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Background

Neonatal cardiopulmonary resuscitation (CPR) requires a skilled team including pediatric registered nurses (pRNs) who must manage complex, high-stress situations. This study aimed to describe pRNs' experiences of neonatal CPR and to interpret these in relation to two levels of clinical expertise, novice and expert, using Benner's framework.

Design and methods

A qualitative secondary analysis included two strategically selected novices and two experts from three level III and IV NICUs in Sweden. Data were analyzed using abductive content analysis framed by the Swedish competence description for pRNs and Benner's nursing theory.

Results

Novices relied on guidelines and familiar team members to manage stress and ensure patient safety. Experts demonstrated confidence in team dynamics, anticipatory decision-making, and mentoring behaviors.

Conclusion

The findings highlight differences in how novice and expert pRNs experience neonatal resuscitation and emphasize the importance of mentorship and structured support for professional development.

BackgroundRecommendations are limited regarding the placement of oral endotracheal tube (ETT), and umbilical arterial/venous catheter (UAC/UAC) in the tiniest extremely preterm infants. We aimed to determine optimal insertion depths, and assess the impact of a too deep ETT position on outcomes.

MethodsAll infants born at 22-23 weeks gestation in 2019-2024 at Uppsala University Hospital, Sweden, were evaluated radiologically for accurate positions defined as: ETT (not right-sided/in main bronchus), UAC (T6-9 or L3–4), and UVC (right atrium/inferior vena cava junction). ETT position was further analyzed in relation to time to first extubation, respiratory severity score, duration of mechanical ventilation, bronchopulmonary dysplasia, and mortality.

ResultsThe cohort (n = 75; 22w n = 39; 23w n = 36) had a survival rate of 41 and 64%, respectively. The ETT was accurately placed in 75%, and lower birth weight was associated with a too deep tip position (p = 0.018). The optimal median (IQR) insertion depths were: ETT 5.5 (5.5–6.0); low UAC 6.0 (5.5–6.5); high UAC 9.6 (9.2–10.3), and UVC 5.5 (5.0–6.1) cm. ETT position was not associated with respiratory outcomes or mortality.

ConclusionThe suggested insertion depths can be expected to result in accurate positioning of ETTs and umbilical lines in infants born at 22-23 weeks gestation.

Background: This multicentre, international, retrospective study aimed to investigate whether respiratory system reactance (X rs) assessed by respiratory oscillometry on day 7 of life is associated with respiratory outcomes in preterm infants below 32 weeks gestational age (GA).

Methods: Sinusoidal pressure oscillations (2-5 cmH2O peak-to-peak, 10 Hz) were superimposed on the positive end-expiratory pressure. We assessed the association of X rs z-score with the duration of respiratory support using linear regression and with bronchopulmonary dysplasia (BPD) using logistic regression. We used the likelihood ratio test to evaluate whether X rs z-score adds significantly to clinical predictors, including GA, birthweight (BW) and the National Institute of Child Health and Human Development (NICHD) BPD prediction model.

Results: 137 infants (median (interquartile range) 28.43 (26.11-30.29) weeks GA) were included; 44 (32%) developed BPD. X rs z-score was significantly associated with the duration of respiratory support (R2=0.35). X rs z-score was significantly higher in infants who developed BPD (p<0.001); the optimal cut-off value was 2.6, associated with 77% sensitivity and 80% specificity. In univariable analysis, per z-score increase in X rs, the odds ratio for BPD increased by 60% and the respiratory support by 8 days. In multivariable analysis, X rs z-score added significantly to the NICHD model and to GA and BW z-score to predict respiratory support duration (p=0.016 and p=0.014, respectively) and BPD development (p=0.003 and p<0.001, respectively).

Conclusion: X rs z-score on the 7th day after birth improves the prediction of respiratory outcome in preterm infants.

Patient-triggered modes of ventilation are currently the standard of practice in the care of term and preterm infants. Maintaining spontaneous breathing during mechanical ventilation promotes earlier weaning and possibly reduces ventilator-induced diaphragmatic dysfunction. A further development of assisted ventilation provides support in proportion to the respiratory effort and enables the patient to have full control of their ventilatory cycle. In this paper we will review the literature on two of these modes of ventilation: neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV), propose future studies and suggest clinical applications of these modes.

Background:Teamwork during neonatal resuscitation is essential. Situations arise quickly and unexpectedly and are highly stressful, requiring pediatric registered nurses (pRN) to respond effectively and in a structured manner. In Sweden, pRNs work in all pediatric settings including the neonatal intensive care unit. The experience and actions of pRNs are seldom explored, and studies within this area could develop and improve strategies for neonatal resuscitation situations.

Purpose:To describe pRNs' experiences and actions during neonatal resuscitation.

Methods:A qualitative interview study based on the critical incident technique was performed. Sixteen pRNs from 4 neonatal intensive care units in Sweden were interviewed.

Results:Critical situations were divided into 306 experiences and 271 actions. pRNs' experiences were divided into 2 categories: individual- and team-focused experiences. Critical situations were managed by individual- or team-focused actions.Experiences revealed were variation of alarms, psychological impact, parental presence, structured working methods, the team's interactions, professional experience and resource availability, and the impact of the environment. Actions revealed were being prepared, managing the psychological impact, adopting a professional attitude toward parents, working in a structured way, and competence/resource reinforcement.

