Liou, Jesse; Doherty, Daniel; Gillin, Tom; Emberger, John; Yi, Yeonjoo; Cardenas, Luis; Benninghoff, Michael; Vest, Michael; Deitchman, Andrew Author Information

OBJECTIVES:. Acute respiratory distress syndrome is treated by utilizing a lung protective ventilation strategy. Obesity presents with additional physiologic considerations, and optimizing ventilator settings may be limited with traditional means. Transpulmonary pressure (PL) obtained via esophageal manometry may be more beneficial to titrating positive end-expiratory pressure (PEEP) in this population. We sought to determine the feasibility and impact of implementation of a protocol for use of esophageal balloon to set PEEP in obese patients in a community ICU. DESIGN:. Retrospective cohort study of obese (body mass index [BMI] ≥ 35 kg/m2) patients undergoing individualized PEEP titration with esophageal manometry. Data were extracted from electronic health record, and Wilcoxon signed rank test was performed to determine whether there were differences in the ventilatory parameters over time. SETTING:. Intensive care unit in a community based hospital system in Newark, Delaware. PATIENTS:. Twenty-nine mechanically ventilated adult patients with a median BMI of 45.8 kg/m2 with acute respiratory distress syndrome (ARDS). INTERVENTION:. Individualized titration of PEEP via esophageal catheter obtained transpulmonary pressures. MEASUREMENTS AND MAIN RESULTS:. Outcomes measured include PEEP, oxygenation, and driving pressure (DP) before and after esophageal manometry at 4 and 24 hr. Clinical outcomes including adverse events (pneumothorax and pneumomediastinum), increased vasopressor use, rescue therapies (inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, and new prone position), continuous renal replacement therapy, and tracheostomy were also analyzed. Four hours after PEEP titration, median PEEP increased from 12 to 20 cm H2O (p < 0.0001) with a corresponding decrease in median DP from 15 to 13 cm H2O (p = 0.002). Subsequently, oxygenation improved as median Fio2 decreased from 0.8 to 0.6 (p < 0.0001), and median oxygen saturation/Fio2 (S/F) ratio improved from 120 to 165 (p < 0.0001). One patient developed pneumomediastinum. No pneumothoraces were identified. Improvements in oxygenation continued to be seen at 24 hr, compared with the prior 4 hr mark, Fio2 (0.6–0.45; p < 0.004), and S/F ratio (165–211.11; p < 0.001). Seven patients required an increase in vasopressor support after 4 hours. Norepinephrine and epinephrine were increased by 0.05 (± 0.04) µg/kg/min and 0.02 (± 0.01) µg/kg/min on average, respectively. CONCLUSIONS:. PL-guided PEEP titration in obese patients can be used to safely titrate PEEP and decrease DP, resulting in improved oxygenation.

Abstract Background Hand hygiene (HH) is widely regarded as the most important factor in preventing transmission of infections. Since 2012 our health system has utilized unit-based direct observation to measure HH compliance. Although direct observation is widely used and considered gold standard, the discrepancy between unit-based HH compliance (UB-HH) and Infection Prevention validation HH audits (IP-HH) was increasing over time. To understand the drift in HH compliance, we began a Lean Six Sigma (LSS) Green Belt project to improve UB-HH observation accuracy. Methods The IP LSS Green Belt team included nursing, respiratory care, and human factors, and analyzed factors leading to inaccurate UB-HH using LSS tools including the Voice of the Customer, process mapping, fishbone diagrams, and failure modes and effects analysis. We updated HH observer web-based education; implemented a new process to ensure observer training; and eliminated unit report card penalties for poor UB-HH. We implemented a new, more accessible observation tool, which provides a dashboard for real-time access to HH results by all staff. IPs began weekly validation HH audits. Results Baseline data revealed a 34% discrepancy between UB-HH and IP-HH compliance (95% vs 61%) over 4 different monthly validation events; only 27% of observers had completed web-based training. Goal conflicts were discovered: units were penalized for poor HH, yet the observations were unit level self-report. These results prompted design changes to the online tool and the process flow of UB-HH observation; units implemented the new program sequentially between 9/20 and 12/20. These changes resulted in 99% of observers being web-trained; however, between 10/21-3/22, UB-HH compliance averaged 98% (n=19,940), while IP-HH compliance averaged 53% (n=579) (difference, 45%). Conclusion Using multidisciplinary process improvement, we enhanced our manual HH observation processes; however, no improvement in HH accuracy was observed. Unit-based staff, who lack dedicated time for HH observation, are biased to document HH compliance over non-compliance, even with recent re-training in non-biased HH observation processes and elimination of penalties. To improve HH accuracy, we recommend either dedicated neutral HH observers or automated systems. Disclosures All Authors: No reported disclosures.

