Mohammed Ajaz Mohammed Haneef Shaikh^1*, Rajendra Hiralal Bedmutha²

^1,2Associate Professor, Department of Paediatrics, Dr.Ulhas Patil  Medical College, Jalgaon, Maharashtra, INDIA.

Email: ajazhanif1970@gmail.com , drrajubaid@gmail.com

Table 1: Comparison of mechanically ventilated neonates in terms of the outcomes (n=156).

(* - statistically significant)

In present study Acidosis(pH<7.2), use of inotropes, preterm gestation, use of blood products, birth weight <2.5kg , positive blood culture, presence of sepsis and IUGR were noted as factors significantly associated with mortality.

Table 2: Prediction of mortality

(* - statistically significant)

DISCUSSION

Many of admitted newborns are critically sick and require mechanical ventilation. The survival of sick neonates have improved significantly with the widespread use of mechanical ventilation in NICUs.⁷ Several studies show that weight and gestational age are major determinants of neonatal mortality.^8,9 It is also related with severity of illness at admission, complications related to ventilator techniques and strategies and occurrence of co-morbid conditions like sepsis, coagulopathy, multi organ dysfunction, congenital malformations etc.¹⁰ Monsef AR et al.,¹¹ studied 141 mechanically ventilated neonates, 55.3% (n=78) were males. The mean of neonatal age, mean gestational age and mean birth weight were, 4.67 ± 6.58 days, 35.51 ± 3.88 weeks, and 2779.37 ± 827.06 g, respectively. RDS (58.9%) was the most common indication for mechanical ventilation. The overall rate of neonatal recovery was 51.8%. The results of unilabiate analysis showed a significant relationship between indications of mechanical ventilation, gestational age, neonatal birth weight, acidosis (pH <7.1), duration of mechanical ventilation, duration of hospitalization and the disease outcomes (P<0.05). They noted that respiratory distress syndrome, low gestational age and birth weight, acidosis and duration of mechanical ventilation would lead to increased death in mechanically ventilated neonates. Yadav M et al.,¹² studied of 50 ventilated newborns, m:f ratio was 2.1:1. The most common gestational age 28–36 weeks (60%) and mostly were appropriate for gestational age (66%). Survival rate 40% (20/50) being directly proportional to the gestational age and intrauterine growth pattern (P < 0.01). Babies by LSCS Lower Segment Cesarean Section survived more than born by normal vaginal delivery (46.7% vs. 37.1%). The initial assessment of APGAR score of >7 had a better outcome (56.3%; P < 0.03). The most common indication of ventilation was hyaline membrane disease (19/50) but the survival rate best in babies with meconium aspiration syndrome (54.5%). The most prevalent complication was sepsis (survival rate 60%) while conditions such as shock, intraventricular hemorrhage, disseminated intravascular coagulation, air leak syndrome, and pulmonary hemorrhage had 100% mortality. Thus, the outcome as survival is constrained by many factors; newborn’s profile, conditions at birth, and postnatal resuscitation. Shrestha P et al.,¹³ noted that one-third of admitted neonates in NICU required mechanical ventilation (MV). Commonest indication was severe respiratory distress (70%) followed by perinatal asphyxia (12%) and recurrent apnea (8%). Disease pattern were sepsis (37.2%), RDS of prematurity (17.6%), perinatal asphyxia (11.7%), meconium aspiration syndrome (9.8%), apnea of prematurity (7.8%) and congenital pneumonia (4%). Hospital acquired sepsis was a major complication occurring in 47% patients on mechanical ventilation. Survival rate among neonates on MV was 33%. Survival was better with increasing birth weight and gestational age. Survival was 100% in congenital pneumonia, 50% in perinatal asphyxia, 50% in recurrent apnea, 26% in sepsis, 20% in MAS and 0% in RDS of prematurity. Survival rate of neonates on mechanical ventilation in NICU was 33%. Sepsis was a major problem in NICU, which must be addressed to improve outcome. Similar findings were noted in present study. Prajakta D¹⁴ studied 206 neonates, males comprised of 56.8% of ventilated neonates. The most common indication of ventilation was birth asphyxia, in 29.1% neonates, followed by neonatal sepsis (22.3%), respiratory distress syndrome (18.4%), and meconium aspiration syndrome (13.1%). Complications were seen in 35.9% neonates, the most common complication was ventilator associated pneumonia (50%), sepsis (40.5%), pneumothorax (16.2%). Survival rate among the ventilated neonates was 45.6%. Neonates with birth asphyxia and sepsis were the major problems in NICU, which must be addressed to improve outcome. Iqbal Q et al.,¹⁵ studied 300 ventilated neonates, 52% were male. Mean age, weight, and gestational age were 21 ± 62 h, 2320 ± 846.2 g, and 35.2 ± 4.9 weeks, respectively. 130 (43%) neonates died. Respiratory distress syndrome (RDS) (31.1%), sepsis (22.7%), and birth asphyxia (18%) were the most common indications for ventilation. Mortality in ventilated patients with sepsis, pneumonia, RDS or birth asphyxia was 64.7%, 60%, 44.6%, and 33.3%, respectively. Weight <2500 g, gestation <34 weeks, initial pH <7.1, presence of sepsis, apnea, shock, pulmonary hemorrhage, hypoglycemia, neutropenia, and thrombocytopenia were significantly associated with mortality (P < 0.05). Resuscitation at birth, seizures, intra ventricular hemorrhage, pneumothorax, ventilator-associated pneumonia, PO2, or PCO2 did not have a significant association with mortality. On logistic regression, gestation <34 weeks, initial pH <7.1, pulmonary hemorrhage, or shock were independently significant predictors of mortality. Conclusions: Weight <2500 g, gestation <34 weeks, initial arterial pH <7.1, shock, pulmonary hemorrhage, apnea, hypoglycemia, neutropenia, and thrombocytopenia were significant predictors of mortality in ventilated neonates. Meconium-stained babies should be aggressively managed to prevent complications like perinatal asphyxia and respiratory failure which may lead to the mortality. Those neonates with risk for adverse outcome should be managed with special focus on respiratory care with use of assisted ventilation and inhaled nitric oxide and extracorporeal membrane oxygenation, where available. Increasing gestational age, appropriate intrauterine growth pattern and increasing hospital stay were associated with better outcome whereas low-APGAR score was associated with higher mortality.

CONCLUSION

Mechanical ventilation reduces the neonatal mortality, hence facilities for neonatal ventilation should be included in the regional and central hospitals providing intensive care for neonates. A good understanding of different types of assisted mechanical ventilation modes with underlying pathophysiology of lung condition will provide optimal respiratory support in critically ill newborn infants.

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