1
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Greenough A, Milner AD. Early origins of respiratory disease. J Perinat Med 2023; 51:11-19. [PMID: 35786507 DOI: 10.1515/jpm-2022-0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 01/20/2023]
Abstract
Chronic respiratory morbidity is unfortunately common in childhood, particularly in those born very prematurely or with congenital anomalies affecting pulmonary development and those with sickle cell disease. Our research group, therefore, has focused on the early origins of chronic respiratory disease. This has included assessing antenatal diagnostic techniques and potentially therapeutic interventions in infants with congenital diaphragmatic hernia. Undertaking physiological studies, we have increased the understanding of the premature baby's response to resuscitation and evaluated interventions in the delivery suite. Mechanical ventilation modes have been optimised and randomised controlled trials (RCTs) with short- and long-term outcomes undertaken. Our studies highlighted respiratory syncytial virus lower respiratory tract infections (LRTIs) and other respiratory viral LRTIs had an adverse impact on respiratory outcomes of prematurely born infants, who we demonstrated have a functional and genetic predisposition to respiratory viral LRTIs. We have described the long-term respiratory outcomes for children with sickle cell disease and importantly identified influencing factors. In conclusion, it is essential to undertake long term follow up of infants at high risk of chronic respiratory morbidity if effective preventative strategies are to be developed.
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Affiliation(s)
- Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anthony David Milner
- NIHR Biomedical Research Centre Based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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2
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Aeration strategy at birth does not impact carotid haemodynamics in preterm lambs. Pediatr Res 2022; 93:1226-1232. [PMID: 35974157 PMCID: PMC10132978 DOI: 10.1038/s41390-022-02244-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The impact of different respiratory strategies at birth on the preterm lung is well understood; however, concerns have been raised that lung recruitment may impede cerebral haemodynamics. This study aims to examine the effect of three different ventilation strategies on carotid blood flow, carotid artery oxygen content and carotid oxygen delivery. METHODS 124-127-day gestation apnoeic intubated preterm lambs studied as part of a larger programme primarily assessing lung injury were randomised to positive pressure ventilation with positive end-expiratory pressure (PEEP) 8 cmH2O (No-RM; n = 12), sustained inflation (SI; n = 15) or dynamic PEEP strategy (DynPEEP; maximum PEEP 14 or 20 cmH2O, n = 41) at birth, followed by 90 min of standardised ventilation. Haemodynamic data were continuously recorded, with intermittent arterial blood gas analysis. RESULTS Overall carotid blood flow measures were comparable between strategies. Except for mean carotid blood flow that was significantly lower for the SI group compared to the No-RM and DynPEEP groups over the first 3 min (p < 0.0001, mixed effects model). Carotid oxygen content and oxygen delivery were similar between strategies. Maximum PEEP level did not alter cerebral haemodynamic measures. CONCLUSIONS Although there were some short-term variations in cerebral haemodynamics between different PEEP strategies and SI, these were not sustained. IMPACT Different pressure strategies to facilitate lung aeration at birth in preterm infants have been proposed. There is minimal information on the effect of lung recruitment on cerebral haemodynamics. This is the first study that compares the effect of sustained lung inflation and dynamic and static positive end-expiratory pressure on cerebral haemodynamics. We found that the different ventilation strategies did not alter carotid blood flow, carotid oxygen content or carotid oxygen delivery. This preclinical study provides some reassurance that respiratory strategies designed to focus on lung aeration at birth may not impact cerebral haemodynamics in preterm neonates.
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3
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Chao KY, Lin YW, Chiang CE, Tseng CW, Mu SC. Sustained inflation: The lung recruitment maneuvers for neonates. Paediatr Respir Rev 2020; 36:142-150. [PMID: 32386887 DOI: 10.1016/j.prrv.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 07/11/2019] [Accepted: 09/07/2019] [Indexed: 10/25/2022]
Abstract
Establishing effective respiration is vital in the transition from fetal to neonatal life. Respiratory support mainly facilitates and creates functional residual capacity and maintains adequate gas exchange. Sustained inflation (SI) delivers prolonged inflation and rapidly creates and establishes the functional residual capacity. The use of SI in preterm infants in the delivery room is still controversial. The optimum settings of SI remain unknown. Animal studies and clinical reports have demonstrated the advantages and disadvantages of SI. In this article, the current literature was reviewed to examine the efficacy of SI in infants.
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Affiliation(s)
- Ke-Yun Chao
- Department of Respiratory Therapy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan; School of Physical Therapy, Graduate Institute of Rehabilitation Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Wen Lin
- Department of Nursing, Fu Jen Catholic University Hospital, Fu Jen University, New Taipei City, Taiwan
| | - Chen-En Chiang
- Department of Respiratory Therapy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chi-Wei Tseng
- Department of Respiratory Therapy, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Shu-Chi Mu
- Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Medical College, Fu Jen Catholic University, New Taipei City, Taiwan.
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4
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den Boer MC, Houtlosser M, Foglia EE, Lopriore E, de Vries MC, Engberts DP, Te Pas AB. Deferred consent for delivery room studies: the providers' perspective. Arch Dis Child Fetal Neonatal Ed 2020; 105:310-315. [PMID: 31427459 DOI: 10.1136/archdischild-2019-317280] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 07/22/2019] [Accepted: 08/03/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To gain insight into neonatal care providers' perceptions of deferred consent for delivery room (DR) studies in actual scenarios. METHODS We conducted semistructured interviews with 46 neonatal intensive care unit (NICU) staff members of the Leiden University Medical Center (the Netherlands) and the Hospital of the University of Pennsylvania (USA). At the time interviews were conducted, both NICUs conducted the same DR studies, but differed in their consent approaches. Interviews were audio-recorded, transcribed and analysed using the qualitative data analysis software Atlas.ti V.7.0. RESULTS Although providers reported to regard the prospective consent approach as the most preferable consent approach, they acknowledged that a deferred consent approach is needed for high-quality DR management. However, providers reported concerns about parental autonomy, approaching parents for consent and ethical review of study protocols that include a deferred consent approach. Providers furthermore differed in perceived appropriateness of a deferred consent approach for the studies that were being conducted at their NICUs. Providers with first-hand experience with deferred consent reported positive experiences that they attributed to appropriate communication and timing of approaching parents for consent. CONCLUSION Insight into providers' perceptions of deferred consent for DR studies in actual scenarios suggests that a deferred consent approach is considered acceptable, but that actual usage of the approach for DR studies can be improved on.