Background: Previously no device existed to manage partial occlusions of the neonatal endotracheal tube (ETT). Suctioning with or without lavage could be used with potential consequences of the lavage. An ETT that is partially obstructed and causing difficult ventilation would require elective or emergent reintubation as the only option. A new device has been designed to clear the ETT lumen of secretions causing a partial obstruction. We wanted to determine if this new device could clean the neonatal ETT lumen after secretions had partially occluded the tube. Methods: A bench study was performed to test the new device (Restore Neonate, endOclear LLC) to clean neonatal ETTs. A Drager VN500 with pressure-controlled settings was connected to an ASL 5000 test lung via an ETT. Three sizes of ETTs were tested: 2.5, 3.0 and 3.5 with a sequence of 3 partial occlusions each. The occlusions were created with simulated mucus (a propylene glycol mixture that was colored blue and was within the published range of human mucus viscosity). The occlusions were created by depositing 0.25 to 0.75 mL of simulated mucus until there was a brief airway occlusion as noted on the ventilator. A single pass of the catheter was used to clear the ETT each time. Flow-volume loops as well as breath to breath resistance measurements from the ventilator were used to evaluate effectiveness of the device to clean the ETT lumen. Results: Average ventilator resistance measurements (cm H2O/L/s) from the 3 simulated occlusions for each of the ETT were as follows. Size 2.5 ETT resistance measurements: 130-new ETT, 175-partial ETT occlusion, 135-post ETT cleaning. Size 3.0 ETT resistance measurements: 106-new ETT, 206-partial ETT occlusion, 108-post ETT cleaning. Size 3.5 ETT resistance measurements: 87-new ETT, 190-partial ETT occlusion, 86-post ETT cleaning. See figure for a representative set of flow-volume loops for the new ETT, the partial occlusion and the ETT after cleaning. Conclusions: The Restore Neonate appears to have fully recovered the lumen of the neonatal ETT in our bench study with a partial occlusion of simulated mucus as evidenced by resistance measurement returning to values similar to the new ETT as well as the flow-volume loops returning to the same shape as the new ETT. This new device may be valuable for cleaning the ETT of neonates instead of having to reintubate when partial obstructions occur.

Background: Two devices are available to clear partial occlusions of the adult endotracheal tube (ETT). Both devices claim the removal of secretions and biofilm from the ETT. There is limited information in the published literature about these devices and to our knowledge, no head to head comparisons on the performance of these devices to clear the lumen of a partially occluded ETT. We wanted to compare both devices in a bench model with simulated mucus for effectiveness to clear the ETT of a partial obstruction. Methods: A bench study was performed to test both devices: Restore 2, endOclear LLC (a balloon tipped catheter with a wiper) and CAM Rescue Cath, Omneotech (a balloon tipped catheter with mesh covering). A Drager V500 with volume-controlled settings was connected to an ASL 5000 test lung via an ETT. An adult size 8.0 ETT was tested with a sequence of 3 partial occlusions for each device. The occlusions were created with simulated mucus (a propylene glycol mixture that was colored blue - within the published range of human mucus viscosity). The occlusions were created by depositing approximately 2 mL of simulated mucus until there was a brief airway occlusion as noted on the ventilator. The devices were evaluated after a single pass of the catheter. Pressure-volume loops as well as breath to breath resistance measurements from the ventilator were used to evaluate the effectiveness of each device to clean the ETT lumen. Results: Average resistance measurements (cm H2O/L/s) for an 8.0 ETT with each device were as follows: CAM Rescue Cath: 23 (new ETT), 34 (ETT partially occluded), 24 (post ETT cleaning). Restore 2: 24 (new ETT), 34.5 (ETT partially occluded), 24.5 (post ETT cleaning). Both devices returned the measured resistance to within 1 cm H2O/L/s of a new ETT after clearing the partial obstructions of simulated mucus. Upon inspection of the endotracheal tubes post cleaning, the Restore 2 had no visible blue color remaining, but the CAM Rescue Cath left a visible film of blue throughout the endotracheal tube. See figure for a representative set of pressure-volume loops displaying the partial obstruction and the loop after cleaning the ETT. Conclusions: Both devices fully restored the original lumen of the ETT in our bench study after clearing a simulated partial occlusion based on the resistance measurements and pressure-volume loops. The Restore 2 visibly removed the blue coloring but with the CAM Rescue Cath a blue film was visible after cleaning.

