Neonatal Mechanical
Ventilation-Early Experiences in central India
Dutt RD1, Dutt C2, Ambey R3
1Dr R D Dutt, Associate Professor, Department of
Pediatrics,2Dr. Chandrakala Dutt, Assistant Professor,
Department of Surgery,3Dr. Ravi Ambey, Assistant Professor,
Department of Pediatrics. All are affiliated with Kamla Raja Hospital
& G R, Medical College, Gwalior, MP, India
Address for correspondence:
Dr R D Dutt, Email:
drrddutt@rediffmail.com
Abstract
Introduction:
This innovative technology of mechanical ventilation had been started
since 1960s and reached to significant level in affluent nation but in
our nation, it is in nascent stage. This is first kind of study
measuring outcome of neonatal mechanical ventilation in central part of
India. Methodology:
Study was conducted for one year after permission from Institutional
Research board at Neonatal intensive care unit (NICU), of Kamla Raja
Hospital, G.R. Medical College, Gwalior (M.P.). It was a prospective
observational study & statistically, SSSP-10 system was applied
for study. In our study, we used time cycled, pressure limited,
continuous flow ventilator (DRAGGER-8000). Out of total 1160 admission
during study period over one year in our NICU, 79 newborns (6.81%)
requiring mechanical ventilation were enrolled. 70 (88.60%) newborn
were given SIMV mode and 9 (11.40%) were given exclusive CPAP as per
their indication. Results:
The overall survival rate was 48.10% (SIMV 42.85% (20 cases) and CPAP
88.88% (8 cases) respectively. The inborn babies were 35.44% (28 cases)
and out born were 64.56% (51 cases) but survival was much better in
inborn babies 64.28% (18 cases) compared to out born babies 39.21% (20
cases) which is statistically significant (p<0.05). Though male
neonates were predominant 64.55% (51 cases), but outcome was better in
female newborns 57.14% survival than Male. Conclusion:
Mechanical ventilation is in evolving phase in central part of India.
In hands training & experience will further improve outcome
after few decades.
Key words:
CPAP, Mechanical ventilation, Ventilator, Neonate.
Manuscript received:
1st May 2014, Reviewed:
20th May 2014
Author Corrected:
23rd May 2014, Accepted
for Publication: 10th June 2014
Introduction
Mechanical ventilation can be noninvasive or invasive. In
today’s world every country is competing equally to provide
better health care services to their citizen. Even developing countries
have achieved a great success in reducing mortality rates and providing
good health care system. A great impact of such facilities can be
observed from maternal mortality rate (MMR). As in our country we have
implemented many programmes to reduce MMR & provide better MCH
(Mother and Child health) service as a result of it we have drastically
reduced MMR from 407 in 1997 to nearly around 301 to 2003 as a result
of this more maternal life have been saved and due to this the number
of preterm and complicated deliveries turning in successful one have
been increased so we are facing a new challenge to our health care
system as Neonatal Mortality rate. Through we have achieved a great
success in reducing Neonatal Mortality rate to around 37 in 2006.
Although we have achieved so many millstones in our health service but
still this high NMR comparative to western data is a big road block for
our progress.
This innovative technology of mechanical ventilation had been started
since 1960s and reached to significant level in affluent nation but in
our national it is in only nascent stage. But due its high cost, expert
skill requirement has limited its use in developing countries. Though
this sophisticated technology has started around 1990s in India. This
is first kind of study measuring outcome of mechanically ventilated
neonates in India, in this study, we would like to report our
experience with neonatal mechanical ventilation or up on 79 sick
newborns required mechanical ventilation.
Material
and methods
This is a prospective observational study conducted at Neonatal
Intensive Care Unit, Kamla Raja Hospital, Gwalior (M.P.) over a period
of one year i.e. from August 2009 to July 2010. We have included both
inborn and outborn neonates. Out of total 1160 admission during study
period over one year in our NICU,79 newborn requiring mechanical
ventilation were enrolled after taking written informed consent of
parents and also explaining ethical issues. 70 newborn were given SIMV
mode and 9 were given exclusive CPAP perinatal history, associated risk
factors, indications for mechanical ventilation were recorded on
Performa. Major surgical anomalies (e.g. TEF, TGA etc) and parents not
given consent were excluded. Newborn were ventilated as per standard
protocol babies were nursed under servo control open care system.
Continuous clinical monitoring of Heart Rate, Respiratory Rate SPo2
temp.,
ECG, NIBP and Blood gases were done every 12 hourly in stable babies or
even more frequently in unstable babies and also with each change in
ventilator settings blood glucose reading were taken by glucometer
sepsis work up done regularly and endotracheal aspirate were sent for
suspected pneumonia blood culture was sent for suspected septicemia
Chest X-rays were taken for suspected air leak. Neonates were weaned
off on clinical and radiological improvement and normal blood gases
values with minimum ventilator support Dexamethasone were given prior
to extubation was done for >72 hours. Babies were kept under
oxygen hood after extubation. Outcomes were analysed for different
variables like gestational age birth weight, indications, maternal risk
factors and complications. All the observations were analyzed and
appropriate statistical tests were applied on observations.
