Management of Neonatal Respiratory Distress in Transport

The purpose of this QI initiative was to develop evidence-based bubble continuous positive airway pressure (bCPAP) versus intubation guidelines designed to direct a course of action for the neonatal transport team retrieving neonates in respiratory distress from outside facilities. When researching evidence for the guideline initiative we discovered there are no transport national guidelines for respiratory management of neonates who require transport to level IV neonatal facilities. For decades, the treatment for neonates with respiratory compromise has been intubation with assisted ventilation. However, evidence suggests mechanical ventilation has a higher potential for damaging neonatal alveoli resulting in long term respiratory disability. The practice of using the alternative of bCPAP has become more prevalent in treating neonates in respiratory distress which has resulted in less intubations in neonates. The question now becomes how far to push the bCPAP before intubation is needed to stabilize a neonates airway for transport. In hospital use of bCPAP has more leeway in how far they push the bCPAP before a neonate must be intubated in a controlled environment. In an effort to improve delivery of care and stabilization of the airway during transport, clinical guidelines for bCPAP versus intubating neonates were developed and initiated by our Transport Team. Guidelines for a wide range of pediatric pathologies are needed for teams who transport ill children to high level care facilities. However, due to the significant morbidity and mortality associated with neonatal respiratory distress, writing a guideline directing the care of neonates who continue to struggle despite the application of bCPAP was a priority. Training included literature searches, epidemiology, design, biostatistics, culture change, dissemination of findings, and writing abstracts, policies and procedures. Using the Johns Hopkins Model, evidence from multiple sources was analyzed. Subsequently, an algorithm was developed and incorporated in a guideline. In the event of CPAP failure, the team should intubate the infant, obtain a tracheal aspirate, and depending on the infant's weight, instill lung surfactant with budesonide. The goal: to clarify actions and reduce variability for neonatal airway management during transport and reduce the need for endotracheal intubation. Our guidelines were initiated during the 3 quarter of 2017. We plan to gather QI data points starting at the one ye