Background: At our institution, respiratory therapists may be certified to perform endotracheal intubation in the adult population. Annual intubation certification includes both performing a certain number of successful endotracheal intubations as well as a passing a skills and knowledge test. Our practice has transitioned in the past few years from primarily using direct laryngoscopy to using video laryngoscopy. In the past, direct laryngoscopy was the main method available. Recently, our system placed a video laryngoscopy platform in all adult ICUs and Emergency Departments. We wanted to determine if respiratory therapists at our facility were more successful with endotracheal intubation when using video laryngoscopy. Methods: A retrospective review of intubation documentation by respiratory therapists was conducted for two different periods, January 2015 to December 2016 (direct - primary laryngoscopy type) and July 2017 to May 2019 (video - primary laryngoscopy type). Successful tracheal intubation versus unsuccessful tracheal intubation attempt were noted for each occurrence of intubation by a respiratory therapist. Data was also collected specifically for video versus direct laryngoscopy from January 2019 to May 2019, when video vs direct was added to the electric medical record as a discreet data element. Results: See data table for success rate during the time when direct (Jan 15-Dec 16) and video (Jul 17-May 19) were the primary type of laryngoscopy. Success rate increased 8% from 86% to 94% when video laryngoscopy became the primary type. The table also includes discreet data from January 2019 to May 2019 comparing video versus direct success rate. Video is currently used 3 times more frequently than direct (100 vs 32) and has a success rate 8% higher than direct. Conclusions: The success rate of a respiratory therapists certified in endotracheal intubation increased 8% when video laryngoscopy became readily available in our system. With both types currently available, respiratory therapists opt to use video laryngoscopy three times more frequently.

Background: The Center for Disease Control (CDC) and National Health Safety Network (NHSN) have defined VAE as a deterioration in respiratory status following a period of stability-determined by PEEP or FIO2, evidence of inflammation or infection-determined by patient temperature and white blood cell count or lab evidence of a respiratory infection. VAE rate is defined as the number of events per 1000 ventilator days. The VAE rate had been higher than expected in our adult Surgical/Trauma and Neuro ICUs. We wanted to determine if a performance improvement process could reduce that rate. METHOD: This is a retrospective review of all ventilator patients in our Surgical/Trauma and Neuro ICUs during the baseline (January 2013 to September 2018) and pilot (September 2018 to present) periods. We employed a PDCA performance improvement process. The main performance improvement implementations that occurred were caregiver education on the VAE criteria and initiating a new standard baseline PEEP setting of 6 cm H2O for all ventilator patients instead of 8 cm H2O. Results: Mean VAE rates for the Surgical/Trauma and Neuro ICUs were 18.9 and 15.7, respectively, prior to project implementation. After implementation, VAE rates fell to 3.7 and 2.6, yielding an 80% and 83% reduction in the VAE rate. The reduction is statistically significant for both ICUs (P

