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Trusts urged to adopt best practice for monitoring neonatal breathing in intensive care

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Some intensive care units may be putting babies and children at risk by not implementing standardised monitoring of breathing, a new survey has highlighted.

The survey which was published last week in the journal Anaesthesia indicated that variations in the practice of airway management in intensive care units across the UK were putting children and particularly new-born babies at risk.

“Capnography, which detects exhaled carbon dioxide breath by breath, is a simple tool”

Fiona Kelly

Led by clinicians from the Royal United Hospitals Bath NHS Foundation Trust, the survey found lessons from a landmark study in 2011 had not been put into practice in all paediatric intensive care unit and neonatal intensive care units.

The 4th National Audit Project (NAP4) study, carried out in 2011 by the Royal College of Anaesthetists and the Difficult Airway Society, studied major complications of airway management, establishing and maintaining a patient on a ventilator.

It found that the absence of a simple method of monitoring breathing, called capnography, contributed to 74% of deaths from these events.

A capnograph measures how much carbon dioxide is present in the patient’s breath and helps confirm that the lungs are being adequately ventilated.

As a result of their findings, the NAP4 authors recommended universal use of capnography in intensive care units, together with changes in policy, equipment provision and training to improve airway safety.

However, the new research – called the United Kingdom Paediatric and Neonatal Intensive Care Airway Management: the PIC-NIC survey – found the 2011 recommendations had not been put into practice consistently.

“The findings indicate that the NAP4 recommendations have been adopted into only a small number of neonatal intensive care units”

Fiona Kelly

Staff from all of the UK’s PICUs and 90% of NICUs were interviewed for the new study, which revealed that most respondents – representing 98% of NICUs and 75% of PICUs – reported they were unaware of the 2011 study.

The survey also highlighted that, despite capnography being used in almost 100% of adult ICUs as a direct result of the NAP4, it had not been widely implemented in NICUs.

According to the latest findings, only 46% of NICUs reported having capnography available and it was rarely used.

Key findings from the PIC-NIC survey team also highlighted that 78% of PICUs and 34% NICUs do not formally identify patients with a difficult airway at staff handover.

This finding was also reflected by the relatively low number of units (40% of NICUs and 67% of PICUs) with protocols for high risk patients in place compared to 90% of adult ICUs.

In addition, of the 129 NICUs and 27 PICUs that responded to the survey, 34 and five, respectively, reported death or serious harm in their unit as a result of complications of airway management in the last five years.

Study author Dr Fiona Kelly, a consultant in anaesthesia and intensive care medicine at Royal United Hospitals, said: “The findings of this survey indicate that the NAP4 recommendations have been adopted into routine practice by some paediatric intensive care units, but into only a small number of neonatal intensive care units.”

Dr Kelly highlighted that there were many differences between adult, paediatric and especially neonatal practice, but said monitoring the breathing of a patient on a ventilator was “fundamental to safe practice in any ICU”.

“We recommend that lessons from adult ICUs are shared widely with our NICU and PICU colleagues”

Tim Cook

She said: “Capnography, which detects exhaled carbon dioxide breath by breath, is a simple tool and can detect misplaced tubes or disconnections from a ventilator.

“It is of concern that this technology is only used in a few NICUs,” she said. “This variation in practice, which is potentially putting lives at risk, merits further investigation.”

Fellow author Professor Tim Cook, a consultant in anaesthesia and intensive care medicine at the same trust, said: “We recommend that lessons from adult ICUs are shared widely with our NICU and PICU colleagues and hope that this survey will prompt discussion about the feasibility of routine capnography monitoring.”

Professor Cook said he hoped that the NICUs where capnography was currently being used could “share best practice with other colleagues to help implement this important technology more widely”.

“In the case of low weight neonates, more research is needed to establish the utility of capnography and improve reliability of care. The current situation of half of UK NICUs using capnography and it not being available in the other half needs addressing,” he added.

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