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Affiliation(s)
- Maria C den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands .,Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Mirjam Houtlosser
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Enrico Lopriore
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Martine Charlotte de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands.,Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Dirk P Engberts
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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5
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Foglia EE, te Pas AB, Kirpalani H, Davis PG, Owen LS, van Kaam AH, Onland W, Keszler M, Schmölzer GM, Hummler H, Lista G, Dani C, Bastrenta P, Localio R, Ratcliffe SJ. Sustained Inflation vs Standard Resuscitation for Preterm Infants: A Systematic Review and Meta-analysis. JAMA Pediatr 2020; 174:e195897. [PMID: 32011661 PMCID: PMC7042947 DOI: 10.1001/jamapediatrics.2019.5897] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Most preterm infants require respiratory support to establish lung aeration after birth. Intermittent positive pressure ventilation and continuous positive airway pressure are standard therapies. An initial sustained inflation (inflation time >5 seconds) is a widely practiced alternative strategy. OBJECTIVE To conduct a systematic review and meta-analysis of sustained inflation vs intermittent positive pressure ventilation and continuous positive airway pressure for the prevention of hospital mortality and morbidity for preterm infants. DATA SOURCES MEDLINE (through PubMed), Embase, the Cumulative Index of Nursing and Allied Health Literature, and the Cochrane Central Register of Controlled Trials were searched through June 24, 2019. STUDY SELECTION Randomized clinical trials of preterm infants born at less than 37 weeks' gestation that compared sustained inflation (inflation time >5 seconds) vs standard resuscitation with either intermittent positive pressure ventilation or continuous positive airway pressure were included. Studies including other cointerventions were excluded. DATA EXTRACTION AND SYNTHESIS Two reviewers assessed the risk of bias of included studies. Meta-analysis of pooled outcome data used a fixed-effects model specific to rarer events. Subgroups were based on gestational age and study design (rescue vs prophylactic sustained inflation). MAIN OUTCOMES AND MEASURES Death before hospital discharge. RESULTS Nine studies recruiting 1406 infants met inclusion criteria. Death before hospital discharge occurred in 85 of 736 infants (11.5%) treated with sustained inflation and 62 of 670 infants (9.3%) who received standard therapy for a risk difference of 3.6% (95% CI, -0.7% to 7.9%). Although analysis of the primary outcome identified important heterogeneity based on gestational age subgroups, the 95% CI for the risk difference included 0 for each individual gestational age subgroup. There was no difference in the primary outcome between subgroups based on study design. Sustained inflation was associated with increased risk of death in the first 2 days after birth (risk difference, 3.1%; 95% CI, 0.9%-5.3%). No differences in the risk of other secondary outcomes were identified. The quality-of-evidence assessment was low owing to risk of bias and imprecision. CONCLUSIONS AND RELEVANCE There was no difference in the risk of the primary outcome of death before hospital discharge, and there was no evidence of efficacy for sustained inflation to prevent secondary outcomes. These findings do not support the routine use of sustained inflation for preterm infants after birth.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Arjan B. te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University, Leiden, the Netherlands
| | - Haresh Kirpalani
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Peter G. Davis
- Newborn Research Center, The Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Louise S. Owen
- Newborn Research Center, The Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Anton H. van Kaam
- Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Wes Onland
- Emma Children’s Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Martin Keszler
- Department of Pediatrics, Women and Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence
| | - Georg M. Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gianluca Lista
- Department of Pediatrics, Neonatal Intensive Care Unit, Ospedale dei Bambini V.Buzzi ASST-FBF-Sacco, Milan, Italy
| | - Carlo Dani
- Department of Neuroscience, Psychology, Pharmacology and Child Health, University of Florence, Florence, Italy
| | - Petrina Bastrenta
- Department of Pediatrics, Neonatal Intensive Care Unit, Ospedale dei Bambini V.Buzzi ASST-FBF-Sacco, Milan, Italy
| | - Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarah J. Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville
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6
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Bruschettini M, O'Donnell CPF, Davis PG, Morley CJ, Moja L, Calevo MG. Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes. Cochrane Database Syst Rev 2020; 3:CD004953. [PMID: 32187656 PMCID: PMC7080446 DOI: 10.1002/14651858.cd004953.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable gas exchange. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs. OBJECTIVES To assess the benefits and harms of an initial sustained lung inflation (SLI) (> 1 second duration) versus standard inflations (≤ 1 second) in newborn infants receiving resuscitation with intermittent PPV. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 3), MEDLINE via PubMed (1966 to 1 April 2019), Embase (1980 to 1 April 2019), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 1 April 2019). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth. DATA COLLECTION AND ANALYSIS We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data; and mean standard deviation (SD), and weighted mean difference (WMD) for continuous data. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS Ten trials enrolling 1467 infants met our inclusion criteria. Investigators in nine trials (1458 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review: mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40 (I² not applicable); typical RD 0.00, 95% CI -0.02 to 0.02; I² = 0%; 5 studies, 479 participants); and mortality during hospitalisation (typical RR 1.09, 95% CI 0.83 to 1.43; I² = 42%; typical RD 0.01, 95% CI -0.02 to 0.04; I² = 24%; 9 studies, 1458 participants). The quality of the evidence was low for death in the delivery room because of limitations in study design and imprecision of estimates (only one death was recorded across studies). For death before discharge the quality was moderate: with longer follow-up there were more deaths (n = 143) but limitations in study design remained. Among secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; I² = 95%; 5 studies, 524 participants; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study at high risk of bias: when this study was removed from the analysis, the size of the effect was reduced (MD -1.71 days, 95% CI -3.04 to -0.39; I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. risk of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.91, 95% CI 0.79 to 1.04; I² = 65%; 5 studies, 811 participants); risk of surfactant administration during hospital admission (typical RR 0.99, 95% CI 0.91 to 1.08; I² = 0%; 9 studies, 1458 participants); risk of chronic lung disease (typical RR 0.99, 95% CI 0.83 to 1.18; I² = 0%; 4 studies, 735 participants); pneumothorax (typical RR 0.89, 95% CI 0.57 to 1.40; I² = 34%; 8 studies, 1377 infants); or risk of patent ductus arteriosus requiring pharmacological treatment (typical RR 0.99, 95% CI 0.87 to 1.12; I² = 48%; 7 studies, 1127 infants). The quality of evidence for these secondary outcomes was moderate (limitations in study design ‒ GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates ‒ GRADE). We could not perform any meta-analysis in the comparison of the use of initial sustained inflation versus standard inflations in newborns receiving resuscitation with chest compressions because we identified only one trial for inclusion (a pilot study of nine preterm infants). AUTHORS' CONCLUSIONS Our meta-analysis of nine studies shows that sustained lung inflation without chest compression was not better than intermittent ventilation for reducing mortality in the delivery room (low-quality evidence ‒ GRADE) or during hospitalisation (moderate-quality evidence ‒ GRADE), which were the primary outcomes of this review. However, the single largest study, which was well conducted and had the greatest number of enrolled infants, was stopped early for higher mortality rate in the sustained inflation group. When considering secondary outcomes, such as rate of intubation, rate or duration of respiratory support, or bronchopulmonary dysplasia, we found no benefit of sustained inflation over intermittent ventilation (moderate-quality evidence ‒ GRADE). Duration of mechanical ventilation was shortened in the SLI group (low-quality evidence ‒ GRADE); this result should be interpreted cautiously, however, as it might have been influenced by study characteristics other than the intervention. There is no evidence to support the use of sustained inflation based on evidence from our review.
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Affiliation(s)
- Matteo Bruschettini
- Lund University, Skåne University HospitalDepartment of Clinical Sciences Lund, PaediatricsLundSweden
- Skåne University HospitalCochrane SwedenWigerthuset, Remissgatan 4, first floorroom 11‐221LundSweden22185
| | - Colm PF O'Donnell
- National Maternity HospitalDepartment of NeonatologyHolles StreetDublin 2Ireland
| | - Peter G Davis
- The Royal Women’s HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
- Murdoch Children's Research InstituteMelbourneAustralia
- University of MelbourneDepartment of Obstetrics and GynecologyMelbourneAustralia
| | - Colin J Morley
- University of CambridgeDepartment of Obstetrics and GynecologyCambridgeUK
| | - Lorenzo Moja
- University of MilanDepartment of Biomedical Sciences for HealthVia Pascal 36MilanMilanItaly20133
- IRCCS Galeazzi Orthopaedic InstituteUnit of Clinical EpidemiologyMilanItaly
| | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics Unit, IRCCSGenoaItaly16147
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7
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Tingay DG, Pereira-Fantini PM, Oakley R, McCall KE, Perkins EJ, Miedema M, Sourial M, Thomson J, Waldmann A, Dellaca RL, Davis PG, Dargaville PA. Gradual Aeration at Birth Is More Lung Protective Than a Sustained Inflation in Preterm Lambs. Am J Respir Crit Care Med 2020; 200:608-616. [PMID: 30730759 DOI: 10.1164/rccm.201807-1397oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale: The preterm lung is susceptible to injury during transition to air breathing at birth. It remains unclear whether rapid or gradual lung aeration at birth causes less lung injury.Objectives: To examine the effect of gradual and rapid aeration at birth on: 1) the spatiotemporal volume conditions of the lung; and 2) resultant regional lung injury.Methods: Preterm lambs (125 ± 1 d gestation) were randomized at birth to receive: 1) tidal ventilation without an intentional recruitment (no-recruitment maneuver [No-RM]; n = 19); 2) sustained inflation (SI) until full aeration (n = 26); or 3) tidal ventilation with an initial escalating/de-escalating (dynamic) positive end-expiratory pressure (DynPEEP; n = 26). Ventilation thereafter continued for 90 minutes at standardized settings, including PEEP of 8 cm H2O. Lung mechanics and regional aeration and ventilation (electrical impedance tomography) were measured throughout and correlated with histological and gene markers of early lung injury.Measurements and Main Results: DynPEEP significantly improved dynamic compliance (P < 0.0001). An SI, but not DynPEEP or No-RM, resulted in preferential nondependent lung aeration that became less uniform with time (P = 0.0006). The nondependent lung was preferential ventilated by 5 minutes in all groups, with ventilation only becoming uniform with time in the No-RM and DynPEEP groups. All strategies generated similar nondependent lung injury patterns. Only an SI caused greater upregulation of dependent lung gene markers compared with unventilated fetal controls (P < 0.05).Conclusions: Rapidly aerating the preterm lung at birth creates heterogeneous volume states, producing distinct regional injury patterns that affect subsequent tidal ventilation. Gradual aeration with tidal ventilation and PEEP produced the least lung injury.
