Treatment of persistent pulmonary hypertension of the newborn without hyperventilation: an assessment of diffusion of innovation.

OBJECTIVE

The treatment of neonates with persistent pulmonary hypertension of the newborn (PPHN) is controversial with no consensus on diagnostic criteria or treatments. Hyperventilation has been the therapeutic mainstay. However, two widely variant alternative approaches have been proposed: ventilation without induced alkalosis, or more aggressive therapies such as high frequency ventilation or extracorporeal membrane oxygenation. We wished to determine the extent to which these alternative treatments have diffused into practice.

METHODS

A forced choice questionnaire was mailed to a sample representing 10% of 3740 practicing neonatologists. Sixty percent of those surveyed responded. Data on treatment practices was tabulated. Subanalyses with respect to training era, practice site, and geographic region were performed.

RESULTS

In patients with meconium aspiration syndrome, without evidence of PPHN, 36% described their initial management as hyperventilation. If PPHN was confirmed, hyperventilation was used in 90% of patients by 44% of the respondents. Muscular paralysis and inotropic support were also used frequently. Alkali and vasodilator infusion were used less frequently. The gentle ventilation strategy proposed by Wung and James at Columbia Babies Hospital was used infrequently by 47% of respondents. Gentle ventilation was used more frequently by board-certified neonatologists than those not certified. No significant differences in practice were identified by geographic region or era of training. When standard treatment failed, only 40% of the respondents utilized rescue treatments such as high frequency ventilation or extracorporeal membrane oxygenation.

CONCLUSIONS

This study documents that gentle ventilation, an easily and inexpensively adopted innovation, has not diffused into practice significantly while more expensive high technology treatments, such as high frequency ventilation and extracorporeal membrane oxygenation, have penetrated more significantly.