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Baldursdottir S, Gunnarsdottir K, Donaldsson S, Jonsson B, Drevhammar T. Skin-to-skin stabilisation and uninterrupted respiratory support for preterm infants after birth: feasibility of a new and simplified rPAP system. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2023-326409. [PMID: 38514168 DOI: 10.1136/archdischild-2023-326409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/15/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND The rPAP respiratory support system, used for delivery room stabilisation with nasal prongs, has been shown to reduce the need for intubation in extremely preterm infants. A simplified version of the system has been developed. The purpose of this study was to determine the feasibility of providing uninterrupted respiratory support with the simplified rPAP from birth up to 4 hours of life and to assess ease of use for skin-to skin stabilisation. METHODS This was a non-randomised feasibility study conducted at Karolinska University Hospital, Sweden. Respiratory support with continuous positive airway pressure (CPAP) and positive pressure ventilation if needed was given with the simplified rPAP using heated humidified gases. Respiratory support was provided in the delivery room, during transportation and in the neonatal unit, for a maximum of 4 hours. RESULTS 32 preterm infants with a mean (SD) gestational age of 33.4 weeks (±1.2) were included. Of 17 infants born vaginally, 13 were stabilised skin-to-skin. The remaining infants were stabilised on a resuscitation table. All infants received CPAP and nine received positive pressure ventilation. 31 infants received continued support during transport and after arrival in the neonatal unit. Minor interruptions in CPAP support occurred in all infants. The study did not reveal problems with usability of the system. CONCLUSION It is feasible to stabilise preterm infants with the simplified respiratory support system both skin-to-skin and on a resuscitation table, and to provide continued respiratory support with the same system during transportation and in the neonatal unit. TRIAL REGISTRATION NUMBER NCT04244890.
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Affiliation(s)
- Sonja Baldursdottir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Kolbrun Gunnarsdottir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Snorri Donaldsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Neonatology, Icelandic State University Hospital, Reykjavik, Iceland
| | - Baldvin Jonsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Thomas Drevhammar
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesiology, Östersunds sjukhus, Ostersund, Sweden
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Heesters V, Dekker J, Panneflek TJ, Kuypers KL, Hooper SB, Visser R, Te Pas AB. The vocal cords are predominantly closed in preterm infants <30 weeks gestation during transition after birth; an observational study. Resuscitation 2024; 194:110053. [PMID: 37979668 DOI: 10.1016/j.resuscitation.2023.110053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/06/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023]
Abstract
AIM Studies in animals have shown that vocal cords (VCs) close during apnoea before and after birth, thereby impairing the effect of non-invasive ventilation. We tested the feasibility of visualising VCs using ultrasonography (US) and investigated the position and movement of the VCs during non-invasive respiratory support of preterm infants at birth. METHODS In an observational study, VCs were visualised using US in infants <30 weeks gestation during both stabilisation after birth and at one hour after birth. Respiratory efforts were simultaneously recorded. The percentage of time the VCs were closed in the first ten minutes was determined from videoframes acquired at 15 Hz and compared with respiratory flow patterns measured using a respiratory function monitor. RESULTS US of the VCs could be performed in 20/20 infants included (median (IQR) gestational age 27+6 (27+1-28+6) weeks) without interfering with stabilisation, of whom 60% (12/20) were initially breathing and 40% (8/20) were apnoeic at birth. In breathing infants, the VCs closed between breaths and during breath holds, which accounted for 57% (49-66) of the time. In apnoeic infants receiving positive pressure ventilation, the VCs were closed for 93% (81-99) of the time. US at one hour after birth could be performed in 14/20 infants, VCs were closed between breaths and during breath holds, accounting for 46% (27-52) of the time. CONCLUSION Visualising VCs in preterm infants at birth using US is feasible. The VCs were closed during apnoea, in between breaths and during breath holds, impairing the effect of ventilation given.
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Affiliation(s)
- Veerle Heesters
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, the Netherlands.
| | - Janneke Dekker
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, the Netherlands
| | - Timothy Jr Panneflek
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, the Netherlands
| | - Kristel Lam Kuypers
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, the Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Department of Obstetrics and Gynecology, Monash University, Melbourne, VIC, Australia
| | - Remco Visser
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, the Netherlands
| | - Arjan B Te Pas
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, the Netherlands
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Roberts CT, O'Shea JE. Alternatives to neonatal intubation. Semin Fetal Neonatal Med 2023; 28:101488. [PMID: 38000926 DOI: 10.1016/j.siny.2023.101488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.
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Affiliation(s)
- Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.
| | - Joyce E O'Shea
- Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
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Tarnow-Mordi WO, Robledo K, Marschner I, Seidler L, Simes J. To guide future practice, perinatal trials should be much larger, simpler and less fragile with close to 100% ascertainment of mortality and other key outcomes. Semin Perinatol 2023:151789. [PMID: 37422415 DOI: 10.1016/j.semperi.2023.151789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
The Australian Placental Transfusion Study (APTS) randomised 1,634 fetuses to delayed (≥60 s) versus immediate (≤10 s) clamping of the umbilical cord. Systematic reviews with meta-analyses, including this and similar trials, show that delaying clamping in preterm infants reduces mortality and need for blood transfusions. Amongst 1,531 infants in APTS followed up at two years, aiming to delay clamping for 60 s or more reduced the relative risk of the primary composite outcome of death or disability by 17% (p = 0.01). However, this result is fragile because nominal statistical significance (p < 0.05) would be abolished by only 2 patients switching from a non-event to an event, and the primary composite outcome was missing in 112 patients (7%). To achieve more robust evidence, any future trials should emulate the large, simple trials co-ordinated from Oxford which reliably identified moderate, incremental improvements in mortality in tens of thousands of participants, with <1% missing data. Those who fund, regulate, and conduct trials that aim to change practice should repay the trust of those who consent to participate by doing everything possible to minimise missing data for key outcomes.
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Affiliation(s)
- William Odita Tarnow-Mordi
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia; Neonatal and Perinatal Trials, NHMRC Clinical Trials Centre, Medical Foundation Building, Medical Levels 4-6, 92-94 Parramatta Rd, Camperdown NSW 2050, Australia.
| | - Kristy Robledo
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - Ian Marschner
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - Lene Seidler
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - John Simes
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
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5
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Baldursdottir S, Donaldsson S, Palleri E, Drevhammar T, Jonsson B. Respiratory outcomes after delivery room stabilisation with a new respiratory support system using nasal prongs. Acta Paediatr 2023; 112:719-725. [PMID: 36627506 DOI: 10.1111/apa.16665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/04/2023] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
AIM To study if stabilisation using a new respiratory support system with nasal prongs compared to T-piece with a face mask is associated with less need for mechanical ventilation and bronchopulmonary dysplasia. METHODS A single-centre follow-up study of neonates born <28 weeks gestation at Karolinska University Hospital, Stockholm included in the multicentre Comparison of Respiratory Support after Delivery (CORSAD) trial and randomised to initial respiratory support with the new system versus T-piece. Data on respiratory support, neonatal morbidities and mortality were collected up to 36 weeks post-menstrual age. RESULTS Ninety-four infants, 51 female, with a median (range) gestational age of 25 + 2 (23 + 0, 27 + 6) weeks and days, were included. Significantly fewer infants in the new system group received mechanical ventilation during the first 72 h, 24 (52.2%) compared with 35 (72.9%) (p = 0.034) and during the first 7 days, 29 (63.0%) compared with 39 (81.3%) (p = 0.045) in the T-piece group. At 36 weeks post-menstrual age, 13 (28.3%) in the new system and 13 (27.1%) in the T-piece group were diagnosed with bronchopulmonary dysplasia. CONCLUSION Stabilisation with the new system was associated with less need for mechanical ventilation during the first week of life. No significant difference was seen in the outcome of bronchopulmonary dysplasia.
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Affiliation(s)
- Sonja Baldursdottir
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Snorri Donaldsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Landspitali University Hospital, Reykjavik, Iceland
| | - Elena Palleri
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Drevhammar
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Anaesthesiology, Östersund Hospital, Östersund, Sweden
| | - Baldvin Jonsson
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Neonatology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside. CHILDREN 2023; 10:children10030535. [PMID: 36980093 PMCID: PMC10047523 DOI: 10.3390/children10030535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
Extremely preterm infants frequently require some form of respiratory assistance to facilitate the cardiopulmonary transition that occurs in the first hours of life. Current resuscitation guidelines identify as a primary determinant of overall newborn survival the establishment, immediately after birth, of adequate lung inflation and ventilation to ensure an adequate functional residual capacity. Any respiratory support provided, however, is an important contributing factor to the development of bronchopulmonary dysplasia. The risks correlated to invasive ventilatory techniques increase inversely with gestational age. Preterm infants are born at an early stage of lung development and are more susceptible to lung injury deriving from mechanical ventilation. Any approach aiming to reduce the global burden of preterm lung disease must implement lung-protective ventilation strategies that begin from the newborn’s first breaths in the delivery room. Neonatologists today must be able to manage both invasive and noninvasive forms of respiratory assistance to treat a spectrum of lung diseases ranging from acute to chronic conditions. We searched PubMed for articles on preterm infant respiratory assistance. Our narrative review provides an evidence-based overview on the respiratory management of preterm infants, especially in the acute phase of neonatal respiratory distress syndrome, starting from the delivery room and continuing in the neonatal intensive care unit, including a section regarding exogenous surfactant therapy.
