Kim Firestone, MS

The need for qualified and competent respiratory therapists (RTs) in the neonatal/pediatric arena is imperative, and the developmental care plan must be incorporated to establish a comprehensive neuroprotective strategy addressing the multifaceted needs of premature infants. RTs bring specialized expertise in respiratory physiology and management, making them integral multidisciplinary team members responsible for caring for preterm infants in the neonatal intensive care unit (NICU). Their involvement should be viewed not merely as an adjunct to care but as an essential component that enhances the quality and effectiveness of interventions promoting optimal neurodevelopmental outcomes. 

The neonatal respiratory therapist possesses a unique skill set that includes a deep understanding of respiratory mechanics, ventilation strategies, and airway management techniques explicitly tailored to the delicate physiology of premature infants. This specialized knowledge equips RTs to play a pivotal role in providing respiratory support, from conventional mechanical ventilation to advanced modalities such as high-frequency oscillatory and non-invasive ventilation. By actively participating in multidisciplinary care rounds and collaborative decision-making processes, RTs contribute valuable insights that contribute to developing and implementing individualized respiratory care plans tailored to each neonate’s unique needs, creating a healing environment. Recommendations for positioning, oral feeding support, pain and stress management, skin care, and sensory stimulation can be incorporated into the plans. 

Additionally, RTs bring to the table a wealth of experience in assessing and managing the respiratory consequences of common neonatal morbidities such as respiratory distress syndrome, bronchopulmonary dysplasia, and apnea of prematurity. Their ability to anticipate and promptly address respiratory complications is instrumental in mitigating the risk of adverse outcomes and optimizing long-term respiratory function in preterm infants. In addition to providing direct patient care, RTs play a vital role in caregiver education. Randomized clinical trials have shown that early discharge is possible without adverse health effects when discharged with preterm infants based on physiologic criteria. The RTs can empower parents to participate actively in the respiratory care of their infants and foster a supportive environment conducive to family-centered care. 

A hallmark practice in developmental care is kangaroo care, which involves prolonged skin-to-skin contact between infants and their parents. While the benefits of kangaroo care in promoting bonding, thermoregulation, and neurodevelopmental outcomes are well documented, emerging evidence suggests that this intervention may also positively impact respiratory function. Studies have shown that kangaroo care significantly reduces respiratory efforts in ventilated preterm infants, enhances the diaphragm’s electrical activity, improves respiratory muscle strength, and reduces the duration of respiratory support required for preterm infants. RTs can help optimize respiratory outcomes while fostering parental involvement and confidence in caring for their infants by encouraging kangaroo care into routine caregiving practices and providing guidance on safe and effective positioning techniques. Education can be provided to families with bedside simulation with the RT and team to perform standing transfer, stabilization of equipment, and the endotracheal tube. Proper education reinforces confidence for all team members, including the parents. 

Despite advances in neonatal respiratory care, unplanned extubation remains a significant concern in the NICU, posing both immediate risks to the infant’s respiratory status and potential long-term consequences for neurodevelopment. Preventing unplanned extubation requires a multifaceted approach that addresses technical factors, such as securement methods and equipment selection, and human factors, such as caregiver education and vigilance. RTs are well positioned to contribute to developing and implementing comprehensive unplanned extubation prevention protocols, leveraging their expertise in airway management and ventilator technology to identify risk factors and implement proactive strategies. By collaborating with families to educate them on the importance of maintaining a secure airway and providing ongoing support and reinforcement, RTs can help alleviate the risk of unplanned extubation and promote safe and effective respiratory care practices in the NICU. 

The involvement of respiratory therapists in developmental care initiatives for preterm infants is essential for optimizing respiratory outcomes and fostering holistic neurodevelopmental support. By providing their specialized knowledge, clinical expertise, and collaborative approach to care, RTs contribute valuable insights and interventions that complement the efforts of the multidisciplinary team. Through proactive engagement in respiratory care planning, caregiver education, and unplanned extubation prevention, RTs are necessary in promoting the health, well-being, and developmental potential of preterm infants in the NICU. 

References: 

1. Walsh BK, Gentile MA. Grenier BM. Orienting New Respiratory Therapists Into the Neonatal/Pediatric Environment: A Survey of Educators and Managers. Respiratory Care. 2011 Aug; 56 (8): 1122-1129.  DOI: 10.4187/respcare.00972
2. Roark TH, DePreist D, Moore B, Write L, Carpenter A, Willet K, Bhandary P, Giannone P, Hanna M, Patra A, Jenkins S. Standardizing a Method to Safely Perform Kangaroo Care for Neonates While on High-Frequency Jet Ventilation. Respiratory Care. 2019 Oct; 64 (Suppl 10) 3235709. 
3. Kato Y, Takemoto A, Oumi C, Tomomi H, Shimaji Y, Takaoka M, Moriyama H, Hirata K, Wada K. Effects of skin-to-skin care on electrical activity of the diaphragm in preterm infants during neurally adjusted ventilatory assist. Early Human Development. 2021 June; (157) 105379. DOI: 10.1016/j.earlhumdev.2021.105379