Guest Editorial

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There is no one working in the neonatal intensive care unit (NICU) who has not been touched by a patient with respiratory distress. Sometimes, the respiratory distress is a symptom of an illness unrelated to lung status, but in many cases, it is pulmonary in origin. Although these infants often present as comparatively uncomplicated, treatments have changed significantly over the years. When neonatology first began, there were no ventilators available. With necessity being the mother of invention, one was adapted from the adult world to be used in neonates. Others followed, again adapted from adult medicine, to fit smaller lungs. However, these created problems. Oxygen, coming on the scene before ventilators, was also lifesaving but created diseases not seen before. These diseases, chronic lung disease and rentinopathy of prematurity, are still present in our nurseries today. We still struggle with how to avoid them and, too often, how to treat them. Even today, new respiratory treatments are available and often put into use without adequate research. Clinicians are tempted to use these modalities, believing that complications might be avoided, when in fact, other complications might surface.

Because there are so many choices in modes of treatment, including invasive and noninvasive ventilation, types of surfactants, and others, how do we make those choices? Once the choice is made, it is no longer just a matter of plugging it in and turning it on! This is more true in the neonate than any other population, as the disease process and developmental status of the lungs will affect how and which treatment may be best provided. However, without adequate research, we may find that what is helpful in the short term is damaging in the long term, or what is helpful to some infants may be detrimental to more.

The first article in this journal, a review for many readers, will help to set the stage for the remaining articles. Remembering the process of lung development and disease pathology commonly treated in the neonate will provide a basis for the discussions to follow. Blood gas interpretation is also important in determining the need for and/or success of the chosen treatment.

The 2002 March of Dimes statistics on birth outcome still showed prematurity as the second leading cause of infant mortality, and respiratory distress syndrome, the fourth leading cause.¹ Although respiratory distress syndrome is a disease that has been treated for years, there is still a lot to learn. You will read, in the article on surfactants, that all surfactants are not equal and obtain guidance on how one might select the most appropriate surfactant for the disease. Discussion of new research on the horizon follows. Oxygen, one of the most common and first drugs given to neonates, is discussed. Ellen Mack points out areas where mistakes in attempting to do what was believed to be the best for the patient resulted in catastrophic outcomes because of lack of knowledge of how oxygen administration affects the developing newborn. Even with all we have learned about oxygen, questions remain. Just because we can increase the oxygen saturation, should we? If so, how far?

In the not-so-distant past, a time many of us remember clearly in our careers, ventilator choices in the NICU were limited, and lung function monitoring, nonexistent. Now, surrounded with choices in ventilator modalities and bombarded with graphs and loops, how can this information be analyzed to help make intelligent decisions about ventilator modality and weaning? Dr Mitchell Goldstein provides a discussion of lung function measures and how this information should be applied clinically. With more focus on the use of early nasal continuous positive airway pressure (CPAP), it seemed appropriate to reprint an article by Amer Ammari and colleagues. Discussed in these 2 articles are considerations of the benefits of nasal CPAP and the challenges. In an effort to avoid complications, are some infants being treated with CPAP who may benefit from earlier intubation? A review of historical experience from Columbia may be helpful in guiding decisions.

Nitric oxide has prevented more invasive means of support for many infants but has not been the “silver bullet” many hoped it might be but, rather, another adjunct to other treatments. A discussion of the continuing research in this area is presented. Suctioning the endotracheal tube is something many clinicians do several times a day, some in much the same way it has been done for 10, 20, or even 30 years. Robin Koeppel reviews the literature, including some surveys of clinical practice. As you read this article, I encourage you to think about your own practice and the variety of suctioning practices you may see in your own unit. Could the incidence of chronic lung disease or ventilator associated pneumonia be decreased by something so simple as a slight modification of these practices?

Hopefully, this issue will help bring history to life for some newer healthcare providers in the NICU and bring back memories for others! At the same time, lessons learned need to be renewed again from time to time to remind us of the importance of questioning every practice to be certain that we are providing more good than harm to our patients. Although great strides have been made in survival of the smallest infants, the focus is now on decreasing morbidity suffered by those who do survive. Some of this morbidity is due to the treatments that are provided. Questioning old practices, never accepting that we continue to do something because “we've always done it that way,” and looking for better treatments are the basis of research. You will find mention in several articles that there are no sufficient controlled clinical trials to support our current practices. Some research upon which we base our most common practices were done in a different patient population than we currently see in our neonatal intensive care units. Should we be doing things differently for patients we are seeing now? If nothing else, I hope that reading this issue will spark research questions and motivate readers to do the research into old practices that have never been proven to benefit this population.

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Reference 

1. March of Dimes, United States Infant Mortality. Available at: http://www.marchofdimes.com/peristats March of Dimes, 2004 [accessed 2/27/2006].
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