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Mahmoud RA, Schmalisch G, Oswal A, Christoph Roehr C. Non-invasive ventilatory support in neonates: An evidence-based update. Paediatr Respir Rev 2022; 44:11-18. [PMID: 36428196 DOI: 10.1016/j.prrv.2022.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/22/2022] [Indexed: 12/14/2022]
Abstract
Non-invasive ventilatory support (NIV) is considered the gold standard in the care of preterm infants with respiratory distress syndrome (RDS). NIV from birth is superior to mechanical ventilation (MV) for the prevention of death or bronchopulmonary dysplasia (BPD), with a number needed to treat between 25 and 35. Various methods of NIV are available, some of them extensively researched and with well proven efficacy, whilst others are needing further research. Nasal continuous positive airway pressure (nCPAP) has replaced routine invasive mechanical ventilation (MV) for the initial stabilization and the treatment of RDS. Choosing the most suitable form of NIV and the most appropriate patient interface depends on several factors, including gestational age, underlying lung pathophysiology and the local facilities. In this review, we present the currently available evidence on NIV as primary ventilatory support to preventing intubation and for secondary ventilatory support, following extubation. We review nCPAP, nasal high-flow cannula, nasal intermittent positive airway pressure ventilation, bi-level positive airway pressure, nasal high-frequency oscillatory ventilation and nasal neurally adjusted ventilatory assist modes. We also discuss most suitable NIV devices and patient interfaces during resuscitation of the newborn in the delivery room.
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Affiliation(s)
- Ramadan A Mahmoud
- Department of Pediatrics, Sohag Faculty of Medicine, Sohag University, Egypt; Department of Neonatology, Maternity and Child Hospital, Al-kharj, Saudi Arabia
| | - Gerd Schmalisch
- Department of Neonatology, Charité University Medical Center, Berlin, Germany
| | - Abhishek Oswal
- Newborn Care, Southmead Hospital, North Bristol Trust, Bristol, UK
| | - Charles Christoph Roehr
- Newborn Care, Southmead Hospital, North Bristol Trust, Bristol, UK; University of Bristol, Faculty of Medicine, Bristol, UK.
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Gaertner VD, Minocchieri S, Waldmann AD, Mühlbacher T, Bassler D, Rüegger CM. Prophylactic surfactant nebulisation for the early aeration of the preterm lung: a randomised clinical trial. Arch Dis Child Fetal Neonatal Ed 2022; 108:217-223. [PMID: 36424125 DOI: 10.1136/archdischild-2022-324519] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The effect of prophylactic surfactant nebulisation (SN) is unclear. We aimed to determine whether prophylactic SN improves early lung aeration. DESIGN Parallel, randomised clinical trial, conducted between March 2021 and January 2022. SETTING Delivery room (DR) of a tertiary neonatal centre in Zurich, Switzerland. PATIENTS Preterm infants between 26 0/7 and 31 6/7 weeks gestation INTERVENTIONS: Infants were randomised to receive positive distending pressure alone or positive distending pressure and additional SN (200 mg/kg; poractant alfa) using a customised vibrating membrane nebuliser. SN commenced with the first application of a face mask immediately after birth. MAIN OUTCOME MEASURES Primary outcome was the difference in end-expiratory lung impedance from birth to 30 min after birth (∆EELI30min). EELI correlates well with functional residual capacity. Secondary outcomes included physiological and clinical outcomes. RESULTS Data from 35 infants were collected, and primary outcome data were analysed from 32 infants (n=16/group). Primary outcome was not different between intervention and control group (median (IQR): 25 (7-62) vs 10 (0-26) AU/kg, p=0.21). ∆EELI was slightly higher in the intervention group at 6 and 12 hours after birth, particularly in the central areas of the lung. There were no differences in cardiorespiratory and clinical parameters. Two adverse events were noted in the intervention group. CONCLUSIONS Prophylactic SN in the DR did not significantly affect ∆EELI30min and showed only minimal effects on lung physiology. Prophylactic SN in the DR was feasible. There were no differences in clinical outcomes. TRIAL REGISTRATION NUMBER NCT04315636.
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Affiliation(s)
- Vincent D Gaertner
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Stefan Minocchieri
- Department of Neonatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Andreas D Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Tobias Mühlbacher
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Dirk Bassler
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Christoph Martin Rüegger
- Newborn Research Zurich, Department of Neonatology, University Hospital and University of Zurich, Zurich, Switzerland
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Higher CPAP levels improve functional residual capacity at birth in preterm rabbits. Pediatr Res 2022; 91:1686-1694. [PMID: 34294868 DOI: 10.1038/s41390-021-01647-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/03/2021] [Accepted: 06/17/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preterm infants are commonly supported with 4-8 cm H2O continuous positive airway pressures (CPAP), although higher CPAP levels may improve functional residual capacity (FRC). METHODS Preterm rabbits delivered at 29/32 days (~26-28 weeks human) gestation received 0, 5, 8, 12, 15 cm H2O of CPAP or variable CPAP of 15 to 5 or 15 to 8 cm H2O (decreasing ~2 cm H2O/min) for up to 10 min after birth. RESULTS FRC was lower in the 0 (6.8 (1.0-11.2) mL/kg) and 5 (10.1 (1.1-16.8) mL/kg) compared to the 15 (18.8 (10.9-22.4) mL/kg) cm H2O groups (p = 0.003). Fewer kittens achieved FRC > 15 mL/kg in the 0 (20%), compared to 8 (36%), 12 (60%) and 15 (73%) cm H2O groups (p = 0.008). While breathing rates were not different (p = 0.096), apnoea tended to occur more often with CPAP < 8 cm H2O (p = 0.185). CPAP belly and lung bulging rates were similar whereas pneumothoraces were rare. Lowering CPAP from 15 to 5, but not 15 to 8 cm H2O, decreased FRC and breathing rates. CONCLUSION In all, 15 cm H2O of CPAP improved lung aeration and reduced apnoea, but did not increase the risk of lung over-expansion, pneumothorax or CPAP belly immediately after birth. FRC and breathing rates were maintained when CPAP was decreased to 8 cm H2O. IMPACT Although preterm infants are commonly supported with 4-8 cm H2O CPAP at birth, preclinical studies have shown that higher PEEP levels improve lung aeration. In this study, CPAP levels of 15 cm H2O improved lung aeration and reduced apnoea in preterm rabbit kittens immediately after birth. In all, 15 cm H2O CPAP did not increase the risk of lung over-expansion (indicated by bulging between the ribs), pneumothorax, or CPAP belly. These results can be used when designing future studies on CPAP strategies for preterm infants in the delivery room.
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Murphy MC, McCarthy LK, O'Donnell CPF. Research in the Delivery Room: Can You Tell Me It's Evolution? Neoreviews 2022; 23:e229-e237. [PMID: 35362035 DOI: 10.1542/neo.23-4-e229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Many of the recommendations for newborn care in the delivery room (DR) are based on retrospective observational studies, preclinical studies of mannequins or animal models, and expert opinion. Conducting DR research is challenging. Many deliveries occur in fraught circumstances with little prior warning, making it difficult to get prospective consent from parents and buy-in from clinicians. Many DR interventions are difficult to mask for the purpose of a clinical trial and it is not easy to identify appropriate outcomes for studies that are sufficiently "short-term" that they are likely to be influenced by the intervention, yet sufficiently "long-term" to be considered clinically important. However, despite these challenges, much information has been accrued from clinical studies in recent years. In this article, we outline our experience of conducting clinical research in the DR. In our initial studies almost 20 years ago, we found wide variation in the equipment used both nationally and internationally, reflecting the paucity of evidence to support practice. This started a journey that has included many observational studies and randomized controlled trials that have attempted to refine how we care for newborn infants in the DR. Each has given further information and, inevitably, raised many more questions about the approach to caring for newborns in the DR.