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Affiliation(s)
- David G Tingay
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Neonatology, The Royal Children's Hospital, Parkville, Victoria, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Paediatrics and
| | - Prue M Pereira-Fantini
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics and
| | - Regina Oakley
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Karen E McCall
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Neonatology, The Royal Children's Hospital, Parkville, Victoria, Australia
| | - Martijn Miedema
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Neonatology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Magdy Sourial
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Jessica Thomson
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | | | - Raffaele L Dellaca
- Dipartimento di Elettronica, Informazione e Ingegneria Biomedica, Politecnico di Milano University, Milan, Italy
| | - Peter G Davis
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter A Dargaville
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Neonatal and Paediatric Intensive Care Unit, Royal Hobart Hospital, Hobart, Tasmania, Australia; and.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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8
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An experience with a bubble CPAP bundle: is chronic lung disease preventable? Pediatr Res 2020; 88:444-450. [PMID: 31952073 PMCID: PMC7223768 DOI: 10.1038/s41390-020-0763-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 01/01/2020] [Accepted: 01/03/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is associated with marginal decrease in chronic lung disease (CLD). This study aims to report outcomes, with focus on CLD, of preterm infants managed with a bubble CPAP (b-CPAP) bundle of care. METHODS Infants <1500 g were stratified into four groups depending on intubation status through first 3 days of life. The incidence of mortality, CLD and other morbidities were compared over four chronological epochs. Outcomes of the most recent epoch were compared to contemporaneous benchmarks from Vermont Oxford Network (VON). RESULTS Of 773 infants (median GA = 28 weeks, average BW = 995 g), 24.5% were intubated in DR and 11.7% in the first day of life. Mechanical ventilation, bCPAP and oxygen days in survivors were 1.5, 29 and 14, respectively. Overall incidence of CLD was 6.4% that remained consistent in the four epochs (7.6%, 7.5%, 5.8% and 5%), respectively. In comparison to VON, CLD was significantly less (p < 0.001). Initial DR intubation was not associated with increased CLD compared to initial management with CPAP that required subsequent intubation. CONCLUSION It is feasible and sustainable to administer a b-CPAP bundle of care to decrease CLD. Cluster randomized trials are needed to validate the reproducibility of this approach.
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9
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Current insights in non-invasive ventilation for the treatment of neonatal respiratory disease. Ital J Pediatr 2019; 45:105. [PMID: 31426828 PMCID: PMC6700989 DOI: 10.1186/s13052-019-0707-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 08/13/2019] [Indexed: 11/10/2022] Open
Abstract
Deleterious consequences of the management of respiratory distress syndrome (RDS) with invasive ventilation have led to more in-depth investigation of non-invasive ventilation (NIV) modalities. NIV has significantly and positively altered the treatment outcomes and improved mortality rates of preterm infants with RDS. Among the different NIV modes, nasal intermittent positive pressure ventilation (NIPPV) has shown considerable benefits compared to nasal continuous positive airway pressure (NCPAP). Despite reports of heated humidified high-flow nasal cannula’s (HHHFNC) non-inferiority compared to NCPAP, some trials have been terminated due to high treatment failure rates with HHHFNC use. Moreover, RDS management with the combination of INSURE (INtubation SURfactant Extubation) technique and NIV ensures higher success rates. This review elaborates on the currently used various modes of NIV and novel techniques are also briefly discussed.
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10
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Nenna R, Hunt KA, Dassios T, Collins JJ, Rottier RJ, Liu NM, Rottier B, Goutaki M, Karadag B, Prayle A, Fernandes RM, Parisi G, Barben J, Rubbo B, Snijders D, Makrinioti H, Hall G, Pijnenburg MW, Grigg J. Key paediatric messages from the 2018 European Respiratory Society International Congress. ERJ Open Res 2019; 5:00241-2018. [PMID: 31044141 PMCID: PMC6487274 DOI: 10.1183/23120541.00241-2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/23/2019] [Indexed: 11/29/2022] Open
Abstract
In this article, the Group Chairs and early career members of the European Respiratory Society (ERS) Paediatric Assembly highlight some of the most interesting findings in the field of paediatrics which were presented at the 2018 international ERS Congress.
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Affiliation(s)
- Raffaella Nenna
- Dept of Paediatrics, Sapienza University of Rome, Rome, Italy
- Asthma and Airway Disease Research Center, The University of Arizona, Tucson, AZ, USA
| | - Katie A. Hunt
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jennifer J.P. Collins
- Dept of Paediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Robbert J. Rottier
- Dept of Paediatric Surgery, Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Norrice M. Liu
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University London, London, UK
| | - Bart Rottier
- Beatrix Children's Hospital, University Medical Centre Groningen, Groningen, The Netherlands
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Bülent Karadag
- Division of Pediatric Pulmonology, Marmara University, School of Medicine, Istanbul, Turkey
| | - Andrew Prayle
- Child Health, Obstetrics and Gynaecology, The University of Nottingham, Nottingham, UK
| | - Ricardo M. Fernandes
- Dept of Pediatrics, Santa Maria Hospital, Lisbon, Portugal
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | | | - Jürg Barben
- Division of Paediatric Pulmonology, Children's Hospitals of Eastern Switzerland, St. Gallen, Switzerland
| | - Bruna Rubbo
- Primary Ciliary Dyskinesia Centre, NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University of Southampton, Faculty of Medicine, Academic Unit of Clinical and Experimental Science, Southampton, UK
| | - Deborah Snijders
- Dept of Women's and Children Health, University of Padova, Padova, Italy
| | | | - Graham Hall
- Telethon Kids Institute and Curtin University, Perth, Australia
| | - Mariëlle W. Pijnenburg
- Dept of Paediatrics, Division of Paediatric Pulmonology and Allergology, Erasmus MC-Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Jonathan Grigg
- Centre for Paediatrics, Queen Mary University London, London, UK
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11