Background: RB creates unique challenges for ventilation of the patient. While manual jet ventilation is the accepted standard, we have also used an LTV-1200 or a Respironics V60 ventilator. A common and recommended practice during RB is packing the oropharynx with gauze to reduce the leak and improve ventilation to the patient1. The purpose of this study was to perform a bench simulation of RB to evaluate if packing the oropharynx with gauze improves ventilation. Methods: We performed a bench study of RB with an intubation mannikin attached to the Ingmar ASL-5000 test lung with a Novametrix NM3-NICO flow sensor between the mannikin airway and the ASL-5000. Normal apneic adult settings were used on the ASL-5000. The manual jet was tested at 40 and 60 PSI with two breath types, Burst - short i-time and Hold - long i-time. The V60 was tested with I-Times of 0.6 s and 1 s, with a delta pressure of 20 cm H2O and 30 cm H2O. Two different leak scenarios were tested: Low Leak - typical setup of the RB with the silicon cap in place. High Leak - setup without silicon cap in place. All of the above variables were tested either with the mannikin9s oropharynx packed with gauze as is typical during RB or not packed with gauze. Inspiratory tidal volumes were collected with each of the different scenario combinations with the NM3 device. Minitab 18 was used for statistical analysis. Results: See graphic for the results of the inspiratory volume delivered with various representative devices and settings with or without gauze packing or no gauze packing. Pearson correlation coefficient between both paired groups of tidal volumes (packed paired with unpacked) was 0.994 (P=0.000). Conclusions: Regardless of the ventilation device and settings used during RB, there is no difference in the tidal volume delivered if the oropharynx is packed with gauze or if it is not packed with gauze. The only values that differ with and without packing is during large tidal volumes of the manual jet, but the results are opposite of the purpose of packing. The tidal volume is greater without packing and may be associated with extra entrainment when packing is not present. The results of this study show that packing the oropharynx solely to maintain better ventilation is not necessary, packing does not improve ventilation during rigid bronchoscopy. 1. Ventilation and Anesthetic Approaches for Rigid Bronchoscopy. Ann Am Thorac Soc 2014;11(4):628-634.

Background: Evidence exists that lung protective ventilation (LPV) reduces mortality1, compliance with LPV affects mortality2 and major centers struggle complying with LPV2. We have had ongoing efforts to increase compliance with LPV at our health system. Our efforts focus on 8 mL/kg for all adult patients and 4 to 6 mL/kg for ARDS patients. We wanted to determine what percentage of our patients were never exposed to > 8. 25 mL/kg and the outcomes associated with being 100% compliant with LPV. Methods: A retrospective review was conducted for all ventilator patients in our adult ICUs since January 2015. We collected tidal volume, height and gender of patients on volume ventilation. For each patient-ventilator assessment on volume ventilation, ideal body weight and tidal volume in mL/kg was calculated. Patients were divided into 2 groups. Group 1: 100% compliant with LPV, defined as ALL exhaled tidal volumes during volume ventilation Results: 7,034 ventilator patients had volume ventilation at sometime while mechanically ventilated (2,062-Cardiac ICU, 2,536-Medical ICU, 954-Neuro ICU, 1,482-Surgical ICU). Group 1 Data: n=4,610 (66%), mortality=17.2%, home discharge=45.2%. Group 2 Data: n=2,424 (34%) mortality=18.9%, home discharge=28.9%. Outcomes were significantly different (P Conclusions: Complying with LPV is associated with lower mortality, higher percentages of discharges home and less discharges to other facilities after the acute hospitalization across all adult ICU9s. To have maximum positive impact for patients, mechanisms such as education, dashboards, electronic indicators and automatic protocols that promote LPV on all patients all of the time should be maximized. 1. N Engl J Medicine 2000;342(18):1301-1308. 2. Br Med J 2012;344:e2124.

Background: Data describing an endotracheal tube holder both for securing an endotracheal tube (ETT) and reducing skin breakdown compared to cloth tape or other methods of securing the ETT in adult intensive care units (ICU) are limited. Pressure injuries associated with ETTs are concerning due to increased morbidity, treatment cost, and reduced reimbursement. Having a device specific to secure an ETT may reduce variation and improve outcomes. We have used cloth tape to secure ETTs for many years at our hospital. We hypothesize that using a device designed to secure the ETT would reduce hospital-acquired pressure injuries to the mouth and face and secure the airway better than tape. Methods: The Hollister AnchorFast ETT holder was initiated on all intubated patients that met criteria in our adult intensive care units starting in August 2017. Data was retrospectively collected on number of skin injuries to the mouth/face and unplanned extubations compared to ETTs secured with 1 inch cloth adhesive tape. We collaborated with the ICU nurses to ensure that the ETT holder would be repositioned as recommended every two hours. Two data periods were analyzed, PRE - January 2016 to August 2017, POST - August 2017 to present. Results: 7,614 patients received mechanical ventilation in the adult ICU9s since January of 2016, 5,286 patients in the prior to the ETT holder (PRE) and 2328 patients during use of the ETT holder (POST). See data table for incidence of injury and unplanned extubations. Conclusions: Pressure injuries associated with the ETT had a significant decrease from 2.93% (PRE) to 1.97% (POST). Along with the reduction in skin breakdown, the number of unplanned extubations was unchanged. Future studies should investigate the quality of mouth care given when using an ETT holder versus cloth tape.