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Affiliation(s)
- Madeleine C Murphy
- National Maternity Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- The Hospital for Sick Children, Toronto, Canada
| | - Lisa K McCarthy
- School of Medicine, University College Dublin, Dublin, Ireland
- The Hospital for Sick Children, Toronto, Canada
| | - Colm P F O'Donnell
- School of Medicine, University College Dublin, Dublin, Ireland
- The Hospital for Sick Children, Toronto, Canada
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Robledo KP, Tarnow-Mordi WO, Rieger I, Suresh P, Martin A, Yeung C, Ghadge A, Liley HG, Osborn D, Morris J, Hague W, Kluckow M, Lui K, Soll R, Cruz M, Keech A, Kirby A, Simes J, Popat H, Reid S, Gordon A, De Waal K, Wright IM, Wright A, Buchan J, Stubbs M, Newnham J, Simmer K, Young C, Loh D, Kok Y, Gill A, Strunk T, Jeffery M, Chen Y, Morris S, Sinhal S, Cornthwaite K, Walker SP, Watkins AM, Collins CL, Holberton JR, Noble EJ, Sehgal A, Yeomans E, Elsayed K, Mohamed AL, Broom M, Koh G, Lawrence A, Gardener G, Fox J, Cartwright DW, Koorts P, Pritchard MA, McKeown L, Lainchbury A, Shand AW, Michalowski J, Smyth JP, Bolisetty S, Adno A, Lee G, Seidler AL, Askie LM, Groom KM, Eaglen DA, Baker EC, Patel H, Wilkes N, Gullam JE, Austin N, Leishman DE, Weston P, White N, Cooper NA, Broadbent R, Stitely M, Dawson P, El-Naggar W, Furlong M, Hatfield T, de Luca D, Benachi A, Letamendia-Richard E, Escourrou G, Dell'Orto V, Sweet D, Millar M, Shah S, Sheikh L, Ariff S, Morris EA, Young L, Evans SK, Belfort M, Aagaard K, Pammi M, Mandy G, Gandhi M, Davey J, Shenton E, Middleton J, Black R, Cheng A, Murdoch J, Jacobs C, Meyer L, Medlin K, Woods H, O'Connor KA, Bice C, Scott K, Hayes M, Cruickshank D, Sam M, Ireland S, Dickinson C, Poulsen L, Fucek A, Hegarty J, Rogers J, Sanchez D, Zupan Simunek V, Hanif B, Pahl A, Metayer J, Duley L, Marlow N, Schofield D, Bowen J. Effects of delayed versus immediate umbilical cord clamping in reducing death or major disability at 2 years corrected age among very preterm infants (APTS): a multicentre, randomised clinical trial. THE LANCET CHILD & ADOLESCENT HEALTH 2022; 6:150-157. [DOI: 10.1016/s2352-4642(21)00373-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/04/2021] [Accepted: 11/17/2021] [Indexed: 01/07/2023]
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12
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Song S, Zhu Y, Li J, Wang Q, Gong H, Zhong X, Wu Y. Individualized dynamic PEEP (dynPEEP) vs. positive pressure ventilation in delivery room management: A retrospective cohort study. Front Pediatr 2022; 10:1007632. [PMID: 36714644 PMCID: PMC9874145 DOI: 10.3389/fped.2022.1007632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 12/12/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Although nasal continuous positive airway pressure (nCPAP) is recommended in delivery room (DR) management for preterm infants, the effect of delivering nCPAP at 6-8 cmH2O is not satisfactory. Therefore, we conducted this retrospective cohort study to compare the effects of individualized dynamic positive end-expiratory pressure (dynPEEP) vs. positive pressure ventilation (PPV) in the DR on clinical outcomes. METHODS Preterm infants with a gestational age (GA) less than 30 weeks who received PPV (peak inspiratory pressure, PIP/PEEP 15-25/6-8 cmH2O) from August 2018 to July 2020 were included as Cohort 1 (PPV group, n = 55), and those who received dynPEEP (nCPAP 8-15 cmH2O) from June 2020 to April 2022 were included as Cohort 2 (dynPEEP group, n = 62). Primary outcomes included the DR intubation rate and the bronchopulmonary dysplasia (BPD) rate. The secondary outcomes included DR stabilization, transfer, admission, respiratory function, and other outcomes. RESULTS The percentage of singleton infants was higher in the PPV group (63.6%) than in the dynPEEP group (22.6%, p = 0.000). The DR intubation and chest compression rates were higher in the PPV group (80.0% and 18.2%, respectively) than in the dynPEEP group (45.2%, p = 0.000; 3.0%, p = 0.008, respectively). The percentage of patients with 5-min Apgar scores < 5 was higher in the PPV group (9.1%) than in the dynPEEP group (0%, p = 0.016). The partial pressure of carbon dioxide was lower in the PPV group (49.77 ± 11.28) than in the dynPEEP group (56.44 ± 13.17, p = 0.004), and lactate levels were higher in the PPV group (3.60 (2.10, 5.90)) than in the dynPEEP group (2.25 (1.38, 3.33), p = 0.002). No significant differences in the BPD rate or other secondary outcomes were noted. CONCLUSIONS In this retrospective cohort study, the dynPEEP strategy reduced the need for DR intubation compared with PPV. The dynPEEP strategy is feasible and potentially represents an alternative respiratory strategy to PPV. Nevertheless, a randomized control trial is needed to evaluate the dynPEEP strategy.
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Affiliation(s)
- Sijie Song
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yefang Zhu
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Li
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Wang
- Department of Pediatrics, Chongqing Health Center for Women and Children, Chongqing, China
| | - Hua Gong
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyun Zhong
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yan Wu
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, China
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13
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Niemuth M, Küster H, Simma B, Rozycki H, Rüdiger M, Solevåg AL. A critical appraisal of tools for delivery room assessment of the newborn infant. Pediatr Res 2021:10.1038/s41390-021-01896-7. [PMID: 34969993 DOI: 10.1038/s41390-021-01896-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/19/2021] [Indexed: 11/09/2022]
Abstract
Assessment of an infant's condition in the delivery room represents a prerequisite to adequately initiate medical support. In her seminal paper, Virginia Apgar described five parameters to be used for such an assessment. However, since that time maternal and neonatal care has changed; interventions were improved and infants are even more premature. Nevertheless, the Apgar score is assigned to infants worldwide but there are concerns about low interobserver reliability, especially in preterm infants. Also, resuscitative interventions may preclude the interpretation of the score, which is of concern when used as an outcome parameter in delivery room intervention studies. Within the context of these changes, we performed a critical appraisal on how to assess postnatal condition of the newborn including the clinical parameters of the Apgar score, as well as selected additional parameters and a proposed new scoring system. The development of a new scoring system that guide clinicians in assessing infants and help to decide how to support postnatal adaptation is discussed. IMPACT: This critical paper discusses the reliability of the Apgar score, as well as additional parameters, in order to improve assessment of a newborn's postnatal condition. A revised neonatal scoring system should account for infant maturity and the interventions administered. Delivery room assessment should be directed toward determining how much medical support is needed and how the infant responds to these interventions.
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Affiliation(s)
- Mara Niemuth
- Department for Neonatology and Pediatric Intensive Care, Clinic for Pediatric and Adolescence Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Helmut Küster
- Clinic for Pediatric Cardiology, Intensive Care and Neonatology, University Medical Center Göttingen, Göttingen, Germany
| | - Burkhard Simma
- Department of Paediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - Henry Rozycki
- Division of Neonatal Medicine, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, VA, USA
| | - Mario Rüdiger
- Department for Neonatology and Pediatric Intensive Care, Clinic for Pediatric and Adolescence Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Anne Lee Solevåg
- The Department of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
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14
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Owen LS, Manley BJ, Hodgson KA, Roberts CT. Impact of early respiratory care for extremely preterm infants. Semin Perinatol 2021; 45:151478. [PMID: 34474939 DOI: 10.1016/j.semperi.2021.151478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite advances in neonatal intensive care, more than half of surviving infants born extremely preterm (EP; < 28 weeks' gestation) develop bronchopulmonary dysplasia (BPD). Prevention of BPD is critical because of its associated mortality and morbidity, including adverse neurodevelopmental outcomes and respiratory health in later childhood and beyond. The respiratory care of EP infants begins before birth, then continues in the delivery room and throughout the primary hospitalization. This chapter will review the evidence for interventions after birth that might improve outcomes for infants born EP, including the timing of umbilical cord clamping, strategies to avoid or minimize exposure to mechanical ventilation, modes of mechanical ventilation and non-invasive respiratory support, oxygen saturation targets, postnatal corticosteroids and other adjunct therapies.
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Affiliation(s)
- Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kate A Hodgson
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
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15
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Te Pas A, Roehr CC, Foglia EE, Hooper S. Neonatal resuscitation research: closing the gap. Pediatr Res 2021; 90:1117-1119. [PMID: 33627819 DOI: 10.1038/s41390-021-01403-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/21/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Arjan Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Charles Christopher Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitalsl, NHS Foundation Trust, Oxford, UK.,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Elizabeth E Foglia
- Division of Neonatology, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Stuart Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash, University, Melbourne, VIC, Australia
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16
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Bruckner M, Schmölzer GM. Physiologic Changes during Neonatal Transition and the Influence of Respiratory Support. Clin Perinatol 2021; 48:697-709. [PMID: 34774204 DOI: 10.1016/j.clp.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria.
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17
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Simma B, den Boer M, Nakstad B, Küster H, Herrick HM, Rüdiger M, Aichner H, Kaufmann M. Video recording in the delivery room: current status, implications and implementation. Pediatr Res 2021:10.1038/s41390-021-01865-0. [PMID: 34819653 DOI: 10.1038/s41390-021-01865-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/09/2022]
Abstract
Many factors determine the performance and success of delivery room management of newborn babies. Improving the quality of care in this challenging surrounding has an important impact on patient safety and on perinatal morbidity and mortality. Video recording (VR) offers the advantage to record and store work as done rather than work as recalled. It provides information about adherence to algorithms and guidelines, and technical, cognitive and behavioural skills. VR is feasible for education and training, improves team performance and results of research led to changes of international guidelines. However, studies thus far have not provided data regarding whether delivery room video recording affects long-term team performance or clinical outcomes. Privacy is a concern because data can be stored and individuals can be identified. We describe the current state of clinical practice in high- and low-resource settings, discuss ethical and medical-legal issues and give recommendations for implementation with the aim of improving the quality of care and outcome of vulnerable babies. IMPACT: VR improves performance by health caregivers providing neonatal resuscitation, teaching and research related to delivery room management, both in high as well low resource settings. VR enables information about adherence to guidelines, technical, behavioural and communication skills within the resuscitation team. VR has ethical and medical-legal implications for healthcare, especially recommendations for implementation of VR in routine clinical care in the delivery room. VR will increase the awareness that short- and long-term outcomes of babies depend on the quality of care in the delivery room.
