1. All Wales Audit into the Management of Respiratory Distress Syndrome in Preterm Infants Dr Chris Course (ST2) Dr Ian Morris (Neonatal GRID Trainee) Dr Mallinath Chakraborty (Consultant Neonatologist, UHW)

2. Introduction: Respiratory Distress Syndrome (RDS) is the commonest morbidity of preterm infants. Evidence-based guidelines on the early management of RDS were published in 2013 by the European Association of Perinatal Medicine (Sweet, Carnielli et al. 2013)

3. Aims Collect data on all deliveries at <34 weeks gestation in Welsh neonatal units Audit their management against the 2013 European Consensus Guidelines for the Management of Respiratory Distress Syndrome in Preterm Infants (Sweet, Carnielli et al. 2013) Highlight areas of good practice, and areas which can be targeted for improvement

4. Inclusion Criteria All live-born infants <34 weeks (up to and including 33 +6 weeks). Born between 1st September 2014 and 27th February 2015 (6 month period). Delivered at a Welsh neonatal unit.

5. Demographics Hospital of DeliveryNon-Invasive Respiratory Support $ Hospital NumberCPAP first-line respiratory support used for RDS, if not intubated. Gestation at BirthCPAP delivered through mask or bi-nasal prongs Birth Weight (grams)CPAP pressure of at least 6 cm of water applied Transferred out to another unit? If so, which unit was baby transferred to? Mechanical Ventilation Strategies Prenatal Care: MotherIf baby intubated, documented reason why Received a course of prenatal steroids if gestation between 23 and 34 weeks. * Targeted tidal volume ventilation used. $  If not used, what is documented reason why? (e.g. high leak, other lung pathology etc.) Received a second course of steroids if first course administered more than 2-3 weeks before delivery. # Caffeine used in baby if; apnoea, or, facilitate weaning from MV. $ Received antibiotics if preterm, pre-labour rupture of membranes. Tapering course of steroids (dexamethasone) used if remain on MV after 1-2 weeks. $ Delivery Room Stabilisation $Supportive Care $ Cord clamping delayed for at least 60 seconds (if possible).Parenteral nutrition started on day 1 of life. Stabilisation initiated in 21-30% oxygen.Minimal enteral feeding/trophic feeds started on day 1 of life. Spontaneously breathing baby stabilised with CPAP.PDA, if needing treatment, is medically managed (ibuprofen/indomethacin) If required intubation, received surfactant. If <28 weeks gestation, delivered into a plastic bag. Surfactant Therapy $ Received a natural surfactant preparation (if needed). Received early rescue surfactant if: 30% >26 weeks and FiO2 >40% Received a rescue dose of 200mg/kg surfactant INSURE technique used for rescue surfactant administration. Repeat doses of surfactant given in ongoing evidence of RDS, e.g. O2 requirement/need for MV After surfactant given, rapid reduction in administered FiO2 documented.

6. Results Data collection occurred at seven sites in Wales: University Hospital of Wales, Cardiff, Singleton Hospital, Swansea, Royal Gwent Hospital, Newport, Nevill Hall Hospital, Abergavenny, Prince Charles Hospital, Merthyr Tydfil, West Wales General, Carmarthen, Glan Clwyd Hospital, Bodelwyddan, Rhyl, A total of 225 infants were identified through the audit. 164 infants were born at a tertiary unit, 61 infants were born at a district general hospital.

7. Gestations

8. Antenatal Steroids

9. Delivery The guideline recommends that cord clamping should be delayed for up to 60 seconds.

10. Stabilisation The guideline recommend infants be stabilised in an FiO2 of 21-30%.

11. Delivery into Plastic Bag The guideline recommends that all infants born at <28 weeks gestational age should be delivered into a plastic bag.

12. Surfactant Therapy The guideline recommends administration of surfactant to all infants who require intubation at delivery.

13. Surfactant Therapy The guideline recommends a dose of 200mg/kg for early rescue surfactant.

14. Surfactant Therapy The guideline recommends the use of repeat doses of surfactant for infants requiring ongoing mechanical ventilation or who have a raised oxygen requirement.

15. Mechanical Ventilation The guideline recommends that all infants requiring mechanical ventilation should be on a volume-targeted ventilation mode.

16. Non-Invasive Ventilatory Support The guideline recommends that infants who are on CPAP should have a PEEP of at least 6cmH2O applied.

17. Caffeine Therapy The guideline recommends that caffeine be used in babies to wean respiratory support and/or prevent apnoea a of prematurity.

18. Conclusions High rates of antenatal steroid exposure (92%). High rates of stabilisation in 21-30% oxygen (85%). High rates of early surfactant administration if requiring early intubation (92%). High rates of delivery into a plastic bag if <28 weeks GA (93%). High rates of VTV (84%) and caffeine use (86%) in tertiary units.

19. Conclusions Rates of delayed cord clamping across the whole sample are low (20%). A surfactant dose of 200mg/kg used in 56% of sample, repeat dose if required used in 39% of sample. CPAP PEEP of 6cmH2O used in 52% of sample. Lower incidence of caffeine being used in level 2 units (63% compared to 86%).

20. Discussion Points: Promotion of delayed cord clamping on labour wards. Education regarding optimal rescue surfactant dose/repeat dosing. Education for level 2 units regarding benefits of caffeine for <34 week infants. Development of a network guideline around management of RDS.

21. Further Work: National survey into attitudes towards delayed cord clamping currently underway. Formation of an All Wales Focus Group for RDS Management. Development of an All Wales RDS Management Guideline.

22. Acknowledgements Welsh Research and Education Network and local Consultant links. Regional trainees: Dr. Ian Morris, UHW, Cardiff Dr. Sian Foulkes, Singleton Hospital, Swansea Dr. Andrew Hallet, Nevill Hall Hospital, Abergavenny Dr. Nakul Gupta, Prince of Wales Hospital, Merthyr Tydfil Dr. Matthew Pickup, West Wales General Hospital, Camarthen Dr. Rose Bandla, Glan Clwyd Hospital, Rhyl

23. Many thanks for listening! Any questions? chriscourse@doctors.org.uk mallinath.chakraborty@wales.nhs.uk

24. References: Sweet, DG et al. (2013) European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants - 2013 update. Neonatology. 2013;103(4):353-68.