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Kirpalani H, Ratcliffe SJ, Keszler M, Davis PG, Foglia EE, te Pas A, Fernando M, Chaudhary A, Localio R, van Kaam AH, Onland W, Owen LS, Schmölzer GM, Katheria A, Hummler H, Lista G, Abbasi S, Klotz D, Simma B, Nadkarni V, Poulain FR, Donn SM, Kim HS, Park WS, Cadet C, Kong JY, Smith A, Guillen U, Liley HG, Hopper AO, Tamura M. Effect of Sustained Inflations vs Intermittent Positive Pressure Ventilation on Bronchopulmonary Dysplasia or Death Among Extremely Preterm Infants: The SAIL Randomized Clinical Trial. JAMA 2019; 321:1165-1175. [PMID: 30912836 PMCID: PMC6439695 DOI: 10.1001/jama.2019.1660] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Preterm infants must establish regular respirations at delivery. Sustained inflations may establish lung volume faster than short inflations. OBJECTIVE To determine whether a ventilation strategy including sustained inflations, compared with standard intermittent positive pressure ventilation, reduces bronchopulmonary dysplasia (BPD) or death at 36 weeks' postmenstrual age without harm in extremely preterm infants. DESIGN, SETTING, AND PARTICIPANTS Unmasked, randomized clinical trial (August 2014 to September 2017, with follow-up to February 15, 2018) conducted in 18 neonatal intensive care units in 9 countries. Preterm infants 23 to 26 weeks' gestational age requiring resuscitation with inadequate respiratory effort or bradycardia were enrolled. Planned enrollment was 600 infants. The trial was stopped after enrolling 426 infants, following a prespecified review of adverse outcomes. INTERVENTIONS The experimental intervention was up to 2 sustained inflations at maximal peak pressure of 25 cm H2O for 15 seconds using a T-piece and mask (n = 215); standard resuscitation was intermittent positive pressure ventilation (n = 211). MAIN OUTCOME AND MEASURES The primary outcome was the rate of BPD or death at 36 weeks' postmenstrual age. There were 27 prespecified secondary efficacy outcomes and 7 safety outcomes, including death at less than 48 hours. RESULTS Among 460 infants randomized (mean [SD] gestational age, 25.30 [0.97] weeks; 50.2% female), 426 infants (92.6%) completed the trial. In the sustained inflation group, 137 infants (63.7%) died or survived with BPD vs 125 infants (59.2%) in the standard resuscitation group (adjusted risk difference [aRD], 4.7% [95% CI, -3.8% to 13.1%]; P = .29). Death at less than 48 hours of age occurred in 16 infants (7.4%) in the sustained inflation group vs 3 infants (1.4%) in the standard resuscitation group (aRD, 5.6% [95% CI, 2.1% to 9.1%]; P = .002). Blinded adjudication detected an imbalance of rates of early death possibly attributable to resuscitation (sustained inflation: 11/16; standard resuscitation: 1/3). Of 27 secondary efficacy outcomes assessed by 36 weeks' postmenstrual age, 26 showed no significant difference between groups. CONCLUSIONS AND RELEVANCE Among extremely preterm infants requiring resuscitation at birth, a ventilation strategy involving 2 sustained inflations, compared with standard intermittent positive pressure ventilation, did not reduce the risk of BPD or death at 36 weeks' postmenstrual age. These findings do not support the use of ventilation with sustained inflations among extremely preterm infants, although early termination of the trial limits definitive conclusions. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02139800.
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Affiliation(s)
- Haresh Kirpalani
- Division of Neonatology, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Sarah J. Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville
| | - Martin Keszler
- Warren Alpert Medical School, Department of Pediatrics, Brown University Women and Infants Hospital of Rhode Island, Providence
| | - Peter G. Davis
- Newborn Research Centre, The Royal Women’s Hospital, Melbourne, Victoria, Australia
| | - Elizabeth E. Foglia
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Arjan te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, the Netherlands
| | - Melissa Fernando
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Aasma Chaudhary
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, Philadelphia
| | - Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anton H. van Kaam
- Department of Neonatology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children’s Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Louise S. Owen
- Newborn Research Center and Neonatal Services, The Royal Women’s Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynecology, The University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children’s Research Institute, Melbourne, Victoria, Australia
| | - Georg M. Schmölzer
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Anup Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | - Helmut Hummler
- Division of Neonatology, Department of Pediatrics, Sidra Medicine, Doha, Qatar
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany
| | - Gianluca Lista
- Department of Pediatrics, NICU, Ospedale dei Bambini V. Buzzi, ASST-FBF-Sacco, Milan, Italy
| | - Soraya Abbasi
- Division of Newborn Pediatrics, Pennsylvania Hospital, Philadelphia
| | - Daniel Klotz
- Center for Pediatrics, Medical Center–University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Burkhard Simma
- Department of Pediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Francis R. Poulain
- Division of Neonatology, Department of Pediatrics, University of California, Davis, Sacramento
| | - Steven M. Donn
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, C.S. Mott Children’s Hospital, Michigan Medicine, University of Michigan, Ann Arbor
| | - Han-Suk Kim
- Division of Neonatology, Department of Pediatrics, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Claudia Cadet
- Department of Neonatology, WakeMed Health and Hospitals, Raleigh, North Carolina
| | - Juin Yee Kong
- Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
| | - Alexandra Smith
- Department of Pediatrics, Tufts Clinical and Translational Research Institute, The Floating Hospital for Children at Tufts Medical Center, Boston, Massachusetts
| | | | - Helen G. Liley
- Newborn Services, Mater Mothers’ Hospital and Mater Research, South Brisbane, Queensland, Australia
| | - Andrew O. Hopper
- Division of Neonatology, Department of Pediatrics, Loma Linda University, Loma Linda, California
| | - Masanori Tamura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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12
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Hunt KA, Ling R, White M, Ali KK, Dassios T, Milner AD, Greenough A. Sustained inflations during delivery suite stabilisation in prematurely-born infants - A randomised trial. Early Hum Dev 2019; 130:17-21. [PMID: 30641326 DOI: 10.1016/j.earlhumdev.2019.01.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/04/2019] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Sustained inflations at initial stabilisation in the delivery suite may reduce the need for intubation and result in a shorter duration of initial ventilation, but have not been compared to routine UK practice. AIMS To compare the early efficacy of sustained inflation during stabilisation after delivery to UK practice. STUDY DESIGN A randomised trial was performed of a fifteen second sustained inflation compared to five inflations lasting 2 to 3 s, each intervention could be repeated once if no chest rise was apparent. Respiratory function monitoring was undertaken. SUBJECTS Infants born prior to 34 weeks of gestation. OUTCOME MEASURES The minute volume and maximum end-tidal carbon dioxide level in the first minute after the interventions, the time to the first spontaneous breath after the beginning of stabilisation and the duration of ventilation in the first 48 h. RESULTS There were no significant differences in the minute volume or maximum end tidal carbon dioxide level between the groups. Infants in the sustained inflation group made a respiratory effort sooner (median 3.5 (range 0.2-59) versus median 12.8 (range 0.4-119) s, p = 0.001). The sustained inflation group were ventilated for a shorter duration in the first 48 h (median 17 (range 0-48) versus median 32.5 (range 0-48) h, p = 0.025). CONCLUSIONS A sustained inflation of 15 s compared to five two to three second inflations during initial stabilisation was associated with a shorter duration of mechanical ventilation in the first 48 h after birth.
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Affiliation(s)
- Katie A Hunt
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Kings College London, London, United Kingdom; Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, United Kingdom
| | - Rebecca Ling
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Marie White
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Kamal K Ali
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Theodore Dassios
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, United Kingdom; Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Anthony D Milner
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Kings College London, London, United Kingdom; Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, United Kingdom
| | - Anne Greenough
- MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, Kings College London, London, United Kingdom; Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, United Kingdom; NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, United Kingdom.