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Affiliation(s)
- B Simma
- Department of Paediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria.
| | - M den Boer
- Division of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Leiden, The Netherlands
| | - B Nakstad
- Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
- Division of Paediatrics and Adolescent Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - H Küster
- Clinic for Paediatric Cardiology, Intensive Care and Neonatology, University Medical Centre Göttingen, Göttingen, Germany
| | - H M Herrick
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Rüdiger
- Division of Neonatology and Paediatric Intensive Care Medicine, Department of Paediatrics, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - H Aichner
- Department of Paediatrics, Academic Teaching Hospital, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - M Kaufmann
- Division of Neonatology and Paediatric Intensive Care Medicine, Department of Paediatrics, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Saxony Center for Feto-Neonatal Health, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
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18
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Schwaberger B, Urlesberger B, Schmölzer GM. Delivery Room Care for Premature Infants Born after Less than 25 Weeks' Gestation-A Narrative Review. CHILDREN-BASEL 2021; 8:children8100882. [PMID: 34682147 PMCID: PMC8534639 DOI: 10.3390/children8100882] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
Premature infants born after less than 25 weeks' gestation are particularly vulnerable at birth and stabilization in the delivery room (DR) is challenging. After birth, infants born after <25 weeks' gestation develop respiratory and hemodynamic instability due to their immature physiology and anatomy. Successful stabilization at birth has the potential to reduce morbidities and mortalities, while suboptimal DR care could increase long-term sequelae. This article reviews current neonatal resuscitation guidelines and addresses challenges during DR stabilization in extremely premature infants born after <25 weeks' gestation at the threshold of viability.
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Affiliation(s)
- Bernhard Schwaberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Berndt Urlesberger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, 8036 Graz, Austria; (B.S.); (B.U.)
| | - Georg M. Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB T5H 3V9, Canada
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T5H 3V9, Canada
- Correspondence: ; Tel.: +1-780-735-4660
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19
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Stimulating and maintaining spontaneous breathing during transition of preterm infants. Pediatr Res 2021; 90:722-730. [PMID: 31216570 DOI: 10.1038/s41390-019-0468-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/25/2019] [Accepted: 06/03/2019] [Indexed: 01/30/2023]
Abstract
Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.
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20
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van Leuteren RW, Kho E, de Waal CG, Te Pas AB, Salverda HH, de Jongh FH, van Kaam AH, Hutten GJ. Cardiorespiratory monitoring in the delivery room using transcutaneous electromyography. Arch Dis Child Fetal Neonatal Ed 2021; 106:352-356. [PMID: 33214154 DOI: 10.1136/archdischild-2020-319535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To assess feasibility of transcutaneous electromyography of the diaphragm (dEMG) as a monitoring tool for vital signs and diaphragm activity in the delivery room (DR). DESIGN Prospective observational study. SETTING Delivery room. PATIENTS Newborn infants requiring respiratory stabilisation after birth. INTERVENTIONS In addition to pulse oximetry (PO) and ECG, dEMG was measured with skin electrodes for 30 min after birth. OUTCOME MEASURES We assessed signal quality of dEMG and ECG recording, agreement between heart rate (HR) measured by dEMG and ECG or PO, time between sensor application and first HR read-out and agreement between respiratory rate (RR) measured with dEMG and ECG, compared with airway flow. Furthermore, we analysed peak, tonic and amplitude diaphragmatic activity from the dEMG-based respiratory waveform. RESULTS Thirty-three infants (gestational age: 31.7±2.8 weeks, birth weight: 1525±661 g) were included.18%±14% and 22%±21% of dEMG and ECG data showed poor quality, respectively. Monitoring HR with dEMG was fast (median 10 (IQR 10-11) s) and accurate (intraclass correlation coefficient (ICC) 0.92 and 0.82 compared with ECG and PO, respectively). RR monitoring with dEMG showed moderate (ICC 0.49) and ECG low (ICC 0.25) agreement with airway flow. Diaphragm activity started high with a decreasing trend in the first 15 min and subsequent stabilisation. CONCLUSION Monitoring vital signs with dEMG in the DR is feasible and fast. Diaphragm activity can be detected and described with dEMG, making dEMG promising for future DR studies.
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Affiliation(s)
- Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands .,Amsterdam Reproduction & Development Research Institute, Amsterdam, North-Holland, Netherlands
| | - Eline Kho
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Technical Medicine, University of Twente, Enschede, Overijssel, Netherlands
| | - Cornelia G de Waal
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Hylke H Salverda
- Department of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
| | - Frans H de Jongh
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Faculty of Science and Technology, University of Twente, Enschede, Overijssel, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
| | - Gerard J Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, North-Holland, Netherlands.,Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit, Amsterdam, North-Holland, Netherlands
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21
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Surak A, Elsayed Y. Delayed cord clamping: Time for physiologic implementation. J Neonatal Perinatal Med 2021; 15:19-27. [PMID: 34219673 DOI: 10.3233/npm-210745] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Delayed cord clamping has been shown to be beneficial in both preterm and term babies. Practice guidelines have not been consistent between centers and the practice of delayed cord clamping has not been standardized. The concept of physiologic-based cord clamping emerged into practice as well. Cord milking has different physiological effect and might be harmful in preterm babies.
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Affiliation(s)
- A Surak
- Division of Neonatology, University of Alberta, Edmonton, AB, Canada
| | - Y Elsayed
- Division of Neonatology, Health Sciences Centre, Winnipeg, MB, Canada
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22
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European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation 2021; 161:291-326. [PMID: 33773829 DOI: 10.1016/j.resuscitation.2021.02.014] [Citation(s) in RCA: 234] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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23
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Abstract
The European Resuscitation Council has produced these newborn life support guidelines, which are based on the International Liaison Committee on Resuscitation (ILCOR) 2020 Consensus on Science and Treatment Recommendations (CoSTR) for Neonatal Life Support. The guidelines cover the management of the term and preterm infant. The topics covered include an algorithm to aid a logical approach to resuscitation of the newborn, factors before delivery, training and education, thermal control, management of the umbilical cord after birth, initial assessment and categorisation of the newborn infant, airway and breathing and circulation support, communication with parents, considerations when withholding and discontinuing support.
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24
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Kuypers K, Martherus T, Lamberska T, Dekker J, Hooper SB, Te Pas AB. Reflexes that impact spontaneous breathing of preterm infants at birth: a narrative review. Arch Dis Child Fetal Neonatal Ed 2020; 105:675-679. [PMID: 32350064 DOI: 10.1136/archdischild-2020-318915] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 02/06/2023]
Abstract
Some neural circuits within infants are not fully developed at birth, especially in preterm infants. Therefore, it is unclear whether reflexes that affect breathing may or may not be activated during the neonatal stabilisation at birth. Both sensory reflexes (eg, tactile stimulation) and non-invasive ventilation (NIV) can promote spontaneous breathing at birth, but the application of NIV can also compromise breathing by inducing facial reflexes that inhibit spontaneous breathing. Applying an interface could provoke the trigeminocardiac reflex (TCR) by stimulating the trigeminal nerve resulting in apnoea and a reduction in heart rate. Similarly, airflow within the nasopharynx can elicit the TCR and/or laryngeal chemoreflex (LCR), resulting in glottal closure and ineffective ventilation, whereas providing pressure via inflations could stimulate multiple receptors that affect breathing. Stimulating the fast adapting pulmonary receptors may activate Head's paradoxical reflex to stimulate spontaneous breathing. In contrast, stimulating the slow adapting pulmonary receptors or laryngeal receptors could induce the Hering-Breuer inflation reflex or LCR, respectively, and thereby inhibit spontaneous breathing. As clinicians are most often unaware that starting primary care might affect the breathing they intend to support, this narrative review summarises the currently available evidence on (vagally mediated) reflexes that might promote or inhibit spontaneous breathing at birth.
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Affiliation(s)
- Kristel Kuypers
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tessa Martherus
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Tereza Lamberska
- Neonatology, General University Hospital in Prague, Prague, Czech Republic
| | - Janneke Dekker
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Arjan B Te Pas
- Neonatology, Leiden University Medical Center, Leiden, The Netherlands
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25
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Roberts CT. Inherent device: Are neonatologists cool with the face mask for resuscitation at birth, or is further investigation required? Resuscitation 2020; 156:270-272. [PMID: 32976964 DOI: 10.1016/j.resuscitation.2020.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Clayton, Victoria, Australia; Department of Paediatrics, Monash University, Clayton, Victoria, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia.
