Predictive monitoring for respiratory decompensation leading to urgent unplanned intubation in the neonatal intensive care unit

Department of Chemical Engineering, University of Virginia, Charlottesville, VA 22904.
Pediatric Research (Impact Factor: 2.31). 11/2012; 73(1). DOI: 10.1038/pr.2012.155
Source: PubMed


Infants admitted to the neonatal intensive care unit (NICU), and especially those born with very low birth weight (VLBW; <1500 grams), are at risk for respiratory decompensation requiring endotracheal intubation and mechanical ventilation. Intubation and mechanical ventilation are associated with increased morbidity, particularly in urgent unplanned cases.Methods
We tested the hypothesis that the systemic response associated with respiratory decompensation can be detected from physiological monitoring, and that statistical models of bedside monitoring data can identify infants at increased risk of urgent, unplanned intubation. We studied 287 VLBW infants consecutively admitted to our NICU and found 96 events in 51 patients, excluding intubations occurring within 12 hours of a previous extubation.ResultsIn order of importance in a multivariable statistical model, we found the characteristics of reduced O(2) saturation, especially as heart rate was falling, increased heart rate correlation with respiratory rate, and the amount of apnea all were significant independent predictors. The predictive model, validated internally by bootstrap, had receiver-operating characteristic area of 0.84 + 0.04.Conclusions
We propose that predictive monitoring in the NICU for urgent unplanned intubation may improve outcomes by allowing clinicians to intervene non-invasively before intubation is required.Pediatric Research (2012); doi:10.1038/pr.2012.155.

Download full-text


Available from: Douglas E Lake, Oct 07, 2014
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose of review: Predictive monitoring is an exciting new field involving analysis of physiologic data to detect abnormal patterns associated with critical illness. The first example of predictive monitoring being taken from inception (proof of concept) to reality (demonstration of improved outcomes) is the use of heart rate characteristics (HRC) monitoring to detect sepsis in infants in the neonatal ICU. The commercially available 'HeRO' monitor analyzes electrocardiogram data from existing bedside monitors for decreased HR variability and transient decelerations associated with sepsis, and converts these changes into a score (the HRC index or HeRO score). This score is the fold increase in probability that a patient will have a clinical deterioration from sepsis within 24 h. This review focuses on HRC monitoring and discusses future directions in predictive monitoring of ICU patients. Recent findings: In a randomized trial of 3003 very low birthweight infants, display of the HeRO score reduced mortality more than 20%. Ongoing research aims to combine respiratory and HR analysis to optimize care of ICU patients. Summary: Predictive monitoring has recently been shown to save lives. Harnessing and analyzing the vast amounts of physiologic data constantly displayed in ICU patients will lead to improved algorithms for early detection, prognosis, and therapy of critical illnesses.
    Current opinion in pediatrics 02/2013; 25(2). DOI:10.1097/MOP.0b013e32835e8fe6 · 2.53 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Bronchopulmonary dysplasia (BPD), or chronic lung disease of prematurity, occurs in ∼30% of preterm infants (15,000 per year) and is associated with a clinical history of mechanical ventilation and/or high inspired oxygen at birth. Here, we describe changes in ventilatory control that exist in patients with BPD, including alterations in chemoreceptor function, respiratory muscle function, and suprapontine control. Because dysfunction in ventilatory control frequently revealed when O2 supply and CO2 elimination are challenged, we provide this information in the context of four important metabolic stressors: stresses: exercise, sleep, hypoxia, and lung disease, with a primary focus on studies of human infants, children, and adults. As a secondary goal, we also identify three key areas of future research and describe the benefits and challenges of longitudinal human studies using well-defined patient cohorts.
    Respiratory Physiology & Neurobiology 07/2013; 189(2). DOI:10.1016/j.resp.2013.07.015 · 1.97 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To identify clinical conditions associated with a large increase (spike) in the heart rate characteristics index in very low birth weight (VLBW) infants. Retrospective medical record review within a day of all large heart rate characteristics index spikes (increase of ≥3 from the previous 5-day average) in VLBW infants at a single center enrolled from 2007 to 2010 in a multicenter trial of heart rate characteristics monitoring. In the trial, infants were randomized to having their heart rate characteristics index displayed to clinicians or not displayed. Of 274 eligible infants, 224 large heart rate characteristics spikes occurred in 105 infants. Thirty-three spikes were associated with surgery or procedures requiring anesthetic or anticholinergic medications, and infection-related conditions were the most common clinical association with the other spikes. Of the first spikes in 47 infants randomized to conventional monitoring (heart rate characteristics index not displayed to clinicians), 53% were associated with suspected or proven infection. Respiratory deterioration without suspected infection occurred with 34%, and no association was identified in 13%. Infants randomized to having their heart rate characteristics index displayed were more likely to have antibiotics initiated around the time of a large heart rate characteristics index spike. Sepsis, other infectious or systemic inflammatory conditions, respiratory deterioration, and surgical procedures are the most common clinical associations with a large increase in the heart rate characteristics index in VLBW infants. This information may improve use of heart rate characteristics monitors in patients in the neonatal intensive care unit.
    The Journal of pediatrics 01/2014; 164(4). DOI:10.1016/j.jpeds.2013.11.038 · 3.79 Impact Factor
Show more