Current Challenges in the Respiratory Management of Preterm Infants at a Regional and National Level

Abstract

Preterm birth remains a leading public health challenge and is associated with significant mortality and long-term morbidity. Bronchopulmonary dysplasia (BPD) is one of the most common complications of prematurity and is associated with life-long poor neurodevelopmental and respiratory outcomes. The aims of this thesis were to understand the challenges facing the respiratory management of high-risk preterm infants and explore approaches to overcome these that could potentially improve outcomes. This thesis composed of five studies linking neonatal respiratory care. Firstly, understanding the recent incidence of BPD and respiratory support used in neonatal units in England and Wales from 2010 to 2017 by conducting a population-based retrospective cohort study using a national neonatal database. The findings demonstrate improving survival but BPD affects 1 in 3 extremely and very preterm infants and is on a rising trend. In parallel, there has been a significant shift from continuous positive airway pressure to high flow respiratory support. Secondly, assessing the association between early preterm transfer and development of BPD or lung injury by conducting a national retrospective cohort study. This study found no association between early preterm transfer and BPD. Thirdly, a rodent vibration exposure study to investigate the impact of vibration, as observed during ambulance transportation, on lung. The findings revealed no evidence of lung injury observed after vibration exposure. The fourth study evaluated the current respiratory monitoring in a local neonatal setting by performing a targeted oxygen saturation quality improvement (QI) project. The QI project found oxygen saturation targeting was achieved 34% of the time and post QI this improved to 43%. Finally, the fifth study was a feasibility observational study using routinely collected vital signs to early predict respiratory deterioration. The observational study found that only 8.5% of cardiorespiratory adverse events were recorded on manual nursing documentation compared with electronic monitoring. In addition, a pattern of cardiorespiratory events was associated with the need for mechanical ventilation. In conclusion, the survival of extremely and very preterm infants continues to improve. However, BPD is increasing at a time non-evidence based respiratory management is also increasing. The findings presented suggest the need for exploration of the current modifiable risk factors for BPD, optimisation of respiratory management with better monitoring and delivery of care. These steps, at both a national and local level, could help reverse the worrying trend of increasing BPD and improve the long-term health of this high-risk population.