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26
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Kuypers KLAM, Lamberska T, Martherus T, Dekker J, Böhringer S, Hooper SB, Plavka R, Te Pas AB. Comparing the effect of two different interfaces on breathing of preterm infants at birth: A matched-pairs analysis. Resuscitation 2020; 157:60-66. [PMID: 33075437 DOI: 10.1016/j.resuscitation.2020.10.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 09/16/2020] [Accepted: 10/05/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Applying a face mask could provoke a trigeminocardiac reflex. We compared the effect of applying bi-nasal prongs with a face mask on breathing and heart rate of preterm infants at birth. METHODS In a retrospective matched-pairs study of infants <32 weeks of gestation, the use of bi-nasal prongs for respiratory support at birth was compared to the use of a face mask. Infants who were initially breathing at birth and subsequently received respiratory support were matched for gestational age (±4 days), birth weight (±300 g), general anaesthesia and gender. Breathing, heart rate and other parameters were collected before and after interface application and in the first 5 min thereafter. RESULTS In total, 130 infants were included (n = 65 bi-nasal prongs, n = 65 face mask) with a median (IQR) gestational age of 27+2 (25+3-28+4) vs 26+6 (25+3-28+5) weeks. The proportion of infants who stopped breathing after applying the interface was not different between the groups (bi-nasal prongs 43/65 (66%) vs face mask 46/65 (71%), p = 0.70). Positive pressure ventilation was given more often when bi-nasal prongs were used (55/65 (85%) vs 40/65 (62%), p < 0.001). Heart rate (101 (75-145) vs 110 (68-149) bpm, p = 0.496) and oxygen saturation (59% (48-87) vs 56% (35-84), p = 0.178) were similar in the first 5 min after an interface was applied in the infants who stopped breathing. CONCLUSION Apnoea and bradycardia occurred often after applying either bi-nasal prongs or a face mask on the face for respiratory support in preterm infants at birth.
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Affiliation(s)
- Kristel L A M Kuypers
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Tereza Lamberska
- Division of Neonatology, Department of Obstetrics and Gynaecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Tessa Martherus
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Janneke Dekker
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Stefan Böhringer
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynaecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, The Netherlands
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27
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Pryor EJ, Kitchen MJ, Croughan MK, Crossley KJ, Wallace MJ, Lee K, Te Pas AB, McGillick EV, Hooper SB. Improving lung aeration in ventilated newborn preterm rabbits with a partially aerated lung. J Appl Physiol (1985) 2020; 129:891-900. [PMID: 32816641 DOI: 10.1152/japplphysiol.00426.2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Preterm newborns commonly receive intermittent positive pressure ventilation (iPPV) at birth, but the optimal approach that facilitates uniform lung aeration is unknown, particularly in a partially aerated lung. As both inflation time and exogenous surfactant facilitate uniform lung aeration, we investigated whether they can improve lung aeration and lung mechanics in a partially aerated lung immediately after birth. Preterm rabbit kittens (29 days of gestation, term ~32 days) were delivered by caesarean section and partial lung aeration was created by intubating and mechanically ventilating the right lung. The tube was then withdrawn to ventilate both lungs using inflation times of 0.2 s or 1.0 s, with or without exogenous surfactant (200 mg/kg; Curosurf) and a tidal volume (Vt) of 8 mL/kg. Simultaneous phase contrast X-ray imaging and plethysmography were used to measure lung aeration and mechanics. Kittens ventilated with longer inflation times (1.0 s) reached their target Vt with fewer inflations, required lower inflation pressures (28.5 ± 1.1 vs. 33.5 ± 1.3 cmH2O, P = 0.01) and had higher dynamic lung compliances (0.54 ± 0.3 vs. 0.40 ± 0.3 cmH2O·mL-1·kg-1, P = 0.003). Surfactant increased functional residual capacity (FRC; 31.9 ± 3.2 vs. 18.0 ± 3.9 mL/kg, P = 0.02) and the proportion of the Vt entering the previously unaerated lung but had no effect on dynamic lung compliance. Combining early surfactant treatment with longer inflation times increases FRC levels, improves dynamic lung compliance, reduces inflation pressures and markedly increases the proportion of the lungs being ventilated during iPPV in preterm kittens with a partially aerated lung.NEW & NOTEWORTHY Preterm newborns commonly receive intermittent positive pressure ventilation (iPPV) at birth, but the optimal approach that facilitates uniform lung aeration is unknown, particularly in a partially aerated lung. Using phase contrast X-ray imaging, we showed that combining a long inflation time (1.0 s) with surfactant improved lung mechanics and aeration in the immediate newborn period. The current clinical practice of using short inflation times during iPPV might be suboptimal and a different approach is needed.
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Affiliation(s)
- Emily J Pryor
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Michelle K Croughan
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Megan J Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Katie Lee
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Paediatrics, Leiden University Medical Centre, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia.,The Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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28
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Murphy MC, McCarthy LK, O'Donnell CPF. Crying and breathing by new-born preterm infants after early or delayed cord clamping. Arch Dis Child Fetal Neonatal Ed 2020; 105:331-333. [PMID: 31085675 DOI: 10.1136/archdischild-2018-316592] [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: 11/22/2018] [Revised: 03/28/2019] [Accepted: 04/16/2019] [Indexed: 11/04/2022]
Abstract
Guidelines recommend delayed cord clamping (DCC) of at least 30 s for vigorous preterm infants who do not require resuscitation. It is not known whether DCC affects the rate of crying and breathing after birth. We reviewed videos of 80 preterm infants in the delivery room. Most infants cried and breathed after both immediate and delayed cord clamping before respiratory support was given. Infants arrived at the resuscitaire in similar physiological condition, regardless of the time after birth at which they arrived.
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Affiliation(s)
- Madeleine C Murphy
- Neonatal Unit, National Maternity Hospital, Dublin 2, Ireland.,National Children's Research Centre, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
| | - Lisa K McCarthy
- Neonatal Unit, National Maternity Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland
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29
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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: 45] [Impact Index Per Article: 11.3] [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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30
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Owen LS, Manley BJ, Davis PG. Delivery room emergencies: Respiratory emergencies in the DR. Semin Fetal Neonatal Med 2019; 24:101039. [PMID: 31645310 DOI: 10.1016/j.siny.2019.101039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of newborns transition to extra uterine life without support. However, respiratory emergencies in the delivery room are a common occurrence. Whilst some situations are predictable e.g. the anticipated birth of an extremely preterm infant, others are less so. In this chapter we address the most frequent scenarios that result in delivery room respiratory emergencies and discuss the latest recommendations for their management. We outline the need for a trained resuscitation team and appropriate equipment to provide respiratory support at every birth. We address the basic care that all infants should receive, the detailed application of non-invasive ventilation and the use of advanced airway techniques. We discuss the unique challenges presented by extreme prematurity including umbilical cord management, use of supplemental oxygen, initial modes of respiratory support and surfactant delivery. We will explore optimal techniques in the management of infants with lung hypoplasia, pneumothorax and meconium aspiration.
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Affiliation(s)
- Louise S Owen
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Brett J Manley
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
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31
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Kuypers KL, Lamberska T, Martherus T, Dekker J, Böhringer S, Hooper SB, Plavka R, te Pas AB. The effect of a face mask for respiratory support on breathing in preterm infants at birth. Resuscitation 2019; 144:178-184. [DOI: 10.1016/j.resuscitation.2019.08.043] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 11/24/2022]
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32
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O’Donnell CP. Face mask respiratory support for preterm infants: Takes their breath away? Resuscitation 2019; 144:189-190. [DOI: 10.1016/j.resuscitation.2019.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/14/2019] [Indexed: 11/28/2022]
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33
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Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology 2019; 115:432-450. [PMID: 30974433 PMCID: PMC6604659 DOI: 10.1159/000499361] [Citation(s) in RCA: 654] [Impact Index Per Article: 130.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, United Kingdom,
| | - Virgilio Carnielli
- Department of Neonatology, Polytechnic University of Marche, and Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Pediatrics and Adolescence, Oulu University Hospital, and PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan Te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C Roehr
- Department of Paediatrics, University of Oxford, Medical Sciences Division, Newborn Services, John Radcliffe Hospitals, Oxford, United Kingdom
| | - Ola D Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
| | - Umberto Simeoni
- Division of Pediatrics, CHUV & University of Lausanne, Lausanne, Switzerland
| | - Christian P Speer
- Department of Pediatrics, University Children's Hospital, Würzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerhard H A Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, United Kingdom
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34
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Te Pas AB, Hooper SB, Dekker J. The Changing Landscape in Supporting Preterm Infants at Birth. Neonatology 2019; 115:392-397. [PMID: 30974440 PMCID: PMC6604262 DOI: 10.1159/000497421] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/19/2022]
Abstract
Noninvasive ventilation for preterm infants at birth has been recommended and universally adopted. The umbilical cord is often clamped immediately in order to provide the support the infant needs for stabilization. However, recent scientific data from experimental studies that involve animals in transition and human studies using physiological measurements at birth have increased awareness as to how little we know about how these interventions interact and integrate with the infant's changing physiology. It has become clear that in apneic infants the larynx is closed immediately after birth, which can completely negate the effect of noninvasive ventilation of the lung. For this reason, stimulating and supporting spontaneous breathing could enhance the success of noninvasive ventilation. Animal data also demonstrated that the large swings in blood pressure, blood flow, and oxygenation caused by immediate cord clamping can be avoided by postponing cord clamping until lung aeration has been established. In this review we will focus on these "game changers" that have the potential to completely change the approach used in stabilizing preterm infants at birth.