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13
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Kakkilaya V, Jubran I, Mashruwala V, Ramon E, Simcik VN, Marshall M, Brown LS, Jaleel MA, Kapadia VS. Quality Improvement Project to Decrease Delivery Room Intubations in Preterm Infants. Pediatrics 2019; 143:peds.2018-0201. [PMID: 30602545 PMCID: PMC6361361 DOI: 10.1542/peds.2018-0201] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/07/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Avoidance of delivery room intubation (DRI) reduces death or bronchopulmonary dysplasia (BPD) in preterm neonates. Our objective with this quality improvement project was to decrease DRI rates by improving face mask positive pressure ventilation (Fm-PPV) among infants born ≤29 weeks' gestation. METHODS Key drivers of change were identified from a retrospective review of resuscitation records. A resuscitation bundle to optimize Fm-PPV including the use of a small round mask and end-tidal CO2 detectors, increasing peak inspiratory pressure when indicated, and debriefing after each intubation were implemented in consecutive plan-do-study-act cycles. The DRI rate was tracked by using a control chart. Resuscitation practice and outcomes of pre-quality improvement cohort (QIC) (January 2014-September 2015) were compared with post-QIC (October 2015-December 2016). RESULTS Of the 314 infants who were resuscitated, 180 belonged to the pre-QIC and 134 to the post-QIC. The antenatal steroid administration rate was higher in the post-QIC (54% vs 88%). More infants in the post-QIC had resolution of bradycardia after Fm-PPV (56% vs 77%, P = .02). Infants in the post-QIC had lower DRI rates (58% vs 37%, P < .01), lower need for mechanical ventilation (85% vs 70%, P < .01), lower rates of BPD (26% vs 13%, P < .01), and severe retinopathy of prematurity (14% vs 5%, P = .01). Rates of DRI, BPD, and severe retinopathy of prematurity remained lower even after controlling for the potential confounders. CONCLUSIONS Implementation of a resuscitation bundle decreased the DRI rate and improved outcomes of preterm infants.
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Affiliation(s)
| | - Ihab Jubran
- University of Texas Southwestern Medical Center, Dallas, Texas; and
| | | | - Emma Ramon
- Parkland Hospital and Health Systems, Dallas, Texas
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14
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Chest Compressions in the Delivery Room. CHILDREN-BASEL 2019; 6:children6010004. [PMID: 30609872 PMCID: PMC6352088 DOI: 10.3390/children6010004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/18/2018] [Accepted: 12/26/2018] [Indexed: 12/23/2022]
Abstract
Annually, an estimated 13–26 million newborns need respiratory support and 2–3 million newborns need extensive resuscitation, defined as chest compression and 100% oxygen with or without epinephrine in the delivery room. Despite such care, there is a high incidence of mortality and neurologic morbidity. The poor prognosis associated with receiving chest compression alone or with medications in the delivery room raises questions as to whether improved cardiopulmonary resuscitation methods specifically tailored to the newborn could improve outcomes. This review discusses the current recommendations, mode of action, different compression to ventilation ratios, continuous chest compression with asynchronous ventilations, chest compression and sustained inflation optimal depth, and oxygen concentration during cardiopulmonary resuscitation.
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15
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Kirpalani H, Keszler M, Foglia EE, Davis P, Ratcliffe S. Considering the Validity of the SAIL Trial-A Navel Gazers Guide to the SAIL Trial. Front Pediatr 2019; 7:495. [PMID: 31828052 PMCID: PMC6890806 DOI: 10.3389/fped.2019.00495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/14/2019] [Indexed: 11/24/2022] Open
Abstract
This article explores the validity of the Sustained Aeration Inflation for Infant Lungs (SAIL) randomized controlled clinical trial. The SAIL trial enrolled 460 infants out of a planned 600, but the trial was stopped early for harm. We ask here, whether there were any threats to validity in the trial as conducted. We then explore what design elements of the trial could have been improved upon. Finally, we consider what the implications are for future trials in this arena. Clinical Trial Registration: www.clinicaltrials.gov, Identifier: NCT02139800.
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Affiliation(s)
- Haresh Kirpalani
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Martin Keszler
- Department of Pediatrics, Warren Alpert Medical School, Women and Infants Hospital of Rhode Island, Brown University, Providence, RI, United States
| | - Elizabeth E Foglia
- Division of Neonatology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, United States
| | - Peter Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia
| | - Sarah Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, United States
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16
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Fischer HS, Schmölzer GM, Cheung PY, Bührer C. Sustained inflations and avoiding mechanical ventilation to prevent death or bronchopulmonary dysplasia: a meta-analysis. Eur Respir Rev 2018; 27:27/150/180083. [PMID: 30487291 DOI: 10.1183/16000617.0083-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/23/2018] [Indexed: 11/05/2022] Open
Abstract
Sustained inflations and avoidance of endotracheal mechanical ventilation (eMV) are delivery room interventions aimed at preventing bronchopulmonary dysplasia (BPD). Their effectiveness is the subject of the present meta-analysis.The databases MEDLINE, EMBASE and CENTRAL were searched for randomised controlled trials (RCTs) of preterm infants that compared: 1) sustained inflations with intermittent positive-pressure ventilation; and 2) a non-intubated strategy of respiratory support with one that prescribed eMV at an earlier stage. Data extraction and analysis followed the standard methods of the Cochrane Collaboration. The primary outcome was death or BPD, defined as need for oxygen or positive pressure treatment at 36 weeks' postmenstrual age.Avoiding eMV (nine RCTs, 3486 infants) reduced the risk of death or BPD, with a risk ratio of 0.90 (95% CI 0.84-0.97) and a number needed to treat of 35. After sustained inflations (six RCTs, 854 infants), the risk ratio was 0.85 (95% CI 0.65-1.12). A current multicentre RCT of sustained inflations in very preterm infants was halted for increased early mortality in the sustained inflations arm.While strategies aimed at avoiding eMV had a small but significant impact on preventing BPD, sustained inflations had no effect and may even increase mortality in very preterm infants.
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Affiliation(s)
- Hendrik S Fischer
- Dept of Neonatology, Charité University Medical Centre, Berlin, Germany
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Dept of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Dept of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Christoph Bührer
- Dept of Neonatology, Charité University Medical Centre, Berlin, Germany
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17
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Foglia EE, te Pas AB. Effective ventilation: The most critical intervention for successful delivery room resuscitation. Semin Fetal Neonatal Med 2018; 23:340-346. [PMID: 29705089 PMCID: PMC6288818 DOI: 10.1016/j.siny.2018.04.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Lung aeration is the critical first step that triggers the transition from fetal to postnatal cardiopulmonary physiology after birth. When an infant is apneic or does not breathe sufficiently, intervention is needed to support this transition. Effective ventilation is therefore the cornerstone of neonatal resuscitation. In this article, we review the physiology of cardiopulmonary transition at birth, with particular attention to factors the caregiver should consider when providing ventilation. We then summarize the available clinical evidence for strategies to monitor and perform positive pressure ventilation in the delivery room setting.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, The Children’s Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia PA, USA,
| | - Arjan B. te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands,
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18
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Wright CJ, Sherlock L, Sahni R, Polin RA. Preventing Continuous Positive Airway Pressure Failure: Evidence-Based and Physiologically Sound Practices from Delivery Room to the Neonatal Intensive Care Unit. Clin Perinatol 2018; 45:257-271. [PMID: 29747887 PMCID: PMC5953203 DOI: 10.1016/j.clp.2018.01.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Routine use of continuous positive airway pressure (CPAP) to support preterm infants with respiratory distress is an evidenced-based strategy to decrease incidence of bronchopulmonary dysplasia. However, rates of CPAP failure remain unacceptably high in very premature neonates, who are at high risk for developing bronchopulmonary dysplasia. Using the GRADE framework to assess the quality of available evidence, this article reviews strategies aimed at decreasing CPAP failure, starting with delivery room interventions and followed through to system-based efforts in the neonatal intensive care unit. Despite best efforts, some very premature neonates fail CPAP. Also reviewed are predictors of CPAP failure in this vulnerable population.
