Variability of Respiratory Rate Measurements in Neonates- Every Minute Counts

Background: Respiratory rate is difficult to measure, especially in neonates who have an irregular breathing pattern. The World Health Organisation recommends a one-minute count, but there is limited data to support this length of observation. We sought to evaluate agreement between the respiratory rate (RR) derived from capnography in neonates, over 15 seconds, 30 seconds, 120 seconds and 300 seconds, against the recommended 60 seconds. Methods: : Neonates at two hospitals in Nairobi were recruited and had capnograph waveforms recorded using the Masimo Rad 97. A single high quality 5 minute epoch was randomly chosen from each subject. For each selected epoch, the mean RR was calculated using a breath-detection algorithm applied to the waveform. The RR in the first 60 seconds was compared to the mean RR measured over the first 15 seconds, 30 seconds, 120 seconds, full 300 seconds, and last 60 seconds. We calculated bias and limits of agreement for each comparison and used Bland-Altman plots for visual comparisons. Results: : A total of 306 capnographs were analysed from individual subjects. The subjects had a median gestation age of 39 weeks with slightly more females (52.3%) than males (47.7%). The majority of the population were term neonates (70.1%) with 39 (12.8%) having a primary respiratory pathology. There was poor agreement between all the comparisons based on the limits of agreement [confidence interval], ranging between 11.9 [-6.79 to 6.23] breaths per minute in the one versus two minutes comparison, and 34.7 [-17.59 to 20.53] breaths per minute in the first versus last minute comparison. Worsening agreement was observed in plots with higher RRs. Conclusions: : Neonates have high variability of RR, even over a short period of time. A slight degradation in the agreement is noted over periods shorter than one minute. However, this is smaller than observations done three minutes apart in the same subject. Longer periods of observation also reduce agreement. For device developers, precise synchronization is needed when comparing devices to reduce the impact of RR variation. For clinicians, where possible, continuous or repeated monitoring of neonates would be preferable to one time RR measurements.