies, brand names, and manufacturers.

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Disclosures

• JoDee Anderson, MD, MEd, FAAP, disclosed that she has a paid consultant relationship with SimHealth and the STABLE Program.

• Josef Neu, MD, FAAP, disclosed that he serves as a consultant to

Abbott Nutrition, BioGaia, Mead Johnson, Medela, and Fonterra Foods; he receives honoraria from Nestlé and Danone; and he has research grants with Covidien and Gerber.

NeoReviews™

Vol.15 No.6 June 2014

Articles

e220

Commentary:

Tribute to Claudine Amiel-Tison

Alistair G.S. Philip

Nursing Perspectives:

Transforming NICU Culture: The Power

e221

of Meaningful Recognition

Cindy Lefton

e225

Ventilator-Associated Pneumonia in Neonates:

An Update

Jeffery S. Garland

e236

Surfactant for Respiratory Distress Syndrome

Alan Jobe

Index of Suspicion in the Nursery:

Seizures Presenting

e246

at 10 Days of Age

Gunjan Dokania, Hitesh Agrawal, Paul N. Severin

e249

Strip of the Month:

June 2014

Maurice L. Druzin, Nancy Peterson

Video Corner:

Pigtail Catheter Placement for Pneumothorax

e257

Evacuation

Akshaya Vachharajani, Aimee Moore

e260

Visual Diagnosis:

Newborn With Multiple Congenital Anomalies

Sheshashree Seshadri, Vallier Ojadi

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Commentary

Tribute to Claudine Amiel-Tison

There are many things that contribute to the success of a journal. In addition to the members of our Editorial Board who provide substantial support by re-viewing articles submitted to NeoReviews, we also established an International Advisory Board (soon after the journal started) to obtain insights from other countries. As many of our readers will know, one of the major contributors to our International Advisory Board was Dr (Prof) Claudine Amiel-Tison. Those who have perused the Historical Perspec-tives that we collected as “Milestones in Neonatal-Perinatal Medicine” to com-memorate our 10th anniversary will recognize the important contributions she made to the neurological evaluation of the neonate and the changes that occur with advancing gestational age. (1)(2) This followed in the tradition of doctors Andre´ Thomas and Suzanne Saint-Anne Dargassies, whose work she

was always quick to acknowledge, be-cause most of their work was published in French.

Claudine not only contributed sev-eral articles herself to NeoReviews, she also suggested many other contributors and was a strong supporter of the jour-nal. It is my sad duty to report that she died of cancer in December 2013 (she was born in 1929). It is particularly dif-ficult for me to acknowledge her death because I had known her for almost 45 years. We first met when I was attached to Hoˆpital Baudelocque and Hoˆpital Port-Royal with Prof Alexandre Minkowski in Paris and evaluated patients and con-ducted research under her supervision. She was one of a wonderful group of women assembled by Prof Minkowski at the Centre de Recherche Neonatale, whose contributions were outlined by Paul Toubas in an article in NeoReviews. (3) Subsequently, I was the recipient of

her gracious hospitality over several decades, and we shared some difficult times together. It is hard to think that her dynamic personality and wicked sense of humor are no longer with us, but the lessons she taught us about evaluating neonates and older children live on.

References

1. Amiel-Tison C. Historical perspectives: neurologic maturation of the neonate. NeoReviews. 2003;4:e199–e205 2. Philip AGSP, ed. Milestones in

Neonatal/Perinatal Medicine. Elk Grove Village, IL: American Academy of Pediatrics; 2010

3. Toubas PL. Pioneer women in neonatology: Part 3: the roaring sixties (1960–1980). NeoReviews. 2011;12: e361–e367

Alistair G.S. Philip, MD Editor-in-Chief, NeoReviews

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Culture:

The Power of Meaningful Recognition

Cindy Lefton, PhD, RN* Author Disclosure Dr Lefton has disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device.

Abstract

Amazing care delivery happens in neonatal intensive care units (NICUs) around the globe, 24/7. As you are reading this abstract, thousands of acts involving extraordinary nursing have occurred in NICUs (babies have been held by their parents for the first time, parents have been comforted and given hope for their child’s future, a few extra milliliters of a tube feeding were tolerated, and children were successfully weaned off ventilators). Behind each of these amazing acts are nurses who come together not only to deliver clinical excellence but also to create a NICU culture that turns fear and un-certainty into hope and optimism. Derived from the collective behaviors of staff, the culture of a NICU can also be influenced and shaped by recognizing the contributions nurses make every day. Research involving The DAISY Award (an acronym for “dis-eases attacking the immune system”), which recognizes nurses in a meaningful way for their extraordinary contributions, found that this type of acknowledgment benefits in-dividuals, units, and organizations. This article explores the impact meaningful recog-nition can have on the NICU culture and how this type of feedback can be used to sustain healthy work environments.

The DAISY Foundation (an acronym for“diseases attacking the immune system”) was founded in 1999 by the family of J. Patrick Barnes, who died at age 33 of complications of the autoimmune disease idiopathic thrombocytopenic purpura. During Patrick’s 8-week hospitalization, his family was deeply touched by the care of his nurses, not only their clinical excellence but especially the compassion and sensitivity they brought to Patrick and his family. In gratitude to the nurs-ing profession, they created The DAISY Award for Extraordinary Nurses to honor and cel-ebrate the special things nurses do every day in all health-care settings. Today, The DAISY Award is celebrated in more than 1,600 facilities throughout the United States and in nine other countries (http://www.DAISYfoundation.org). This article links the concept of meaningful rec-ognition as represented by The DAISY Award to the speciﬁc care provided by nurses working in Neonatal Intensive Care Units (NICUs) and how such recognition can inﬂuence the culture of these units.

Entering a neonatal intensive care unit (NICU), one’s senses are immediately stimulated by the sounds of infusion pumps and ventilators and the sight of the tiniest human beings surrounded by myriad tubes. Accompanying these sights and sounds are nurses engaged in the ongoing process of combining their clinical expertise with technology, not only to care clinically for these babies but also to deliver care that helps transform family members’ fear, anxiety, and apprehension to hope, optimism, and dreams of a bright future. Although a part of this transformation rests on how clinical expertise and technology are integrated into care delivery, the culture of the NICU also provides a strong inﬂuence on how family members perceive their experience and successfully cope with an unplanned hospitaliza-tion. The nature of a NICU culture, an environment where precious and vulnerable infants are entrusted by parents to the care of nurses, lays the foundation for lasting memories, emotional connections, and lifelong gratitude to occur.