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Affiliation(s)
- Clyde J. Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Laurie Sherlock
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Rakesh Sahni
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Richard A. Polin
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
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19
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Foglia EE, Jensen EA, Kirpalani H. Delivery room interventions to prevent bronchopulmonary dysplasia in extremely preterm infants. J Perinatol 2017; 37:1171-1179. [PMID: 28569744 PMCID: PMC5687993 DOI: 10.1038/jp.2017.74] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 03/31/2017] [Accepted: 04/27/2017] [Indexed: 12/11/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic respiratory complication of preterm birth. Preterm infants are at risk for acute lung injury immediately after birth, which predisposes to BPD. In this article, we review the current evidence for interventions applied during neonatal transition (delivery room and first postnatal hours of life) to prevent BPD in extremely preterm infants: continuous positive airway pressure (CPAP), sustained lung inflation, supplemental oxygen use during neonatal resuscitation, and surfactant therapy including less-invasive surfactant administration. Preterm infants should be stabilized with CPAP in the delivery room, reserving invasive mechanical ventilation for infants who fail non-invasive respiratory support. For infants who require endotracheal intubation and mechanical ventilation soon after birth, surfactant should be given early (<2 h of life). We recommend prudent titration of supplemental oxygen in the delivery room to achieve targeted oxygen saturations. Promising interventions that may further reduce BPD, such as sustained inflation and non-invasive surfactant administration, are currently under investigation.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Erik A. Jensen
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Haresh Kirpalani
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
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20
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Lista G, Maturana A, Moya FR. Achieving and maintaining lung volume in the preterm infant: from the first breath to the NICU. Eur J Pediatr 2017; 176:1287-1293. [PMID: 28795220 DOI: 10.1007/s00431-017-2984-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 07/24/2017] [Accepted: 08/03/2017] [Indexed: 12/31/2022]
Abstract
UNLABELLED The main goal for the neonatologist is to facilitate the adaptation to extra-uterine life during initial transition, while minimizing lung injury opening and protecting the premature lung from the first breath onwards. An appropriate management from birth should lead to the achievement of an early functional residual capacity (FRC), and the following steps should aim at maintaining an adequate lung volume. To date, different strategies are available to optimize fetal-neonatal transition and promote lung recruitment. New ventilation approaches, such as sustained lung inflation (SLI) and "open lung strategy", well-established ventilation techniques with a more tailored application and less invasive modalities to administer surfactant have been recently introduced in clinical practice with promising results. CONCLUSIONS given the current status of neonatal care, it seems that lung injury and BPD could be reduced with multiple strategies starting early in the delivery room. Literature underlines the importance of a respiratory tailored management of preterm infants from birth and during the whole NICU stay. What is Known: • Experimental and clinical studies have shown that the transition from fetal to adult type cardiorespiratory circulation needs an adequate lung ventilation. An appropriate management in the delivery room should lead to the achievement of an early FRC, and through the following steps, the neonatologist should aim at maintaining an adequate lung volume. • Literature underlines the importance of a respiratory tailored management of preterm infants during the whole NICU stay to maintain the benefits of a successful postnatal adaption. What is New: • Herewith, we describe the most relevant and recent interventions which can be performed from the delivery room to the NICU stay to guarantee an adequate tradition to postnatal life and an effective cardiorespiratory stability.
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Affiliation(s)
- Gianluca Lista
- NICU "V. Buzzi" Children's Hospital, ASST-FBF-Sacco, Via Castelvetro, 32, 20154, Milan, Italy.
| | | | - Fernando R Moya
- Coastal Carolina Neonatology, Coastal Children's Services, PLLC, Wilmington, NC, 28401, USA
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21
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Bruschettini M, O'Donnell CPF, Davis PG, Morley CJ, Moja L, Zappettini S, Calevo MG. Sustained versus standard inflations during neonatal resuscitation to prevent mortality and improve respiratory outcomes. Cochrane Database Syst Rev 2017; 7:CD004953. [PMID: 28707404 PMCID: PMC6483306 DOI: 10.1002/14651858.cd004953.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND At birth, infants' lungs are fluid-filled. For newborns to have a successful transition, this fluid must be replaced by air to enable effective breathing. Some infants are judged to have inadequate breathing at birth and are resuscitated with positive pressure ventilation (PPV). Giving prolonged (sustained) inflations at the start of PPV may help clear lung fluid and establish gas volume within the lungs. OBJECTIVES To assess the efficacy of an initial sustained (> 1 second duration) lung inflation versus standard inflations (≤ 1 second) in newly born infants receiving resuscitation with intermittent PPV. SEARCH METHODS We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1), MEDLINE via PubMed (1966 to 17 February 2017), Embase (1980 to 17 February 2017), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 17 February 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles to identify randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing initial sustained lung inflation (SLI) versus standard inflations given to infants receiving resuscitation with PPV at birth. DATA COLLECTION AND ANALYSIS We assessed the methodological quality of included trials using Cochrane Effective Practice and Organisation of Care Group (EPOC) criteria (assessing randomisation, blinding, loss to follow-up, and handling of outcome data). We evaluated treatment effects using a fixed-effect model with risk ratio (RR) for categorical data and mean, standard deviation (SD), and weighted mean difference (WMD) for continuous data. We assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. MAIN RESULTS Eight trials enrolling 941 infants met our inclusion criteria. Investigators in seven trials (932 infants) administered sustained inflation with no chest compressions. Use of sustained inflation had no impact on the primary outcomes of this review - mortality in the delivery room (typical RR 2.66, 95% confidence interval (CI) 0.11 to 63.40; participants = 479; studies = 5; I² not applicable) and mortality during hospitalisation (typical RR 1.01, 95% CI 0.67 to 1.51; participants = 932; studies = 7; I² = 19%); the quality of the evidence was low for death in the delivery room (limitations in study design and imprecision of estimates) and was moderate for death before discharge (limitations in study design of most included trials). Amongst secondary outcomes, duration of mechanical ventilation was shorter in the SLI group (mean difference (MD) -5.37 days, 95% CI -6.31 to -4.43; participants = 524; studies = 5; I² = 95%; low-quality evidence). Heterogeneity, statistical significance, and magnitude of effects of this outcome are largely influenced by a single study: When this study was removed from the analysis, the effect was largely reduced (MD -1.71 days, 95% CI -3.04 to -0.39, I² = 0%). Results revealed no differences in any of the other secondary outcomes (e.g. rate of endotracheal intubation outside the delivery room by 72 hours of age (typical RR 0.93, 95% CI 0.79 to 1.09; participants = 811; studies = 5; I² = 0%); need for surfactant administration during hospital admission (typical RR 0.97, 95% CI 0.86 to 1.10; participants = 932; studies = 7; I² = 0%); rate of chronic lung disease (typical RR 0.95, 95% CI 0.74 to 1.22; participants = 683; studies = 5; I² = 47%); pneumothorax (typical RR 1.44, 95% CI 0.76 to 2.72; studies = 6, 851 infants; I² = 26%); or rate of patent ductus arteriosus requiring pharmacological treatment (typical RR 1.08, 95% CI 0.90 to 1.30; studies = 6, 745 infants; I² = 36%). The quality of evidence for these secondary outcomes was moderate (limitations in study design of most included trials - GRADE) except for pneumothorax (low quality: limitations in study design and imprecision of estimates - GRADE). AUTHORS' CONCLUSIONS Sustained inflation was not better than intermittent ventilation for reducing mortality in the delivery room and during hospitalisation. The number of events across trials was limited, so differences cannot be excluded. When considering secondary outcomes, such as need for intubation, need for or duration of respiratory support, or bronchopulmonary dysplasia, we found no evidence of relevant benefit for sustained inflation over intermittent ventilation. The duration of mechanical ventilation was shortened in the SLI group. This result should be interpreted cautiously, as it can be influenced by study characteristics other than the intervention. Future RCTs should aim to enrol infants who are at higher risk of morbidity and mortality, should stratify participants by gestational age, and should provide more detailed monitoring of the procedure, including measurements of lung volume and presence of apnoea before or during the SLI.