Background: Oxygen Saturation Index (OSI) has been shown to correlate with the Oxygen Index (OI) and is associated with increased mortality on the day of ARDS diagnosis1. OSI is calculated by (FIO2 X 100 X MAP) / SpO2. OSI is readily available data with no ABG required as is needed with OI. OSI can be calculated with every ventilator-patient assessment. There is limited information concerning the use of OSI outside of ARDS patients at the time of ARDS diagnosis. We wanted to determine if early changes in OSI on all adult ventilator patients would be associated with differences in patient outcomes. Methods: This study is a retrospective review of all mechanically ventilated patients in our adult ICUs since January 2014 who were ventilated in an ICU at least 48 hours. We collected the FIO2, mean airway pressure, SpO2 and location for each documented patient-ventilator assessment on day 1 and day 2 of ventilation. We excluded SpO2 values > 97% and FIO2 values of 100% because large changes in oxygenation only result in small changes of SpO2 in this range, similar to other OSI studies1. We calculated the maximum OSI on day 1 and day 2 of ventilation. We collected the outcomes (death, home discharge or other facility discharge) for all of the included patients. Patients were divided into two groups. Group 1: Maximum OSI decreased from day 1 to day 2. Group 2: Maximum OSI increased from day 1 to day 2. Minitab 18 was used for the data analysis. Results: 2,870 patients received ventilation > 48 h in an ICU since January 2014. Group 1 data: n=1,829, mortality=21.0%, home discharge=31.1%. Group 2 data: n=1,041, mortality=30.6%, home discharge=24.3%. Outcomes were significantly different between groups (P Conclusions: OSI can be calculated with readily available information at bedside. This study shows that the direction of change in the OSI between day one and day two of mechanical ventilation correlates to significant changes in mortality and home discharge of mechanically ventilated ICU patients. Awareness of the changes in OSI could help guide care towards more protective therapies if OSI is worsening. Future prospective studies could match patients by disease and severity to better understand the impact on those specific populations. 1. Chest 2017;152(6):1151-1158.

Background: Rigid bronchoscopy yields a unique challenge for mechanical ventilation. An uncuffed and rigid bronchoscope requires mechanical ventilation strategies not often used. Manual jet ventilation is the most common approach and gold standard. At our hospital, we previously used either manual jet or an LTV-1200 ventilator during rigid bronchoscopy. We recently started using the Philips Respironics V60 ventilator because of its capabilities to ventilate with a leak. The rigid bronchoscopy cases subjectively had better and more stable ventilation. The purpose of this study was to perform a bench evaluation of various leak conditions comparing the V60 to the manual jet for ventilation during simulated rigid bronchoscopy. Methods: We performed a bench evaluation of rigid bronchoscopy with an intubation mannikin airway attached to the Ingmar ASL-5000 test lung with a Novametrix NM3-NICO flow sensor between the mannikin airway and the ASL-5000. Normal apneic adult settings were used on the ASL-5000. The manual jet was tested at 40 and 60 PSI with two breath types, Burst - shortest but full actuation of the jet valve and Hold - full actuation until inspiration ended. The V60 was tested with I-Times of 0.6 seconds and 1 second, with a delta pressure of 20cm H2O and 30 cm H2O. Two different leak scenarios were tested: Low Leak - typical setup of the rigid bronchoscope with the silicon cap in place. High Leak - setup without silicon cap in place. Inspiratory tidal volume was collected with each of the different scenario combinations with the NM3 device. Results: See graphic for the results of the inspiratory volume delivered with each device for the different scenarios. Conclusions: While the manual jet produced similar results regardless of leak it also produced the widest variation in tidal volumes: volumes that would be too low to maintain stable gas exchange (burst breaths) and large tidal volumes that could cause lung injury (hold breaths). This is dependent on the duration of the actuation of the manual jet with no user feedback for breaths that are too large. The V60 produced reasonable breaths during low leak (~300 to 500 mL) and dropped to ~100 mL during high leak. The results of this bench show that the V60 may be better from a lung injury standpoint and should support the patient through rigid bronchoscopy if high leak situations are kept short.