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Affiliation(s)
- Arjan B Te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands,
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Janneke Dekker
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.,The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Victoria, Australia
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35
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Martherus T, Oberthuer A, Dekker J, Hooper SB, McGillick EV, Kribs A, Te Pas AB. Supporting breathing of preterm infants at birth: a narrative review. Arch Dis Child Fetal Neonatal Ed 2019; 104:F102-F107. [PMID: 30049727 DOI: 10.1136/archdischild-2018-314898] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/14/2018] [Accepted: 07/02/2018] [Indexed: 11/03/2022]
Abstract
Most very preterm infants have difficulty aerating their lungs and require respiratory support at birth. Currently in clinical practice, non-invasive ventilation in the form of continuous positive airway pressure (CPAP) and positive pressure ventilation (PPV) is applied via facemask. As most very preterm infants breathe weakly and unnoticed at birth, PPV is often administered. PPV is, however, frequently ineffective due to pressure settings, mask leak and airway obstruction. Meanwhile, high positive inspiratory pressures and spontaneous breathing coinciding with inflations can generate high tidal volumes. Evidence from preclinical studies demonstrates that high tidal volumes can be injurious to the lungs and brains of premature newborns. To reduce the need for PPV in the delivery room, it should be considered to optimise spontaneous breathing with CPAP. CPAP is recommended in guidelines and commonly used in the delivery room after a period of PPV, but little data is available on the ideal CPAP strategy and CPAP delivering devices and interfaces used in the delivery room. This narrative review summarises the currently available evidence for why PPV can be inadequate at birth and what is known about different CPAP strategies, devices and interfaces used the delivery room.
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Affiliation(s)
- Tessa Martherus
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - André Oberthuer
- Department of Neonatology, Children's Hospital University of Cologne, Cologne, Germany
| | - Janneke Dekker
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute for Medical Research, Clayton, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Angela Kribs
- Department of Neonatology, Children's Hospital University of Cologne, Cologne, Germany
| | - Arjan B Te Pas
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
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36
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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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37
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Martherus T, Oberthuer A, Dekker J, Kirchgaessner C, van Geloven N, Hooper SB, Kribs A, Te Pas AB. Comparison of Two Respiratory Support Strategies for Stabilization of Very Preterm Infants at Birth: A Matched-Pairs Analysis. Front Pediatr 2019; 7:3. [PMID: 30761276 PMCID: PMC6362425 DOI: 10.3389/fped.2019.00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/04/2019] [Indexed: 01/19/2023] Open
Abstract
Objective: Respiratory support for stabilizing very preterm infants at birth varies between centers. We retrospectively compared two strategies that involved either increasing continuous positive airway pressures (CPAP), or increasing oxygen supplementation. Methods: Matched-pairs of infants (<28 weeks of gestation) were born either at the Leiden University Medical Center [low-pressure: CPAP 5-8 cmH2O and/or positive pressure ventilation (PPV) and fraction of inspired oxygen (FiO2) 0.3-1.0; n = 27], or at the University Hospital of Cologne (high-pressure: CPAP 12-35 cmH2O, no PPV and FiO2 0.3-0.4; n = 27). Respiratory support was initiated non-invasively via facemask at both units. Infants (n = 54) were matched between centers for gestational age and birth weight, to compare physiological and short-term clinical outcomes. Results: In the low-pressure group, 20/27 (74%) infants received 1-2 sustained inflations (20, 25 cm H2O) and 22/27 (81%) received PPV (1:19-3:01 min) using pressures of 25-27 cm H2O. Within 3 min of birth [median (IQR)], mean airway pressures [12 (6-15) vs. 19 (16-23) cmH2O, p < 0.001] and FiO2 [0.30 (0.28-0.31) vs. 0.22 (0.21-0.30), p < 0.001] were different in low- vs. high-pressure groups, respectively. SpO2 and heart rates were similar. After 3 min, higher FiO2 levels [0.62 (0.35-0.98) vs. 0.28 (0.22-0.38), p = 0.005] produced higher SpO2 levels [77 (50-92) vs. 53 (42-69)%, p < 0.001] in the low-pressure group, but SpO2/FiO2 and heart rates were similar. While intubation rates during admission were significantly different (70 vs. 30%, p = 0.013), pneumothorax rates (4 vs. 19%, p = 0.125) and the occurrence of spontaneous intestinal perforations (0 vs. 15%, p = 0.125) were similar between groups. Conclusion: Infants (<28 weeks) can be supported non-invasively at birth with either higher or lower pressures and while higher-pressure support may require less oxygen, it does not eliminate the need for oxygen supplementation. Future studies need to examine the effect of high pressures and pressure titration in the delivery room.
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Affiliation(s)
- Tessa Martherus
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - André Oberthuer
- Department of Neonatology, Children's Hospital University of Cologne, Cologne, Germany
| | - Janneke Dekker
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Nan van Geloven
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Angela Kribs
- Department of Neonatology, Children's Hospital University of Cologne, Cologne, Germany
| | - Arjan B Te Pas
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
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38
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Dekker J, Hooper SB, Croughan MK, Crossley KJ, Wallace MJ, McGillick EV, DeKoninck PLJ, Thio M, Martherus T, Ruben G, Roehr CC, Cramer SJE, Flemmer AW, Croton L, Te Pas AB, Kitchen MJ. Increasing Respiratory Effort With 100% Oxygen During Resuscitation of Preterm Rabbits at Birth. Front Pediatr 2019; 7:427. [PMID: 31696099 PMCID: PMC6817611 DOI: 10.3389/fped.2019.00427] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/07/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Spontaneous breathing is essential for successful non-invasive respiratory support delivered by a facemask at birth. As hypoxia is a potent inhibitor of spontaneous breathing, initiating respiratory support with a high fraction of inspired O2 may reduce the risk of hypoxia and increase respiratory effort at birth. Methods: Preterm rabbit kittens (29 days gestation, term ~32 days) were delivered and randomized to receive continuous positive airway pressure with either 21% (n = 12) or 100% O2 (n = 8) via a facemask. If apnea occurred, intermittent positive pressure ventilation (iPPV) was applied with either 21% or 100% O2 in kittens who started in 21% O2, and remained at 100% O2 for kittens who started the experiment in 100% O2. Respiratory rate (breaths per minute, bpm) and variability in inter-breath interval (%) were measured from esophageal pressure recordings and functional residual capacity (FRC) was measured from synchrotron phase-contrast X-ray images. Results: Initially, kittens receiving 21% O2 had a significantly lower respiratory rate and higher variability in inter-breath interval, indicating a less stable breathing pattern than kittens starting in 100% O2 [median (IQR) respiratory rate: 16 (4-28) vs. 38 (29-46) bpm, p = 0.001; variability in inter-breath interval: 33.3% (17.2-50.1%) vs. 27.5% (18.6-36.3%), p = 0.009]. Apnea that required iPPV, was more frequently observed in kittens in whom resuscitation was started with 21% compared to 100% O2 (11/12 vs. 1/8, p = 0.001). After recovering from apnea, respiratory rate was significantly lower and variability in inter-breath interval was significantly higher in kittens who received iPPV with 21% compared to 100% O2. FRC was not different between study groups at both timepoints. Conclusion: Initiating resuscitation with 100% O2 resulted in increased respiratory activity and stability, thereby reducing the risk of apnea and need for iPPV after birth. Further studies in human preterm infants are mandatory to confirm the benefit of this approach in terms of oxygenation. In addition, the ability to avoid hyperoxia after initiation of resuscitation with 100% oxygen, using a titration protocol based on oxygen saturation, needs to be clarified.