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Affiliation(s)
| | - Colm PF O'Donnell
- National Maternity HospitalDepartment of NeonatologyHolles StreetDublin 2Ireland
| | | | - Colin J Morley
- University of CambridgeDepartment of Obstetrics and GynecologyCambridgeUK
| | | | | | - Maria Grazia Calevo
- Istituto Giannina GasliniEpidemiology, Biostatistics and Committees UnitGenoaItaly16147
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22
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Biniwale M, Wertheimer F. Decrease in delivery room intubation rates after use of nasal intermittent positive pressure ventilation in the delivery room for resuscitation of very low birth weight infants. Resuscitation 2017; 116:33-38. [DOI: 10.1016/j.resuscitation.2017.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 04/11/2017] [Accepted: 05/01/2017] [Indexed: 11/29/2022]
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23
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Nosherwan A, Cheung PY, Schmölzer GM. Management of Extremely Low Birth Weight Infants in Delivery Room. Clin Perinatol 2017; 44:361-375. [PMID: 28477666 DOI: 10.1016/j.clp.2017.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Extremely low birth weight (ELBW) infants are particularly vulnerable at birth, and stabilization in the delivery room (DR) remains challenging. After birth, ELBW infants are at high risk for the development of thermal dysregulation, respiratory insufficiency, and hemodynamic instability due to their immature physiology and anatomy. Although successful stabilization facilitates the transition and reduces acute morbidity, suboptimal care in the DR could cause long-term sequelae. This review addresses the challenges in stabilization in the DR and current neonatal resuscitation guidelines and recommendations.
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Affiliation(s)
- Asma Nosherwan
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada.
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24
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Manley BJ, Owen LS, Hooper SB, Jacobs SE, Cheong JLY, Doyle LW, Davis PG. Towards evidence-based resuscitation of the newborn infant. Lancet 2017; 389:1639-1648. [PMID: 28443558 DOI: 10.1016/s0140-6736(17)30547-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/23/2016] [Accepted: 11/25/2016] [Indexed: 01/07/2023]
Abstract
Effective resuscitation of the newborn infant has the potential to save many lives around the world and reduce disabilities in children who survive peripartum asphyxia. In this Series paper, we highlight some of the important advances in the understanding of how best to resuscitate newborn infants, which includes monitoring techniques to guide resuscitative efforts, increasing awareness of the adverse effects of hyperoxia, delayed umbilical cord clamping, the avoidance of routine endotracheal intubation for extremely preterm infants, and therapeutic hypothermia for hypoxic-ischaemic encephalopathy. Despite the challenges of performing high-quality clinical research in the delivery room, researchers continue to refine and advance our knowledge of effective resuscitation of newborn infants through scientific experiments and clinical trials.
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Affiliation(s)
- Brett J Manley
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia.
| | - Louise S Owen
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC Australia
| | - Susan E Jacobs
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Jeanie L Y Cheong
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Lex W Doyle
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - Peter G Davis
- Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
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25
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Abstract
Lung aeration is the most critical task newborns must accomplish after birth. Almost all extremely preterm infants require respiratory support during this process, but the best method to promote lung aeration in preterm infants is unknown. The current standard practice is intermittent positive pressure ventilation with positive end-expiratory pressure. Sustained inflation is a promising alternative strategy for lung liquid clearance and aeration. Here we review the physiologic rationale for sustained inflation and the available clinical evidence for sustained inflation in preterm infants.
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Affiliation(s)
- Elizabeth E Foglia
- Division of Neonatology, The Children's Hospital of Philadelphia, The Hospital of the University of Pennsylvania, The University of Pennsylvania Perelman School of Medicine, 8th Floor Ravdin Building, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, Netherlands
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26
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Wright CJ, Polin RA. Noninvasive Support: Does It Really Decrease Bronchopulmonary Dysplasia? Clin Perinatol 2016; 43:783-798. [PMID: 27837759 DOI: 10.1016/j.clp.2016.07.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Noninvasive support of preterm infants with respiratory distress is an evidenced-based strategy to decrease the incidence of bronchopulmonary dysplasia. Continuous positive airway pressure (CPAP) is the only noninvasive strategy with sufficient evidence to support its use in acute respiratory distress syndrome. It is unclear if one method for delivering CPAP is superior to another. Future research will focus on strategies (eg, sustained lung inflation, and administration of surfactant using a thin plastic catheter) that increase the likelihood of success with CPAP, especially in infants with a gestational age of less than 26 weeks.
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Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, Perinatal Research Center, Children's Hospital Colorado, University of Colorado School of Medicine, Mail Stop F441, 13243 East 23rd Avenue, Aurora, CO 80045, USA.
| | - Richard A Polin
- Department of Pediatrics, Morgan Stanley Children's Hospital, 3959 Broadway, New York, NY 10032, USA
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27
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Abstract
"Golden 60 minutes "or "Golden Hour" is defined as the first hour of the newborn after birth. This hour includes resuscitation care, transport to nursery from place of birth and course in nursery. The concept of "Golden hour" includes evidence based interventions that are done in the first 60 min of postnatal life for the better long term outcome of the preterm newborn especially extreme premature, extreme low birth weight and very low birth weight. The evidence shows that the concept of "Golden 60 minutes" leads to reduction in neonatal complications like hypothermia, hypoglycemia, intraventricular hemorrhage, chronic lung disease and retinopathy of prematurity. In this review, we have covered various interventions included in "Golden hour" for preterm newborn namely delayed cord clamping, prevention of hypothermia, respiratory and cardiovascular system support, prevention of sepsis, nutritional support and communication with family.
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28
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Tingay DG, Rajapaksa A, Zannin E, Pereira-Fantini PM, Dellaca RL, Perkins EJ, Zonneveld CEE, Adler A, Black D, Frerichs I, Lavizzari A, Sourial M, Grychtol B, Mosca F, Davis PG. Effectiveness of individualized lung recruitment strategies at birth: an experimental study in preterm lambs. Am J Physiol Lung Cell Mol Physiol 2016; 312:L32-L41. [PMID: 27881405 DOI: 10.1152/ajplung.00416.2016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/20/2016] [Indexed: 02/02/2023] Open
Abstract
Respiratory transition at birth involves rapidly clearing fetal lung liquid and preventing efflux back into the lung while aeration is established. We have developed a sustained inflation (SIOPT) individualized to volume response and a dynamic tidal positive end-expiratory pressure (PEEP) (open lung volume, OLV) strategy that both enhance this process. We aimed to compare the effect of each with a group managed with PEEP of 8 cmH2O and no recruitment maneuver (No-RM), on gas exchange, lung mechanics, spatiotemporal aeration, and lung injury in 127 ± 1 day preterm lambs. Forty-eight fetal-instrumented lambs exposed to antenatal steroids were ventilated for 60 min after application of the allocated strategy. Spatiotemporal aeration and lung mechanics were measured with electrical impedance tomography and forced-oscillation, respectively. At study completion, molecular and histological markers of lung injury were analyzed. Mean (SD) aeration at the end of the SIOPT and OLV groups was 32 (22) and 38 (15) ml/kg, compared with 17 (10) ml/kg (180 s) in the No-RM (P = 0.024, 1-way ANOVA). This translated into better oxygenation at 60 min (P = 0.047; 2-way ANOVA) resulting from better distal lung tissue aeration in SIOPT and OLV. There was no difference in lung injury. Neither SIOPT nor OLV achieved homogeneous aeration. Histological injury and mRNA biomarker upregulation were more likely in the regions with better initial aeration, suggesting volutrauma. Tidal ventilation or an SI achieves similar aeration if optimized, suggesting that preventing fluid efflux after lung liquid clearance is at least as important as fluid clearance during the initial inflation at birth.