Although clinical expertise and technology are key aspects of NICU care, the ability of a nurse to connect on an emotional level with family members is also critical to the child’s well-being. NICU cultures that actively promote the development of these types of relation-ships between nurses and their family members are more readily able to embrace healthy work environments. (1,2) NICUs that embrace and value healthy work environments are in a position to use employee emotional and professional well-being as strategies to have

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a positive impact on the unit and organization’s culture, overall performance, and the patient experience. (3)

Healthy Work Environment and

Organizational Culture

A key piece of a healthy work environment is the culture of an organization. An organizational culture is best de-scribed as the shared values of the workplace (what the organization deems important, what people believe re-garding how work is accomplished, and the norms that guide how people go about completing their jobs). (4) Cultures are formed at the organizational level, as well as within individual units and can occur even between dif-ferent shifts. The common thread among the cultural el-ements of shared values, beliefs, and norms is behavior. In other words, through our behaviors, we demonstrate our beliefs about our ability to have an impact on patients, families, and workplace. Our actions also convey what is important and valued by the organization and individual units. In turn, our behaviors demonstrate how committed we are to following the established and accepted care de-livery norms within each individual unit, as well as through-out the entire organization.

Nurses often encounter cultural differences when they get pulled to another area. These differences include in-care delivery variations related to the age of the child and the nature of the illness/injury, but often more com-plex are the different cultural nuances that drive how the work gets accomplished in each area. A common example of the impact a culture can have on an individual unit in-volves how you and your coworkers deal with consistent supply and/or equipment shortages. The culture (norms, values, and beliefs) on your unit may deem taking supplies from other ﬂoors as an acceptable solution to deal with the shortage. In another unit, the lack of necessary equipment and supplies triggers a process in which supply levels are immediately re-evaluated and changed to meet patient and staff needs. In these examples, the culture drives the solutions that address supply and equipment shortages. Along with tangible items such as supplies and equipment, intangible acts such as feedback, team cohesion, and sup-port from colleagues and leaders can also strongly inﬂu-ence our behaviors, beliefs, norms, values, and the health of our work environments. The impact teamwork, leadership support, and positive feedback have on creating and sustaining healthy work environments has been well documented. (1,3,5–8)

In 2005, the American Association of Critical-Care Nurses (AACN) released the standards of a healthy work environment; these included Skilled Communication,

True Collaboration, Effective Decision Making, Authentic Leadership, Appropriate Staffing, and Meaningful Recogni-tion. These standards provided evidence demonstrating the impact intangible cultural attributes can and do have on the health of one’s work environment. Much of the research exploring these standards has focused on the influence as-sociated with leadership, collaboration, communication, decision-making, and staffing. Interestingly, less emphasis has been devoted to understanding the powerful influence of meaningful recognition. (7) Often mistaken for an “atta girl” or “atta boy” pat on the back, meaningful recognition goes much deeper than a “thank you” or “good job.” A powerful form of positive feedback, meaningful recognition acknowledges how a person’s actions affect the life of an-other, is relevant to the recipient, and is equivalent to his or her contribution. (9) In other words, meaningful recog-nition involves heartfelt feedback describing how a per-son made a difference in the lives of others and is delivered in a way that is meaningful to the recipient.

Studying the Power of Meaningful

Recognition

One of the most powerful ways to influence a culture in-volves devising a feedback process that allows staff and families the opportunity to recognize all of the extraordi-nary nursing occurring in a unit and/or organization. (5,7,10) Currently, 1,630 health-care facilities use The DAISY Award as a vehicle to acknowledge in a meaningful way how extraordinary nursing positively shapes patient and family member experiences. Research involving the analysis of more than 2,000 patient, family, and colleague DAISY Award nominations, interviews with chief nurse leaders, and DAISY Award recipients from 20 hospitals across the country found that recognizing nurses in a meaningful way positively influenced honorees’ percep-tions about their work, as well as the culture of their orga-nization and team spirit within individual work areas. (7,11) Specifically, this research demonstrated that provid-ing meanprovid-ingful recognition can elevate the value of nurs-ing, reconnect people with why they became nurses, nurture team spirit, increase one’s self-awareness of the im-pact they had on the lives of others, instill individual pride, and motivate extraordinary nursing. (7)

“She has helped us get through some tough times here and never fails to help us ﬁnd the positives. We look forward to seeing her on her shifts and feel very comfortable leaving at night and know our precious daughters will be safe in her care.” —NICU parents

Along with the cultural and individual beneﬁts, mean-ingful recognition processes such as The DAISY Award also serve as a continuous feedback mechanism devoted solely

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to catching “all the right going on” in a unit and an orga-nization. Feeding back to staff “all the right going on” re-inforces these behaviors associated with extraordinary care. Recognizing extraordinary care in a meaningful way con-veys that employee actions are valued. When people feel val-ued by their workplace and colleagues, they experience elevations in self-esteem and feel more committed to their work group and organizations. (5,6,8,12–18)

In the NICU, recognizing extraordinary nursing serves as a catalyst to creating and sustaining cultures in which trust and emotional connections, combined with clinical excel-lence, produce a robust outcome: premature infants grow-ing into healthy babies. The intensity of gratitude connected to the cultural attributes consisting of trust, emotional con-nections, and clinical excellence is demonstrated in NICUs across the country where unit walls are lined with updated pictures of former patients, many of whom return, year after year, with their parents to recognize the staff for their ex-traordinary work.

