We determined the demographic and clinical characteristics of study infants including sex, race, inborn status, antenatal steroid use, postnatal day at NICU admission, BW, GA, and Clinical Risk Index for Babies (CRIB) score by querying local NICU research databases manually curated by trained research nurses in each unit and electronic health records using Epic’s Clarity database (Epic Systems Corporation, Verona, WI). The initial FiO 2 was defined as the recorded value on each ventilator at the same time as the initial VT. Patients with missing ventilator data, defined as those for whom ventilator data at the beginning of the ventilation course were not downloaded, were excluded from the study. We determined the initial VT and FiO 2 by downloading data directly from the mechanical ventilators. Each initial VT was then classified as congruent or not with the available literature according to the birth weight of the infant: <700 g (g) (5.5–6 mL/kg), 700 – <1250 g (4.5–5 mL/kg), and ≥1250 g (4–4.5 mL/kg). We defined the initial VT as the first VT that was used for 15 or more consecutive minutes after initiating MV. The primary outcome for each infant was the initial VT used during the first MV course in mL per kg of birth weight (BW). These guidelines were not present at the Jackson-Madison County General Hospital NICU during the study period. At VUMC, existing unit guidelines were based on the limited-evidence available for choosing initial VT settings. High frequency jet ventilation is generally used as the first ventilation modality for all non-vigorous infants less than 25 weeks GA. Both study units utilized flow sensors placed at the proximal end of the endotracheal tube. During the study, both NICUs primarily used either flow-cycled or time-cycled modes with the volume guarantee feature and leak compensation on the Dräger Evita Infinity V500 ventilator (Drägerwerk AG and Co, Lübeck, Germany) activated. For infants who receive endotracheal intubation, conventional VTV modes are the most common ventilator modalities used. In both NICUs, non-invasive ventilation is the primary mode of respiratory support for all infants born at less than 32 weeks’ gestational age (GA). The VUMC institutional review board approved the study with a waiver of consent. We excluded infants who received PLV or high frequency ventilation prior to receiving VTV and infants with congenital pulmonary airway malformations. We included all infants who received VTV as the initial ventilation modality prior to postnatal day 14. We collected data from Octoto Februat the VUMC NICU and from Mato Septemin the Jackson-Madison NICU with differences in study periods due to local infrastructure for data collection and restrictions on clinical research during the COVID-19 pandemic. We performed a retrospective observational cohort study using prospectively collected data in the 98-bed, level IV Vanderbilt University Medical Center (VUMC) NICU and the 30-bed, level III Jackson-Madison County General Hospital NICU from October 2018 to September 2020. The objectives of our study were to quantify initial VT used during neonatal VTV and to characterize the frequency with which initial VT agreed with the limited-evidence available for neonatal VTV use. However, no studies have described initial VTs in clinical practice. A previous survey showed that the initially chosen VT often does not agree with these recommendations. Based on the results of those studies, one manuscript provided recommendations for initial VT based on weight and respiratory physiology. Several small studies have evaluated short-term physiologic outcomes with different tidal volumes. One of the most important decisions neonatal clinicians must make when using VTV is to choose an initial tidal volume (VT) that is appropriate for each infant’s respiratory pathology and size. However, only 42% of NICUs in the US and Canada report VTV as their primary ventilation modality. Compared to PLV modes, VTV is associated with lower rates of death or BPD, pneumothorax, intraventricular hemorrhage, and fewer days of MV. In neonates receiving MV, volume-targeted ventilation (VTV) results in improved clinical outcomes compared to pressure-limited ventilation (PLV). Despite improvements in neonatal care, BPD occurs in 40% of very low birth weight infants in the United States (US). However, MV in preterm infants is associated with increased mortality, neurodevelopmental impairment, structural changes in the central nervous system, and bronchopulmonary dysplasia (BPD). Mechanical ventilation (MV) in the Neonatal Intensive Care Unit (NICU) is a life-saving therapy.
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