Implications for Practice: Developing a structured role distribution within the neonatal resuscitation program and ensuring clear communication in the team during simulation training and in intense situations can increase pRNs' feeling of safety and allow them to further develop their professional role in neonatal resuscitation situations.

Objective: To evaluate whether noninvasive-neurally adjusted ventilatory assist (NIV-NAVA) decrease respiratory efforts compared to nasal continuous positive airway pressure (NCPAP) during the first hours of life.

Methods: Twenty infants born between 28+0 and 31+6 weeks were randomized to NIV-NAVA or NCPAP. Positive end-expiratory pressure was constantly kept at 6 cmH(2)O for both groups and the NAVA level was 1.0 cmH(2)O/mu V for NIV-NAVA group. The electrical activity of diaphragm (Edi) were recorded for the first two hours.

Results: Peak and minimum Edi decreased similarly in both groups (P = 0.98 and P = 0.59, respectively). Leakages were higher in the NIV-NAVA group than in the NCPAP group (P < 0.001). The neural apnea defined as a flat Edi for >= 5 s were less frequent in NIV-NAVA group than in NCPAP group (P = 0.046).

Conclusions: Immediately applied NIV-NAVA in premature infants did not reduce breathing effort, measured as peak Edi. However, NIV-NAVA decreased neural apneic episodes compared to NCPAP.

Lung immaturity and acute respiratory failure are the major problems in the care of extremely preterm infants. Most infants with gestational age (GA) 22-24 weeks will need mechanical ventilation and many will depend on some type of respiratory support, invasive and non-invasive for extended periods. There is ongoing gap in knowledge regarding optimal respiratory support and applying strategies that are effective in more mature populations is not easy or even suitable because lung maturation differs in smaller infants. Better strategies on how to avoid lung damage and to promote growth and development of the immature lung are warranted since increased survival is accompanied by increasing rates of bronchopulmonary dysplasia and concerns over long-standing reductions in lung function.

This review focuses on some aspects of respiratory care of infants born at 22-24 weeks of GA.

Background

Early hypocapnia in preterm infants is associated with intraventricular hemorrhage (IVH) and bronchopulmonary dysplasia (BPD). Volume targeted ventilation (VTV) has been shown to reduce hypocapnia in preterm infants. Less is known of VTV in infants born at <26 weeks gestational age (GA).

Objectives

Our aim was to investigate the short- and long-term effects of early VTV as compared to pressure limited ventilation (PLV) in extremely preterm infants on the incidence of hypocapnia, days on ventilatory support, IVH, and BPD.

Study Design

A retrospective observational study of 104 infants born at 22–25 weeks GA (mean ± SD; 24⁺⁰ ± 1⁺¹ GA; birth weight 619 ± 146 g), ventilated with either VTV (n = 44) or PLV (n = 60) on their first day of life. Ventilatory data and blood gases were collected at admission and every fourth hour during the first day of life, together with perinatal characteristics and outcomes.

Results

Peak inflation pressure (PIP) was lower in the VTV-group than in the PLV-group during the first 20 h of life (p < .05), without any difference in respiratory rate or FiO₂. Incidence of hypocapnia (PaCO₂< 4.5 kPa) was lower with VTV than PLV during the first day of life (32% vs. 62%; p < .01). Infants in the VTV-group were more frequently extubated at 24 h (30% vs. 13%; p < .05). IVH Grade ≥3, BPD, and time on mechanical ventilation did not differ between the groups.

Conclusions

VTV is safe to apply in infants born at <26 GA and was observed to result in a lower incidence of hypocapnia compared to infants ventilated by PLV, without any differences in outcomes.

Objective The aim of this study is to determine patterns of neurally adjusted ventilatory assist (NAVA) use in ventilator-dependent preterm infants with evolving or established severe bronchopulmonary dysplasia (sBPD) among centers of the BPD Collaborative, including indications for its initiation, discontinuation, and outcomes.

Study Design Retrospective review of infants with developing or established sBPD who were placed on NAVA after ≥4 weeks of mechanical ventilation and were ≥ 30 weeks of postmenstrual age (PMA).

Results Among the 13 sites of the BPD collaborative, only four centers (31%) used NAVA in the management of infants with evolving or established BPD. A total of 112 patients met inclusion criteria from these four centers. PMA, weight at the start of NAVA and median number of days on NAVA, were different among the four centers. The impact of NAVA therapy was assessed as being successful in 67% of infants, as defined by the ability to achieve respiratory stability at a lower level of ventilator support, including extubation to noninvasive positive pressure ventilation or support with a home ventilator. In total 87% (range: 78–100%) of patients survived until discharge.

Conclusion We conclude that NAVA can be used safely and effectively in selective infants with sBPD. Indications and current strategies for the application of NAVA in infants with evolving or established BPD, however, are highly variable between centers. Although this pilot study suggests that NAVA may be successfully used for the management of infants with BPD, sufficient experience and well-designed clinical studies are needed to establish standards of care for defining the role of NAVA in the care of infants with sBPD.