Inclusion Criteria
: Sick newborns admitted in NICU, KRH, Gwalior having indications of
mechanical ventilation.
Exclusion Criteria:
1.Preterm < 30 weeks with Small for G.A.
2. Newborn weighing < 1000 gms.
3. Terminal newborns with major surgically uncorrected lethal anomalies
(TEF, TGA etc.)
4. Parent not willing or not given consent for ventilation.
5. Newborns ventilated < 12 hours.
Aims and objectives:
1. To assess the various indication, course of illness and outcomes in
mechanically ventilated newborns.
2. To observe mortality rates in sick mechanically ventilated newborns.
3. To study various complications in mechanically ventilated newborns.
4. To assess various factors affecting outcome in mechanically
ventilated neonates.
Observation
During study period of one year 79 (6.81%) admitted babies required
mechanical ventilation were enrolled in our study.
Table No 1: Distribution
and Outcome According to Sex
|
|
No. of cases
|
Survived
|
|
Male
|
51 (64.55%)
|
22 (43.13%)
|
|
Female
|
28 (35.44%)
|
16 (57.14%)
|
|
Total
|
79
|
38
|
During study period male newborn were 65 % but outcome was
better in female newborns. {Female 57.14% (16 cases) than Male 43.13%
(22 cases)}
Table No 2: Distribution
and Outcome According To Mural Status
|
Indications
|
No. of cases
|
Survival
|
|
Inborn
|
28 (35.44%)
|
18 (64.28%)
|
|
Outborn
|
51 (64.56%)
|
20 (39.21%)
|
|
P-Value
|
|
P<0.05
|
|
Total
|
79
|
38
|
Inborn babies were 35.44% (28 cases) and out born were
64.56% (51 cases) of total population but survival was much better in
inborn babies 64.28% (18 cases) compared to out born babies 39.21% (20
cases) which is statistically significant (p<0.05).
Table No 3: Distribution
and Outcome According To Birth Weight
|
|
No. of cases
|
Survived
|
|
1000-1499gm
|
13 (16.45%)
|
5 (38.46%)
|
|
1500-2000gm
|
19 (24.05%)
|
8 (42.10%)
|
|
2000-2500gm
|
15 (18.98%)
|
7 (46.66%)
|
|
>2500gm
|
32 (40.50%)
|
18 (56.25%)
|
|
Total
|
79
|
38
|
Survival rate increases with increase in gestational age.
Table No 4: Distribution
and outcome according to gestational age
|
Gestational age
|
No. of cases
|
Survived
|
|
<32 weeks
|
13 (16.45%)
|
4 (30.76%)
|
|
32-34 weeks
|
16 (20.25%)
|
6 (37.5%)
|
|
34-37 weeks
|
15 (18.98%)
|
8 (53.33%)
|
|
>37 weeks
|
35 (44.30%)
|
20 (57.14%)
|
|
Total
|
79
|
38
|
Preterm <37 wks, Term 37 to 42 wks, Post term 42 wks
or more
Table No 5: Distribution
and outcome according to indication
|
|
No. of cases
|
Survived
|
|
Sepsis
|
22 (27.84%)
|
8 (36.36%)
|
|
MAS
|
18 (22.78%)
|
11 (61.11%)
|
|
HMD
|
15 (18.98%)
|
8 (53.33%)
|
|
Asphyxia
|
10 (12.65%)
|
4 (40.00%)
|
|
Apnoea of Prematurity
|
6 (7.59%)
|
3 (50.00%)
|
|
Aspiration Pneumonia
|
4 (5.06%)
|
3 (50.00%)
|
The most common indication for ventilation was
septicemia-27.84% (22 cases) followed by hyaline membrane
disease-18.98% (9 cases), birth asphyxia-12.65% (10 cases), apnea of
prematurity-7.59% (6 cases), aspiration pneumonia-5.06% (4 cases) and
Persistent Pulmonary Hypertension of newborns- 5.06% (4 cases). The
overall survival rate was 48.10% (SIMV 42.85% (20 cases) and CPAP
88.88% (8 cases). Among maternal factor mother’s with
previous neonatal losses, Eclampsia/ Pre-eclampsia has poor survival
and having mortality as 69.24% (9 cases) & 60.00% (3 cases)
respectively. The best survival among indication was seen in babies
with MAS 61.11% (11 cases) and HMD-53.33% (15 cases). Babies with birth
asphyxia, septicemia and PPHN have survival as 40% (4 cases), 36.36% (8
cases), 25% (1 cases) respectively. Complications were septicemia
31.64% (25 cases), tube block-15.18% (15 cases), pneumothorrax-7.59% (6
cases), ventilator associated pneumonia-5.06% (4 cases), IVH-5.06%(4
cases) weaning failure-3.79% (3 cases) and pulmonary Hemorrhage-2.53%
(2 cases).