“We are given a new being that has yet to have an essence. Every decision that we make, every action that we execute, will impact this new person’s destiny.” —NICU RN

Along with helping family members experience hope and enabling premature infants to grow into children with the potential of leading healthy lives, the NICU culture also serves as a role model for integrating family members into care delivery. The ability to consistently and success-fully integrate and engage family members in the care of their child is one of the critical pieces associated with ac-countable care. Using feedback to acknowledge how NICU nurses help families cope with the situation, inspire them to learn how to care for their child with conﬁdence, and alleviate fear reinforces nursing behaviors that promote the delivery of accountable care. Recognizing “all the right going on” also provides a “continuous stream” of real-time patient and family member feedback regarding how effec-tive NICU nurses are in delivering accountable care.

“He works diligently to help parents learn what they need to know to take care of their babies at home, helping them over-come incredible obstacles such as illiteracy, language barriers, and limited resources with dealing with health and caring for their child.” —NICU nurse colleague

A “continuous stream” of “all the right going on” also allows NICUs to use meaningful recognition as a strat-egy to implement and measure effective accountable care practices. Empowering nurses to recognize the differ-ence they make in the lives of those they serve and acknowledge their extraordinary behaviors reinforces a cul-ture in which engaging families in the child’s care is the

norm and a valued part of the NICU experience. Recog-nizing and celebrating “all the right going on” sustains cultural norms that guide nurses in helping families simultaneously grasp the reality of their situation, em-brace optimism and hope, and gain the courage to actively engage in their child’s care. When new nurses and families enter a NICU with a culture that embraces a healthy work environment, they pick up on these cues and quickly learn that extraordinary is not only a practice but also “the way work is done” in the unit. Along with feedback from the families, NICU nurses working in units where meaningful recognition is ﬁrmly embedded in the culture routinely recognize “all the right going on” and acknowledge their colleagues’ contributions. When this recognition occurs, coworker nurturing becomes a normal part of the cultural NICU fabric, which strengthens work-group connections, intensiﬁes personal commitments to the unit, and increases both the frequency of experiencing personal pride in one’s work and elevation of one’s self-esteem. (7)

“She touched the family by her presence. Her gentle spirit, backed by her expertise, provided a sense of peace. We are hon-ored to work with such a caring nurse who so generously shares her amazing gifts with her coworkers and patients.” —NICU RN colleague

The norms, values, and beliefs created by the staff inﬂu-ence how compassion and professionalism are combined with clinical excellence and integrated into care delivery. The “how” that encompasses nurse behaviors melded with cultural norms, beliefs, and values set the stage for emotional connections with family members and patients that often last a lifetime. These unique attributes of NICU cultures allow an environment to emerge in which dreams are restarted and initial sadness evolves into joy and hope as the nurses are able to convince families that whatever the future holds, they can and will rise to the challenges before them. Recog-nizing in a meaningful way “how” NICU nurses help families embrace these difﬁcult situations can be used as a feedback mechanism to consistently reinforce a cul-ture of extraordinary nursing.

“She went above and beyond with answering questions, com-forting our concern, and by listening while we talked ourselves out of being scared” —NICU parents

Conclusions

Recognizing the extraordinary work of NICU nurses in a meaningful way creates a culture in which grief is trans-formed into encouragement, optimism, and engagement. Although this amazing transformation occurs daily in NICUs across the country, much of the feedback in

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health-care revolves around what went wrong with a pa-tient and/or their family, and performance improvement op-portunities often focus on correcting “broken” processes. Although a robust performance improvement process is necessary, many health-care organizations would likely benefit from devoting time to study the minutia of “all the right going on.” At one of the most horrific times a parent can experience, NICU nurses use their tangible and intangible skills to help families rise above the fear and apprehension often experienced when a child is a NICU patient. This combination of clinical nursing excellence, care, genuine compassion, professionalism, an emotional connection, and contagious positive at-titude helps devastated family members, who are often paralyzed by the unknown and unanticipated, become joy-ful, encouraged, and engaged in the care of their child. This remarkable transformation would likely benefit from a better understanding of the cultural influences associ-ated with “all the right going on” and devising systems, technology, policies, and practices that allow “all the right” to flourish. Recognizing extraordinary nursing is a budget-neutral tool that reinforces and celebrates “all the right going on.” Combining meaningful rec-ognition with the NICU nurses’ skills of engaging par-ents in care delivery and their clinical savvy is the perfect formula for ensuring that all patients, regardless of age, size, illness, or injury, and their family members are engaged recipients of accountable health-care.

ACKNOWLEDGMENT.I thank Bonnie Barnes, FAAN,

co-founder and president of The DAISY Foundation, for her support and help in preparing this article. The Barnes family and The DAISY Foundation are nursing’s best cheerleaders, and we thank you for your passion and re-lentless pursuit of ensuring that we recognize the extraor-dinary work of nurses each and every day.

References

1.Avery JB, Wernsing TS, Mhatre KH. A longitudinal analysis of positive psychological constructs and emotions on stress, anxiety and well-being. J Leadersh Organ Stud. 2011;18(2):216–228

2.Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med. 1998;47(10): 1611–1617

3.Grawitch MJ, Gottschalk M, Munz DC. The path to a healthy workplace: a critical review linking healthy workplace practices, employee well-being, and organizational improvements. Consult Psychol J Pract Res. 2006;58(3):129–147

4.Daft RL. Organization Theory and Design. St Paul, MN: West Publishing Company; 1992

5.Froman L. Positive psychology in the workplace. J Adult Dev. 2010;17(2):59–69

6.Kalisch BJ, Lee H, Rochman M. Nursing staff teamwork and job satisfaction. J Nurs Manag. 2010;18(8):938–947

7.Lefton C. Strengthening the workforce through meaningful recognition. Nurs Econ. 2012;30(6):331–338, 355

8.Ulrich BT, Lavandero R, Hart KA, et al. Critical care nurses’ work environments 2008: a follow-up report. Crit Care Nurse. 2009;29(2):93–102

9.American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence. Am J Crit Care. 2005;14(3):187–197

10.Nahrgang JD, Morgeson FP, Hofmann DA. Safety at work: a meta-analytic investigation of the link between job demands, job resources, burnout, engagement, and safety outcomes. J Appl Psychol. 2011;96(1):71–94

11.Barnes B, Lefton C. The power of meaningful recognition in a healthy work environment. AACN Adv Crit Care. 2013;24(2): 114–116

