Neonatal transport medicine is a specialized field that involves complex coordination and skilled clinicians in a resource-limited environment. Although many transported infants require pediatric specialty consultations, the most common reason for a transport request is respiratory distress. This article discusses neonatal respiratory problems and their management needs during transport.
Very low-birth-weight (VLBW) infants who are at the highest risk for respiratory distress have better outcomes when born in a hospital with a neonatal intensive care unit (NICU).1About 30% of these infants are delivered outside a tertiary perinatal center.2 According to the American Academy of Pediatrics, having specialized and regionalized intensive care services for infants and children improves outcomes.3Specifically, having a transport team trained in neonatal respiratory stabilization and management is essential to decrease infant mortality and morbidity rates when they are born in nontertiary settings.
Historically, neonatal transports to a hospital began in the early 1920s with the creation of premature ambulance services and the invention of the first transport isolettes in Chicago, Illinois.4,5 The premature ambulance service consisted of a nurse and a driver pair who specialized in bringing premature infants from home to hospital.4Home births during this era were common. During this time, even mildly distressed infants had a very high mortality rate because of the unsanitary birth conditions.
n addition to the advances in transport, infant mortality rate was further decreased by the introduction of perinatology as a medical specialty. The safety of a hospital delivery was recognized and many births gradually transitioned from home to hospital. Pediatrician-led teams began to attend deliveries of high-risk infants and NICUs became more advanced to address the needs of smaller premature infants, especially after invention of the Babybid ventilator. Transport medicine also advanced with the availability of an automated heat source, oxygen, monitor, and ventilator. Transport isolettes transitioned from primitive heat sources to advanced, portable systems capable of safely transporting sick infants from the birth hospital to the tertiary center.
Today, neonatal teams have expanded their equipment to include more technologically complex isolettes with advanced modes of respiratory management. Transport teams typically include specially trained nurses and respiratory therapists (RTs) as team members.3,8Although NICU advances in respiratory care led to advanced neonatal transport technology, the often-challenging transport environment continues to limit novel respiratory therapies and the empirical evidence to support neonatal transport medicine is still minimal.
Neonatal transport teams can often offer the same advanced respiratory management techniques that are currently used in the NICU. Transport respiratory management is accomplished by having a team of clinicians with advanced neonatal resuscitation skills, including registered nurses and RTs, with level III to IV NICU experience. Obstacles to respiratory management are size and feasibility of equipment, method of transport, team composition, and lack of research and evidence to support transport practice. To overcome these obstacles, teams are advised to encourage equipment manufacturers to develop portable ventilator systems feasible for neonatal transport. Teams should also regularly participate in flight training and provide input into medical helicopter and fixed wing aircraft modifications. Because many neonates are transported for respiratory conditions, it is optimal for tertiary centers to have RTs on their team. To promote transport medicine, teams should also regularly participate in research and disseminate their findings to add to the body of knowledge.
Future endeavors for neonatal transport teams may include other forms of respiratory management currently being used in some NICUs. Neotech’s RAM cannula (Valencia, California) is a softer form of nasal continuous positive airway pressure that allows the infant to move more freely and to lie prone if needed. T-pieced resuscitators are commonly used in delivery rooms and some NICUs, but the equipment currently available is not feasible for many transport teams. Other modalities not available to neonatal transport include neurally adjusted ventilatory assist and pressure and volume limited ventilation. Neurally adjusted ventilatory assist uses electrical signals from the infant’s diaphragm to allow the infant to control ventilation. Pressure limited ventilators limit the amount of pressure that can be delivered during inspiration and support synchronized ventilation. As early as 2011, volume ventilation began replacing pressure limited ventilation because it provides a controlled, consistent tidal volume with lower PIP to reduce lung damage.27 Neonatal transport teams are encouraged to extend these modes of respiratory support into the transport environment to prevent infant morbidity.