SESSION TITLE: Respiratory Care Posters SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: Average Volume Assured Pressure Support (AVAPS) is a form of noninvasive ventilation that provides a targeted tidal volume with adjustable inspiratory and expiratory pressures. AVAPS is being used for patients with chronic hypercapnic respiratory failure due to COPD, thoracic rib cage or neuromuscular disease, or obesity hypoventilation syndrome. The aim of our study was to determine the impact of AVAPS initiation on hospital admissions. METHODS: We retrospectively evaluated patients admitted to Christiana Care Health System (Newark, DE) from December 2012 to December 2014 with acute on chronic hypercapnic respiratory failure who were initiated on AVAPS at time of discharge. Baseline data collected included sex, age, BMI, pH and pCO2. The number of all-cause and respiratory admissions were analyzed 1 year prior to and 1 year after AVAPS initiation. RESULTS: There were 80 subjects initiated on AVAPS during the evaluation period. 34 subjects (42.5%) were male; mean age 64 ± 13 years, BMI 40 ± 14 kg/m2. Admission arterial blood gas revealed a mean pH 7.31 ± 0.09, mean pCO2 67 ± 19 mm Hg. and mean total CO2 37 ± 8 mmol/L. There were 247 admissions (mean 3.1 ± 2.9 admissions per subject) the year prior to AVAPS initiation, and 138 admissions (mean 1.7 ± 2.4 admissions per subject) the year after AVAPS initiation. 78.7% of subjects were admitted at least once during the year prior to AVAPS initiation and 62.5% of subjects had at least one admission during the year after AVAPS initiation. The admission rates pre and post AVAPS initiation at 30, 90 and 180 days were 94 vs. 46 (p<0.001), 152 vs. 83 (p=0.036), and 175 vs. 88 (p=0.010) respectively. The respiratory admission rates pre and post AVAPS initiation at 30, 90 and 180 days were 29 vs. 14 (p = 0.012), 54 vs. 25 (p = 0.018) and 62 vs. 25 (p=0.004) respectively. CONCLUSIONS: The initiation of AVAPS for use at home in subjects hospitalized for acute on chronic hypercapnic respiratory failure led to a significant reduction in hospital admissions. CLINICAL IMPLICATIONS: Patients with chronic hypercapnic respiratory failure are frequent utilizers of the health care system. Initiation of AVAPS in this high-risk population has been shown to reduce admissions. This intervention may lead to decreased health care expenditures and improved quality of life. DISCLOSURE: The following authors have nothing to disclose: Jacki Cherry, Carol Gray, John Emberger, Gerald O'Brien, Patty McGraw, Jeffrey Stewart No Product/Research Disclosure Information

