Ventilation on a Low Resource Setting Neonatal Unit: Just Because We Can, does that mean we Should?

Background: There is minimal research on prolonged unmonitored neonatal ventilation in low resource settings. Zambia`s only tertiary Neonatal unit, based at University Teaching Hospital, Lusaka has four ventilators. The decision to intubate is clinical, with oxygen saturations the only monitoring. The mortality rate of these patients unknown. There is no carbon dioxide monitoring, no blood gases, no chest Xray. Therefore we cannot monitor for hypocapnia or hyperoxemia if ventilated for a prolonged period. Is it right to intubate and ventilate those infants without ways to safely monitor?

Method: A retrospective review of intubated and ventilated patients over a three month period. Exclusion criteria for ventilation was infants less than 1kg, those with congenital abnormalities and ventilator availability. A proforma was filled out including gestation, weight, reason for intubation, intubator grade, tube size, premedication used, length of intubation, how they extubated and outcome.

Results: In total 44 patients, average weight 2.5kg. Main reason for admission was HIE 64%, main reason for intubation was respiratory distress 34%. Registrars were responsible for 55% of intubations. 75% noted ETT size, 5% documented number of attempts. No one was premedicated and 9% received surfactant. No documentation of ETT length. 14% documented air entry post intubation, no other ETT confirmaton method documented. Average length of intubation was 23 hours. 30% were planned extubations, 36% self extubated. 25% survived to discharge. 68% died prior to discharge.

Conclusion: Whilst this is a small cohort of patients, it gives some indication of outcomes of ventilated infants. The question remains an uncomfortable unanswered one, for which further work is needed. An intubation check list has been created to aid documentation, teaching of nursing and medical staff includes how to intubate, use of premedication, how to secure ETT and ventilation. We will re audit to see if these interventions have made any difference.