12.Blegen MA, Goode CJ, Johnson M, Maas ML, McCloskey JC, Moorhead SA. Recognizing staff nurse job performance and achievements. Res Nurs Health. 1992;15(1):57–66

13.Bargagliotti LA. Work engagement in nursing: a concept analysis. J Adv Nurs. 2012;68(6):1414–1428

14.Hayes LJ, O’Brien-Pallas L, Dufﬁeld C, et al. Nurse turnover: a literature review. Int J Nurs Stud. 2006;43(2):237–263

15.Lu H, While AE, Barriball KL. Job satisfaction among nurses: a literature review. Int J Nurs Stud. 2005;42(2):211–227

16.O’Driscoll MP, Randall DM. Perceived organizational support, satisfaction with rewards, and employee job involvement and organizational commitment. Appl Psychol-Int Rev. 1999;48(2): 197–209

17.Qaseem B, Shea J, Connor SR, Casarett D. How well are we supporting hospice staff? Initial results of the Survey of Team Attitudes and Relationships (STAR) validation study. J Pain Symptom Manage. 2007;34(4):350–358

18.Tourangeau AE, Cummings G, Cranley LA, Ferron EM, Harvey S. Determinants of hospital nurse intention to remain employed: broadening our understanding. J Adv Nurs. 2010;66 (1):22–32

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Neonates:

An Update

Jeffery S. Garland, MD, SM* Author Disclosure Dr Garland has disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device.

Practice Gaps

1. Accurately determining the specific organism responsible for ventilator-associated pneumonia is challenging in neonates.

2. Few randomized trials have been conducted to evaluate measures to prevent ventilator-associated pneumonia in neonates.

3. It is not known whether a level or head-elevated position influences the risk of ventilator-associated pneumonia (VAP).

Abstract

Health-care–associated infections affect neonatal morbidity and mortality, as well as length of stay and hospital costs. Ventilator-associated pneumonia (VAP) accounts for 6.8% to 32.2% of these infections. Low birthweight, duration of mechanical ven-tilation, opiate treatment for sedation, frequent suctioning, and reintubation have all been shown to increase the risk of VAP. Both Gram-positive and Gram-negative or-ganisms that originate from endogenous or exogenous sources are responsible for VAP. Accurately diagnosing VAP in neonates is challenging because procedures such as tracheal aspirate culture and Gram-stain have low sensitivity, speciﬁcity, and positive predictive value. Although several authors have shown that bronchial aspirates through nonbronchoscopic bronchoalveolar lavage improve diagnostic accuracy, further stud-ies are needed to investigate the diagnostic value and safety proﬁle of these procedures. Very few randomized trials have been conducted in neonates to evaluate methods to prevent VAP, and thus most neonatal VAP prevention recommendations are based on adult trials. This review summarizes the epidemiology, pathogenesis, diagnosis, and treatment of VAP and touches on a number of practical steps to prevent VAP in neonates.

Objectives

After completing this article, the reader should be able to: 1. Describe the risk factors for neonatal ventilator-associated pneumonia (VAP). 2. Describe the current methods used to diagnose neonatal VAP.

3. List the most common organisms responsible for neonatal VAP. 4. Explain initial treatment of neonatal VAP.

5. Outline steps to prevent neonatal VAP.

Introduction

The Centers for Disease Control and Prevention (CDC) deﬁnes ventilator-associated pneumonia (VAP) as an episode of pneumonia in a patient who requires a device to assist or control respiration through a tracheostomy or endotracheal tube within 48 hours before the onset of the infection. (1) Although the exact incidence of VAP is difﬁcult to determine, VAP may be responsible for as many as one-third of the health-care–related infections in neonates. (2)(3)(4)(5)(6) The present review summarizes the epidemiology, suspected pathogenesis, diagnosis, treat-ment, and strategies for the prevention of VAP in neonates.

Abbreviations

CDC: Centers for Disease Control and Prevention NHSN: National Healthcare Safety Network SDD: selective digestive tract decontamination VAP: ventilator-associated pneumonia

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Epidemiology

Increased permeability of the skin and mucous mem-branes, decreased complement activity, lower concen-trations of immunoglobulins, and an immature and dysregulated immune system together increase the risk of health-care–acquired infections in critically ill neo-nates. Multiple physiologic mechanisms optimally protect the lung parenchyma from infection, including: anatom-ical barriers; the cough reﬂex; the tracheobronchial mu-cociliary lining and secretions; and cell-mediated and humoral immunity, including the phagocytic functions of alveolar macrophages and neutrophils. If these de-fenses are impaired, absent, or overcome by a high inoculum of organisms or those of unusual virulence, pneumonitis ensues.

Data from the CDC’s National Healthcare Safety Net-work (NHSN) (2006–2008) at 304 participating hospi-tals revealed VAP rates of 2.36 and 2.08 per 1,000 device-days among neonates weighing less than 750 g and between 750 and 1,000 g, respectively. (7) The true rate of neonatal VAP is difficult to establish. Radiographic identification of neonatal pneumonia is difficult, compro-mised by evolving parenchymal changes due to broncho-pulmonary dysplasia and frequent episodes of atelectasis. Diagnostic procedures commonly used in adults to diag-nose VAP (eg, bronchoscopic bronchoalveolar lavage, protected specimen brushing) are

rarely used in the neonatal intensive care unit (NICU), in part due to the small size of neonatal endotracheal tubes. Retrospective cohort studies conducted at single institutions re-port higher VAP rates (10.9–52 in-fections per 1,000 ventilator-days) than NHSN data. (2)(8)(9)(10) (11)(12)(13) Risk factors reported to be signiﬁcantly associated with VAP among ventilated neonates also vary from study to study. Low birthweight, prolonged mechanical ventilation, opiate treatment for se-dation, frequent suctioning and re-intubation, bloodstream infection, and steroid use have all been noted to be associated with increased risk of VAP. (14)(15)

Pathogenesis

Organisms responsible for VAP can originate from endogenous or

exogenous sources (Figs 1 and 2). A number of inves-tigators have described the role of pharyngeal and subglottic secretions in the development of VAP in adults. (16)(17)(18)(19)(20) Contaminated oral or gastric secretions of intubated, ventilated adult patients can pool above the cuff of the endotracheal tube, leak around the cuff, and enter the lower respiratory tract. Be-cause neonates are ventilated with uncuffed endotracheal tubes, they are likely at greater risk for aspiration of con-taminated oral or gastric secretions. Within the ﬁrst 48 hours of mechanical ventilation, (21)(22) Gram-positive oral organisms begin to colonize the trachea and endotra-cheal tube, and Gram-negative bacilli generally colonize endotracheal tubes in place for longer than 48 hours. One study provided some evidence that neonatal position-ing may inﬂuence the incidence of lower respiratory tract bacterial colonization. (23) In this study, tracheal coloni-zation was less common among neonates placed in a lateral position compared with neonates nursed in a supine position.