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Affiliation(s)
- David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia; .,Neonatology, The Royal Children's Hospital, Parkville, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Anushi Rajapaksa
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Emanuela Zannin
- TBM Laboratory, Dipartimento di Elettronica, Informazione e Ingegneria Biomedica-DEIB, Politecnico di Milano University, Milano, Italy
| | - Prue M Pereira-Fantini
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Raffaele L Dellaca
- TBM Laboratory, Dipartimento di Elettronica, Informazione e Ingegneria Biomedica-DEIB, Politecnico di Milano University, Milano, Italy
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Neonatology, The Royal Children's Hospital, Parkville, Australia
| | | | - Andy Adler
- Systems and Computer Engineering, Carleton University, Ottawa, Canada
| | - Don Black
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia
| | - Inéz Frerichs
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anna Lavizzari
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università degli Studi di Milano, Milano, Italy
| | - Magdy Sourial
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia
| | - Bartłomiej Grychtol
- Fraunhofer Project Group for Automation in Medicine and Biotechnology, Mannheim, Germany; and
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università degli Studi di Milano, Milano, Italy
| | - Peter G Davis
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
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29
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El-Chimi MS, Awad HA, El-Gammasy TM, El-Farghali OG, Sallam MT, Shinkar DM. Sustained versus intermittent lung inflation for resuscitation of preterm infants: a randomized controlled trial. J Matern Fetal Neonatal Med 2016; 30:1273-1278. [DOI: 10.1080/14767058.2016.1210598] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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30
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Wright CJ, Polin RA, Kirpalani H. Continuous Positive Airway Pressure to Prevent Neonatal Lung Injury: How Did We Get Here, and How Do We Improve? J Pediatr 2016; 173:17-24.e2. [PMID: 27025910 DOI: 10.1016/j.jpeds.2016.02.059] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 01/25/2016] [Accepted: 02/24/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Clyde J Wright
- Section of Neonatology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | - Richard A Polin
- College of Physicians and Surgeons, Columbia University, New York, NY
| | - Haresh Kirpalani
- Division of Neonatology, The Children's Hospital of Philadelphia at the University of Pennsylvania, Philadelphia, PA
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31
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Lista G, Cavigioli F, Castoldi F, Zimmermann LJI. Sustained inflation: Prophylactic or rescue maneuver? Semin Fetal Neonatal Med 2016; 21:135-8. [PMID: 26923502 DOI: 10.1016/j.siny.2016.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Application of nasal continuous positive airway pressure (nCPAP) in the delivery room is a valid alternative to mechanical ventilation in the management of respiratory failure of preterm infants, with reduced occurrence of bronchopulmonary dysplasia and death. nCPAP at birth is still burdened by a high failure rate. Sustained inflation appears to be an intriguing approach to allow the respiratory transition at birth by clearing the lung fluid, thus obtaining an adequate functional residual capacity. This may enhance nCPAP success. Sustained inflation reduces the need for mechanical ventilation in the first 72 h of life, with no changes in the incidence of bronchopulmonary dysplasia and death. The efficacy of sustained inflation seems to be related to the presence of open glottis with active breathing of the infant. Further studies are needed to recommend the application of sustained inflation during delivery room management of preterm infants at risk of respiratory distress or with clinical signs of respiratory failure.
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Affiliation(s)
- G Lista
- NICU -"V. Buzzi" Children's Hospital, ICP, Milan, Italy.
| | - F Cavigioli
- NICU -"V. Buzzi" Children's Hospital, ICP, Milan, Italy
| | - F Castoldi
- NICU -"V. Buzzi" Children's Hospital, ICP, Milan, Italy
| | - L J I Zimmermann
- Faculty of Health, Medicine and Life Sciences, School of Oncology and Developmental Biology, Department of Pediatrics, Maastricht University, Maastricht, The Netherlands
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32
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McCall KE, Davis PG, Owen LS, Tingay DG. Sustained lung inflation at birth: what do we know, and what do we need to know? Arch Dis Child Fetal Neonatal Ed 2016; 101:F175-80. [PMID: 26527635 DOI: 10.1136/archdischild-2015-309611] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 10/10/2015] [Indexed: 11/04/2022]
Abstract
A sustained inflation has been advocated as a potential method of augmenting lung aeration at birth. Clinical trials have suggested that a sustained inflation may lead to a reduced need for intubation and ventilation in the first few days of life, without cardiovascular compromise or increased lung injury. Despite this, a sustained inflation is not currently a standard of practice, mainly due to a lack of clarity regarding the optimal delivery method. Animal trials have sought to refine delivery techniques. This review will outline current recommendations regarding a sustained inflation, discuss potential strategies for its optimal delivery and suggest priorities for future research.
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Affiliation(s)
- Karen E McCall
- Newborn Research, Murdoch Children's Research Institute, Melbourne, Australia School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Peter G Davis
- Newborn Research, Murdoch Children's Research Institute, Melbourne, Australia Department of Obstetrics, University of Melbourne, Melbourne, Australia Neonatal Research, Royal Women's Hospital, Melbourne, Australia
| | - Louise S Owen
- Newborn Research, Murdoch Children's Research Institute, Melbourne, Australia Department of Obstetrics, University of Melbourne, Melbourne, Australia Neonatal Research, Royal Women's Hospital, Melbourne, Australia
| | - David G Tingay
- Newborn Research, Murdoch Children's Research Institute, Melbourne, Australia Neonatal Research, Royal Women's Hospital, Melbourne, Australia Department of Neonatology, Royal Children's Hospital, Melbourne, Australia Department of Paediatrics, University of Melbourne, Melbourne, Australia
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33
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Torres-Cuevas I, Cernada M, Nuñez A, Escobar J, Kuligowski J, Chafer-Pericas C, Vento M. Oxygen Supplementation to Stabilize Preterm Infants in the Fetal to Neonatal Transition: No Satisfactory Answer. Front Pediatr 2016; 4:29. [PMID: 27148504 PMCID: PMC4835680 DOI: 10.3389/fped.2016.00029] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Accepted: 03/17/2016] [Indexed: 12/04/2022] Open
Abstract
Fetal life elapses in a relatively low oxygen environment. Immediately after birth with the initiation of breathing, the lung expands and oxygen availability to tissue rises by twofold, generating a physiologic oxidative stress. However, both lung anatomy and function and the antioxidant defense system do not mature until late in gestation, and therefore, very preterm infants often need respiratory support and oxygen supplementation in the delivery room to achieve postnatal stabilization. Notably, interventions in the first minutes of life can have long-lasting consequences. Recent trials have aimed to assess what initial inspiratory fraction of oxygen and what oxygen targets during this transitional period are best for extremely preterm infants based on the available nomogram. However, oxygen saturation nomogram informs only of term and late preterm infants but not on extremely preterm infants. Therefore, the solution to this conundrum may still have to wait before a satisfactory answer is available.
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Affiliation(s)
| | - Maria Cernada
- Neonatal Research Group, Health Research Institute La Fe , Valencia , Spain
| | - Antonio Nuñez
- Neonatal Research Group, Health Research Institute La Fe , Valencia , Spain
| | - Javier Escobar
- Neonatal Research Group, Health Research Institute La Fe , Valencia , Spain
| | - Julia Kuligowski
- Neonatal Research Group, Health Research Institute La Fe , Valencia , Spain
| | | | - Maximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain; Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain; Spanish Maternal, Infant and Developmental Network (Red SAMID), Spanish Ministry of Economy and Competitiveness, Madrid, Spain
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34
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Lista G, La Verde PA, Castoldi F. Sustained Inflation and Its Role in the Delivery Room Management of Preterm Infants. Neonatology 2016; 109:366-8. [PMID: 27251566 DOI: 10.1159/000444899] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A noninvasive approach in the delivery room in place of intubation and mechanical ventilation can reduce rates of bronchopulmonary dysplasia and death. Nevertheless, the rate of nasal continuous positive airway pressure failure still remains high. In order to prevent lung injury and to enhance the success of continuous positive airway pressure, sustained inflation (administration by face mask or nasopharyngeal tube of a high peak pressure of 20-25 cm H2O, maintained for 10-15 s) has been recently proposed to establish an early and efficient functional residual capacity in the delivery room. Sustained inflation is an intriguing therapy, although the results of clinical trials are controversial in terms of respiratory outcomes. A critical role in the success of sustained inflation could be the presence of open or closed glottis and the contribution of spontaneous breathing that allows air to enter the lungs during the maneuver. Recent neonatal resuscitation guidelines suggest that sustained inflation may be considered in individual clinical circumstances or research settings.
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Affiliation(s)
- Gianluca Lista
- NICU-Ospedale dei Bambini x2018;V. Buzzi' - ASST Fatebenefratelli/Sacco, Milan, Italy
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