Background: Current ventilator bundles primarily aim to prevent pneumonia. New ventilator-associated event (VAE) definitions launched by the National Healthcare Safety Network (NHSN) in Jan 2013 detect other physiologic processes than pneumonia. Use of higher positive end-expiratory pressure (PEEP) may reduce other causes of VAE, such as atelectasis and acute lung injury. Methods: We initiated a pilot project in a 22-bed surgical/trauma ICU, part of a large community-based academic health care system, in December 2013. The project involved initiating PEEP of 8 cm H20, rather than 5, as the standard option for all newly ventilated patients in the study ICU. Respiratory therapists were educated as to the protocol and conducted spontaneous breathing trials and ventilator weaning per their usual practice. We tracked number and rate of VAEs (per 1000 ventilator-days), mean ventilator-days per month, and mean ICU days per month. Results: During the 4-month pilot, 263 patients underwent mechanical ventilation in the study ICU. The total VAE, IVAC, and possible/probable VAP rates decreased during the pilot, while the VAC rate remained stable. Compared to the preceding 4 months (with 291 ventilated patients), average ventilator days decreased slightly during the PEEP trial (4.6 ± 4.8 days vs. 5.1 ± 5.9 days, p = 0.3) and average ICU length of stay remained stable (6.7 ± 8.3 days vs. 6.8 ± 7.9 days). No barotrauma or other complications were detected. Discussion: Pilot data suggest that higher standard PEEP levels at time of initiation of mechanical ventilation may help to reduce VAE, without increasing harm. Other ventilator bundle components were utilized simultaneously and likely also contributed to decreased events. Further study is warranted in additional ICUs, for longer duration, and of additional outcomes such as antimicrobial utilization. CONCLUSIONS • Although PEEP of 5 cm H20 often habitual, increasing PEEP at lower levels of FiO2 standardized in published protocols & supported by improved outcomes • Increasing baseline amount of PEEP from 5 to 8 cm H20: • Not difficult to implement with appropriate planning & training of RTs (to overcome sentiment that patients on 8 of PEEP “sicker,” ensure that spontaneous breathing trials still performed daily, as to not trigger VACs)

BACKGROUND AND OBJECTIVE:Pneumothorax is common in very low birth weight (VLBW) infants. In our NICU, we noted an above average incidence of pneumothorax compared with similar NICUs based on Vermont Oxford Network benchmarking. The quality improvement project was designed to decrease the incidence of pneumothorax in VLBW infants in a tertiary care NICU.METHODS:The project was divided into 2 periods. During period 1, all VLBW infants were followed for 6 months for the presence of pneumothorax. A multidisciplinary team met regularly to review cases of pneumothorax and identify potential causes. High tidal volumes (VT) (>6 mL/kg) were noted around the time of occurrence of pneumothorax. Guidelines were developed for improved monitoring and rapid feedback of VT and peak inspiratory pressure between nursing staff and clinicians. During period 2, these guidelines were implemented and VLBW infants were again followed for 6 months. The incidence of pneumothorax was tracked. Run charts were used to monitor changes.RESULTS:The incidence of pneumothorax in VLBW infants decreased from 10.4% to 2.6% after the intervention (P = .04). By using process control, a reduction in pneumothorax was achieved in period 2.CONCLUSIONS:Increased vigilance and real-time monitoring of VT and peak inspiratory pressure decreased the incidence of pneumothorax in our population of VLBW infants. These interventions can be considered in other NICUs with an above-average risk adjusted incidence of pneumothorax in VLBW infants. Our data illustrate the benefits of comparative benchmarking and organized quality improvement in advancing patient care outcomes.

BACKGROUND: Chronic lung disease (CLD) is one of the most severely disabling conditions of extremely low-birth-weight infants. Systemic corticosteroids are effective but cause many adverse effects. Targeted therapy with inhaled corticosteroids may be an effective and less toxic alternative. STUDY OBJECTIVE: To evaluate the additive effect of inhaled corticosteroids on markers of lung inflammation in infants receiving a 7-day course of systemic steroids. METHODS: Preterm neonates weighing 1 kg or less and aged 12 to 28 days who were prescribed a 7-day course of systemic corticosteroids for evolving CLD were studied prospectively and randomized to receive either a tapering 4-week course of beclomethasone metered-dose inhaler (MDI) (n = 5) or placebo MDI (n = 6). Primary outcome variables were the levels of pro- and anti-inflammatory cytokines, IL-8, TNF-alpha, IL-1alpha, and sIL-2R. RESULTS: This study was terminated early following literature reports of the adverse neurodevelopmental effects of dexamethasone. Measurements of respiratory and serum IL-8, IL-1alpha and TNF-alpha were similar between the study group taking inhaled and systemic corticosteroids and the study group taking systemic steroids alone. No differences were found between the two groups in relation to dynamic compliance or resistance. CONCLUSIONS: The addition of inhaled corticosteroids to a 7-day systemic course of corticosteroids did not alter cytokine response or improve pulmonary function.