Organisms responsible for VAP may also originate from the stomach, although the exact role gastric ﬂora plays in the pathogenesis of VAP has been questioned. (24)(25) Torres et al (26) noted that VAP in adults was more common among supine patients compared with semi-recumbent patients. Farhath et al (27) noted

Figure 1. Endogenous sources of organisms responsible for ventilator-associated pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare. From: NeoreviewsPlus August 2010, Question 8, by AAP.)

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that pepsin, a marker for gastric contents, was detected in the trachea of 92% of a cohort of ventilated neonates, sug-gesting that contaminated gastric contents could make their way into the trachea of ventilated neonates. Based on trials that used rigorous culturing techniques and stan-dard deﬁnitions of VAP, oropharyngeal colonization likely plays a greater role than aspiration of contaminated gastric secretions. (22) Although previous bloodstream infection has been identiﬁed as a risk factor for VAP, these infections do not seem to be the source of VAP. (13) Bloodstream infections and translocation of bacteria from the gastroin-testinal tract are also believed to be an uncommon source of endogenous organisms responsible for VAP.

Exogenous sources may also be responsible for the pathogens causing VAP (Fig 2). Shortly after intubation, bacteria can coat the surface of endotracheal tubes and become enveloped within a biofilm produced by the mi-crobes. This biofilm can serve as an exogenous source of organisms responsible for VAP. In a study of adult pa-tients, Adair et al (28) noted that 70% of patients who have VAP had the same pathogens isolated from endotra-cheal biofilms and traendotra-cheal secretions. Pathogens that contaminate ventilator circuits, airway suctioning equip-ment, humidifiers, nebulizers, and, most importantly, care-givers’ hands (29) are sources of exogenous contamination

that can lead to VAP. Gram-negative organisms, which often colonize en-dotracheal tubes, are frequently noted in the ﬂora that colonize the hands of caregivers. (30)(31)

Microbiology

In adult and pediatric patients in whom reliable cultures can be ob-tained, Staphylococcus aureus and Gram-negative organisms (Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae, Enterobacterspecies, and Acinetobacterspecies) are the most common pathogens responsible for VAP. Gram-negative organisms were noted in 94% of tracheal aspirates from neonates who had VAP in a co-hort reported by Apisarnthanarak et al. (13) S aureus was recovered from w25% of cases, and multiple organisms were recovered from air-way secretions in 58% of cases. In a re-cent work by Cernada et al, (32) gram-negative organisms (particu-larly P aeruginosa) were responsible for 62% of VAP cases. This study diagnosed VAP by using bronchoalveolar lavage with a blind protected catheter; with this tech-nique, only 3 (16.7%) of 18 neonates had polymicrobial infections.

Diagnosis

The primary controversy regarding VAP in neonates is the criteria used to establish the diagnosis. (33) The CDC’s NHSN VAP criteria included radiographic, clin-ical, and microbiologic elements. (1) The difficulty in ob-taining noncontaminated microbiologic specimens that meet quantitative definitions for infection led the CDC to include a purely clinical definition of VAP for infants aged £1 year, as shown in Table 1. The criteria have not been validated in neonates, and they are often open to subjective interpretation because they overlap with a number of disease processes. As of January 1, 2014, the CDC and NHSN no longer analyze data for neonatal pneumonia because the diagnosis is so subjective accord-ing to a CDC workaccord-ing group. (34) Neonatal units may still perform internal VAP surveillance, but the data will not be analyzed by the NHSN.

Microbiologic criteria for VAP are shown in Table 2. (1) Note that these criteria presume that pulmonary specimens are obtained by using invasive testing, such

Figure 2. Exogenous sources of organisms responsible for ventilator-associated pneumonia (VAP). (Courtesy of Walt Earhart, Wheaton Franciscan Healthcare. From: NeoreviewsPlus August 2010, Question 8, by AAP.)

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as those obtained with bronchoalveolar lavage or through a protected specimen brush, frequently used to diagnose VAP in adults. As mentioned earlier, both techniques need to be performed through a bronchoscope, thus pre-cluding their widespread use in intubated neonates. Köksal et al (35) used invasive testing with nonbroncho-scopic bronchoalveolar lavage to obtain specimens from ventilated neonates with suspected pneumonia. Ninety percent of the 40 neonates who had clinically diagnosed

VAP had positive lavage culture results. Sensitivity, spec-ificity, and positive and negative predictive values were 90%, 90%, 70%, and 97%, respectively. The presence of intracellular bacteria in polymorphonuclear cells on Giemsa-stained smears was significantly higher in neo-nates who have VAP compared with colonized neoneo-nates. There were no significant complications, but because the procedure is blind to what actually is being cultured, it is possible that the samples were taken more proximally

Table 1.

