The Prevalence and Outcome of Chronic Lung Disease

Babies in a Tertiary Neonatal UnitQUAD NETWORK RESEARCH STUDY DAY

Anju SinghAmy Walker

Shree Vishna Rasiah

Background

• Chronic lung disease – major morbidity among preterm babies especially

those extremely low birth babies (<1000grams)– prolonged hospital stays– discharge from the hospital with oxygen therapy– frequent readmission to the hospital in the first

year of life– risk of neurodevelopmental delays

Chronic lung disease

– morbidity and mortality more so in those with evidence of pulmonary hypertension

– need for additional ongoing medical support whilst on the neonatal unit and at home

Early CPAP Vs Intubation

• SUPPORT NEJM (1316 infants, 24 weeks- 27+6)

• VON, 2010(648 infants, 26 – 29 +6)• COIN, NEJM (610 infants, 25-28+6), Morley

2008• CURPAP Paeds ( 208 infants, 25-28+6), Sandri

et al No difference in the primary outcome of Death

or BPD

Stevens T.P., Blennow M., Myers E.H. et al. (2007) Early surfactant administration with brief ventilation vs. selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003063. DOI: 10.1002/14651858. CD003063.pub3

• 6 RCT’s• Lower incidence – mechanical ventilation [typical RR 0.67, 95% CI 0.57, 0.79],– air leak syndromes [typical RR 0.52, 95% CI 0.28, 0.96] – BPD [typical RR 0.51, 95% CI 0.26, 0.99]

• Lower treatment threshold (FIO2 < 0.45) reduced incidences of airleak syndromes and BPD

• Higher treatment threshold (FIO2 at study > 0.45) was associated with increased risk of PDA

Wheeler K, Klingenberg C, McCallion N, Morley CJ, Davis PG. Volume-targeted versus pressure-limited ventilation in the neonate. Cochrane Database of

Systematic Reviews 2010, Issue 11. Art. No.: CD003666. DOI: 10.1002/14651858.CD003666.pub3

• 12 RCT’s• Use of VTV modes – reduction in the combined outcome of death or

bronchopulmonary dysplasia [typical RR 0.73 (95% CI 0.57 to 0.93), NNT8

– Reductions in pneumothorax– days of ventilation – hypocarbia– combined outcome of PVL or grade 3-4

intraventricular haemorrhage

Aims

• To understand the prevalence and outcomes of CLD cases in a tertiary neonatal unit

Methods

• Badger database for all cases of CLD (defined by oxygen requirement at 36 weeks corrected gestational age)

• Outcomes• Impact on the neonatal services in the last 3

years.

Results

• Admissions: 3860

• CLD: 97

Results: demographics

Inborn babies Outborn babies

n 50 47

Mean Gestational Age in weeks (range)

26 (24-30) 25 (23-31)

Mean Birth Weight in grams (range)

820 (470- 1610) 830 (480-1430)

Male/ Female 27/23 27/20

Results: Plurality and EthinicityInborn Outborn

Singletons 36 39

Twins 14 7

Triplet 1

Ethinicity

British/ White other 34 32

Black Carebean 2 3

Asian 8 3

Mixed 2 8

Black african/ other 1 4

Results: steroids & deliveryAntenatal Steroids Inborn Outborn

Complete 37 21

Incomplete 6 15

None 3 9

Not known 3 3

Delivery

SVD 21 26

LSCS 29 21

Results: Ventilation daysInborn Babies Outborn babies

Mean Ventilation Days 21.9 (0-60) 27.3 (3-93)

Mean CPAP days 35.6 (1-82) 39.8 (6-93)

Results: Co-morbiditiesInborn Outborn

ROP Laser 2 8

NEC Surgery 8 14

Grade 3-4 IVH 1 9

Cystic PVL 4 5

PDA 34 36

Ligation 6 13

Ibuprofen/ Indomethacin 13 14

ResultsInborn Outboen

ECHO at 36 weeks 20 12

Evidence of Pulmonary Hypertension (PHN)

4 2

Medication for PHN 3 2

Postnatal Steroids 15 10

Diuretics 34 39

Synergis 13 14

ResultsInborn babies Outborn Babies

Total Deaths 6 2

Death secondary to Pulmonary Hypertension

3 1

Home 44 45

Home oxygen 19 17

Average length of stay (days)

106 119

Conclusion

• Outborns– Less antenatal steroids– More ventilation and CPAP days– More co-morbidities: NEC requiring surgery, ROP requiring

laser, significant PDA , grade 3-4 IVH, PVL– More average length of stay

•Inborns•More postnatal steroids•More Pulmonary hypertension•More deaths

Implications in practice

• Compare time epochs with change in practices

• Compare units within regions

• Compare national outcomes

• Find ways to improve CLD outcomes

Implication for paediatric community services

• British Thoracic Society guidelines:– infants with chronic lung disease (CLD) oxygen saturations < 90% :

increased risk of ALTE– Saturations below 92% : suboptimal growth

• Recommendation: – Oxygen saturations should be maintained at 93% or above– Assess for the suitability of long term oxygen therapy (LTOT)

• LE Pritchard. Audit of National Compliance with British Thoracic Society Guidelines for Neonatal Chronic Lung Disease. Arch Dis Child 2012;97:Suppl 1 A28. 65 units– Only 4% units carried out suitability for LTOT– Only 8% units used the BTS target saturations

Conclusion

• CLD is a major morbidity among preterm babies

• Cases are increasing with increasing survival of extremely preterm babies

• Babies with pulmonary hypertension have significantly increased risk of mortality

• Implications for community services

• Questions?