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Affiliation(s)
- Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Michelle K Croughan
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Megan J Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Marta Thio
- Women's Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia.,Centre of Research Excellence in Newborn Medicine, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Tessa Martherus
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Gary Ruben
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Charles C Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.,Medical Sciences Division, Department of Pediatrics, University of Oxford, Oxford, United Kingdom
| | - Sophie J E Cramer
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands.,Department of Instrumental Affairs, Leiden University Medical Center, Leiden, Netherlands
| | - Andreas W Flemmer
- Department of Neonatology, Dr. v. Haunersches Kinderspital & Perinatal Center Grosshadern, Medical Center of the University of Munich, Munich, Germany
| | - Linda Croton
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
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Dekker J, Hooper SB, Giera M, McGillick EV, Hutten GJ, Onland W, van Kaam AH, Te Pas AB. High vs. Low Initial Oxygen to Improve the Breathing Effort of Preterm Infants at Birth: Study Protocol for a Randomized Controlled Trial. Front Pediatr 2019; 7:179. [PMID: 31134170 PMCID: PMC6514187 DOI: 10.3389/fped.2019.00179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/17/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Although most preterm infants breathe at birth, their respiratory drive is weak and supplemental oxygen is often needed to overcome hypoxia. This could in turn lead to hyperoxia. To reduce the risk of hyperoxia, currently an initial low oxygen concentration (21-30%) is recommended during stabilization at birth, accepting the risk of a hypoxic period. However, hypoxia inhibits respiratory drive in preterm infants. Starting with a higher level of oxygen could lead to a shorter duration of hypoxia by stimulating breathing effort of preterm infants, and combined with subsequent titration based on oxygen saturation, prolonged hyperoxia might be prevented. Study design: This multi-center randomized controlled trial will include 50 infants with a gestational age between 24 and 30 weeks. Eligible infants will be randomized to stabilization with an initial FiO2 of either 1.0 or 0.3 at birth. Hereafter, FiO2 will be titrated based on the oxygen saturation target range. In both groups, all other interventions during stabilization and thereafter will be similar. The primary outcome is respiratory effort in the first 5 min after birth expressed as average minute volume/kg. Secondary outcomes include inspired tidal volumes/kg, rate of rise to maximum tidal volume/kg, percentage of recruitment breaths with tidal volumes above 8 mL/kg, duration of hypoxia and hyperoxia and plasma levels of markers of oxidative stress (8-iso-prostaglandin F2α). Discussion: Current resuscitation guidelines recommend oxygen titration if infants fail to achieve the 25th percentile of the SpO2 reference ranges. It has become clear that, using this approach, most preterm infants are at risk for hypoxia in the first 5 min after birth, which could suppress the breathing effort. In addition, for compromised preterm infants who need respiratory support at birth, higher SpO2 reference ranges in the first minutes after birth might be needed to prevent prolonged hypoxia. Enhancing breathing effort by achieving an adequate level of oxygenation could potentially lead to a lower incidence of intubation and mechanical ventilation in the delivery room, contributing to a lower risk on lung injury in high-risk preterm infants. Measuring 8-iso-prostaglandin F2α could lead to a reflection of the true amount of oxygen exposure in both study groups.
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Affiliation(s)
- Janneke Dekker
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Martin Giera
- Center Proteomics Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - W Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Arjan B Te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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40
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Mythen in der Neonatologie. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0611-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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41
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Affiliation(s)
- Baldvin Jonsson
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
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42
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Dekker J, Hooper SB, Martherus T, Cramer SJE, van Geloven N, Te Pas AB. Repetitive versus standard tactile stimulation of preterm infants at birth - A randomized controlled trial. Resuscitation 2018; 127:37-43. [PMID: 29580959 DOI: 10.1016/j.resuscitation.2018.03.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 03/19/2018] [Accepted: 03/22/2018] [Indexed: 11/26/2022]
Abstract
AIM To evaluate the direct effect of repetitive tactile stimulation on breathing effort of preterm infants at birth. METHODS This randomized controlled trial compared the effect of repetitive stimulation on respiratory effort during the first 4 min after birth with standard stimulation based on clinical indication in preterm infants with a gestational age of 27-32 weeks. All details of the stimulation performed were noted. The main study parameter measured was respiratory minute volume, other study parameters assessed measures of respiratory effort; tidal volumes, rate of rise to maximum tidal volumes, percentage of recruitment breaths, and oxygenation of the infant. RESULTS There was no significant difference in respiratory minute volume in the repetitive stimulation group when compared to the standard group. Oxygen saturation was significantly higher (87.6 ± 3.3% vs 81.7 ± 8.7%, p = .01) while the amount of FiO2 given during transport to the NICU was lower (28.2 (22.8-35.0)% vs 33.6 (29.4-44.1)%, p = .04). There was no significant difference in administration of positive pressure ventilation (52% vs 78%, p = .13), or the duration of ventilation (median (IQR) time 8 (0-118)s vs 35 (13-131)s, p = .23). Caregivers decided less often to administer caffeine in the delivery room to stimulate breathing in the repetitive stimulation group (10% vs 39%, p = .036). CONCLUSION Although the increase in respiratory effort during repetitive stimulation did not reach significance, oxygenation significantly improved with a lower level of FiO2 at transport to the NICU. Repetitive tactile stimulation could be of added value to improve breathing effort at birth.
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Affiliation(s)
- Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Stuart B Hooper
- The Ritchie Center, MIMR-PHI Institute of Medical Research, Melbourne, Australia
| | - Tessa Martherus
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie J E Cramer
- Department of Instrumental Affairs, Leiden University Medical Center, Leiden, The Netherlands
| | - Nan van Geloven
- Department of Medical Statistics and Bio-informatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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43
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Huberts TJP, Foglia EE, Narayen IC, van Vonderen JJ, Hooper SB, Te Pas AB. The Breathing Effort of Very Preterm Infants at Birth. J Pediatr 2018; 194:54-59. [PMID: 29336795 DOI: 10.1016/j.jpeds.2017.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/23/2017] [Accepted: 11/01/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the respiratory effort of very preterm infants receiving positive pressure ventilation (PPV) with infants breathing on continuous positive airway pressure (CPAP), directly after birth. STUDY DESIGN Recorded resuscitations of very preterm infants receiving PPV or CPAP after birth were analyzed retrospectively. The respiratory effort (minute volume and recruitment breaths [>8 mL/kg], heart rate, oxygen saturation, and oxygen requirement were analyzed for the first 2 minutes and in the fifth minute after birth. RESULTS Respiratory effort was analyzed in 118 infants, 87 infants receiving PPV and 31 infants receiving CPAP (median gestational age, 28 weeks [IQR, 26-29] vs 29 weeks [IQR, 29-30; P < .001); birth weight, 1059 g [IQR, 795-1300] vs 1205 g [IQR, 956-1418; P = .06]). The minute volume of spontaneous breaths of infants receiving PPV was lower at 2 minutes (37 mL/kg/minute [IQR, 15-69] vs 188 mL/kg/minute [IQR, 128-297; P < .001]) and at 5 minutes (112 mL/kg/minute [IQR, 46-229] vs 205 mL/kg/minute [IQR, 174-327; P < .001]). Recruitment breaths occurred less in the PPV group at 2 minutes (0 breaths/minute [IQR, 0-1] vs 4 breaths/minute [IQR, 1-8; P < .001]) and 5 minutes (0 breaths/minute [IQR, 0-3] vs 2 breaths/minute [IQR, 0-11; P = .01). The heart rate was lower in the PPV group (94 beats/minute [IQR, 68-128] vs 124 beats/minute [IQR, 100-144; P = .02]) as was oxygen saturation (50% [IQR, 35%-66%] vs 67% [IQR, 34%-80%; P = .04]), but not different at 5 minutes (heart rate, 149 beats/minute [IQR, 131-162] vs 150 beats/minute [IQR, 132-160; P = NS]; oxygen saturation , 91% [IQR, 80%-95%] vs 92% [IQR, 89%-97%; P = NS]). The oxygen requirement was higher (at 2 minutes, 30% [IQR, 21%-53%] vs 21% [IQR, 21%-29%; P = .05]; at 5 minutes, 39% [IQR, 22%-91%] vs 22% [IQR, 21%-31%; P = .003]). CONCLUSION Very preterm infants breathe at birth when receiving PPV, but the respiratory effort was significantly lower when compared with infants receiving CPAP only. The reduced breathing effort observed likely justified applying PPV in most infants.
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Affiliation(s)
- Tom J P Huberts
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth E Foglia
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ilona C Narayen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia; Department of Obstetrics and Gynecology, Monash University, Melbourne, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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Gaertner VD, Flemmer SA, Lorenz L, Davis PG, Kamlin COF. Physical stimulation of newborn infants in the delivery room. Arch Dis Child Fetal Neonatal Ed 2018; 103:F132-F136. [PMID: 28600392 DOI: 10.1136/archdischild-2016-312311] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 04/26/2017] [Accepted: 05/04/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Neonatal resuscitation guidelines recommend that newborn infants are stimulated to assist with the establishment of regular respirations. The mode, site of application and frequency of stimulations are not stipulated in these guidelines. The effectiveness of stimulation in improving neonatal transition outcomes is poorly described. METHODS We conducted a retrospective review of video recordings of neonatal resuscitation at a tertiary perinatal centre. Four different types of stimulation (drying, chest rub, back rub and foot flick) were defined a priori and the frequency and infant response were documented. RESULTS A total of 120 video recordings were reviewed. Seventy-five (63%) infants received at least one episode of stimulation and 70 (58%) infants were stimulated within the first minute after birth. Stimulation was less commonly provided to infants <30 weeks' gestation (median (IQR) number of stimulations: 0 (0-1)) than infants born ≥30 weeks' gestation (1 (1-3); p<0.001). The most common response to stimulation was limb movement followed by infant cry and facial grimace. Truncal stimulation (drying, chest rub, back rub) was associated with more crying and movement than foot flicks. CONCLUSION Less mature infants are stimulated less frequently compared with more mature infants and many very preterm infants do not receive any stimulation. Most infants were stimulated within the first minute as recommended in resuscitation guidelines. Rubbing the trunk may be most effective but this needs to be confirmed in prospective studies.