CDC Alternate Criteria for Diagnosis of VAP Among Infants Age

£1 Year

Radiographic criteriaa

New or progressive infiltrate and persistent infiltrate Consolidation

Cavitation Pneumatoceles Clinical criteria

Worsening gas exchange (eg, oxygen desaturations, increased oxygen requirements, increased ventilator demand) And three of the following

Temperature instability

Leukopenia (<4,000 WBC/mm3) or leukocytosis (>15,000 WBC/mm3) and left shift (>10% band forms)

New onset of purulent sputum or change in character of sputum, or increased respiratory secretions or increased suctioning requirements

Apnea, tachypnea, nasal flaring with retraction of chest wall or nasal flaring with grunting Wheezing, rales, or rhonchi

Cough

Bradycardia (<100 beats per minute) or tachycardia (>170 beats per minute)

CDC¼Centers for Disease Control and Prevention; VAP¼ventilator-assisted pneumonia; WBC¼white blood cell count.

a_{In the absence of underlying conditions, one deﬁnitive chest radiograph is acceptable. Among infants who have underlying conditions, two or more serial}

deﬁnitive radiographs are required. For neonates, underlying pulmonary or cardiac disease may include respiratory distress syndrome, bronchopulmonary dysplasia, pulmonary edema, chronic obstructive pulmonary disease, and/or congenital heart disease.

Table 2.

CDC Microbiologic Criteria for Diagnosis of Common Bacterial or

Fungal VAP

In addition to radiographic and clinical criteria, at least one of the following is present: Positive growth in blood culture not related to another source of infection

Positive growth in culture of pleural fluid

Positive quantitative culture from minimally contaminated lower respiratory tract specimen (eg, BAL, protected specimen brushing)

‡5% BAL-obtained cells contain intracellular bacteria on direct microscopic examination (eg, Gram-stain) Histopathologic examination shows at least one of the following indications of pneumonia:

- Abscess formation or foci of consolidation with intense PMN accumulation in bronchioles and alveoli - Positive quantitative culture of lung parenchyma

- Evidence of lung parenchyma invasion by fungal hyphae or pseudohyphae

BAL¼bronchoalveolar lavage; CDC¼Centers for Disease Control and Prevention; PMN¼polymorphonuclear leukocyte; VAP¼ventilator-assisted pneumonia.

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from the trachea. Cernada et al (32) used a blind pro-tected catheter to assist in diagnosing pneumonia in an-other cohort of neonates who had suspected VAP. They did not report sensitivity or speciﬁcity of the procedure. A limitation of both of these studies is that they were com-pared with clinically diagnosed VAP and not with a gold standard such as a lung biopsy or tissue sample. Larger trials need to be conducted to assess the diagnostic value and safety proﬁle of the procedures.

In many NICUs, tracheal aspirate cultures and Gram-stains are commonly used to try to establish the diagnosis of VAP in neonates. Tracheal aspirates have low sensitiv-ity, specificsensitiv-ity, and positive predictive value for diagnos-ing VAP because it is difficult to distdiagnos-inguish between tracheal colonization and true pneumonia. (36) However, tracheal colonization of the airway with Gram-negative bacteria has been associated with adverse outcomes. (37) Tracheal aspirates from neonates who have sus-pected VAP may play a role in helping to identify or-ganisms colonizing the airway and aid in the choice of appropriate antibiotic therapy. This finding may be of value, given evidence that there is a greater risk of death in adults from VAP if their pneumonia was initially treated with the wrong antibiotic. (38)(39) Furthermore, a sterile tracheal aspirate culture may also be of value in that sterile cultures have a high negative predictive value for VAP. (40)

Routine use of clinical biomarkers such as C-reactive protein, soluble triggering receptor expressed on mye-loid type 1 cells, or procalcitonin to help identify VAP has not been supported in ventilated adults. (41) Stud-ies have not been conducted to determine the utility of biomarkers for the diagnosis of VAP in neonatal patients.

Treatment

There are no clear consensus guidelines for the optimal treatment of neonatal VAP. Most treatment recommen-dations are taken from adult guidelines and are supported by epidemiologic principles. Initial treatment should in-clude broad empiric therapy, preferably informed by local bacterial colonizing and antimicrobial sensitivity data. Local NICU antibiotic combinations for the empiric treatment of late-onset bloodstream infections should be used for suspected VAP, unless individual infant colonizing information is available. Empiric treatment will often include an antipseudomonal agent such as piperacillin/tazobactam or ticarcillin/clavulanate to pro-vide coverage of both Gram-negative and Gram-positive organisms. Carbapenems may be more appropriate for

initial empiric therapy if local ﬂora include extensive beta-lactamase–producing organisms. Additional Gram-negative coverage with an aminoglycoside is controversial but may be indicated when bacteremia is suspected or signiﬁcant systemic symptoms are present. If systemic symptoms are absent and the blood culture result is negative, de-escalating therapy by discontinuing the aminoglycosides may be appropriate. Gram-positive coverage for methicillin-resistant S aureus may be required if local epidemiologic data dictate its use.

Overall, multiple risk factors (eg, prolonged me-chanical ventilation, previous antibiotic exposure, mul-tisystem illness) place neonates at increased risk for multidrug-resistant VAP, and there is no validated means of assessing VAP severity or VAP improvement after treatment, as there is in adults. Because of these factors, most neonates who have VAP will receive a full course of empiric broad-spectrum antibiotic therapy unless speciﬁc culture results allow for the use of more narrow-spectrum therapy. (14)(15)

Prevention of VAP

The CDC (42) and the American Thoracic Society (43) have published guidelines for the prevention of health-care–associated pneumonia. “Bundles” bring together a number of evidence-based practices that, when applied as a single intervention (ie, the bundle), may result in im-provement that is greater than single evidence-based practices. (44)(45)(46) These recommendations address the following speciﬁc items.

Management of secretions and techniques for

suctioning

Adult VAP prevention bundles often include 30° to 45° of head elevation to prevent aspiration of contaminated oropharyngeal and gastric ﬂuids. The results of Aly et al (23) and Farhath et al (27) suggest that gravity may be used to prevent pathogens from gaining entry in-to the lower respirain-tory track of ventilated neonates. Farhath et al showed that a majority of ventilated neo-nates aspirated gastric pepsin, perhaps providing support for elevating the head of the neonatal bed, but this study did not evaluate the association between the presence of pepsin in the trachea and VAP. Aly et al evaluated tracheal colonization in supine and lateral-nursed venti-lated infants and found that the lateral-nursed infants had less tracheal bacterial colonization; however, the study did not speciﬁcally assess VAP. The optimum po-sition to nurse neonates for the prevention of VAP needs further investigation.