Discussion
Neonatal mechanical ventilation has improved survival rates of sick
newborns in NICU. In this study, we have given assisted ventilation to
79 babies out of 1160 admission (6.81%). Nangia et al [1],
Mathur et al [2], and Riyas et el [3] reported 8.9%, 13% and 5.6%
babies required mechanical ventilation. This may be due to different
factors like draining area, inclusion and exclusion criteria,
infrastructure and different admission policies. Overall survival rate
in our study was 48.10% which is comparable to other Indian studies
conducted till now whose survival rates vary from 41.17% to 55.8%. In
CPAP group 88.88% survived which can be compared with 90% survival of
CPAP group in Krishnan et al [4] and 100% survival in Nangia et al
study [1]. In SIMV group we found 42.85% survival, which also vary from
32.7% to 42.18% [3, 6]. Though most babies, we have given assisted
ventilation were out born (64.56%) compared to inborn (35.44%), but
outcome was much better in intramural babies (64.28%) compared to
extramural babies (39.21%), which is statistically significant. This
may be due to early intervention and availability of ventilation for
inborn babies.
In present study female babies have better survival rate 57.14%
compared to male babies 43.13% though we found male babies needed more
assisted ventilation. Most other Indian Studies also showed similar
pattern and this may be contributed to female babies are biologically
strong. Among maternal factor’s mother’s with
previous neonatal losses and Eclampsia/Pre-eclampsia were having poor
survival and have mortality rates as 69.24% & 60.00%
respectively. Mortality in mother’s with previous neonatal
losses may be due to various factors like genetic disorder, Maternal
factor like Pregnancy induced Hypertension.
The commonest indication in our study was septicemia, followed by
Meconium aspiration syndrome, Hyaline membrane disease, birth asphyxia,
apnoea of prematurity, aspiration pneumonia and PPHN. Krishnan et al
[4], Ruchi rai et al [5] also reported sepsis as their most common
indication for ventilation however Singh et al [6], and Maiyya et al
[7] reported HMD as most common indication. Riyas et al [3] reported
birth asphyxia as most common indication. Low incidence of HMD babies
for ventilation can be attributed to more liberal use of antenatal
steroids in mothers of anticipated premature babies.
In this study one or more complication were developed in 46.83% babies.
Major complications were septicemia (31.64%), tube block (15.18%)
pneumothorax (7.59%). Septicemia was the major complication in other
studies as singh et al reported 37% , Mathur et al [2] reported 36.7% ,
Riyas et al [3] reported 38.2% and Nangia et al [1] reported 26%.
Septicemia is still a major complication in ventilated babies due to
frequent intervention like blood gases and prolonged duration of
ventilation. Least possible intervention, minimum possible duration of
ventilation and judicious use of antibiotics may reduce its incidence.
Tube block was seen in 15.18% cases in our study compared to 32.3% in
riyas et al [3] and only 5.8% in Krishnan et al [4] reported. This
lower incidence can be due to frequent endotracheal toilet.
Pnuemothorax was seen in only 7.59% of cases which is comparable with
Mathur et al [2] 6.7% and Krishnan et al [4] 8.8% respectively. Singh
et al [6] (13%) Riyas et al [3] (13.7) reported higher incidences.
Intensive monitoring and early intervention may prove life saving.
Ventilator associated pneumonia incidence was quite low in our study
having 5.06% compared to 30.6% reported by Tripathi et al [8], 28.8% by
Mathur et al [2] and 25% by Maiyya et el [7]. This can be attributed to
careful attention to endotracheal toilet, frequent suctioning, adequate
pressure setting and minimum possible duration of ventilation, well
established nursery and well trained staff. Though neonatal mechanical
ventilation has effective role in reducing mortality in sick newborn
but still we are lagging behind the international data as provided by
H.Tortman [9]. Complications cannot be overlooked as it significantly
affects the outcome but intensive monitoring and early intervention can
reduce its incidence as reported by Lindorth [10]. Care should be taken
for barotraumas and minimum possible intervention to avoid septicemia.
Conclusion
Overall 48.10% of newborns requiring mechanical ventilations for
various indications survived. Out born babies have poor survival
compared to inborn babies. Babies of mother with previous fetal loss
& eclampsia has poor outcome. Out study also reconfirms that
survival rate increase with birth weight and gestational age.
Pnemothorax and VAP were leak complications. Early recognition of
complication related with Ventilator support, frequent monitoring
& good nursing care are keys of successful weaning of any
neonate.
Funding:
Nil, Conflict of interest:
Nil
Permission from IRB:
Yes
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How to cite this article?
Dutt RD, Dutt C, Ambey R. Neonatal Mechanical Ventilation-Early
Experiences in central India. Int J Med Res Rev 2014;2(4):319- 323.doi:10.17511/ijmrr.2014.i04.09