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Affiliation(s)
- Vincent D Gaertner
- Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,School of Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Sophie A Flemmer
- Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,School of Medicine, University Medical Center Regensburg, Regensburg, Germany
| | - Laila Lorenz
- Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Neonatology, University Children's Hospital of Tübingen, Tübingen, Germany
| | - Peter G Davis
- Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Clinical Sciences Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - C Omar Farouk Kamlin
- Neonatal Services, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia.,Clinical Sciences Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
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45
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Crawshaw JR, Kitchen MJ, Binder-Heschl C, Thio M, Wallace MJ, Kerr LT, Roehr CC, Lee KL, Buckley GA, Davis PG, Flemmer A, Te Pas AB, Hooper SB. Laryngeal closure impedes non-invasive ventilation at birth. Arch Dis Child Fetal Neonatal Ed 2018; 103:F112-F119. [PMID: 29054974 PMCID: PMC5868244 DOI: 10.1136/archdischild-2017-312681] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/26/2017] [Accepted: 04/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Non-invasive ventilation is sometimes unable to provide the respiratory needs of very premature infants in the delivery room. While airway obstruction is thought to be the main problem, the site of obstruction is unknown. We investigated whether closure of the larynx and epiglottis is a major site of airway obstruction. METHODS We used phase contrast X-ray imaging to visualise laryngeal function in spontaneously breathing premature rabbits immediately after birth and at approximately 1 hour after birth. Non-invasive respiratory support was applied via a facemask and images were analysed to determine the percentage of the time the glottis and the epiglottis were open. HYPOTHESIS Immediately after birth, the larynx is predominantly closed, only opening briefly during a breath, making non-invasive intermittent positive pressure ventilation (iPPV) ineffective, whereas after lung aeration, the larynx is predominantly open allowing non-invasive iPPV to ventilate the lung. RESULTS The larynx and epiglottis were predominantly closed (open 25.5%±1.1% and 17.1%±1.6% of the time, respectively) in pups with unaerated lungs and unstable breathing patterns immediately after birth. In contrast, the larynx and the epiglottis were mostly open (90.5%±1.9% and 72.3%±2.3% of the time, respectively) in pups with aerated lungs and stable breathing patterns irrespective of time after birth. CONCLUSION Laryngeal closure impedes non-invasive iPPV at birth and may reduce the effectiveness of non-invasive respiratory support in premature infants immediately after birth.
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Affiliation(s)
- Jessica R Crawshaw
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Corinna Binder-Heschl
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia
- Division of Neonatology, Department of Pediatrics, Medical University of Graz, Graz, Austria
| | - Marta Thio
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Vic, Australia
| | - Megan J Wallace
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Lauren T Kerr
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - Charles C Roehr
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia
| | - Katie L Lee
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Genevieve A Buckley
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | - Peter G Davis
- Newborn Research Centre, The Royal Women's Hospital, Melbourne, Vic, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
- The Murdoch Children's Research Institute, Melbourne, Australia
| | - Andreas Flemmer
- Division of Neonatology, University Children's Hospital and Perinatal Center, Ludwig Maximilian University, Munich, Germany
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, Clayton, Australia
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
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Fogarty M, Osborn DA, Askie L, Seidler AL, Hunter K, Lui K, Simes J, Tarnow-Mordi W. Delayed vs early umbilical cord clamping for preterm infants: a systematic review and meta-analysis. Am J Obstet Gynecol 2018; 218:1-18. [PMID: 29097178 DOI: 10.1016/j.ajog.2017.10.231] [Citation(s) in RCA: 306] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 10/25/2017] [Accepted: 10/26/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND The effects of delayed cord clamping of the umbilical cord in preterm infants are unclear. OBJECTIVE We sought to compare the effects of delayed vs early cord clamping on hospital mortality (primary outcome) and morbidity in preterm infants using Cochrane Collaboration neonatal review group methodology. STUDY DESIGN We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Chinese articles, cross-referencing citations, expert informants, and trial registries to July 31, 2017, for randomized controlled trials of delayed (≥30 seconds) vs early (<30 seconds) clamping in infants born <37 weeks' gestation. Before searching the literature, we specified that trials estimated to have cord milking in >20% of infants in any arm would be ineligible. Two reviewers independently selected studies, assessed bias, and extracted data. Relative risk (ie, risk ratio), risk difference, and mean difference with 95% confidence intervals were assessed by fixed effects models, heterogeneity by I2 statistics, and the quality of evidence by Grading of Recommendations, Assessment, Development, and Evaluations. RESULTS Eighteen randomized controlled trials compared delayed vs early clamping in 2834 infants. Most infants allocated to have delayed clamping were assigned a delay of ≥60 seconds. Delayed clamping reduced hospital mortality (risk ratio, 0.68; 95% confidence interval, 0.52-0.90; risk difference, -0.03; 95% confidence interval, -0.05 to -0.01; P = .005; number needed to benefit, 33; 95% confidence interval, 20-100; Grading of Recommendations, Assessment, Development, and Evaluations = high, with I2 = 0 indicating no heterogeneity). In 3 trials in 996 infants ≤28 weeks' gestation, delayed clamping reduced hospital mortality (risk ratio, 0.70; 95% confidence interval, 0.51-0.95; risk difference, -0.05; 95% confidence interval, -0.09 to -0.01; P = .02, number needed to benefit, 20; 95% confidence interval, 11-100; I2 = 0). In subgroup analyses, delayed clamping reduced the incidence of low Apgar score at 1 minute, but not at 5 minutes, and did not reduce the incidence of intubation for resuscitation, admission temperature, mechanical ventilation, intraventricular hemorrhage, brain injury, chronic lung disease, patent ductus arteriosus, necrotizing enterocolitis, late onset sepsis or retinopathy of prematurity. Delayed clamping increased peak hematocrit by 2.73 percentage points (95% confidence interval, 1.94-3.52; P < .00001) and reduced the proportion of infants having blood transfusion by 10% (95% confidence interval, 6-13%; P < .00001). Potential harms of delayed clamping included polycythemia and hyperbilirubinemia. CONCLUSION This systematic review provides high-quality evidence that delayed clamping reduced hospital mortality, which supports current guidelines recommending delayed clamping in preterm infants. This review does not evaluate cord milking, which may also be of benefit. Analyses of individual patient data in these and other randomized controlled trials will be critically important in reliably evaluating important secondary outcomes.
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47
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Affiliation(s)
- Colm P F O'Donnell
- From the National Maternity Hospital, the National Children's Research Centre, and the School of Medicine, University College Dublin - all in Dublin, Ireland
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48
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Dekker J, Hooper SB, van Vonderen JJ, Witlox RSGM, Lopriore E, Te Pas AB. Caffeine to improve breathing effort of preterm infants at birth: a randomized controlled trial. Pediatr Res 2017; 82:290-296. [PMID: 28288150 DOI: 10.1038/pr.2017.45] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 02/08/2017] [Indexed: 01/20/2023]
Abstract
BackgroundCaffeine promotes spontaneous breathing by antagonizing adenosine. We assessed the direct effect of caffeine on respiratory effort in preterm infants at birth.MethodsThirty infants of 24-30 weeks of gestation were randomized for receiving caffeine directly after birth in the delivery room (caffeine DR group) or later in the neonatal intensive care unit (control group). Primary outcome was respiratory effort, expressed as minute volume, tidal volumes, respiratory rate, rate of rise to maximum tidal volume, and recruitment breaths at 7-9 min after birth.ResultsAfter correction for gestational age, minute volumes ((mean±SD; 189±74 vs. 162±70 ml/kg/min; P<0.05) and tidal volumes ((median (interquartile range (IQR)) 5.2 (3.9-6.4) vs. 4.4 (3.0-5.6) ml/kg) were significantly greater in the caffeine DR group. Although respiratory rates were similar ((mean±SD) 35±10 vs. 33±10), RoR increased significantly ((median (IQR) 14.3 (11.2-19.8) vs. 11.2 (7.9-15.2) ml/kg/s), and more recruitment breaths were observed (13 vs. 9%).ConclusionCaffeine increases respiratory effort in preterm infants at birth, but the effect on clinical outcomes needs further investigation.
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Affiliation(s)
- Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Center, MIMR-PHI Institute of Medical Research, Melbourne, Victoria, Australia
| | - Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ruben S G M Witlox
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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49
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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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50
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Tippens JA. Urban Congolese Refugees in Kenya: The Contingencies of Coping and Resilience in a Context Marked by Structural Vulnerability. QUALITATIVE HEALTH RESEARCH 2017; 27:1069-1076. [PMID: 27565703 DOI: 10.1177/1049732316673342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The global increase in refugee migration to urban areas creates challenges pertaining to the promotion of refugee health, broadly conceived. Despite considerable attention to trauma and forced migration, there is relatively little focus on how refugees cope with stressful situations, and on the determinants that facilitate and undermine resilience. This article examines how urban Congolese refugees in Kenya promote psychosocial well-being in the context of structural vulnerability. This article is based on interviews ( N = 55) and ethnographic participant observation with Congolese refugees over a period of 8 months in Nairobi in 2014. Primary stressors related to scarcity of material resources, political and personal insecurity, and emotional stress. Congolese refugees mitigated stressors by (a) relying on faith in God's plan and trust in religious community, (b) establishing borrowing networks, and (c) compartmentalizing the past and present. This research has broader implications for the promotion of urban refugees' psychosocial health and resilience in countries of first asylum.
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