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The CDC recommends that secretions be cleared from above the cuff of the endotracheal tube anytime the tube is repositioned or removed. (42) Neonates are usually cared for with uncuffed endotracheal tubes. Suc-tioning the oropharynx around the endotracheal tube be-fore adjusting it or removing it may reduce risk of microaspiration of contaminated oropharyngeal secre-tions. Although close systems are frequently used for the care of ventilated neonates, they may present the po-tential for bacterial contamination if pooled secretions in the lumen are reintroduced into the respiratory tract with repeated suctioning. Conversely, closed suctioning could potentially reduce environmental contamination of the respiratory tract. In a study of 133 ventilated neonates randomized to a closed or open suction system, no differ-ence was noted in tracheal colonization patterns between groups, nor were there differences in VAP rates among treatment groups. Physiologic disruptions were less with the closed suction systems, and NICU nurses indicated that these systems were easier to use than open suction systems. (47) At minimum, separate suctioning equip-ment should be used for tracheal and oral secretions.

One recent study evaluated a low-sodium, physiolog-ically based solution for suctioning of ventilated neo-nates. (48) A signiﬁcant reduction in the VAP rate was demonstrated after normal saline for airway suctioning was replaced by the novel solution for airway suctioning. Further trials with the solutions are necessary to conﬁrm these results. Finally, respiratory tubing should be drained away from ventilated infants to prevent aspiration of potentially contaminated condensate. (49) Breathing circuits do not need routine changing unless they become visibly soiled or they malfunction. (42)

Extubation procedures

VAP reduction bundles often recommend “sedation va-cations” to assess extubation readiness. Because many centers use minimal or no sedation for ventilated neo-nates, sedation vacations are uncommon in most units. Assessing for extubation readiness should be done on a daily basis. Noninvasive measures such as nasal contin-uous positive airway pressure and nasal prong ventilation may help to reduce VAP rates. (9) Reintubation after ex-tubation should be avoided if possible because of the in-creased risk of VAP associated with reintubation. (50)

Gastrointestinal and oropharyngeal

interventions.

Manipulation of gastrointestinal contents is part of adult VAP prevention. Although H2-blocker treatment is

fre-quently a standard intervention in bundles to prevent

VAP in adults, current data do not support such treat-ment in ventilated neonates. In addition, the use of H2-blockers is associated with increased risk of late-onset

fungal infection and necrotizing enterocolitis among very low birthweight NICU infants. (51)(52)

Selective digestive tract decontamination (SDD) with enteral nonabsorbable antimicrobials and antimicrobials applied directly to the oropharynx can decrease gastroin-testinal colonization and potentially reduce respiratory tract infections from microaspiration of gastrointestinal organisms. CDC guidelines (42) offer no recommenda-tion for the selective decontaminarecommenda-tion of the digestive tract. In a nonrandomized prospective trial of ventilated neonates, those who underwent SDD with polymyxin E, tobramycin, and nystatin had fewer nosocomial infections of intestinal origin. (53) VAP episodes were not reported separately. SDD should be evaluated further before it is considered for neonates outside of clinical trials. The use of probiotic treatment to inﬂuence neonatal gastroin-testinal colonization has focused on reducing late-onset bloodstream infections and necrotizing enterocolitis, but one recent trial of Lactobacillus reuteri administration also demonstrated the effect of probiotic administration on the incidence of VAP. (54)

The CDC recommends a comprehensive oral hygiene program in patients at high risk for health-care–associated pneumonia. (42) Although several groups have noted a reduction in VAP among adult patients treated with oral chlorhexidine gluconate decontamination, the CDC makes no recommendation for the use of an oral chlorhexidine gluconate rinse for the prevention of VAP in ill patients. Chlorhexidine gluconate is not ap-proved for neonates less than age 2 months. Because neo-nates do not have gingivitis or the dental diseases adults often have, oral care may not provide the beneﬁt it does in adult patients. Until further data are available, adhering to the recommendation of the American Dental Associ-ation to wipe off the gums and keep the mouth clean after feedings and when needed seems prudent.

Infection control measures

Hand hygiene is likely the most important infection con-trol intervention in health-care settings to reduce person– person transmission of bacteria. Pathogens responsible for neonatal VAP are carried on health-care workers’ hands and in the infants’ gastrointestinal tracts. Respira-tory equipment can become colonized with these organ-isms. (55) Thorough hand-washing before and after contact with respiratory equipment should reduce cross-contamination between patients.

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Changes in endotracheal tube design have decreased incidence of VAP in adults. A hole in the dorsal aspect of endotracheal tubes above the inﬂated cuff allows for clearing of subglottic secretions. The CDC recommends the use of such tubes in ventilated adults. (42) Unfortu-nately, such tubes are not available for neonates. Silver-coated endotracheal tubes, which are not available for neonates, have also been shown to reduce VAP in adults by reducing bioﬁlm formation and bacterial colonization. Figure 3 summarizes how practical preventative inter-ventions relate to the steps in the pathogenesis of VAP. Improved diagnostic criteria and surveillance tech-niques for VAP in the neonatal population need to be

es-tablished before the effectiveness of these strategies can be accurately assessed.

Figure 3.Relationship between preventative measures and pathogenesis of ventilator-associated pneumonia (VAP). (Adapted from Garland JS. Strategies to prevent ventilator-associated pneumonia in neonates. Clin Perinatol. 2010;37(3):638. Copyright 2010, with permission from Elsevier.)

American Board of Pediatrics Neonatal–Perinatal Content Specifications

• Know the pathogenesis and causative agents in an infant in whom neonatal pneumonia is suspected.

• Plan the clinical, imaging, and laboratory features and the management of an infant in whom neonatal pneumonia is suspected.

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NeoReviews Quiz Requirements

To successfully complete 2014 NeoReviews articles for AMA PRA Category 1 CreditTM, learners must demonstrate a minimum performance level of 60% or higher on this assessment, which measures achievement of the educational purpose and/or objectives of this activity. If you score less than 60% on the assessment, you will be given additional opportunities to answer questions until an overall 60% or greater score is achieved. NOTE: Learners can take NeoReviews quizzes and claim credit online only at: http://neoreviews.org.

1. A 10-day-old, 28-week-gestational-age male infant who has been on the ventilator has worsening clinical status and is suspected of having pneumonia. Which of the following statements regarding the development of ventilator-associated pneumonia (VAP) is correct?

A. Radiographic characteristics of VAP are very distinct and consistent, with a diffuse pattern of consolidation at onset.

B. A patient needs to be intubated for at least 5 days before onset of infection to have an official diagnosis of VAP.

C. Opiate treatment for sedation has been associated with increased risk of VAP.

D. A key feature in effective prevention of VAP is frequent suctioning and periodic replacement of the endotracheal tube.

E. A concurrent bloodstream infection rules out the diagnosis of VAP.

2. In the 10-day-old, 28-week-gestational-age patient, which of the following statements regarding diagnosis of VAP is correct?

A. It would be considered the standard of care to perform bronchoscopic bronchoalveolar lavage for the purpose of diagnosis in this patient.

B. The definition of VAP for neonates has been well established since the 1998 criteria published in a joint effort between the Centers for Disease Control and Prevention and the American Academy of Pediatrics. C. A sterile tracheal aspirate culture has a high negative predictive value for VAP.

D. Tracheal aspirates have excellent sensitivity (>98%) but poor specificity for diagnosis of VAP.

E. C-reactive protein has been very useful in the diagnosis of VAP, for distinguishing VAP from other disease processes, and for use in trials for establishing diagnostic criteria.

3. A tracheal aspirate is obtained from the patient who is suspected of having VAP. Which of the following has been found regarding tracheal aspirates in neonates who have VAP?

A. Gram-positive organisms are the most common bacteria noted in tracheal aspirates.

B. In general, the most common finding from tracheal aspirates of neonates suspected of having VAP are sterile or have a single-organism growth.

C. Streptococcus gallolyticus is found in 50% of neonates who have VAP.

D. Bronchoalveolar lavage with a blind protected catheter generally results in higher recovery of polymicrobial infections.

E. Pseudomonas aeruginosa is a pathogen recovered from airway secretions in VAP by using both tracheal aspirate and bronchoalveolar lavage methods.

4. The clinical care team has determined that the patient has VAP. What are appropriate principles regarding treatment for VAP in neonates at this gestational age?

A. Clear consensus guidelines for the treatment of very low birthweight infants were published by the Centers for Disease Control and Prevention (CDC), first in 1999 and updated in 2010.

B. In the majority of cases, if the patient’s condition is stable, the treatment of VAP is extubation to continuous positive airway pressure or nasal cannula, and does not require antibiotics.

C. Antibiotics should only be started after a pathogenic organism associated with VAP has been identified. D. Empiric treatment may include an antipseudomonal agent such as piperacillin/tazobactam.

E. Because organisms causing VAP are generally derived from mouth flora, penicillin is a reasonable first-line treatment or can be used if treatment is desired when no organism is recovered.

(17)

5. Your neonatal intensive care unit (NICU) is developing a bundle for prevention of VAP. Which of the following components may be a reasonable part of the protocol based on the studies discussed in this article?

A. Neonate should be positioned in the prone position at least one-half of the time if he or she has been intubated for more than 2 days.

B. Separate suctioning equipment should be used for tracheal and oral secretions. C. Respiratory circuits should be changed on a routine basis, daily or twice a day.

D. Normal saline has been shown to be the optimal solution for airway suctioning compared with all other solutions.

E. To minimize gastric aspiration, moderate sedation for vigorously moving infants should be applied, preferably with opioids.

(18)

Surfactant

for Respiratory Distress Syndrome

Alan Jobe, MD, PhD* Author Disclosure Dr Jobe has disclosed he is a consultant for Fisher & Paykel Healthcare, Chiesi Farmaceutici, AbbVie Inc., and Sobi (Swedish Orphan Biovitrum AB). This commentary does contain a discussion of an unapproved/ investigative use of a commercial product/ device.

Educational Gaps

1. There is a lack of recognition of the limitations and confounders for the diagnosis of respiratory distress syndrome (RDS).

2. Some practitioners lack experience with using continuous positive airway pressure (CPAP) in the delivery room to transition infants to spontaneous breathing. 3. There may be a lack of confidence to treat infants with surfactant other than by

intubation.

Abstract

Surfactant treatment is standard of care for infants who have respiratory distress syn-drome (RDS). However, many practical questions remain about what RDS is, and who should be treated and when. This review will attempt to answer these questions on the basis of new clinical trials and a perspective on the goals of treatment. Clinical data now support an initial use of continuous positive airway pressure to stabilize most infants before treatment, but the optimal way to treat an infant is under intense investigation. The best treatment option for an infant ultimately depends on gestational age, clinical status, and the experience of the clinician. The differences in surfactants are minor given the low rates of complications with any surfactant treatment. The clinical man-agement of RDS is the greatest success story in neonatology.

Objectives

After completing this article, readers should be able to:

1. Recognize the limitations of the clinical diagnosis of respiratory distress syndrome (RDS);

2. Decide how to best initially support preterm infants in the delivery room; 3. Assess an infant for the need for surfactant therapy; and

4. Anticipate the development of new approaches for surfactant treatments.

Introduction

Although surfactant for the treatment of respiratory distress syndrome (RDS) has been widely available since 1990, the population of infants who have RDS has changed over the last 24 years. Most infants now have been exposed to antenatal corticosteroids and many are smaller and more immature. (1) Neonatologists also have changed their manage-ment of infants who have RDS since the trials to validate surfactant treatmanage-ments. Recent trials have asked the following questions: Who should be treated? When should an infant be trea-ted? How should the surfactant be given? Which surfactant should be used? I will answer these questions from the perspective of the clinical trials, clinical practice, and my perspective on information about how surfactant works for the treatment of RDS. (2)

Who Should Be Treated With Surfactant?

Surfactants were developed speciﬁcally to replace surfactant deﬁciency, which is the initiating abnormality resulting in progressive respiratory failure in preterm infants. (2) As

Abbreviations

BPD: bronchopulmonary dysplasia CPAP: continuous positive airway pressure INSURE: intubate, surfactant, and extubate RDS: respiratory distress syndrome